Hand-assisted laparoscopic liver surgery

Hand-Assisted Laparoscopic Liver Surgery Yuman Fong, MD, William Jarnagin, MD, and Leslie Blumgart, MD

ver the last two decades, laparoscopic surgery has

O gained acceptance as standard therapy for a number

of benign conditions. For gastric reflux, laparoscopic Nissen fundoplication has become the standard of surgical care. 1 For gallstone disease, laparoscopic cholecystectomy and bile duct exploration have almost completely replaced the open versions of these operations. 2"3 For resections of hollow organs such as the large intestine, laparoscopic resection is gaining acceptance for benign conditions and malignant disease alike. 4'5 Laparoscopic resection of solid organs, such as the spleen and adrenal glands, have now moved beyond major centers for use within the community. 6'7 For hepatic resection, however, progress has been slowed by the difficulty of these operations and by the dire consequences of operative misadventure. Many in the surgical community are still skeptical that laparoscopic liver resections can be performed routinely. Nonetheless, several recent changes have combined to make such resections more technically feasible, a-14 The experience in most major centers with open liver resection has greatly increased over the last decade to the point that open hepatectomy is routine at a large number of hospitals. 15q7 A number of changes in laparoscopic instrumentation, including laparoscopic stapling devices, ultrasonic dissectors, and hand access ports, have also encouraged investigation for laparoscopic liver resection. O b s t a c l e s to L a p a r o s c o p i c H e p a t e c t o m y The major obstacles to laparoscopic hepatectomy are listed in Table 1. Most hepatectomies performed electively are done to treat cancer. Many tumors lie deep within the parenchyma of the liver, and their margins are not always apparent. During open resection, manual palpation aids assessment of the tumor margins and helps guide the resection. In closed laparoscopic resection, in contrast, the risk of violating the tumor margins is increased. Although a number of instruments have been designed to retract the liver, most or all of these are made for static

From the Memorial Sloan-Kettering Cancer Center and Weill Cornell Medical College, New York, NY. Address reprint requests to Yuman Fong, MD, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10021. Copyright 2002, ElsevierScience(USA).All rights reserved. 1524-153X/02/0401-0007535.00/0 doi:10.1053/otgn.2002.30746 88

retraction of the liver. The liver must be maintained in one or only a few positions to enable safe performance of fundoplication or laparoscopic cholecystectomy or other laparoscopic operations that require liver retraction. For laparoscopic liver resection, however, the liver must be moved in multiple positions with fluidity. A retractor has not yet been designed for this purpose. In particular, for patients with fatty livers, use of the current generation of laparoscopic retractors often causes subcapsular bleeding or even capsular tears and hemorrhage. Of greatest concern in liver resection, however, is the risk of tearing major venous structures within the liver, which could lead to hemorrhage or air embolism. In open procedures, if a tear occurs on the hepatic vein, manual compression of the tear decreases blood loss and provides time to repair such injuries. In completely closed laparoscopic surgery, the concern is that if hemorrhage occurred, it would be minutes before the procedure could be converted and bleeding controlled. In addition, given the positive pressure created by carbon dioxide (CO 2) pneumoperitoneum, a tear in the hepatic veins carries a theoretical risk of CO2 embolism and its consequences. Other minor obstacles to laparoscopic resection include the potentially tedious nature of parenchymal transection. In open surgery, the vessels and the biliary radicals are ligated mainly with clips or ligatures. If parenchymal transection was done in the same way laparoscopically it would require multiple exchanges of instruments, which can be quite time-consuming. Finally, the specimen from a liver resection can often be large, and, because assessment of tumor margins is important, removing such specimens intact is crucial and generally cannot be done through a 10-, 12-, or 15-mm port. Laparoscopic ultrasonic dissectors 6"1e and stapling devices 19 have greatly simplified ligation of small and large vessels, respectively, and thus have greatly enhanced the feasibility of laparoscopic resection of solid organs, including the liver. However, the development of the handaccess port probably has contributed the most to the feasibility of such procedures. The hand port gives the surgeon the ability to palpate the tumor and assess for tumor margin. The hand remains the best retractor of the liver. If accidental disruption of major vessels occurs, manual compression can be performed immediately. Hand-assisted laparoscopic surgery also minimizes the wound size during resection while allowing adequate room for removing an intact specimen. These and other

Operative T e c h n i q u e s in General Surgery, Vol 4, No 1 (March), 2002: pp 88-98

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Laparascopic Liver Resection Table 1. Obstacles to Laparoscopic Hepatectomy Margins of tumor not always apparent Difficulties in retraction Risk of hemorrhage Risk of air embolism Tedious parenchymal transection Difficulties in removing specimen

technical developments have made laparoscopic liver resection feasible. This procedure is being examined at a number of major centers where liver resections are performed routinely.

