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Page 14 of 18 Thiruchelvam et al. Hepatoma Res 2021;7:22 I http://dx.doi.org/10.20517/2394-5079.2020.144

diaphragmatic ultrasonographic localisation of the liver tumor, followed by incision of the diaphragm.
It entails single lung ventilation and placement of a chest drain at the end of surgery after repair of the
diaphragm, and should ideally only be utilised for superficial resections that are not close to major hepatic
veins. The single lung ventilation maximises the working space of thoracoscopic instruments without the
use of carbon dioxide insufflation.

A pure thoracoscopic approach may be particularly useful in patients with multiple previous abdominal
[49]
surgeries so as to avoid difficult adhesiolysis in the scarred abdomen . However, if there is a need to access
the porta hepatis and hepatoduodenal ligament for the Pringle manoeuvre as well as survey the left lobe of
the liver with intra-operative ultrasound, the surgery can be modified to involve two steps with an anterior
trans-abdominal approach in the supine position followed by left lateral positioning with transthoracic
[47]
approach . In this approach, the pneumoperitoneum is evacuated prior to transthoracic port placement
and diaphragmatic incision.

Understandably, this trans-thoracic surgical approach raises concerns for potential thoracic complications
such as bilio-pleural fistula, oncological compromise, atelectasis, pneumothorax, and diaphragmatic hernia.

Hand-assisted laparoscopic approach
The adoption of hand-assisted laparoscopic surgery (HALS) for the liver is largely dependent on surgeon
preference and type of resection planned. It may be utilised more for hemi-hepatectomies, whereby the
hand-port incision serves a dual purpose for specimen extraction. It is also viewed by some as an interim
approach for surgeons in their early experience with LLR as the hand-port can be used to facilitate liver
retraction along the parenchymal cut line. The hand-port also allows for immediate compression or
[50]
elevation whenever bleeding is encountered and provides tactile feedback in assessing tumor margins .

HALS right and left hepatectomy described by University of Pittsburgh Medical Center [51,52]
The patient is positioned supine. The hand-port is placed at the start of the operation and when it is not
utilised, a 12 mm trocar is inserted through the gelport.

The main surgeon stands on patient’s left side [Figure 12A].

The main surgeon stands on the patient’s right side. The hand-port is placed lower so as to minimize
conflict with the laparoscopic instruments [Figure 12B].

Single-incision laparoscopy approach
Single port laparoscopic hepatectomies have also been described, most frequently but not exclusively
for minor hepatectomies such as left lateral sectionectomy and wedge resections [53-56] . A trans-umbilical
incision is typically performed ranging between 4-5 cm and limited to lesions that are not larger than 5 cm.
In LLR involving postero-superior lesions, the incision may need to be modified to a right upper quadrant
transverse incision to allow laparoscopic instruments to reach the dome of the liver . Limitations of SILS
[54]
include lack of triangulation, which adds challenge to the surgery and as such, may only be recommended
for experienced surgeons in select cases.

CONCLUSION
With increasing access and advancements in minimally invasive equipment, an increasing proportion of
liver surgeons will adopt LLR as a routine and push boundaries to complete more challenging resections
[57]
using a pure laparoscopy approach . Whilst established frameworks in patient and port positioning exist,
liver surgeons should still aim to be flexible, modifying approaches according to patient’s physique, tumour
size and location, as well as the underlying liver pathology. The LLR learning curve can be steep and the