Giant hemangiomas are defined as >5cm. Surgery is reserved for progressive symptoms, enlarging lesions, or those at risk for rupture. There are no selection criteria for laparoscopic versus open surgery. Typically, open surgical resection is performed for hemangiomas >10cm, but have been resected safely laparoscopically.
This video presents a left extended hepatectomy performed laparoscopically for a giant hepatic hemangioma. A 41-year-old recreational hockey player presented with right upper quadrant discomfort, found to have an 18.7x9.6cm hemangioma within the left liver, abutting the middle hepatic vein.
Abdominal access was obtained with the Veress needle in the supraumbilical position. 5mm trocars placed in left upper quadrant, left and right anterior axillary line, and supraumbilical positions. A 12mm trocar placed in the right upper quadrant. The falciform was divided and used for retraction. Triangle liver retractor was used the retract and compress the hemangioma. The left hepatic artery was identified and divided with the vascular stapler, followed by left portal vein. Initial transection of inflow to the lesion allowed for decompression of the hemangioma with liver retractor for improved visualization throughout dissection. Because the lesion crossed midline up to the cystic plate, the line of transection was marked through segments V/VIII, leaving the gallbladder in place. Liver parenchyma was divided with the Ligasure device. Biliary pedicles were divided with clips. The left bile duct and hepatic veins were divided with the stapler. The specimen was morcellated, then extracted through a Pfannenstiel incision. Pathology confirmed cavernous hemangioma.