Feasible laparoscopic repeat hepatectomy using double intercostal ports and laparoscopic vascular clamp (with video).

BACKGROUND

Laparoscopic repeat hepatectomy is a technically challenging procedure owing to adhesions around the liver, causing difficulties in performing hepatic inflow control by conventional tourniquet method [1], and failure in hepatic mobilization [2].

METHOD

Thus, we introduce our technique using double intercostal ports to manipulate the fixed liver under the rib cage and using the laparoscopic Satinsky vascular clamp to perform hepatic inflow control to overcome the aforementioned concerns in ipsilateral laparoscopic repeat hepatectomy after previous open hepatectomy.

VIDEO

The patient, with histories of abdominal aortic aneurysm repair and open Segment 7 subsegmentectomy, had recurrent hepatocellular carcinoma in the dorsal region of Segment 8. After establishing pneumoperitoneum with five abdominal ports, adhesiolysis around the liver was then performed, followed by identification of the caudal part of Spiegel's lobe as the landmark for the space between the left-side of the hepatoduodenal ligament and the vena cava. Although the space between the right side of the hepatoduodenal ligament and the vena cava was obstructed, the laparoscopic blunt-tip Satinsky vascular clamp successfully was applied on the stiff hepatoduodenal ligament due to previous hepatectomy and made inflow control. Because the liver could not be mobilized at all, double intercostal ports with balloons were introduced [3] for parenchymal resection for exposing the parenchymal resection plane and also to apply the vessel sealing device. A 12-Fr chest tube (Aspiration Kit. Argyle™, Tokyo, Japan) was introduced in the right thoracic cavity as our routine.

RESULTS

The operative time was 243 minutes and the blood loss was 50g. The postoperative course was uneventful and the patient was discharged on the day 8.

CONCLUSIONS

The combination of intercostal ports and laparoscopic Satinsky vascular clamp could be significant aids for performing safe ipsilateral laparoscopic repeat hepatectomy, even after previous open hepatectomy.