Laparoscopic liver resection of segment seven: A case report and review of surgical techniques

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InternationalJournalofSurgeryCaseReports73(2020)168–171

ContentslistsavailableatScienceDirect

International

Journal

of

Surgery

Case

Reports

jo u r n al ho me p a g e :w w w . c a s e r e p o r t s . c o m

Laparoscopic

liver

resection

of

segment

seven:

A

case

report

and

review

of

surgical

techniques

Kosei

Takagi

∗

,

Takashi

Kuise,

Yuzo

Umeda,

Ryuichi

Yoshida,

Fuminori

Teraishi,

Takahito

Yagi,

Toshiyoshi

Fujiwara

DepartmentofGastroenterologicalSurgery,OkayamaUniversityGraduateSchoolofMedicine,Dentistry,andPharmaceuticalSciences,Okayama,Japan

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received27May2020

Receivedinrevisedform24June2020 Accepted25June2020

Availableonline10July2020

Keywords: Laparoscopic Liver Segmentseven

a

b

s

t

r

a

c

t

INTRODUCTION:Laparoscopicliverresectionofsegmentseven(LLR-S7)isatechnicallychallenging pro-cedureduetoitsanatomicallocationanddifﬁcultaccessibility.Herein,wepresentourexperiencewith LLR-S7,anddemonstratealiteraturereviewregardingsurgicaltechniques.

PRESENTATIONOFCASE:A28-year-oldfemalewasdiagnosedwithrectosigmoidcancerandsynchronous livermetastasesatthesegmentthree(S3)andS7,whichweretreatedwithlaparoscopicprocedure.After thecompletelymobilizationoftherightlobe,theGlissoneanpedicleofS7(G7)wasintrahepatically transected.TherighthepaticveinwasexposedtoidentifythevenousbranchofS7(V7).Finallytheliver parenchymabetweenRHVanddissectionlinewasdivided.

DISCUSSION: Various laparoscopicapproaches for S7 havebeen reported including the Glissonian approachfromthehilum,theintrahepaticGlissoneanapproach,thecaudatelobeﬁrstapproach,and thelateralapproachfromintercostalports.ToperformLLR-S7safely,itisimportanttounderstandthe advantageofeachtechniqueincludingthetrocarplacementandapproachestoS7bylaparoscopy. CONCLUSION:WepresentourexperienceofLLR-S7forthetumorlocatedatthetopofS7,successfully performedwiththeintrahepaticGlissoneanapproach.LLR-S7canbeperformedsafelywithadvanced laparoscopictechniquesandsufﬁcientknowledgeonvariousapproachesforS7.

1. Introduction

Laparoscopicliverresectionofsegmentseven(LLR-S7)isa tech-nicallychallenging procedure due to itsanatomical location in proximitytotherighthepaticvein(RHV)andinferiorvenacava (IVC)[1,2]. Properexposureofthesurgicalviewand accessibil-itybysurgicalinstrumentshavebeenreportedtobedifﬁcultin LLR-S7[3].AsseveralapproachesforLLR-S7havebeen demon-stratedtoperformtheproceduresafely,animportantissueisto understandeachcharacteristicofdifferenttechniques.However, nostudyhasperformedaliteraturereviewfocusingondifferent approachestoS7bylaparoscopy.Theaimofthisstudyistopresent ourexperiencewithLLR-S7forthetumorlocatedatthetopofS7, anddemonstratealiteraturereviewwithspecialregardstosurgical techniques.ThestudyispresentedinaccordancewiththeSCARE Guidelines[4].

∗ Correspondingauthorat:DepartmentofGastroenterologicalSurgery,Okayama UniversityGraduateSchoolofMedicine,Dentistry,andPharmaceuticalSciences, 2-5-1Shikata-cho,Kita-ku,Okayama,700-8558,Japan.

E-mailaddress:kotakagi15@gmail.com(K.Takagi).

2. Presentationofcase

A28-year-oldfemalewasreferredtoourhospitalwiththe diag-nosis of rectosigmoid cancerand synchronous liver metastases atthesegmentthree(S3)and S7.Thepatienthad nodrug his-tory,family history includingany relevant geneticinformation, andpsychosocialhistory.Followingchemotherapywithfivecycles ofFOLFOX(5-fluorouracilandoxaliplatin)pluspanitumumab, a partialresponse tolivermetastaseswasidentifiedby radiologi-calimaging,showingthetumorsmeasuring1cminS3and1.5cm inS7.TumorinS7waslocatedatthetopofS7behindtheright hepaticvein, andtherelationshipbetweenthetumor,the Glis-soneanbranchofS7(G7)andthevenousbranchofS7(V7)was depictedinFig.1.Thepatientwassufferedfromthesideeffects ofchemotherapy,thereforelaparoscopicsimultaneous resection forcolonandlivermetastaseswasscheduled.Hepaticfunctional reserve revealed normal function with theChild-Pugh grade A (score5)andindocyaninegreen(ICG)retentionrateat15minof 3.4%.

