Precise laparoscopic anatomical liver segmentectomy by extrahepatic hilar approach with 3D computer-assisted simulation and navigation

Yuta Abe, MD, Osamu Itano, MD, Masahiro Shinoda, MD, Minoru Kitago, MD, Hiroshi Yagi, MD, Taizo Hibi, MD, Yuko Kitagawa, MD. Department of Surgery, Keio University School of Medicine

AIM: Theoretically, anatomical liver resection requires in-depth understanding of liver anatomy and is technically demanding even by laparotomy. We describe our series of pure laparoscopic anatomical liver segmentectomies using 3D computer-assisted simulation and navigation.

METHODS: Precise preoperative evaluation by 3D imaging enabled us to identify each portal pedicle and hepatic vein at the tertiary levels and simulate the cutting plane of the liver while securing adequate tumor margins. In the operating room, we started from isolating the main inflow portal pedicles to the tumor at the hepatic hilum (extrahepatic hilar approach), which could be done easily with the magnified view of laparoscopy. Then, the transection of the liver parenchyma followed the demarcated line by selective clamping of portal pedicles. Once we get inside the liver, the small branches of hepatic veins, which were already identified preoperatively, served as beacons of the boundaries between the resecting liver and the remnant.

RESULTS: During the period between 2013 and 2014, 93 patients with liver tumors underwent laparoscopic liver resections and of 17 patients (Rt liver: 14, Left liver: 3) underwent laparoscopic liver segmentectomies by extrahepatic hilar approach. We successfully performed pure laparoscopic liver resections by identifying all anatomical structures and reproducing the transection plane that was planned preoperatively in all cases. Median number of tertiary glissonean pedicles ligated was 2 (1-4) and median estimated blood loss was 200 (0-550). Surgical margins were all negative.

CONCLUSION: With the combination of precise understanding of the vascular anatomy using 3D imaging and the luxury of magnified view as well as decreased blood loss by laparoscopic surgery, we can now perform a more accurate, “truly” anatomical liver resection according to each tumor location. Pure laparoscopic liver resection and 3D computer-assisted simulation and navigation has taken anatomical liver resections to the next level.

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