Retroperitoneal laparoscopic hepatectomy of recurrent hepatocellular carcinoma: case report and literature review

The patient was a 57-year-old male with a height of 165 cm, a weight of 66 kg and a BMI of 24.2 kg/m2. In September 2016, the patient underwent laparoscopic irregular hepatectomy (V and VI liver segments) for primary HCC in our hospital. In July 2018, contrast-enhanced CT scan imaging revealed a neoplasm that showed enhancement in segment VII of the liver (Fig. 1). The laboratory tumour marker AFP was 157.40 ng/ml. Recurrent HCC was diagnosed, and retroperitoneal laparoscopic hepatectomy was performed with the patient’s full knowledge and consent. Seventy-two hours before the operation, indocyanine green was injected through the peripheral vein at 0.25 mg/kg body weight (ICG-r15 = 13.4%).

Since Professor Reich [10] first reported laparoscopic hepatectomy for benign liver tumours in 1991, the procedure has undergone development for more than 30 years. The safety and clinical efficacy of laparoscopic hepatectomy have been confirmed, and the indications for use have expanded from benign diseases to malignant tumours. The procedure has been widely used for treatment of hepatic haemangioma, lipoma, focal nodular hyperplasia (FNH), hepatocellular carcinoma and other liver diseases [1, 11].

In 2008, in Louisville, USA [12], and in 2014, in Morioka, Japan [13], experts from all over the world met to formulate a series of specifications for the indications, difficulties and techniques of laparoscopic hepatectomy. It is widely accepted that the best indications for laparoscopic hepatectomy are tumours located in segments II, III, IVb, V and VI of the liver. In recent years, with the improvement of laparoscopic equipment and the accumulation of experience, the size of tumours is no longer a constraint of laparoscopic hepatectomy as long as the location of the tumours allows for a certain operating space under laparoscopy [12]. Laparoscopic hepatectomy is becoming increasingly popular as one of the minimally invasive treatments for hepatocellular carcinoma [13]. Generally, the indications of laparoscopic hepatectomy are almost identical to those of open hepatectomy. As long as a comprehensive preoperative assessment of liver function, basic liver diseases, cirrhosis, portal hypertension, and residual liver volume is made, laparoscopic hepatectomy should not be limited due to the size and location of tumours.

In recent years, laparoscopic hepatectomy has had rapid developments, and laparoscopic left lateral lobectomy has become the standard method [14, 15]. With the improvement of laparoscopic surgery techniques and instruments, the indications for laparoscopic hepatectomy are gradually expanding, and even laparoscopic resection in liver donors can be performed [2, 3, 16, 17]. Compared with traditional open hepatectomy, laparoscopic hepatectomy has the advantages of less trauma, clear operative fields, less intraoperative bleeding, fewer postoperative complications, mild pain, quick recovery, short hospitalization times and decreased mortality. Laparoscopic hepatectomy is suitable for benign and malignant tumours of the liver [1, 15, 18‐20] and is also safe and feasible for patients with liver cirrhosis if appropriate cases are selected. In some patients with severe cirrhosis and portal hypertension, the incidence of postoperative liver failure and ascites in laparoscopic hepatectomy is less than that of open surgery [18, 19, 21]. For some patients who are weak, elderly, cirrhotic and obese, the advantages of laparoscopic surgery are more prominent [22, 23]. In addition, during laparoscopic surgery, the traction on the viscera is gentle, and the stress and immune response in patients is less than that in open surgery, which is beneficial for immune function during recovery. Laparoscopic surgery combined with early mobility also decreased the incidence of postoperative reactive pleural effusion and ascites [24].

In laparoscopic surgery, the traditional abdominal incision is replaced by operating ports, which greatly reduces the incision size and the probability of incision complications such as infection, dehiscence and incisional hernia. By using high-definition magnification display equipment, laparoscopic hepatectomy is superior to open surgery for observing and treating the microstructure of liver sections, and the probability of haemorrhage and biliary leakage is reduced. Therefore, laparoscopic hepatectomy is widely used for the treatment of benign and malignant liver diseases [18, 25, 26]. Laparoscopic anatomical hepatectomy has been reported in recent literature for the treatment of primary liver cancer. Not only in perioperative clinical indicators but also in tumour recurrence rate, survival status and other prognostic indicators of long-term postoperative efficacy, the advantages of laparoscopic hepatectomy are increasingly obvious compared with open surgery, which suggests that laparoscopic hepatectomy can be used as a routine operation for the treatment of liver cancer [27].

