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Totally laparoscopic single port hepatic left lobectomy and cholecystectomy for cholangiocarcinoma
Background: Single port (SP) hepatic resection presents a few examples in the recent literature which suggest a clear possibility for better cosmetic results and shorter hospital stay. This video presents a patient who has undergone totally laparoscopic SP left hepatic lobectomy for cholangiocarcinoma and cholecystectomy for cholelitiasis.

The present case shows a 70-year-old woman with a BMI of 26 kg/m2 with documented 45mm hepatic mass and irregular margins involving segment III suggesting intrahepatic cholangiocarcinoma. A 40mm peri-umbilical incision was performed. SP hepatic left lobectomy was performed using a 4-access OCTO™ port (High-Tech Center, Seoul, Korea), with a 30-degree scope, a curved grasping forceps, and Atlas Ligasure™ (Covidien, USA) and Vascular Endo GIA™ (Covidien, USA); specimen retrieval was performed through the right periumbilical incision.

Results: No conversion to open surgery was necessary, neither were additional trocars. Total operative time was 120 minutes and laparoscopic time 80 minutes; liver transection time was 24 minutes. Final umbilical incision length was 40mm. Blood loss was lower than 40cc, no transfusion or abdominal drainage was required. The postoperative course was uneventful and the patient was discharged on postoperative day 2.

Conclusions: Left hepatic lobectomy for localized intrahepatic cholangiocarcinoma and associated cholecystectomy can be safely performed with a periumbilical SP procedure, with macro- and microscopically neoplasia-free margins.
U Cillo, E Gringeri, R Boetto, G Zanus
Surgical intervention
7 years ago
3985 views
31 likes
0 comments
05:20
Totally laparoscopic single port hepatic left lobectomy and cholecystectomy for cholangiocarcinoma
Background: Single port (SP) hepatic resection presents a few examples in the recent literature which suggest a clear possibility for better cosmetic results and shorter hospital stay. This video presents a patient who has undergone totally laparoscopic SP left hepatic lobectomy for cholangiocarcinoma and cholecystectomy for cholelitiasis.

The present case shows a 70-year-old woman with a BMI of 26 kg/m2 with documented 45mm hepatic mass and irregular margins involving segment III suggesting intrahepatic cholangiocarcinoma. A 40mm peri-umbilical incision was performed. SP hepatic left lobectomy was performed using a 4-access OCTO™ port (High-Tech Center, Seoul, Korea), with a 30-degree scope, a curved grasping forceps, and Atlas Ligasure™ (Covidien, USA) and Vascular Endo GIA™ (Covidien, USA); specimen retrieval was performed through the right periumbilical incision.

Results: No conversion to open surgery was necessary, neither were additional trocars. Total operative time was 120 minutes and laparoscopic time 80 minutes; liver transection time was 24 minutes. Final umbilical incision length was 40mm. Blood loss was lower than 40cc, no transfusion or abdominal drainage was required. The postoperative course was uneventful and the patient was discharged on postoperative day 2.

