Simultaneous laparoscopic splenectomy and right hemihepatectomy for littoral cell angiosarcoma accompanied with liver metastases

Surgery was performed under general anesthesia. Laparoscopy was performed under pneumoperitoneum with a maximum pressure of 10 mmHg carbon dioxide. A 30° laparoscope with a diameter of 10 mm was used to explore the abdominal cavity to ensure there was no diffused peritoneal dissemination. For LS, a 10-mm trocar and a 5-mm trocar acted as the working ports (Figure 2). The patient was then placed in the right semi-lateral and head-up tilt position. The spleen-colonic ligament was cut using an ultrasonic scalpel, after which the branches of the splenic artery and splenic vein were ligated and cut one by one. Finally, the spleen-gastric ligament and the spleen-renal ligament were cut using the ultrasonic scalpel.

After LS, the patient was adjusted in a left half-lateral and head-up tilt position and another 3 trocars were introduced for LRH, as shown in Figure 2. The falciform ligament was resected up to the roots of the hepatic vein by using an ultrasonic scalpel; the right lobe of the liver bed was divided from the right triangular and coronary ligaments until the adrenal gland; and the inferior vena cava were exposed. The right liver was mobilized by dividing the cystic artery and the duct of the gallbladder to efficiently expose the liver pedicle. The right hepatic pedicle, including the right hepatic artery, right hepatic portal vein, and right bile duct were transected through the extra-Glissonian approach [4, 5] using linear staplers (45-mm Endo GIA; staple height, 2.5 mm; Tyco healthcare, Norwalk, CT, USA). Along the demarcation line, hepatic parenchyma transection was performed with ultrasound scalpels and Ligasure (Valley Lab, Boulder, CO, USA). Blood vessels larger than 5 mm in diameter were ligated with Hem-o-lok clips (Teleflex Medical, Research Triangle Park, NC, USA). The right liver was lifted anteriorly using two 5-mm graspers to create a tunnel. The posterior attachments of the liver were dissected to expose the retrohepatic inferior vena cava and the right hepatic vein. The right hepatic vein and the inferior right hepatic vein were divided using linear staplers. After the liver transection was finished, the gallbladder was dissected from its bed. An 8-cm midline incision was made between the two trocars (Figure 2). All tissue specimens were removed inside two plastic bags through this wound (Figure 3). Resection margins were carefully examined for bleeding and bile leaks, and abdominal drains were introduced in the spleen fossa and on the liver transection surface.