However, segments I (caudate lobe), IVa, VII and VII of the liver are considered to be difficult sites for laparoscopic surgery because of their deep position, complicated anatomic relationship and unclear surgical field. In the early stage of disease, those segments are regarded as the relative “forbidden zone” of minimally invasive surgery due to the difficulty and high risks [5, 28]. Especially for tumours located in the bare area of the liver, laparoscopic operation is more difficult. The anatomical structure of this area is more complex, and the branches of the hepatic artery, hepatic vein and portal vein are interlaced. Moreover, in patients with hepatocellular carcinoma, there are many vascular networks around the lesion, and the amount of bleeding during operation is large. Therefore, it is easy to lose a clear view of the surgical field. Blind electrocoagulation and clamping after haemorrhage may aggravate tissue damage, which may not only increase the amount of bleeding but also lead to gas embolism. Finally, these complicated procedures force conversion to open surgery and even endanger the life of the patient [29]. Some surgeons have explored new puncture placement, such as the intercostal approach through the chest wall (through intercostal spaces 7–9) and thoracoscopic resection of hepatic tumours in segments VII and VIII through the diaphragm [30]. The advantage of these methods is that they can provide a view of the posterior superior segment of the liver from the top. However, adverse consequences, such as pneumothorax, pulmonary complications and diaphragmatic hernia, which may occur through the thoracic cavity and diaphragm, still need to be carefully considered. Moreover, further multicentre clinical studies are warranted to confirm the safety and long-term oncological benefits of the operation [5, 31].

Based on our experience, laparoscopic hepatectomy for difficult areas of the liver is safe and feasible. However, the location and specific conditions of the tumour must inform the selection of an appropriate surgical position and trocar placement that are conducive to the exposure of the surgical field, thereby reducing the difficulty of resection and improving the safety of the operation. We used the approach of laparoscopic adrenalectomy for reference and performed laparoscopic hepatectomy of segment VII. The patients were placed in the supine position on their left side, with the head higher than the feet. The right retroperitoneal approach was used. The main operating port and observation ports were made at the front, middle and rear axillary lines of the right costal margin to obtain better field exposure and reduce the difficulty of laparoscopic hepatectomy.

It is well known that in patients with a previous history of open hepatectomy or severe cirrhosis, laparoscopic hepatectomy is difficult and has a high conversion rate to open surgery [6, 7]. Most surgeons believe that laparoscopic hepatectomy is more difficult for patients undergoing a second liver surgery [6]. The case described herein involves recurrent hepatocellular carcinoma with severe cirrhosis. During the operation, using the right retroperitoneal approach, the perihepatic ligament is severed, the liver is freed, the right liver is turned forward and downward by gravity so that the operative field is further exposed and the surgery is successfully performed. Laparoscopic resection of recurrent hepatocellular carcinoma via the retroperitoneal space has not been reported before. Of course, this case involves a small hepatocellular carcinoma, which is one of the important reasons for the success of the surgery. If the tumour is more than 10 cm or the lesion is protruding onto the liver surface, which occupies a large amount of space under the pneumoperitoneum, it is difficult for the surgeon to locate enough space to perform the procedure. Hence, these cases are not suitable for laparoscopic hepatectomy [32].

The application of intraoperative ultrasound (IOUS) and indocyanine green (ICG) fluorescence navigation in laparoscopic surgery is also an important factor in the success of this case. Although the development of laparoscopic technology has overcome many of the shortcomings of laparotomy, the surgeon cannot directly contact important organs or structures, and the lack of two-dimensional visual information results in higher risks of laparoscopic surgery than open surgery, which may lead to complications and even death of the patient after surgery [33, 34]. IOUS is a widely used imaging method in clinical settings and has the advantages of convenient operation, high resolution, repeatability and non-invasiveness. The application of IOUS in laparoscopic hepatectomy can overcome the above shortcomings to a certain extent [35]. IOUS can clearly show the diameter and flow of intrahepatic vessels, improve the accuracy of the operation and contribute to the success of laparoscopic hepatectomy [36].

Although IOUS can perform intraoperative tumour identification, it cannot provide real-time and continuous visualization of liver tumours. ICG fluorescence navigation is a real-time and continuous visualization technology that is safe and simple but still has great room for development [37]. With preoperative ICG intravenous injection, fluorescence imaging can be accurate to 2 mm for hepatocellular carcinoma (HCC) and 1.5 mm for hepatic metastases [37, 38]. The role of ICG fluorescent navigation is particularly prominent in laparoscopic hepatectomy because of the loss of tactile feedback and the difficulty of detecting small superficial tumours of the liver [39]. Intraoperative ICG fluorescence navigation combined with IOUS, preoperative CT, MRI, 3D reconstruction and intraoperative frozen pathology can significantly improve the detection and resection of liver lesions.