Conclusions: Left hepatic lobectomy for localized intrahepatic cholangiocarcinoma and associated cholecystectomy can be safely performed with a periumbilical SP procedure, with macro- and microscopically neoplasia-free margins.
Laparoscopic left hepatectomy with extrahepatic inflow and outflow exclusion
This is the case of a 72-year-old woman presenting with a 5cm intrahepatic cholangiocarcinoma arising on an HCV-related well-compensated chronic liver disease without portal hypertension. Laparoscopic left hepatectomy (liver segments 2, 3, and 4) was decided upon. Four ports were placed. The procedure began with a complete abdominal exploration and intraoperative liver ultrasonography, which allowed to identify the tumor between liver segments 2 and 4a in close contact with the left hepatic vein.
Hilar dissection was performed with lymphadenectomy of the common hepatic artery and left hepatic artery.
Before parenchymal transection, both inflow and outflow of the left liver were interrupted. The left hepatic artery and the left portal vein were isolated and divided between clips. The left hepatic vein was isolated after division of the Arantius’ ligament and clamped by means of a laparoscopic vascular clamp. Parenchymal transection was carried out using an ultrasonic dissector (CUSA™), and hemostasis was controlled with a radiofrequency bipolar hemostatic sealer (Aquamantys™) and clips. The biliary duct and the left hepatic vein were managed with vascular staplers. At the end of the operation, a tubular drain was placed. Operative time accounted for 240 minutes and total blood loss was 100mL.
The postoperative course was uneventful and the patient was discharged on postoperative day 6.
The pathology confirmed a 5cm G3 cholangiocarcinoma with invasion of the left hepatic vein and of segment 2 portal branch. Resection margins were negative for tumor invasion and for all lymph nodes retrieved.
C Sposito, D Citterio, C Battiston, V Mazzaferro
Surgical intervention
1 year ago
2886 views
11 likes
2 comments
10:57
Laparoscopic left hepatectomy with extrahepatic inflow and outflow exclusion
This is the case of a 72-year-old woman presenting with a 5cm intrahepatic cholangiocarcinoma arising on an HCV-related well-compensated chronic liver disease without portal hypertension. Laparoscopic left hepatectomy (liver segments 2, 3, and 4) was decided upon. Four ports were placed. The procedure began with a complete abdominal exploration and intraoperative liver ultrasonography, which allowed to identify the tumor between liver segments 2 and 4a in close contact with the left hepatic vein.
Hilar dissection was performed with lymphadenectomy of the common hepatic artery and left hepatic artery.
Before parenchymal transection, both inflow and outflow of the left liver were interrupted. The left hepatic artery and the left portal vein were isolated and divided between clips. The left hepatic vein was isolated after division of the Arantius’ ligament and clamped by means of a laparoscopic vascular clamp. Parenchymal transection was carried out using an ultrasonic dissector (CUSA™), and hemostasis was controlled with a radiofrequency bipolar hemostatic sealer (Aquamantys™) and clips. The biliary duct and the left hepatic vein were managed with vascular staplers. At the end of the operation, a tubular drain was placed. Operative time accounted for 240 minutes and total blood loss was 100mL.
The postoperative course was uneventful and the patient was discharged on postoperative day 6.
The pathology confirmed a 5cm G3 cholangiocarcinoma with invasion of the left hepatic vein and of segment 2 portal branch. Resection margins were negative for tumor invasion and for all lymph nodes retrieved.
LIVE INTERACTIVE SURGERY: Laparoscopic left lateral sectionectomy for echinococcosis alveolaris
Human alveolar echinococcosis is a fatal, chronically progressive hepatic infestation. It has a long asymptomatic period. The lesions are invasive, tumor-like, multivesiculated with exogenous budding containing mucoid material with surrounding fibrous stroma. The lesions vary in size from a pin point to a hen’s egg size and are never huge. There are no daughter cysts and scolices are never present. The liver is the most common site for the alveolar form.
Alveolar echinococcosis of the liver behaves like a slow-growing liver cancer.
Differential diagnoses of alveolar echinococcosis include several hepatic tumors such as cystadenoma, cystadenocarcinoma, peripheral cholangiocarcinoma, and metastasis. These tumors can be differentiated from alveolar echinococcosis because they are usually enhanced and rarely calcified.
Lack of enhancement is a characteristic feature of alveolar echinococcosis lesions and might aid in the differential diagnosis of hepatic lesions.
The mainstay of treatment is surgical in localized lesions. Medical therapy only stabilizes the lesions in some cases. Liver transplantation may be required in advanced cases. Metastasis of the disease occurs in advanced cases resulting in lesions in the lung and the brain.
Radical surgical procedures are the best chance of definite cure of the disease because the cyst is removed from the patient's body as a whole, leaving no chance for recurrence.
Recurrence after primary treatment of echinococcosis multilocularis liver disease is an important issue. The major hepatic resection, which is a radical procedure is a safe and effective option for treatment of liver echinococcosis multilocularis.
Non-anatomic hepatic resections should be performed for cysts of a relatively small size and subcapsular location whereas anatomical resections should be performed for cysts impairing most of liver segments.
A Prado de Resende
Surgical intervention
3 years ago
1670 views
66 likes
0 comments
26:34
LIVE INTERACTIVE SURGERY: Laparoscopic left lateral sectionectomy for echinococcosis alveolaris
Human alveolar echinococcosis is a fatal, chronically progressive hepatic infestation. It has a long asymptomatic period. The lesions are invasive, tumor-like, multivesiculated with exogenous budding containing mucoid material with surrounding fibrous stroma. The lesions vary in size from a pin point to a hen’s egg size and are never huge. There are no daughter cysts and scolices are never present. The liver is the most common site for the alveolar form.
Alveolar echinococcosis of the liver behaves like a slow-growing liver cancer.
Differential diagnoses of alveolar echinococcosis include several hepatic tumors such as cystadenoma, cystadenocarcinoma, peripheral cholangiocarcinoma, and metastasis. These tumors can be differentiated from alveolar echinococcosis because they are usually enhanced and rarely calcified.
Lack of enhancement is a characteristic feature of alveolar echinococcosis lesions and might aid in the differential diagnosis of hepatic lesions.
The mainstay of treatment is surgical in localized lesions. Medical therapy only stabilizes the lesions in some cases. Liver transplantation may be required in advanced cases. Metastasis of the disease occurs in advanced cases resulting in lesions in the lung and the brain.
Radical surgical procedures are the best chance of definite cure of the disease because the cyst is removed from the patient's body as a whole, leaving no chance for recurrence.
Recurrence after primary treatment of echinococcosis multilocularis liver disease is an important issue. The major hepatic resection, which is a radical procedure is a safe and effective option for treatment of liver echinococcosis multilocularis.
Non-anatomic hepatic resections should be performed for cysts of a relatively small size and subcapsular location whereas anatomical resections should be performed for cysts impairing most of liver segments.
Laparoscopic right hepatectomy: intra-hepatic Glissonian approach
This video demonstrates a totally laparoscopic approach to right hemi-hepatectomy. The right portal pedicle is first divided with an endoscopic stapler. The liver parenchyma is then divided with a combination of ultrasonic scalpel, Cavitron Ultrasound Surgical Aspirator (CUSA), bipolar cautery and clips.