Patient Selection Patients should be selected with regard to safety of the procedure as well as for ability to confidently remove

all tumors. The best patients for laparoscopic resection are those with tumors near the lower and lateral edges of the liver (Fig 1). Patients with tumors in the left lateral segment or in segment IVB, V, or VI are the ideal candidates for such resection. Laparoscopic lobectomies and trisegmentectomies can be performed b u t are not r e c o m m e n d e d except for surgeons facile in these procedures in the open setting. The most important determinant of patient selection is the tumor's proximity to the major inflow or outflow vasculature. If a t u m o r is in direct approximation to the hilus or the hepatic veins, it is highly unlikely that laparoscopic resection will clear the tumor. Additionally, if the tumor is near the confluence of the hepatic veins with the vena cava, the difficulty of dissection is great and the risk of hemorrhage too high to justify laparoscopic resection at this time.

1 MRI illustrating an ideal tumor for hand-assisted laparoscopic liver resection. Note that the tumor is attached to the bottom of segments V and VI. It is far away from inflow and outflow vasculature and does not show any clear invasion into surrounding adjacent organs. Note, however, the satellitosis around the base of the tumor. Manual palpation will help identify these lesions and ensure negative margin.

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SURGICAL TECHNIQUE Left Lateral Segmentectomy

Trocar AI

,r later of 5mm cautery Trocar in right upper quadrant

c seal sertion ;ision

2 The procedure begins by drawing the outlines of a bilateral subcostal incision on the patient's skin. The port sites are chosen to lie on these incisions so that if conversion becomes necessary, the laparoscopic ports will be incorporated into the open incision. The first port placed is usually a 10-mm port in the left upper quadrant to allow laparoscopic visual and ultrasonographic assessment of the peritoneal cavity and liver. If the tumor looks resectable, then the outline of the hand port is applied on the abdominal wall with the abdomen inflated. This allows a port to be placed in the appropriate position for use. The hand assist port for a left lateral segmentectomy or a left lobectomy is usually placed in the left subcostal area. It should be placed about halfway between the costal margin and the iliac crest. If conversion is necessary in these left-sided resections, we usually use a left subcostal hockey stick-type incision for the open procedure. After the hand-assist port is placed, a hand is introduced and the liver and the abdominal cavity again assessed by manual palpation. The lesser sac is usually entered after the lesser omentum is sharply divided, and palpation of the celiac nodes as well as the portal caval nodes is then performed manually through the foramen of Winslow. If the lesion is deemed resectable, then a third laparoscopic port (usually a 10 or 12 mm) is placed in the right upper quadrant. The original 10-mm port can also be now switched to a 12-mm port to allow use of the stapling devices through this port. When new ports are being introduced through the abdominal wall, the hand must be removed from the abdominal cavity for safety. When previously placed ports are being exchanged for larger sizes, the hand within the abdominal cavity can serve as a useful guide. A finger can be placed from within the abdomen through the port site as the first trocar is removed. Pneumoperitoneum is maintained, and the new port can be easily guided into the abdominal cavity. Additional 5-mm ports can be placed later if needed for additional approaches using cautery or ultrasonic dissector.

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Laparascopic Liver Resection Line of division of

Tumor in left lobe

Bulldc on portal triad (Pringle maneuver)

(potential origin of accessory left hepatic a.)

3 A bulldog clamp is introduced into the abdominal cavity through the hand port for use in the Pringle maneuver. An umbilical tape is tied to the back of the bulldog clamp so that it can be found easily during laparoscopy. Laparotomy gauze can also be introduced into the abdominal cavity to achieve hemostasis and to aid in retraction. There are also a number of short clamps and scissors designed to be placed within the abdominal cavity for use in hand-assisted surgery. We have not found any of these essential for hand-assisted liver resection, however. Some differences from an open operation need to be emphasized. One difference is that in laparoscopic resection, the falciform and the triangular ligament are left intact to allow countertraction while the hand produces traction on the liver and the lesion. These ligaments are divided at the end of the operation. Additionally, during an open operation, instruments are brought to the site of transection. In laparoscopic resection, because the instruments are fixed with a limited number of angles, the liver must be moved a lot more to put it in line with the best mechanical advantage of the instruments. Laparoscopic ultrasonography should be performed again at this time to verify the positions of the major vasculature, including the inflow pedicles and the hepatic veins. For a left lateral segmentectomy, for example, the segment II and Ill inflow pedicles, as well as the left hepatic vein, must be identified. Knowing the approximate position of these vessels will help ensure safe parenchymal transection. In addition, the line of transection of the liver for tumor clearance should be determined by laparoscopic ultrasound and manual palpation. This is marked by electrocautery on the liver surface for later reference.

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Division of parenchyma v harmonic scal Large vessels and ducts to be divided later

4 Parenchymal transection is begun. With the hand applying traction on the specimen, a harmonic scalpel (ultrasonic dissector) is used to transect the parenchyma in those areas thought to be far away from major inflow and outflow vasculature. This parenchymal transection is performed after application of the Pringle maneuver. At our institution, we use such vascular occlusion in an intermittent fashion, applying it for 10 minutes at a time and releasing it for approximately 5 minutes between applications. As the major inflow vasculature is approached, blunt dissection is performed with either a blunt clamp or a suction apparatus until the pedicles are identified.

