Juan M. Sarmiento, MD, FACS; Aziz M. Merchant, MD; Edward Lin, DO
Laparoscopic formal right hepatectomy remains a technical challenge. We demonstrate a procedure can be accomplished efficiently with standard laparoscopic techniques, in ordered sequence, using smaller incisions, and having identical outcomes as the open procedure.
We use four trocars, and a wound protector-hand port (Gelport). Bipolar and monopolar cautery, and ultrasonic shears are the primary energy sources. Instruments consist of atraumatic graspers, fine-tip dissectors, 30 and 45 degree angled videoscopes is used. Hepatic vessels are ligated with grey-load endoscopic staplers and white-load staplers are used for liver parenchyma. The technique is divided into: (1) hilar dissection of cystic duct/artery, right hepatic artery, right portal vein, (2) release of IVC and hepatic vein attachments, (4) ligation of the right hepatic vein, (5) division of liver parenchyma.
In all our cases of formal right hepatectomy, we have consistently adopted this approach and sequence of dissection. Each case requires two surgeons and total operative times range from 120-150 minutes. We have had one conversion to open in an unresectable hilar cholangiocarcinoma with gangrenous cholecystitis. The liver lobe is removed through a 7 cm protected midline incision.
Laparoscopic-assisted formal right hepatectomy with vascular isolation can be efficiently performed using a standard approach.