Takeaki Ishizawa, MD, PhD, FACS, Hirofumi Ichida, MD, PhD, Masayuki Tanaka, MD, PhD, Muga Terasawa, MD, Genki Watanabe, MD, Yoshinori Takeda, MD, Ryota Matsuki, MD, Masaru Matsumura, MD, Taigo Hata, MD, Yoshihiro Mise, MD, PhD, Yosuke Inoue, MD, PhD, Yu Takahashi, MD, PhD, Akio Saiura, MD, PhD. Cancer Institute Hospital, Japanese Foundation for Cancer Research
INTRODUCTION: Laparoscopic resection for right subphrenic hepatic tumors only with abdominal trocars often needs full mobilization of the right liver to obtain sufficient field of view and working space, even for small subcapsular tumors.
METHODS AND PROCEDURES: Patients were placed in the left lateral decubitus position with the right arm suspended (Fig. 1A). In addition to three or four abdominal trocars, two balloon-tipped trocars, one 12mm (caudal side) and one 5mm (cranial side), were deployed through the diaphragm in this order, following identification of lower edge of the lung with the use of ultrasonography from patient’s body surface (Fig. 1B). When these intercostal trocars were placed, respiration movement of the lung edge was also identified by laparoscope and the cranial side of the diaphragm was compressed with the forceps introduced through the abdominal trocar, to exclude the lung from the pleural space around the trocar sites. The 5mm cranial trocar was used by operator’s left hand and the 12mm caudal one was used as a camera port (Fig. 1C). Hepatic transection line was determined by using intraoperative ulstrasonography and indocyanine green-fluorescence imaging, following minimal mobilization of the liver. Hepatic parenchyma was dissected with bipolar forceps and vessel sealing systems under intermittent inflow occlusion. When the transthoracic trocars were removed after hepatectomy, the incisions on the diaphragm were sutured. Prophylactic chest drain was not used.
RESULTS: Transthoracic trocars were used in 12 laparoscopic hepatectomies for hepatic tumors located in Couinaud’s segment 7 (4 nodules) or segment 8 (8 nodules). The maximum diameter of the lesions and the width of the surgical margin were 12 (6-21) mm and 10 (1-15) mm, respectively (median [range]). The operation time and the amount of blood loss were respectively 205 (109-317) minutes and 65 (25-310) mL. The postoperative hospital stay was 9 (6-19) days. No postoperative complications associated with transthoracic trocars occurred.
CONCLUSIONS: Placement of transthoracic trocars is safe and facilitates laparoscopic resection for subphrenic hepatic tumors.