Kim Seok-Hwan, Kim Ki-Hun, Kirchner Varvara A, Lee Sang-Kyung
Department of Hepato-biliary and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-Ro 43-Gil, Songpa-gu, Seoul, 138-736, Korea.
Division of Transplantation, Department of Surgery, University of Minnesota, Minneapolis, MN, USA.
Surg Endosc. 2017 May;31(5):2338-2339. doi: 10.1007/s00464-016-5224-z. Epub 2016 Sep 12.
Laparoscopic major hepatectomy remains a challenging procedure [1, 2]. In the case of giant tumors in the right liver, conventional approach (complete mobilization of the right liver before parenchymal transection) could be dangerous during mobilization because of large volume and weight [3, 4]. We present the case of a pure laparoscopic right hepatectomy for a giant hemangioma using an anterior approach.
We achieved the informed consent with this patient and approved by the Ethics Committee of the Asan Medical Center. Giant hemangioma (13 × 11 × 14 cm) was located in right liver. After glissonean approach [5], Pringle maneuver was performed during the hepatic parenchymal transection. For the transection, the Cavitron Ultrasonic Surgical Aspirator was used. Small hepatic vein branches along the middle hepatic vein and small glissonean pedicles were sealed and divided with a THUNDERBEATTM (Olympus), which is the device with integration of both bipolar and ultrasonic energies delivered simultaneously. iDriveTM Ultra Powered Stapling device (Medtronic) was used for division of right glissonean pedicle and large hepatic veins. Hemangioma was removed through the lower abdominal transverse incision using the endo-bag. This technique has the advantage of avoiding excessive bleeding caused by avulsion of the hepatic vein and caval branches, iatrogenic tumor rupture [3].
By means of the anterior approach, pure laparoscopic right hepatectomy was performed successfully without intraoperative complications and transfusions. The operation time was 202 min, and the estimated blood loss was less than 150 ml. On postoperative day 3, computed tomographic scan showed no pathological findings. The patient was discharged on postoperative day 5 without complications. Laparoscopic approach has good results because of the view with magnification enabling meticulous hemostasis and the small wounds that give patients less pain [6, 7].
The authors recommend that the laparoscopic anterior approach is safe and feasible for right hepatectomy, even for giant tumors.
腹腔镜下肝大部切除术仍是一项具有挑战性的手术[1,2]。对于右肝巨大肿瘤，传统方法（实质离断前完全游离右肝）在游离过程中因肿瘤体积大、重量重可能存在危险[3,4]。我们报告一例采用前路法行纯腹腔镜下右肝巨大血管瘤切除术的病例。
我们获得了该患者的知情同意，并经峨山医学中心伦理委员会批准。巨大血管瘤（13×11×14cm）位于右肝。采用Glissonean入路[5]，在肝实质离断过程中进行Pringle手法。对于离断，使用了Cavitron超声外科吸引器。沿肝中静脉的小肝静脉分支和小Glissonean蒂用THUNDERBEATTM（奥林巴斯）进行封闭和离断，该设备同时集成了双极和超声能量。使用iDriveTM Ultra动力吻合器（美敦力）离断右Glissonean蒂和大肝静脉。通过下腹横切口使用内袋取出血管瘤。该技术的优点是避免了肝静脉和腔静脉分支撕裂、医源性肿瘤破裂导致的大量出血[3]。
通过前路法成功实施了纯腹腔镜下右肝切除术，术中无并发症且未输血。手术时间为202分钟，估计失血量少于150毫升。术后第3天，计算机断层扫描未发现病理改变。患者术后第5天出院，无并发症。腹腔镜手术效果良好，因为放大视野便于精确止血，且伤口小，患者疼痛轻[6,7]。
作者建议，即使对于巨大肿瘤，腹腔镜前路法行右肝切除术也是安全可行的。
