title: Video: laparoscopic right hepatectomy and partial resection of the diaphragm for liver metastases.
abstract: BACKGROUND
  Indications for minimally invasive major hepatectomies have been increasing as experience with these techniques grows. Invasion into the diaphragm is considered a contraindication to the laparoscopic approach. At their institution, the authors have begun approaching all tumors laparoscopically. This report presents the techniques necessary to perform right hepatectomy, partial diaphragm resection, and repair using totally laparoscopic techniques.
  
  
  METHODS
  Five trocars are placed in a semilunar fashion approximately one handbreadth apart along a line one handbreadth below the right subcostal margin. The hepatic inflow is taken extraparenchymally before transection of the hepatic parenchyma in an anterior-to-posterior fashion. The hepatic inflow then is transected, and the involved portion of diaphragm is transected with ultrasonic shears. Next, the diaphragm is repaired primarily and buttressed with an absorbable material to decrease the incidence of recurrent diaphragmatic hernia.
  
  
  RESULTS
  Laparoscopic treatment was attempted for ten patients and successfully completed for nine of these patients (90%). All 10 patients had secondary liver tumors. Three patients required concomitant partial diaphragm resection. The median estimated blood loss (EBL) was 500 ml (range, 300-3,000 ml). All margins were negative, and the average hospital stay was 8 days (range, 5-17 days). Two patients (20%) experienced complications, which consisted of biliary leaks, which were treated with percutaneous drainage. One of these patients underwent conversion to an open procedure due to an inferior vena cava injury. No mortality occurred at 30 or 90 days of follow-up evaluation.
  
  
  CONCLUSIONS
  The minimally invasive approach to secondary tumors requiring right hepatectomy is feasible and safe even when there is diaphragmatic involvement. Larger series with long-term follow-up evaluation are needed to determine whether these short-term results translate into durable benefits.
authors.affiliation: Department of Surgical Oncology, Summit Medical Group, Berkeley Heights, NJ 07922, USA. aagumbs@gmail.com
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Gumbs
authors.forename: Abraham
authors.initials: A
authors.lastname: Leventhal
authors.forename: John P
authors.initials: JP
authors.lastname: Hoffman
mesh_terms: D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D003964:Diaphragm / Q000601:surgery*; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D007902:Length of Stay / Q000706:statistics & numerical data; D008113:Liver Neoplasms / Q000556:secondary / Q000601:surgery*; D011183:Postoperative Complications; D016896:Treatment Outcome