title: Two-stage laparoscopic liver resection for bilateral colorectal liver metastasis.
abstract: BACKGROUND
  Hepatectomy may prolong the survival of colorectal cancer patients with liver metastases. Two-stage liver surgery is a valid option for the treatment of bilobar colorectal liver metastasis. This video demonstrates technical aspects of a two-stage pure laparoscopic hepatectomy for bilateral liver metastasis. To the authors' knowledge, this is the first description of a two-stage laparoscopic liver resection in the English literature.
  
  
  METHODS
  A 54-year-old man with right colon cancer and synchronous bilobar colorectal liver metastasis underwent laparoscopic right colon resection followed by oxaliplatin-based chemotherapy. The patient then was referred for surgical treatment of liver metastasis. Liver volumetry showed a small left liver remnant. Surgical planning was for a totally laparoscopic two-stage liver resection. The first stage involved laparoscopic resection of segment 3 and ligature of the right portal vein. The postoperative pathology showed high-grade liver steatosis. After 4 weeks, the left liver had regenerated, and volumetry of left liver was 43%. The second stage involved laparoscopic right hepatectomy using the intrahepatic Glissonian approach. Intrahepatic access to the main right Glissonian pedicle was achieved with two small incisions, and an endoscopic vascular stapling device was inserted between these incisions and fired. The line of liver transection was marked following the ischemic area. Liver transection was accomplished with the Harmonic scalpel and an endoscopic stapling device. The specimen was extracted through a suprapubic incision. The falciform ligament was fixed to maintain the left liver in its original anatomic position, avoiding hepatic vein kinking and outflow syndrome.
  
  
  RESULTS
  The operative time was 90 min for stage 1 and 240 min for stage 2 of the procedure. The recoveries after the first and second operations were uneventful, and the patient was discharged on postoperative days 2 and 7, respectively.
  
  
  CONCLUSIONS
  Two-stage liver resections can be performed safely using laparoscopy. The intrahepatic Glissonian approach is a useful tool for pedicle control of the right liver, especially after previous dissection of the hilar plate.
authors.affiliation: Department of Gastroenterology, LIM-37, University of São Paulo, Sao Paulo, Brazil. dr@drmarcel.com.br
authors.forename: M A
authors.initials: MA
authors.lastname: Machado
authors.forename: F F
authors.initials: FF
authors.lastname: Makdissi
authors.forename: R C
authors.initials: RC
authors.lastname: Surjan
authors.forename: G T
authors.initials: GT
authors.lastname: Kappaz
authors.forename: N
authors.initials: N
authors.lastname: Yamaguchi
mesh_terms: D015179:Colorectal Neoplasms / Q000473:pathology*; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy; D008113:Liver Neoplasms / Q000556:secondary* / Q000601:surgery*; D008297:Male; D008875:Middle Aged