Regardingtheprocedure,LLRwasinitiallystarted.Thepatient wasplaced inthesupine positionwiththeoperator(KT) atthe rightsideand theassistantand scopist(TKand HA)attheleft side.Aftertheintroductionofﬁvetrocarsattheumbilicalportion forthecameraand atthesubcostalarea(Fig.2), theleft

semi-https://doi.org/10.1016/j.ijscr.2020.06.107

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K.Takagietal./InternationalJournalofSurgeryCaseReports73(2020)168–171 169

Fig.1.Thethree-dimensionalimagingbasedoncomputedtomographyshowed colorectallivermetastasis,locatedatthetopofsegment7behindtherighthepatic vein.

IVC,inferiorvenacava;RHV,righthepaticvein;G7,Glissoneanpedicleofsegment 7;andV7,venousbranchofsegment7.

Fig.2.Trocarplacementwiththesubcostaltype.

Fig.3. Intraoperativeﬁndings.(A)TheGlissoneanpedicleofsegment7(G7)was identiﬁedanddivided.(B)Therighthepaticveinwasexposedtoidentifythevenous branchofsegment7(V7).

decubituspositionwiththerightsideelevatedapproximately20 degreeswasapplied.Firsttherightlobewascompletelymobilized withtransectionofafewshorthepaticveins.Intraoperative ultra-soundwasusedtoconﬁrmthetumoratS7,andthedissectionline whichsecureda2cmmarginfromthetumorwasdecided.The liverparenchymawasdissectedusingtheCavitronUltrasonic Sur-gicalAspirator(CUSA)andUltrasonicshears(Harmonicscalpel), andtheG7wasdivided(Fig.3A).TheRHVwasalsoexposed to transecttheV7(Fig.3B).TheparenchymabetweenRHVand dissec-tionlinewasdividedfromthedorsalside,afterwardsthespecimen ofS7wasremoved(SupplementaryVideo1).Followingadditional partialresectionofS3,LLRforlivermetastaseswascompleted. Sub-sequently,laparoscopiclowanteriorresectionwithcoveringstoma forrectosigmoidcancerwasperformedbythecolorectalsurgery team.Thetotaloperativetimewas506min,including180minfor LLRand336minforcolorectalsurgery.Theestimatedbloodloss wasminimalintotal.

Thepostoperativecoursewasuneventfulwiththepatientbeing dischargedonpostoperativeday9.Pathologicalexaminationofthe liverspecimensconﬁrmedcolorectalmetastaseswithfreesurgical margins.

3. Discussion

Thepresent studypresentsourexperienceofLLR-S7for the tumorlocatedatthetopofS7,successfully performedwiththe intrahepatic Glissonean approach. Several important points of viewshouldbeacknowledgedtoachievesaferapproachtoS7by laparoscopy.Thereforealiteraturereviewwasperformedinorder tosummarizesurgicaltechniquesforLLR-S7.

Regarding patient positioning,the left semi-decubitus posi-tion withthe rightside elevatedapproximately from30 to45 degreesismostlyintroduced[1,3].Incontrast,anotheroptionisthe

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170 K.Takagietal./InternationalJournalofSurgeryCaseReports73(2020)168–171

Fig.4. Trocarplacement.(A)Thesubcostaltypewithfourorﬁvetrocarstechniques(circle).Oneortwointercostaltrocarscanbeaddedifnecessary(blackcircle).(B)The reverseLtypewithfourorﬁvetrocarstechniques(circle).

semi-proneposition[5].Inourexperience,theleftsemi-decubitus positionwaseasiertointroduce,anddidnotrequiretounderstand unfamiliaranatomicaldistortions.

Thetrocarplacementcanbedividedintotwotypes,including thesubcostaltypeorreverseLtype(Fig.4).Insubcostaltype,three orfourtrocarsareplacedalongtheloweredgeoftherightribs. Oneortwointercostaltrocarscanbeaddedifnecessary.Theuse ofintercostaltrocarswouldhelpinacasewithdifficult mobiliza-tionoftherightlobeorunclearvisualizationofthesuperiorpartof theliver.Insertingalaparoscopethroughanintercostaltrocarcan allowadirectviewtowardtheRHVandIVC,andcouldavoidmutual interferenceofsurgicalinstruments[2,6].Theadvantagesand fea-sibilityofintercostaltrocarsonLLR-S7havebeendemonstrated [2,6].However,potentialrisksassociatedwithintercostaltrocars shouldberecognized.Ontheotherhand,threeorfourtrocars tech-niqueisavailableinthereverseLtype.TheincisionforthePringle maneuverisoftenplacedontheleftmiddle-upperabdomen.In ourcase,subcostaltypewithoutintercostaltrocarswasintroduced. Actually,thecompletemobilizationoftherightlobewassafely per-formed,andsufficientsurgicalfieldwasobtainedwithoutmutual interferenceofsurgicalinstrumentsusingthismethod.

