Department of Gastroenterology, LIM-37, University of São Paulo, Sao Paulo, Brazil.
Surg Endosc. 2010 Aug;24(8):2044-7. doi: 10.1007/s00464-009-0859-7. Epub 2010 Jan 28.
Hepatectomy may prolong the survival of colorectal cancer patients with liver metastases. Two-stage liver surgery is a valid option for the treatment of bilobar colorectal liver metastasis. This video demonstrates technical aspects of a two-stage pure laparoscopic hepatectomy for bilateral liver metastasis. To the authors' knowledge, this is the first description of a two-stage laparoscopic liver resection in the English literature.
A 54-year-old man with right colon cancer and synchronous bilobar colorectal liver metastasis underwent laparoscopic right colon resection followed by oxaliplatin-based chemotherapy. The patient then was referred for surgical treatment of liver metastasis. Liver volumetry showed a small left liver remnant. Surgical planning was for a totally laparoscopic two-stage liver resection. The first stage involved laparoscopic resection of segment 3 and ligature of the right portal vein. The postoperative pathology showed high-grade liver steatosis. After 4 weeks, the left liver had regenerated, and volumetry of left liver was 43%. The second stage involved laparoscopic right hepatectomy using the intrahepatic Glissonian approach. Intrahepatic access to the main right Glissonian pedicle was achieved with two small incisions, and an endoscopic vascular stapling device was inserted between these incisions and fired. The line of liver transection was marked following the ischemic area. Liver transection was accomplished with the Harmonic scalpel and an endoscopic stapling device. The specimen was extracted through a suprapubic incision. The falciform ligament was fixed to maintain the left liver in its original anatomic position, avoiding hepatic vein kinking and outflow syndrome.
The operative time was 90 min for stage 1 and 240 min for stage 2 of the procedure. The recoveries after the first and second operations were uneventful, and the patient was discharged on postoperative days 2 and 7, respectively.
Two-stage liver resections can be performed safely using laparoscopy. The intrahepatic Glissonian approach is a useful tool for pedicle control of the right liver, especially after previous dissection of the hilar plate.
肝切除术可能延长结直肠癌伴肝转移患者的生存时间。两阶段肝切除术是治疗双侧结直肠肝转移的有效选择。本视频演示了双侧肝转移的两阶段纯腹腔镜肝切除术的技术方面。据作者所知，这是英文文献中首次描述两阶段腹腔镜肝切除术。
一名 54 岁男性，患有右结肠癌和同步双侧结直肠肝转移，接受了腹腔镜右半结肠切除术和奥沙利铂为基础的化疗。然后，患者转至外科治疗肝转移。肝体积测量显示左肝体积较小。手术计划为完全腹腔镜两阶段肝切除术。第一阶段包括腹腔镜切除第 3 段和结扎右门静脉。术后病理显示高级别肝脂肪变性。4 周后，左肝再生，左肝体积为 43%。第二阶段包括使用肝内 Glisson 入路进行腹腔镜右半肝切除术。通过两个小切口实现肝内主要右 Glisson 蒂的入路，并在这些切口之间插入内镜血管吻合器并击发。根据缺血区标记肝切割线。使用 Harmonic 超声刀和内镜吻合器完成肝切割。标本通过耻骨上切口取出。将镰状韧带固定在原位以保持左肝的原始解剖位置，避免肝静脉扭曲和流出综合征。
第一阶段的手术时间为 90 分钟，第二阶段的手术时间为 240 分钟。第一次和第二次手术后的恢复均顺利，患者分别于术后第 2 天和第 7 天出院。
两阶段肝切除术可以安全地使用腹腔镜完成。肝内 Glisson 入路是控制右肝蒂的有用工具，尤其是在先前解剖肝门板后。
