Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
Tufts University School of Medicine, Boston, MA, USA.
Surg Endosc. 2023 Oct;37(10):8154-8155. doi: 10.1007/s00464-023-10310-8. Epub 2023 Aug 29.
Minimally invasive liver surgery of postero-superior segments (S4a, S7, S8) remains a challenge. The caudal view, an increased distance between trocars and the operative field, and the liver fulcrum limiting the view, contribute to the difficulty [1, 2]. We and other groups have previously reported the use of intercostal trocars to access subdiaphragmatic tumors (transdiaphragmatic approach) [3-5], only few reports on a laparoscopic total transthoracic approach, none (to our knowledge) dynamic manuscripts of a total transthoracic robotic approach, and none (to our knowledge) that use preoperative port site and anatomic modelling exist. Further, we developed a total transthoracic (thoracoscopic) approach to avoid a hostile abdomen, while bringing viewing axis and instruments close to the target [6-10]. In this context, this report details the advantages of a laparoscopic vs. robotic transthoracic approach. According to institutional protocol, reports of individual cases in print or video format do not require institutional review board approval.
A 68-year-old male on peritoneal dialysis with left colon adenocarcinoma and a single synchronous liver metastasis in S6-7 close to the root of the right hepatic vein underwent a laparoscopic transdiaphragmatic metastasectomy. Two years later, the patient developed a recurrent 1.5 cm liver metastasis in S7, which lend itself to a robotic transthoracic approach.
Following 3-D modelling and virtual port placement planning, the first metastasectomy was performed laparoscopically using a transdiaphragmatic approach. The recurrence was managed transthoracically due to more apical, subdiaphragmatic location. For this operation, a robotic approach was optimal as robotic wrist articulation facilitates manipulation via the limited intercostal space. This was particularly helpful during the diaphragmatic reconstruction.
Total transthoracic liver surgery is certainly an advanced procedure requiring superior MIS liver skills. Recommendations for starting with a total transthoracic approach are not unlike from starting a standard, none-transthoracic liver surgery. Early on in the experience we recommend advanced liver MIS skills, and single, small, subdiaphragmatic tumors away from major vessels. Nonetheless, when these recommendations are followed a total transthoracic approach may be safer and result in less access trauma, than traversing a hostile abdomen to reach the posterior-superior liver. Both laparoscopic and robotic transthoracic approaches can facilitate the resection of subdiaphragmatic tumors, especially in patients with hostile abdomens. While the laparoscopic approach has advantages due to a broader spectrum of available surgical tools (flexible tip camera, parenchymal dissection, and energy devices), the robotic wrist articulation facilitates manipulation via the restricted intercostal space.
后上肝段（S4a、S7、S8）的微创肝手术仍然是一个挑战。由于尾侧视图、套管针与手术区域之间的距离增加以及肝脏支点限制了视野，这增加了手术难度[1,2]。我们和其他小组之前已经报道了使用肋间套管针来进入膈下肿瘤（经膈入路）[3-5]，只有少数关于腹腔镜全经胸入路的报道，我们（据我们所知）没有关于全经胸机器人入路的动态手稿，也没有（据我们所知）使用术前端口位置和解剖建模的报道。此外，我们开发了一种全经胸（胸腔镜）入路来避免敌对的腹部，同时使观察轴和器械靠近目标[6-10]。在这种情况下，本报告详细介绍了腹腔镜与机器人经胸入路的优势。根据机构协议，以印刷或视频格式报告的个别病例不需要机构审查委员会的批准。
一名 68 岁男性，因左侧结肠癌和单个同步肝转移灶 S6-7 靠近肝右静脉根部而接受腹腔镜经膈转移瘤切除术。两年后，患者在 S7 处出现了 1.5 厘米的复发性肝转移瘤，适合机器人经胸入路。
在进行三维建模和虚拟端口放置规划后，首次使用经膈入路进行腹腔镜下转移瘤切除术。由于复发肿瘤位于更尖顶、膈下位置，因此采用经胸入路进行治疗。对于这种手术，机器人方法是最佳的，因为机器人手腕的铰接性便于通过有限的肋间空间进行操作。这在膈肌重建过程中特别有帮助。
全经胸肝手术肯定是一项需要高级微创肝脏手术技能的先进手术。开始全经胸入路的建议与开始标准的非经胸肝手术的建议类似。在经验的早期，我们建议采用高级的微创肝脏手术技能，并采用单个、小的、膈下肿瘤，远离主要血管。尽管如此，如果遵循这些建议，那么全经胸入路可能比穿过敌对的腹部到达后上肝更安全，创伤更小。腹腔镜和机器人经胸入路都可以促进膈下肿瘤的切除，尤其是在有敌对腹部的患者中。虽然腹腔镜入路具有由于具有更广泛的可用手术工具（灵活尖端摄像头、实质解剖和能量设备）而具有优势，但机器人手腕的铰接性便于通过受限的肋间空间进行操作。
