BACKGROUND: Laparoscopic formal right hepatectomy remains a technical challenge. We propose that the procedure can be accomplished efficiently with standard laparoscopic techniques, in ordered sequence, using smaller incisions, and having identical outcomes as the open procedure.
METHOD: We reviewed 25 consecutive video recordings of formal laparoscopic right hepatectomy performed over a 4 month period. Instruments include 3 – 4 trocars, and a wound protector-hand port (Gelport). Bipolar (Ligasure) and monopolar cautery, and ultrasonic shears are the primary energy sources. Instruments consist of atraumatic graspers and fine-tip dissectors. The 30- and 45-degree angled videoscope are used. Hepatic vessels are ligated with grey-load endoscopic staplers and white-load staplers are used for liver parenchyma. The technique is parceled into five sequences: (1) hilar dissection to divide cystic duct/artery, right hepatic artery, right portal vein, (2) release ligamentous attachments laterally and superiorly, (3) divide retro-hepatic veins to IVC, (4) isolate/ligate right hepatic vein, (5) divide liver parenchyma. All staplers and sutures are pre-loaded.
RESULTS: In all cases of formal right hepatectomy, we have consistently adopted this approach and sequence of dissection for efficiency and teaching. Each case requires two surgeons and total operative times range from 120 – 150 mins (average time requirements for the five major sequences are: hilar dissection 20 mins, attachments 10 mins, retrohepatic veins 15 mins, right HV 10 mins, parenchyma 10 mins). Typically, 4 grey-load staplers and 5 white-load staplers are used in a case, depending on the size of the liver. The liver lobe and gallbladder are removed through a 7 cm protected midline incision.
CONCLUSIONS: Efficiency of laparoscopic-assisted formal right hepatectomy with vascular isolation can be enhanced with a consistent approach and sequence. We advocate deconstructing this major operation into smaller parcels for instructional purposes, which also enables the team to prepare and anticipate requirements for each sequence.
Program Number: P429