Birgin Emrullah, Reissfelder Christoph, Rahbari Nuh N
Chirurgische Klinik, Universitätsklinikum Mannheim, Mannheim, Deutschland.
Zentralbl Chir. 2023 Apr;148(2):129-132. doi: 10.1055/a-1923-4341. Epub 2022 Sep 14.
Caroli's syndrome is a rare disease characterised by non-obstructive dilation of intrahepatic bile ducts, hepatic fibrosis, and an increased risk of developing cholangiocarcinoma. Minimally invasive liver resection has recently been increasingly adopted for the treatment of patients with localised Caroli's syndrome. However, robot-assisted liver resection for the treatment of Caroli's syndrome has not been published.
We report a case of a 72-year-old Asian female who was referred to our hospital with multifocal cystic dilation of liver segments II, III, and IV. She had no family history of congenital cysts. Her past medical history was uneventful except for an open appendectomy. The liver function tests were normal, with a negative echinococcus serology test. On MRI, the biliary anatomy at the hilum and right liver appeared to be regular. Therefore, a robotic left hepatectomy was carried out for the unilobar involvement of Caroli's syndrome using the Da Vinci Xi-system.
We performed a Glissonean pedicle approach while preserving the caudate lobe. After removing surgical adhesions from the anterior abdominal wall using robotic scissors, a routine cholecystectomy was performed. An aberrant left hepatic artery arising from the left gastric artery was clipped and divided. The left portal pedicle was controlled after lowering the hilar plate. The ischemic demarcation line on the liver surface was followed after clamping the left pedicle, and parenchymal dissection was performed using Maryland bipolar forceps. A Pringle manoeuvre was not applied. The left pedicle and the left hepatic vein were transected using a GIA stapling device while the middle hepatic vein was preserved. Indocyanin green fluorescence imaging confirmed adequate perfusion of the remnant liver tissue including the caudate lobe. The specimen was placed in an extraction bag and removed via a Pfannenstiel incision. The total operation time was 239 min, including a total blood loss of 100 ml. The postoperative course was uneventful. The patient was discharged on postoperative day 5. On 6 months follow-up, the patient had normal liver function and no signs of recurrent disease.
Robotic left hepatectomy using an extrahepatic Glissonean pedicle approach is technically feasible.
卡罗里氏综合征是一种罕见疾病，其特征为肝内胆管非梗阻性扩张、肝纤维化以及胆管癌发生风险增加。近年来，微创肝切除术越来越多地被用于治疗局限性卡罗里氏综合征患者。然而，机器人辅助肝切除术治疗卡罗里氏综合征尚未见报道。
我们报告一例72岁亚洲女性患者，因肝Ⅱ、Ⅲ、Ⅳ段多灶性囊性扩张转诊至我院。她无先天性囊肿家族史。除了一次开腹阑尾切除术外，她既往病史无异常。肝功能检查正常，棘球蚴血清学检查阴性。磁共振成像（MRI）显示，肝门和右肝的胆管解剖结构似乎正常。因此，使用达芬奇Xi系统对单叶受累的卡罗里氏综合征患者实施了机器人辅助左肝切除术。
我们采用肝门部Glisson蒂入路并保留尾状叶。使用机器人剪刀清除前腹壁的手术粘连后，常规行胆囊切除术。夹闭并切断发自胃左动脉的异常左肝动脉。降低肝门板后控制左门静脉蒂。夹闭左蒂后沿肝表面的缺血分界线，使用马里兰双极电镊进行实质分离。未应用Pringle手法。使用GIA缝合器横断左蒂和左肝静脉，同时保留肝中静脉。吲哚菁绿荧光成像证实包括尾状叶在内的残余肝组织灌注良好。将标本放入取出袋，经耻骨上横切口取出。总手术时间为239分钟，总失血量为100毫升。术后过程顺利。患者于术后第5天出院。随访6个月时，患者肝功能正常，无疾病复发迹象。
采用肝外Glisson蒂入路的机器人辅助左肝切除术在技术上是可行的。
