title: Laparoscopic right hepatectomy with intrahepatic transection of the right bile duct.
abstract: BACKGROUND
  Although our earlier videos demonstrated extrahepatic control of the hepatic arterial, portal venous, and biliary system, we have begun transecting the biliary system intraparenchymally for lesions distant from hilar plate and the confluence of the right and left hepatic ducts.1                   (-)                   3
  
  
  METHODS
  The patient was a 50-year old gentleman with synchronous colorectal hepatic metastasis, who underwent 6 cycles of neoadjuvant chemotherapy with a Folfox-based regimen followed by laparoscopic right hepatectomy plus wedge resection of segment 4 and microwave ablation for a lesion in segment 2. This was followed 1 month later by laparoscopic proctocolectomy. Of note, the patient was also treated with Avastin for 1 month, which was stopped 2 months prior to his liver surgery. Pneumoperitoneum was obtained with the Veress needed; alternatively, the open technique may need to be used in patients who have undergone previous surgery. A 12-mm blunt tip balloon trocar was placed approximately 1 hand-breadth below the right costal margin. Two 12-mm working trocars were placed to the left and right of this optic trocar, and trocars were then placed in the left sub xiphoid region and in the right flank for the assistants. The right hepatic artery was triply clipped proximally and twice distally prior to being sharply transected. The right hepatic portal vein was then transected using a laparoscopic vascular GIA stapler device (TriStapler, Covidien, Norwalk, CT). The anterior surface of the liver was examined, and there was a clear line of demarcation along Cantlie's line. Using the ultrasonic shears (Harmonic Scalpel, Ethicon, Cincinnati, OH), the liver parenchyma was then transected. In the area of the right hepatic duct, the liver parenchyma was transected with a single firing of the laparoscopic GIA vascular stapler device. The right hepatic vein was then identified and similarly transected with a single firing of the laparoscopic vascular GIA stapler device. Hemostasis along the hepatic parenchyma was reinforced with the laparoscopic bipolar device. The two trocars on the right of the patient are connected into 1 incision, and a gel port is placed to facilitate removal of the specimen; alternatively, an old incision can be used. For patients who will need a laparoscopic or open colectomy, a lower midline incision is made.
  
  
  RESULTS
  From Jan 2009 to Oct 2010, 13 patients underwent right hepatectomy. The average age was 63.5 years (range, 46-87 years). The indication for surgery were all for cancer including 11 colorectal metastasis, 1 anal cancer metastasis, and 1 cholangiocarcinoma. In these 13 patients, 1 patient (7.7%) required conversion to an open approach because of bleeding, 1 additional patient required laparoscopic hand assistance, and the remaining patients were completed laparoscopically. There were no surgical mortalities at 30 or 90 days. Complications occurred in 2 (15%) patients, and included 1 patient who was converted to an open procedure because of hemorrhage and was complicated by a bile leak; the second patient with complication also developed a 1-bile leak, both of which responded to percutaneous treatments. The mean hospital stay was 7.7 days (range, 5-17 days). The mean operative time was 401 min (range, 220-600 min). The mean estimated blood loss was 878 cm(3) (range, 100-3,000 cm(3)). All patients underwent an R0 resection.
  
  
  CONCLUSIONS
  Laparoscopic major hepatectomy is feasible. As in open hepatectomies, intrahepatic transection of the right bile duct may be safer because there is a decreased risk of injury to the left hepatic duct.4                   (,)                   5 Larger series with longer-term follow-up are necessary.
authors.affiliation: Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
authors.forename: Tzu-Jung
authors.initials: TJ
authors.lastname: Tsai
authors.forename: Elie K
authors.initials: EK
authors.lastname: Chouillard
authors.forename: Andrew A
authors.initials: AA
authors.lastname: Gumbs
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D001652:Bile Ducts / Q000601:surgery*; D015179:Colorectal Neoplasms / Q000188:drug therapy / Q000473:pathology; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008113:Liver Neoplasms / Q000188:drug therapy / Q000556:secondary / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome