Total laparoscopic limited anatomical resection for centrally located hepatocellular carcinoma in cirrhotic liver

A 68-year-old man with a history of diabetes mellitus and hypertension, but without hepatitis B or C virus infection, was sonographically confirmed to have a large hepatic tumor during follow-up. He had undergone exploratory laparotomy for colon diverticulitis 7 years prior. Abdominal computed tomography revealed a 6.5-cm liver mass, which showed typical HCC features of early arterial enhancement and portal venous washout, located at hepatic segments 4, 5, and 8 and compressing the middle hepatic vein (MHV, Fig. 1A–C). The tumor was supplied by the ventral branches of the right anterior Glissonian pedicle (Fig. 1D). Preoperative evaluation of the liver reserve revealed Child–Pugh class A liver cirrhosis and the 15-min retention rate of indocyanine green (ICG₁₅) was 14 %. The serum levels of tumor markers for alpha-fetoprotein and protein induced by vitamin K absence or antagonist-II were 2.6 ng/ml and 132 mAU/ml, respectively. Preoperative surgical planning using the three-dimensional volume analyzer Synapse Vincent™ (FUJIFILM Co., Japan) suggested the feasibility of limited anatomic subsegmental resection (Fig. 2) instead of central bisegmentectomy (which consisted of 493-ml volume, 46.2 % total liver volume) according to Makuuchi’s criteria [11].

We performed total laparoscopic resection of the left medial (segment 4) and right ventroanterior (subsegments 5 and 8) liver segments. The patient was placed in the supine position with the surgeon standing on the right side of the patient. Five trocars were used as shown in Fig. 2. The operation began with adhesiolysis and cholecystectomy. The right triangular and falciform ligaments were divided from the medial to the lateral side in order to avoid any damage to the inferior vena cava (IVC) and for safely locating the root of the right hepatic vein (RHV). Intraoperative sonographic examination was used to confirm the exact tumor location and its relationship to the major blood vessels. Then, parenchymal transection was performed along the medial side of the falciform ligament, thereby exposing the umbilical Glissonian pedicles, which included the arterial, portal, and bile duct branches of segment 4 and which were clipped and divided (Fig. 3A). The Cantlie line demarcation of the liver lobes was identified and the parenchymal resection was continued toward the right liver lobe using specialized surgical instruments (harmonic scalpel for superficial parenchyma and laparoscopic Cavitron Ultrasonic Surgical Aspirator [CUSA; Valleylab, Boulder, CO] for deep parenchymal tissue), until the level of the MHV (Fig. 3B). The ventral branches of the right anterior Glissonian pedicle were identified, clipped, and divided (Fig. 3C). Furthermore, the new demarcation line, which leaves segments 6 and 7 and dorsal subsegments 5 and 8 intact, appeared (Fig. 3D). Right ventroanterior sectionectomy was then performed. Meticulous transection was necessary to avoid massive bleeding from the transected surface. As the transection proceeded toward the root of the MHV, we encountered the drainage vein from segment 8 (fissure vein) and had to divide the vein. The root of the MHV was closed using an automatic stapler and intraoperative sonography was performed to confirm the integrity of the RHV root. The tumor specimen was removed via minilaparotomy (Fig. 4). Because slight bile spillage was observed from the exposed right anterior Glissonian pedicle, fibrin glue and sealant patch (TachoSil^®, Nycomed, Linz, Austria) were applied topically to the surface of the bile duct for cover reinforcement after inserting a bile drainage tube (5-French ureteric catheter), which was placed into the remnant cystic duct by minilaparotomy as shown in Fig. 2.