Total Transthoracic Approach Facilitates Laparoscopic Hepatic Resection in Patients with Significant Prior Abdominal Surgery
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While the oncologic safety of minimally invasive hepatectomy for colorectal liver metastases (CLM) has been demonstrated, lesions in the postero-superior segments may be challenging.1 – 3 For these lesions, a transthoracic approach may be particularly helpful, especially in patients with a hostile/reoperative abdomen or morbid obesity.4 , 5
A 43-year-old man with a body mass index of 36.0 who had undergone rectosigmoid resection for primary cancer 5 years ago recurred with a solitary liver metastasis in SVIII. He had previously undergone the following resections for metachronous CLM: (i) partial resections of SV/VIII and SII/III; (ii) ablation for SVII; and (iii) left hepatectomy, common bile duct resection, and choledochojejunostomy. Following four cycles of FOLFIRI/panitumumab with good response, the patient was considered for his fourth abdominal cancer intervention via a thoracoscopic approach.
In a modified French position with left-lung ventilation, access to the right thoracic cavity was gained. Following thoracic adhesiolysis, transdiaphragmatic intraoperative ultrasonography (IOUS) was performed. To ensure optimal margins, IOUS-guided transthoracic hepatic resection with partial resection of the diaphragm was conducted. The diaphragm was reconstructed and a chest tube placed. Operative time was 247 min, with an estimated blood loss of 100 mL. Postoperative recovery was uneventful; pathology demonstrated no viable tumor, with the closest margin 5 mm from the necrotic area.
Transthoracic hepatic resection of SVIII can optimize the port–target axis while minimizing morbidity. A systematic approach that includes precise port positioning, non-traumatic intrathoracic adhesiolysis, and meticulous transdiaphragmatic IOUS-guided parenchymal transection can optimize outcomes.
Suguru Yamashita, Evelyne Loyer, Hyunseon C. Kang, Thomas A. Aloia, Yun Shin Chun, Reza J. Mehran, Cathy Eng, Jeffrey E. Lee, Jean-Nicolas Vauthey, and Claudius Conrad have no conflicts of interest to declare.
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