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Large hepatic vessels and ducts liaated/divided with

5 An endovascular stapling device is used to transect the pedicles. Stapler application is a bimanual maneuver. The hand within the abdomen guides placement of the stapler and ensures that the stapler completely controls the entire pedicle.

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Resection completed with division of triangular ligament using harmonic scalpel

6 After the parenchyma is completely divided and the left lateral segment is disconnected from the rest of the liver, the triangular ligament is transected. This transection can be performed using either scissors attached to the electrocautery, a stapling device, or an ultrasonic dissector. Care must be taken when dividing the triangular ligament near the tendonous portion of the diaphragm, because inadvertent tearing or disruption of this portion of the diaphragm will immediately cause a left-sided pneumothorax.

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Removal of surgical specimen prior to cautery of hepatic leaks and final closure

7 The specimen is removed from the abdominal cavity. If the specimen is small, hand-assisted simple extraction through the hand port is done. Most hand-assist port devices have built-in wound protectors to prevent seeding of tumor. If the specimen is large, simple extraction through the small wound may rupture the liver or the tumor and disseminate tumor into the peritoneal cavity or disrupt the specimen for pathologic analysis. In those cases, we use a specimen-retrieval bag. This can be introduced into the abdominal cavity by exchanging an existing trocar for the specimen-retrieval bag trocar. The specimen is manually placed within the bag, and the bag is brought out through the hand port. For further hemostasis, an argon beam coagulator, tissue sealants, or collagen-based materials, according to the surgeon's preference can be applied laparoscopically. After hemostasis is ensured and the absence of bile leaks verified, the incisions are closed separately. We prefer to inject local anesthesia around the wounds at the time of closure. We generally do not place drains after liver resection unless there is bile leakage that cannot be resolved by suture ligation.

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Right-Sided Liver Resections Trocar arrangement for laparoscopic assisted right hepatic resection

8 Lesions in the right lobe of the liver that are most amenable to laparoscoplc resection are those in segments V or VI. Although we have performed resections of lesions on segments VII and VIII, even the smallest lesions in these areas are fraught with danger. Laparoscopic resection of the entire right lobe is not recommended except by those surgeons who are completely comfortable with major open resections. In addition, only patients with large tumors of the right lobe that are far away from the inflow and outflow vasculature should be considered for laparoscopic lobectomies. Here, instead of describing the entire right-sided liver resection, we highlight those differences between right and left-sided resection. This illustration shows the placement of the laparoscopic ports. The hand port should be placed as far lateral and as low as feasible. With tumors of segments V and VI, these tumors are often at the costal margin, and hand retraction is made easier with the port located more inferiorly. To provide more room for the hand to work and retract, the patient should be placed in Trendelenberg position. The first port usually placed is a 10-mm port placed in the midclavicular line on the right side. In preparing for a right-sided resection, we also place this port lower than usual. The third port is often placed midline and may be placed periumbilical. When evaluating a right-sided liver lesion, we need to assess involvement of the hepatic flexure. For large hepatocellular carcinomas, attachment of the hepatic flexure or the right colon to the lesion is not unusual. This is why for large right-sided lesions on the lower portion of the liver, we routinely perform preoperative mechanical cleansing of the large bowel in the event of the need for a colon resection. If the colon is free of tumor, it is dissected off and mobilized away from the liver lesion. If it is closely adherent, we leave it attached and transect the liver parenchyma first. After the tumor and surrounding liver parenchyma are disconnected from the remnant liver, a better assessment of colonic involvement can be made by examining the posterior aspects of this attachment. This will either allow safer and easier dissection of the colon off the tumor specimen or allow the specimen with the hepatic flexure to be brought through the hand port and resection of the liver tumor and colon to be done under direct vision.

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B 9 Laparoscopic ultrasound should be performed to identify the right anterior and right posterior pedicles as well as the right hepatic vein. The liver surface is then marked and parenchymal transection performed as discussed earlier for left lateral segmentectomy. Major pedicles and hepatic veins are divided by stapling devices (A), and the liver parenchyma is divided by ultrasonic dissection (B).

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Conclusion A number of technical advances currently allow us to perform safe laparoscopic liver surgery. Resections of two or three segments can be done routinely, particularly if the area to be resected is in the inferior or lateral edges of the liver. Whether such laparoscopic liver resections are a true advance rather than a technical exercise, however, has not been determined. A decreased hospital stay or more rapid return to normal activities would mean very little if such operations increased the risk of tumor recurrence. The technical demands of resecting tumors that are near the vena cava or the major inflow and outflow vessels, and the associated major risks, are such that we believe that such tumors should not be resected laparoscopically at present. Once surgeons who are facile with liver resection become comfortable with laparoscopic surgery and gain experience with such laparoscopic resections, clinical trials using cancer outcome, quality-oflife determinations, and resource usage as endpoints will be in order.

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