Laparoscopic liver resection: when to use the laparoscopic stapler device

Abstract

Minimally invasive hepatic resection was first described by Gagner et al. in the early 1990s and since then has become increasingly adopted by hepatobiliary and liver transplant surgeons. Several techniques exist to transect the hepatic parenchyma laparoscopically and include transection with stapler and/or energy devices, such as ultrasonic shears, radiofrequency ablation and bipolar devices. We believe that coagulative techniques allow for superior anatomic resections and ultimately permit for the performance of more complex hepatic resections. In the stapling technique, Glisson's capsule is usually incised with an energy device until the parenchyma is thinned out and multiple firings of the staplers are then used to transect the remaining parenchyma and larger bridging segmental vessels and ducts. Besides the economic constraints of using multiple stapler firings, the remaining staples have the disadvantage of hindering and even preventing additional hemostasis of the raw liver surface with monopolar and bipolar electrocautery. The laparoscopic stapler device is, however, useful for transection of the main portal branches and hepatic veins during minimally invasive major hepatic resections. Techniques to safely perform major hepatic resection with the above techniques will be described with an emphasis on when and how laparoscopic vascular staplers should be used.

Keywords: benign; hepatic; laparoscopic; major; malignant; minor; resection; stapler; stapling technique.

Figure 1.

Port placement. The camera port (12 mm) is placed approximately 7 cm below the right costal margin along a line in-between the mid-clavicular line and midline. A second port (12 mm) is placed just below the costal margin along the mid-axillary line. Two working ports (5 mm) are placed to the left and the right of the camera port. A fifth port (5 mm) is placed along the right anterior axillary line for liver retraction, and the final port (5 mm) is placed in the sub-xiphoid region.

Figure 2.

Stapler placed on posterior branch of right portal vein (blue).

Figure 3.

Dissection of left hepatic vein in preparation for the completion of a totally laparoscopic left hepatectomy. The middle hepatic vein has been highlighted in purple and the left hepatic vein has been highlighted in blue.

Figure 4.

Transection of right hepatic vein with laparoscopic GIA stapler device, note laparoscopic vascular clamp in right side of the field. This device should always be in the abdomen prior and during to transection of any major vascular structure with the laparoscopic vascular stapler in case torrential hemorrhage should occur.

Figure 5.

Transection of the left hepatic vein with laparoscopic GIA stapler device, note laparoscopic vascular clamp in left side of the field.