**7. Technical considerations**

In general, "peripheral" liver segments can be resected laparoscopically much easier than "central". This applies to the left lateral segment (II & III) and to segments V & VI). Segments adjacent to the diaphragm (segments II, VII, VIII), are more challenging to access and safely resect laparoscopically. A thoracoscopic approach could be considered in these situations, but this is accompanied by the challenges of entering the pleural space and lack of quick hepatic hilum access, should one be needed intraoperatively. In addition a formal hepatic lobectomy is more challenging laparoscopically than it is open. It is therefore intuitive for a novice laparoscopic surgeon to start performing the easier, peripheral, resections first, and build a routine in mobilizing the liver, addressing problems, controlling hemorrhage etc., before embarking in bigger resections. The reported learning curve is 50 cases before a surgeon can take on more challenging cases, including laparoscopic lobectomy. It should be emphasized that during the first 50 cases, conversion rate can be as high as 50%, which is never worrisome and should never be considered a sign of failure. In almost all case, conversion is a sign of surgical maturity on behalf of the surgeon.

In is important to underline that the key initial steps are standard in pursuing laparoscopic liver resection, be it for a minor segmentectomy or a lobectomy. Set up, important for all surgical operations, is of paramount significance when it comes to LLR. The wrong setup can render a straightforward case into a very difficult one, necessitating needless conversion to open exploration. During LLR there is no surgical hand in the abdomen to gently but swiftly retract the liver and enable its mobilization, and/or tamponade a bleeding vessel. Surgical ingenuity has led to utilization of gravity to assist in retracting and mobilization, or the opposite in the event of hemorrhage during LLR.

We present herein a step by step laparoscopic approach through a video which highlights key points including surgical set up, placement of trocars, full mobilization of a liver lobe, facilitating access and resection of lesions in subdiaphragmatic hepatic segments through a minimally invasive peritoneal approach.

#### **8. Technique**

The video presented herein concerns the laparoscopic resection of a 2 cm liver mass in segment 7. The patient had a solid mass but in Computed Tomography and Magnetic Resonance imaging, and was FDG avid on PET CT. The patient, an otherwise healthy 51-year-old woman, with no past medical or surgical history. Of note, the patient provided consent to use the recorded video of her operation while protecting her privacy and maintaining her anonymity. In this video, we summarize key steps/technical tips with laparoscopic liver resections from our experience with minimally invasive hepatectomies, and highlight the challenges of

#### *Laparoscopic Liver Resection for Hepatocellular Carcinoma DOI: http://dx.doi.org/10.5772/intechopen.102981*

subdiaphragmatic liver lesion resections. As mentioned, several key maneuvers are highlighted which apply to laparoscopic liver resection, of all segments.

One of the most important key elements of laparoscopic liver resection especially for resection of the right lobe, is positioning the patient in a full left lateral decubitus position, with the patient's trunk at 90-degree angle to the operating room table and the right upper extremity position securely over the patient's right chest. Drawing from the experience of laparoscopic adrenalectomies, the full left lateral position allows for easier, lateral access to the right lobe of the liver. "Jackknifing" the table opens up the working space at the far right of the abdominal musculature even more.

This approach is taking advantage of the weight of the liver itself, which is rotated medially by gravity as mobilization progresses, and obviates the need for an additional port for a liver retractor. An arm rest for the patient's right upper extremity should be employed to position it at a comfortable position over and above the upper right chest. Appropriate padding should be placed under the left axilla and at all pressure points of the trunk. The patient's abdomen, particularly the right upper quadrant at a minimum, should be left unobstructed for laparoscopic port placement but also for a quick laparotomy (through a generous right subcostal incision), should the need arise intraoperatively. The patient's body should be secured on the operating table in a fashion that will enable steep Trendelenburg and reverse Trendelenburg positioning, as well as rotation of the table to the right and left without patient slipping. We favor a belt around the patient's hip as well as stop latches at the lower spine and suprapubic areas. Intravenous fluid administration should be kept to a minimum until parenchymal transection, as is true for all liver resections.

Initially, just three 5 mm ports are placed, as shown in image 1, one for a high definition 5 mm camera and two for the laparoscopic instruments. Insufflation of the abdomen is instituted at a pressure of 12 mm Hg, with the ability to increase the intra-abdominal pressure up to 20 mm Hg should venous or low-pressure parenchymal bleeding is encountered. Depending on the most beneficial camera view and angle of approach, one of the 5 mm working ports is converted into a 12 mm port, once the desirable degree of hepatic mobilization is obtained. The upsized port can accommodate a vascular cartridge-loaded stapler or the laparoscopic ultrasound probe for intraoperative sonographic examination of the parenchyma.

