Laparoscopic liver resection in the semiprone position for tumors in the anterosuperior and posterior segments, using a novel dual-handling technique and bipolar irrigation system

Abstract

Background: Hepatic tumors in the lower edge and lateral segments are commonly treated by laparoscopic liver resection. Tumors in the anterosuperior and posterior segments are often large and locally invasive, and resection is associated with a higher risk of insufficient surgical margins, massive intraoperative bleeding, and breaching of the tumor. Laparoscopic surgery for such tumors often involves major hepatectomy, including resection of a large volume of normal liver tissue. We developed a novel method of laparoscopic resection of tumors in these segments with the patient in the semiprone position, using a dual-handling technique with an intercostal transthoracic port. The aim of this study was to evaluate the safety and usefulness of our technique.

Methods: Of 160 patients who underwent laparoscopic liver resection at our center from June 2008 to May 2013, we retrospectively reviewed those with tumors in the anterosuperior and posterior segments. Patients were placed supine or semilateral during surgery until January 2010 and semiprone from February 2010.

Results: Before the introduction of the semiprone position in February 2010, a total of 7 of 40 patients (17.5%) with tumors in the anterosuperior and posterior segments underwent laparoscopic liver resection, and after introduction of the semiprone position, 69 of 120 patients (57.5%) with tumors in the anterosuperior and posterior segments underwent laparoscopic liver resection (P < 0.001). There were no conversions to open surgery, reoperations, or deaths. The semiprone group had a significantly higher proportion of patients who underwent partial resection or segmentectomy of S7 or S8, lower intraoperative blood loss, and shorter hospital stay than the supine group (all P < 0.05). Postoperative complication rates were similar between groups.

Conclusions: Laparoscopic liver resection in the semiprone position is safe and increases the number of patients who can be treated by laparoscopic surgery without increasing the frequency of major hepatectomy.

Figures

Fig. 1

Illustration of liver segments. Patients who underwent laparoscopic resection of malignant tumors of the anterosuperior segment (S8), posterosuperior segment (S7), posteroinferior segment (S6), and right superior portion of the caudate lobe (S1) were included in this study. a Right anterior view. b Right posterior view

Fig. 2

Laparoscopic liver resection in the semiprone position for tumors in the posteroinferior segment (S6) and right inferior portion of the caudate lobe (S1). a Right posterior view immediately after inserting the laparoscope. b Right inferior view when the lower surface of S6 is rising to the ventral side. c Semiprone position during surgery. d Port sites: one port was placed in the right pararectal line 10 cm below the subcostal margin for the camera, and three trocars were inserted through ports below the subcostal margin in the right pararectal line, anterior axillary line, and posterior axillary line

Fig. 3

Laparoscopic liver resection in the semiprone position for tumors in the posterosuperior segment (S7), anterosuperior segment (S8), and right superior portion of the caudate lobe (S1). a Right anterior view before the right triangular and coronary ligaments are divided. b Right anterior view after the right triangular and coronary ligaments are divided. c Semiprone position during surgery. The patient position is almost the same as in Fig. 2. As the surgeon stands on the cranial side to use the intercostal port, the left hand of the patient is moved towards the head. d Port sites: an additional intercostal port was inserted at the seventh intercostal space in the anterior axillary line