VariouslaparoscopicapproachesforS7havebeenreportedso far.First,theGlissonianapproachtotheG7fromtheliverhilum hasbeenshown[7,8].Thistechniquerequiresincisingthe Rou-vieresulcusand exposing therightposterior hepaticpedicle in ordertoidentifytheG7,thereforeincidentalbiliarycomplications andbleedingmighthappen.Moreadvancedlaparoscopicskillsand experiencesaremandatorytousetheGlissonianapproach.ICG ﬂu-orescenceimaging maybeusefultorecognizetheparenchymal transectionline[8].Second,theintrahepaticGlissoneanapproach

hasbeendemonstrated[1,9].In this approach,theparenchyma isdividedabovetheIVCfromtherootoftherighthepaticvein toidentifytheG7.Afterwards,theRHVisexposedfromtheroot totheperipheraltoavoidincidentalinjuryoftheRHV.This tech-niquecaneliminatetheriskofbiliarycomplicationscomparedto theGlissonianapproachwhichrequiredthedissectionaroundthe liverhilum.However,theproperidentificationoftheG7might bedifficult. Third,thecaudate lobefirst approach is suggested [5,10].In thistechnique,thecaudatelobeisfirstdividedatthe middlefromthecaudalsidetodetachthecaudateprocessfrom theposteriorGlissoneanpedicle,andtheG7canbeidentified. Suf-ficientanatomicalunderstandingwouldenablethisapproachto beperformed.Finally,thelateralapproachfromintercostalports isreported asdescribedabove [2,11].Use ofintercostaltrocars canprovideaclearvisualizationofthesuperiorpartoftheliver, andmighthelpreducetheoperator’sstress.Inthepresentcase, weintroducedtheintrahepaticGlissoneanapproachsinceother approachesrequireadditionaldissectionaroundtheliverhilum andcaudateprocess,whichmightcausebiliarycomplicationsand bleeding.

Withrespecttoretractionsystem,theadvantageofrubberband retractionmethodandslingtechniquehavebeenreported[3,12]. However,experiencesshouldberequiredtousethesemethods successfully.

SeverallimitationsshouldbedisclosedregardingLLR-S7.The evidence of each approach for S7 was based onsmall number ofexperiences.Althoughdifferenttechniqueshavebeen demon-strated,nostudywasperformedtocompareoutcomesbetween thesetechniques.Furthermore,long-termoutcomesfollowing LLR-S7forcancersarestillunknown.

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4. Conclusion

WereportourexperienceofLLR-S7usingtheintrahepatic Glis-soneanapproach. Inaddition,thepresent studydemonstrates a literaturereviewregardingvarioustechniquesforLLR-S7.LLR-S7 canbeperformedsafelywithadvanced laparoscopictechniques andsufﬁcientknowledgeonvariousapproachesforS7.

DeclarationofCompetingInterest

Theauthorshavenoconﬂictsofinteresttodeclare.

Sourceoffunding

Notapplicable.

Ethicalapproval

Becausethiswasasinglereport,andnotatrialorobservational research,therewasnorequirementforethicalapproval.

Consent

Writteninformedconsentwasobtainedfromthepatientfor publicationofthiscasereportandaccompanyingimages.Acopy ofthewrittenconsentisavailableforreviewbytheEditor-in-Chief ofthisjournalonrequest.

Authorcontributions

Allauthorscontributedtothis work,andapproved theﬁnal manuscript.

Registrationofresearchstudies

Notapplicable.

Guarantor

KoseiTakagi.

Provenanceandpeerreview

Notcommissioned,externallypeer-reviewed.

Acknowledgements

Weappreciatetheallthesurgeonsinvolvedin thiscase.We alsoexpressourgratitudetoKazuhiroYoshida,KazuyaYasui,and HiroyukiArakifortheirsupportinthiscase.

AppendixA. Supplementarydata

Supplementarymaterialrelatedtothisarticlecanbefound,in theonlineversion,athttps://doi.org/10.1016/j.ijscr.2020.06.107.

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