Many surgeons prefer to employ the hand-assisted approach, but in this totally laparoscopic demonstration the author uses the intrahepatic Glissonian approach without the Pringle maneuver. The procedure starts with surgical exploration and laparoscopic evaluation of the liver. The harmonic scalpel divides the hepatic round and falciform ligaments. The author visualizes the suprahepatic inferior vena cava and right hepatic vein, then explores the hepatoduodenal ligament for enlarged lymph nodes. He then mobilizes the right liver as high as possible by transecting the right triangular ligament. Paying attention to the area of the adrenal gland, he dissects the gallbladder hilum, and transects both the cystic artery and duct. He starts the hepatic hilar dissection with an incision of the liver parenchyma, continuing outside the portal pedicle bifurcation toward the right and left sheet. The procedure continues with transection of the right portal pedicle.
B Topal
Surgical intervention
12 years ago
1027 views
40 likes
0 comments
05:54
Laparoscopic right hepatectomy: intra-hepatic Glissonian approach
This video demonstrates a totally laparoscopic approach to right hemi-hepatectomy. The right portal pedicle is first divided with an endoscopic stapler. The liver parenchyma is then divided with a combination of ultrasonic scalpel, Cavitron Ultrasound Surgical Aspirator (CUSA), bipolar cautery and clips.

Many surgeons prefer to employ the hand-assisted approach, but in this totally laparoscopic demonstration the author uses the intrahepatic Glissonian approach without the Pringle maneuver. The procedure starts with surgical exploration and laparoscopic evaluation of the liver. The harmonic scalpel divides the hepatic round and falciform ligaments. The author visualizes the suprahepatic inferior vena cava and right hepatic vein, then explores the hepatoduodenal ligament for enlarged lymph nodes. He then mobilizes the right liver as high as possible by transecting the right triangular ligament. Paying attention to the area of the adrenal gland, he dissects the gallbladder hilum, and transects both the cystic artery and duct. He starts the hepatic hilar dissection with an incision of the liver parenchyma, continuing outside the portal pedicle bifurcation toward the right and left sheet. The procedure continues with transection of the right portal pedicle.