International Hepato-Pancreato-Biliary Association
Laparoscopic liver wedge resection [Case 19]
Watch the following videos of the surgeons preoperative plans for the case. Compare their findings with your own analysis.
Dr. Sapisochin’s patient-specific moments:
Rule out portal hypertension, ascites, splenomegaly
Laparoscopic Sg6 Wedge resection
Proximity of lesion to colon, no invasion
Peripheral lesion away from portal structures
Plan for Pringle maneuver
My name is Gonzalo Sapisochin and I’m an assistant professor at the university of Toronto and a hepatobiliary and pancreatic surgical oncologist.
This patient is a 60-year old gentleman diagnosed with Hepatitis C, recently diagnosed with a mass in his liver. He was referred to me with this single HCC or what looks like to be HCC in the context of Hepatitis C. This case was thoroughly discussed in our HCC multidisciplinary rounds and because of its proximity to the colon, even though the size is small, we decided to perform a laparoscopic wedge resection (laparoscopic Segment 6 resection).
From a patient perspective, of course, what I’ve been thinking with this patient is to make sure that he doesn’t have portal hypertension. We looked at his scans, there’s no signs of ascites. He’s never had any decompensation, his spleen is small, his blood count is normal as well as his bilirubin. I think it's safe to perform a resection. In this case, it's certainly preferred to do a laparoscopic resection which I think it minimizes the risk of decompensation. Any how, in this patient, a resection is going to be small. So I don’t anticipate much of a problem from a liver perspective.
From a surgical perspective, I suspect that we’re going to… As soon as we get in, even though its going to be slightly posterior, I think we’ll be able to access the tumor easily. I think or I hope that the colon is going to be easy to dissect off of this mass. I don’t anticipate any invasion.
Again due to how peripheral this lesion is, it was not adjacent to any of the vessels for the porta so that is something I would check in other cases but in this case this is not something we needed to check. Certainly we need to check if its adjacent to any other organs as I mentioned to the colon and we’ll need to make sure once we put in the scope that there’s no invasion.
In all my laparoscopic cases, I’d like to use a Pringle maneuver. I think it minimizes certainly blood loss and it makes the resection easier. I usually use an external Pringle and I use a chest tube as my Roumelle or my tube to do this Pringle. I don’t anticipate much problems to go around the pedicle to do this Pringle. We’ll put the tape around the pedicle and then we’ll take it out of the body through the left side as this tumor is certainly very close to the right side. Otherwise I think that’s what we’re planning. I don’t think there’s any big tricks or tips here besides I think doing a Pringle maneuver it really facilitates.
Dr. McGilvray’s patient-specific findings:
Left-sided hypertrophy, right-sided atrophy
Laparoscopic peripheral Sg 5-6 Wedge resection
Reflect colon away from liver
Two-plane transection approach
Plan for Pringle maneuver
Dr. Ian McGilvray. Liver and pancreas surgeon at Toronto General Hospital.
So this is a 60 year old patient with evident cirrhosis of the liver on imaging who was found to have a hepatocellular or lesion compatible with hepatocellular cancer. It’s immediately apparent on the MRI, this is the arterial phase, is that there’s left sided hypertrophy of the liver and right-sided atrophy and scrolling down, on the junction of segment 5 and segment 6, there is an arterially hyperenhancing lesion that is somewhat exophytic on the periphery of the liver. At our institution these cases are presented at multidisciplinary rounds and this person’s case the consensus was to proceed with surgery. A good option for that, particularly in the face of his cirrhosis, is a laparoscopic approach with the plan being to undertake a generous Wedge resection of the peripheral aspect of Segments 5 and 6 of the liver.
Not haven’t been given much clinical information about this patient it’s difficult to be too precise but of course the standard thing to worry about is whether this patient will tolerate any operation. As a group, we only operate on patients with hepatocellular cancer if they are Childs A with platelets over 100 and generally with some exceptions, no evidence of portal hypertension. So assuming that is the baseline, then you turn to the technical components of the operation and this patient case that’ll involve reflecting the colon away from the undersurface of the liver and having decent visualization of the area of the liver that you are choosing to resect. In some respect, this is pretty ideal position for a laparoscopic approach because you can approach it from both sides with decent visualization pretty easily and generally just plan to take a two plane approach and join it in the middle with a transection device of your choice and we tend to use the harmonic at our institution.
I think with peripheral lesions, well with any cirrhotic patient with any liver resection, blood loss of course is a concern. One handy trick for this sort of case is to set up to perform a Pringle procedure laparoscopically even before you start transecting the liver parenchyma and that can be accomplished through a chest tube through a laterally placed 5-mm trocar port with an umbilical tape and externally placed clamp to tighten the whole thing down around the porta.
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