title: Operative techniques to avoid near misses during laparoscopic hepatectomy.
abstract: The lack of a complete hepatic overview and tactile feedback during laparoscopic hepatectomy may result in near misses or fatal intraoperative complications despite the advantage of a magnified laparoscopic view. The aim of the study is to describe operative techniques and guiding principles with which to address near misses unique to laparoscopic hepatectomy and evaluate the intraoperative complication rate overtime.
  
  
  
  Data of 408 consecutive patients who underwent laparoscopic hepatectomy were reviewed. Representative operative techniques and guiding principles with which to address near misses and pitfalls unique to laparoscopic hepatectomy were evaluated among the patients by 2 surgeons.
  
  
  
  Most near misses were due to lack of understanding of both the laparoscopic view and anatomic aspects unique to laparoscopic hepatectomy. Operative techniques and/or guiding principles with which to address these issues were demonstrated as follows: starting parenchymal transection at the declivitous parts; no ligation of the right or left portal vein before confirming the bifurcation; dissection of the short hepatic vein using a sealing device; dissection of the root of the hepatic vein using scissors; exposure of the middle hepatic vein, which is anatomically close to the hilar plate; and identification of V8 using intraoperative ultrasonography. The intraoperative massive bleeding due to vessel injury or surgical clip slippage occurred in 25 patients (6.1%), and its rate had a significant trend to decrease with increasing years.
  
  
  
  We demonstrated operative techniques and guiding principles with which to address near misses in laparoscopic hepatectomy. The intraoperative massive bleeding rate trended to decrease over time.
authors: Department of Digestive Diseases, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France; Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan. Electronic address: yokawaguchi-tky@umin.ac.jp.
authors: Yoshikuni
authors: Y
authors: Kawaguchi
authors: Department of Digestive Diseases, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France.
authors: Vimalraj
authors: V
authors: Velayutham
authors: Department of Digestive Diseases, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France; Institut des Systèmes Intelligents et Robotique, Université Pierre et Marie Curie, Paris, France.
authors: David
authors: D
authors: Fuks
authors: Department of Digestive Diseases, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France.
authors: Frederic
authors: F
authors: Mal
authors: Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
authors: Norihiro
authors: N
authors: Kokudo
authors: Department of Digestive Diseases, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France; Institut des Systèmes Intelligents et Robotique, Université Pierre et Marie Curie, Paris, France. Electronic address: brice.gayet@imm.fr.
authors: Brice
authors: B
authors: Gayet
mesh_terms: D000328:Adult; D000368:Aged; D016063:Blood Loss, Surgical; D016208:Databases, Factual; D005260:Female; D005602:France; D006498:Hepatectomy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D007431:Intraoperative Complications / Q000453:epidemiology / Q000517:prevention & control*; D007564:Japan; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods*; D008113:Liver Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D061214:Patient Safety / Q000706:statistics & numerical data; D011322:Primary Prevention / Q000379:methods*; D012189:Retrospective Studies; D018570:Risk Assessment; D016896:Treatment Outcome