Cirrhotic patients bearing hepatocellular carcinomas (HCC) derive benefits from laparoscopic hepatectomy1 – 6 such as reduced bleeding, less overall and liver-specific complications, and fewer adhesions in the case of future reoperation or transplantation.7 – 10 Bleeding is concerning in the setting of cirrhosis,11 – 15 and adequate inflow control reduces blood loss. The caudal approach is the laparoscopic counterpart of the anterior approach to open surgery. It implies in parenchymal transection initiated from the visceral surface of the liver after limited hepatic mobilization, reducing the risk of increased circulating tumoral cells.16 – 18 Venous outflow transection and completion of ligament mobilization are left as last steps.
A 46 years-old-male with hepatitis C virus and alcoholic cirrhosis was diagnosed with a 4-cm HCC (right hepatic lobe). Expected future liver remnant was 45 % of his total liver volume. A totally laparoscopic right hepatectomy was performed using six ports, and the specimen was removed through a Pfannenstiel auxiliary incision. A 10-mm 30° scope was used. The pneumoperitoneum pressure was set to 12 mmHg. The right hepatic pedicle, the caudate lobe, and the major hepatic veins were managed with laparoscopic vascular staplers.
Surgery was performed with limited liver mobilization and en bloc extrafascial right pedicle control (Takasaki’s technique),19 followed by caudal parenchymal transection along the paracaval plane. The operative time was 450 min, and the estimated blood loss was 800 ml (no transfusion was required).
The laparoscopic Takasaki technique and caudal approach are feasible procedures in the setting of cirrhosis, resulting in an oncologic adequate intervention with less morbidity.
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Krüger, J.A. ., Fonseca, G.M., Coelho, F.F. et al. Laparoscopic Right Hepatectomy for Cirrhotic Patients: Takasaki’s Hilar Control and Caudal Approach. Ann Surg Oncol 24, 558–559 (2017) doi:10.1245/s10434-016-5288-y