Monden Kazuteru, Sadamori Hiroshi, Hioki Masayoshi, Takakura Norihisa
Department of Surgery, Fukuyama City Hospital, Fukuyama, Hiroshima, Japan.
Ann Surg Oncol. 2022 Mar 29. doi: 10.1245/s10434-022-11607-z.
Laparoscopic left hepatectomy with resection of the Spiegel lobe remains a technically demanding procedure as it is a deep-seated area surrounding the inferior vena cava (IVC). Mobilization of the Spiegel lobe requires safe exposure of the ventral side of the IVC while dissecting the short hepatic veins from the IVC. Additionally, wide space is needed to isolate the left Glissonean pedicle (Glt). We used a modified caudate lobe-first approach to overcome this challenge Maeda (J Hepato-Bil Pancreat Sci 25:335-41, 2018), Li (J Gastrointest Surg 23:1084-5, 2019), Homma (Surg Endosc 33:3851-7, 2019).
The ischemic area was confirmed after isolating the left and middle hepatic artery and left portal vein. After mobilizing the left lateral section, the Spiegel lobe was divided from the notch, which is the boundary between the caudate lobe and the Spiegel lobe, toward the middle hepatic vein (MHV). The Spiegel lobe was safely detached from the IVC with a short hepatic vein transected with the caudo-dorsal view. The Glt could be easily isolated due to the wide space on the ventral side of the IVC. After dividing the left hepatic duct, the MHV was exposed continuously from the root to the periphery, and parenchymal transection was completed by connecting the demarcation line and MHV.
The total operation time was 430 min, and estimated blood loss was minimal. The patient was discharged on postoperative day 6 without complications.
The modified caudate lobe-first approach can be used to safely perform laparoscopic left hepatectomy combined with the Spiegel lobe resection.
腹腔镜下左肝切除术联合尾状叶切除仍是一项技术要求较高的手术，因为尾状叶是下腔静脉（IVC）周围的深部区域。游离尾状叶需要在从下腔静脉分离肝短静脉时安全暴露下腔静脉的腹侧。此外，需要足够的空间来分离左肝蒂（Glt）。我们采用改良的尾状叶优先入路来应对这一挑战（前田，《肝胆胰外科杂志》25:335 - 41，2018；李，《胃肠外科杂志》23:1084 - 5，2019；本间，《外科内镜杂志》33:3851 - 7，2019）。
在分离左、中肝动脉及左门静脉后确认缺血区域。游离左外叶后，从尾状叶与尾状叶之间的切迹开始，向肝中静脉（MHV）方向分离尾状叶。通过尾背侧视野横断肝短静脉，将尾状叶安全地从下腔静脉分离。由于下腔静脉腹侧有足够的空间，左肝蒂能够轻松分离。切断左肝管后，从肝中静脉根部至外周连续暴露肝中静脉，通过连接分界线与肝中静脉完成实质离断。
总手术时间为430分钟，估计失血量极少。患者术后第6天出院，无并发症。
改良的尾状叶优先入路可用于安全地进行腹腔镜下左肝切除术联合尾状叶切除。