Mobilization of the right lobe can proceed working laterally to medially and freeing up the retroperitoneal attachments and the right triangular ligament of the right lobe as shown in the video, https://www.dropbox.com/s/v247mnbo385shnt/ hatzaras%20lap%20hepatectomy%20S7%202.mp4?dl=0. Gravity works to the surgeon's benefit, medializing the lobe as the dissection proceeds. Dividing fully the right triangular ligament is facilitated by additional gentle liver retraction with the right hand instrument, while a vessel-sealing device is yielded with the left hand. The right adrenal quickly comes into view, and care should be used to avoid injuring the fragile gland or its small feeding vessels (e.g. superior adrenal artery and vein). Caution is especially important in the case of a large tumor in the right lobe of the liver, which has been chronically pressing against the right adrenal gland, fusing the right adrenal with the liver capsule, and causing local venous hypertension in the small venous branches; these should be dissected carefully and clipped individually. Care should also be paid to avoiding injuring the diaphragm, which if entered, would lead to pneumothorax; if this was to occur, it can be repaired laparoscopically with heavy absorbable suture, over a suction device that will empty the air from the ipsilateral hemithorax.

Although not shown in this video, this positioning and initial hepatic mobilization allows for the inferior vena cava (IVC) to be fully exposed, if this lateral to medial dissection is continued more medially. The small direct branches from posterior of the right lobe to the IVC can be dissected, clipped and divided as needed. The IVC

ligament may also be fully dissected, a vessel loop passed around it and a vascular cartridge-loaded stapler used to transect it safely. Lastly the inferior surface of the right hepatic vein can be encountered and skeletonized, and if the bare area superiorly is fully mobilized, the right hepatic vein can be encircled with a vessel loop and ligated with a vascular stapler.

To avoid the necessity of inflow control at the hilum, and outflow control at the hepatic veins, we frequently use microwave ablation to demarcate the target area of resection before transection of the parenchyma (key move#4). We aim for a 1 cm wide by 3 or 4 cm deep thermal ablation zone, which provides a safe, nearly bloodless transection zone. Alternatively, if the goal is to achieve a completely laparoscopic right hemihepatectomy, the surgeon should perform a cholecystectomy; then by using intraoperative laparoscopic ultrasound to identify the right portal bundle immediately superior and posterior the gallbladder fossa. If clearly identified, the operative surgeon can use a Glissonian approach, perform two shallow hepatotomies, each approximately half an inch long and 1 inch apart, in such a way to accommodate a vascular stapler which will ligate intrahepatically the right portal structures. Excellent demarcation of the right lobe will be seen after successful completion of this maneuver.

Once mobilization is completed we laparoscopically place "liver handles", two number one braided sutures though and through the parenchyma of the intended specimen in a figure-of eight fashion (key move#5), ensuring to avoid the tumor itself. These "liver handles" are brought through the abdominal wall from a separate lateral stab incision using a suture passer and we secure them with a hemostatic clamp. This maneuver allows easy, gentle extracorporeal intraoperative manipulation of the liver area to be resected. An alternative option of achieving this retraction in lateral lesions is to place a vessel loop around the fully mobilized right lobe, and exteriorize it from the abdominal cavity with a suture passer through a medial separate stab incision; this allows gentle upward retraction of the right liver lobe, the soon to-be-resected portion falls to the right, "opening the book" for the surgeon to deploy the vessel-sealing device and the vascular staplers. We typically use the Harmonic scalpel (Ethicon/Johnson & Johnson, Somerville, NJ) to transect the superficial portion of the parenchyma, followed by "vascular staplers" for the deeper portion. The 12 mm Hg intra-abdominal pressure in combination with the microwave ablation transection treatment renders the transection field relatively bloodless, a clear benefit of laparoscopic hepatectomy, obviating the need for transfusion. After resection and irrigation, we place a hemostatic agent on the cut surface of the liver. The combination of energy transection and vascular stapling allows the pace of the operation to be brisk, and it is typically completed in under 3 hours. The specimen can be removed through a 5–8 cm incision usually in the Pfannenstiel position. With these maneuvers, LLR can achieve the same outcome as the open approach, in the same time, with the same if not lower risk of transfusion, alas, with a much speedier recovery.

## **9. Conclusion**

In the last two decades, liver surgery has become a much safer surgical procedure to be offered to patients with hepatic malignancies, including Hepatocellular Carcinoma. The laparoscopic approach to liver resection has evolved in parallel. Despite a steep learning curve, LLR can achieve excellent outcomes for well selected patients with Hepatocellular Carcinoma.

*Laparoscopic Liver Resection for Hepatocellular Carcinoma DOI: http://dx.doi.org/10.5772/intechopen.102981*
