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Conversion from laparoscopic to open surgical approach in the semi-prone position can still be achieved
by rotating the operating table to a neutral position, and a right subcostal incision can then be made in the
[15]
left lateral decubitus position .
Left jack-knife position
The left jack-knife position involves adjusting the operating table at the level of the lumbar region to an
[17]
angle of approximately 120 degrees, once the patient is already in a left lateral decubitus position [Figure 3D] .
Lumbar extension increases the operating field by widening the distance between the right costal margin
and the right anterior superior iliac spine, allowing wider space for lateral port placement.

Reverse trendelenburg
In addition to all these varying positions, a reverse Trendelenburg, which can range from 10-30 degrees is
also simultaneously adopted. This serves to decrease hepatic venous pressure by reducing venous return,
and also improves caudal exposure by gravitationally shifting visceral structures away from the liver
[2]
hilum .

A TYPICAL OPERATION THEATRE SET-UP
This is an example of a typical operation theatre set-up [Figure 4]. Depending on the type of surgery, the
patient’s positioning may vary (legs together vs. legs split), and the main surgeon may switch positions to
be on the patient’s right or left.

Dual air supply is recommended routinely for laparoscopic liver resection as it negates the sudden loss
of pneumoperitoneum when there is more liberal use of the surgical aspirator in the context of bleeding.
An alternative to dual air supply is the use of valve-less trocar systems, which is able to maintain a stable
pneumoperitoneum with laminar flow and carbon dioxide recirculation in spite of high flow suction or air-
leak.

Providing a template of the operation theatre layout allows the surgeons, nursing staff, and OT attendants
to plan accurate placements of surgical equipment, optical screens, and appropriate energy device foot
pedals, enhancing the overall efficiency of the set-up for LLR.

PORT PLACEMENT
There is no standard for port positioning in LLR even in surgeries that are as routinely performed as left
lateral sectionectomies, and tweaks are often necessary depending on each unique case [9,18] . In a typical
LLR, up to 4-6 ports may be used, with a minimum of two 12 mm ports - one for the preferred flexi-
tip (e.g., Olympus EndoEye; Olympus Medical System Corp, Tokyo, Japan) or 30-degree camera, and an
additional as a working port for the insertion of the laparoscopic ultrasound probe, stapler, and ultrasonic
aspirator, amongst other 10 mm instruments. In our experience, 3D imaging capability can be useful in
improving depth perception, especially in the context of deep parenchymal transection.

Specimen retrieval sites are typically an extension of the para-umbilical incision or a pfannenstiel incision
for larger specimens. The pfannenstiel incision provides improved cosmetic outcome and reduced post-
operative pain.

In the straight split-leg or modified Llyod-Davies position, the first port placement is most commonly
a supraumbilical 12 mm port with additional working ports then placed along a diameter of concentric
[19]
circles radiating from the tumour . The position of the supra-umbilical port can also vary in distance
from the umbilicus, accommodating for patients with a longer xiphisternum-umbilical distance. An