Simplifying minimally invasive right hepatectomy

Abstract

Background: Extrahepatic transection of the right hepatic artery and right portal vein before parenchymal dissection is a widely used standard for minimal invasive right hepatectomy. Hereby, hilar dissection represents a technical difficulty. We report our results of a simplified approach in which the hilar dissection is omitted and the line of dissection is defined with ultrasound.

Methods: Patients undergoing minimally invasive right hepatectomy were included. Ultrasound-guided hepatectomy (UGH) was defined by the following main steps: (1) ultrasound-guided definition of the transection line, (2) dissection of the liver parenchyma according to the caudal approach, (3) intraparenchymal transection of the right pedicle and (4) of the right liver vein, respectively. Intra- and postoperative outcomes of UGH were compared to the standard technique. Propensity score matching was performed to adjust for parameters of perioperative risk.

Results: Median operative time was 310 min in the UGH group compared to 338 min in the control group (p = 0.013). No differences were observed for Pringle maneuver duration (35 min vs. 25 min; p = ns) nor postoperative transaminases levels (p = ns). There was a trend toward a lower major complication rate in the UGH group (13 vs. 25%) and a shorter median hospital stay (8 days vs. 10 days); however, both being short of statistical significance (p = ns). Bile leak was observed in zero cases of UGH compared to 9 out of 32 cases (28%) for the control group (p = 0.020).

Conclusions: UGH appears to be at least comparable to the standard technique in terms of intraoperative and postoperative outcomes. Accordingly, transection of the right hepatic artery and right portal vein prior to the transection phase can be omitted, at least in selected cases. These results need to be confirmed in a prospective and randomized trial.

Keywords: Glissonean approach; Hepatectomy; Laparoscopic liver surgery; Robotic liver surgery.

Fig. 1

Schema of intraparenchymal pedicle transection after dissection of the liver parenchyma in a caudal approach

Fig. 2

Laparoscopic right hepatectomy with ultrasound-guided (UGH) technique: Demonstration of the 10-step protocol. H hepatic hilum, rPed right hepatic pedicle, rVein right hepatic vein. (A) Identification of the grooves adjacent to the right and the middle hepatic vein (step 1), (B) cholecystectomy (C) Preparation of hepatic inflow occlusion. The hepatoduodenal ligament is encircled with a Mersilene tape (step 3), (D–F) Ultrasound-guided definition of the parenchymal transection line (step 4). (G) Parenchymal transection: Laparoscopic parenchymal transection is performed using ultrasonic shears for surface transection and water jet dissection for deeper transection (step 5). Veins are ligated using polymer clips, (H) intraparenchymal stapler dissection of the right hepatic pedicle (step 6). (I) stapler dissection or the right liver vein (step 7). Steps 8-10 do not differ from the standard technique and are not depicted in the figure.

Fig. 3

Intra- and postoperative outcomes for right hepatectomy comparing the facilitated approach (UGH) to the standard technique (control group)