A Conceptual Technique for Laparoscopic Right Hepatectomy Based on Facts and Oncologic Principles: The Caudal Approach.
OBJECTIVE
To evaluate a new conceptual technique of laparoscopic right hepatectomy.


BACKGROUND
Despite significant improvements in surgical care in the last decades, morbidity is still high after major hepatectomy. Blood loss and transfusions are known to significantly increase the risk of postoperative complications and cancer recurrence after liver resection. A laparoscopic approach may improve perioperative outcomes in these cases, but data in literature are limited and the surgical technique is not yet standardized.


METHODS
A new conceptual technique of right hepatectomy was designed using evidence-based facts and oncologic rules: laparoscopy with pneumoperitoneum, low central venous pressure, intermittent pedicle clamping, anterior approach without mobilization, and parenchymal section with ultrasonic dissector. Thirty patients were prospectively enrolled between October 2011 and September 2013. Primary endpoint was intraoperative blood loss.


RESULTS
Eighty percent of patients underwent surgery for malignant disease and cirrhosis was present in 11 patients. Benign lesions accounted for 13% of indications, whereas living liver donation was performed in 2 cases. Median blood loss was 100 mL (50-700) and transfusion rate was 7%. Five patients (16.6%) required conversion to laparotomy, including 2 using hybrid technique. The median operative time was 360 minutes (210-510). R0 resection rate was 87% (21/24). Postoperative morbidity rate was 23% (7/30) with 8 complications including 6 Clavien III-IV. No respiratory complication occurred. The median hospital stay was 8 days. No patient died.


CONCLUSIONS
This study showed that several evidence-based facts could be combined to define a new conceptual technique of laparoscopic right hepatectomy allowing for low blood loss and morbidity.
*Department of Hepatobiliary Surgery and Liver Transplantation, Université Pierre et Marie Curie, Paris, France; and †Department of Anesthesiology, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France.
Olivier
O
Soubrane
Lilian
L
Schwarz
François
F
Cauchy
Laura Ornella
LO
Perotto
Raffaele
R
Brustia
Denis
D
Bernard
Olivier
O
Scatton
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003210:Concept Formation; D061887:Conversion to Open Surgery; D005260:Female; D006498:Hepatectomy / Q000379:methods* / Q000523:psychology; D006801:Humans; D010535:Laparoscopy; D008103:Liver Cirrhosis / Q000601:surgery; D008107:Liver Diseases / Q000601:surgery*; D008113:Liver Neoplasms / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies