Major anatomical liver resections, initially considered to be unsuitable for laparoscopy, are increasingly reported by several centers worldwide. It is widely accepted that standards of open liver surgery should not be compromised during laparoscopic interventions. The video describes a totally laparoscopic right hepatectomy in an adipose patient (BMI of 44) for metastases of a rectal carcinoma.
24 months after sphincter-preserving radical rectal resection with TME (ypT3, ypN 0 (0/20), M0), metastases of the right liver were diagnosed during routine follow-up. According to MRI, endoscopy and PET-scan, metastases were limited to the right liver.
The procedure includes the following steps: positioning of the adipose patient, intermittent pneumatic calf compression for prevention of deep vein thrombosis, trocar placement, explorative laparoscopy, intraoperative diagnostic ultrasound, cholecystectomy, mobilization of the right liver, preparation of the hepatoduodenal ligament without Pringle’s maneuver, dissection and ligation of the right hepatic artery, right portal branch, and right hepatic duct, parenchymal dissection with ultrasonic surgical aspirator, a bipolar vessel-sealing device, vascular stapler only for larger vessels, ligation of right hepatic vein, sealing of the resection surface with bipolar coagulation, Argon beamer and fibrin glue, extraction of the resected specimen.
During surgery, the central venous pressure was kept low, no blood transfusions were performed and the postoperative course was uneventful. The pathological findings confirmed metastases of an adenocarcinoma with a maximal diameter of 6cm and clear resection margins. The patient was discharged 8 days after resection.
Laparoscopic right hepatectomy was carried out without compromising surgical principles established for open surgery. It is demonstrated that laparoscopic equipment such as intraoperative ultrasound, ultrasonic surgical aspirator, bipolar and Argon beamer coagulation and fibrin glue sealing can be used to their fullest extent. However, proficiency in both open liver surgery and advanced laparoscopy is compulsory.