Page 97 - Read Online

Page 6 of 18 Thiruchelvam et al. Hepatoma Res 2021;7:22 I http://dx.doi.org/10.20517/2394-5079.2020.144

Figure 4. A typical operation theatre set-up.

infra-umbilical port is a useful alternative in the context of a cirrhotic patient to avoid potential bleeding
from the recannulated umbilical vein. In instances where the resection plane is predicted to extend more
superiorly and posteriorly, the optical trocar port can be inserted in the upper right paramedian instead.

In patients with high body mass index, port placements are best referenced from fixed anatomical
landmarks such as the xiphisternum and the costal margin rather than the umbilicus. In contrast, patient’s
with hepatomegaly from severe steatosis or alcoholic liver disease would require port placements to be
inferiorly translocated away from the costal margins to account for a more inferior liver edge. In the
event that an LLR is attempted on a patient with previous open surgery, index port placement is often
the safest via a open cut-down technique at a site away from the previous incisions, with additional ports
placed for adhesiolysis prior to the intended LLR port configuration for the planned liver resection. For
repeat LLRs, omental and bowel adhesions are less common; this upfront allows for port placement of a
desired configuration after initial laparoscopic survey through the optical trocar. However, the liver hilum
may be scarred if it was previously dissected, and the liver tends to be adherent to the diaphragmatic and
retroperitoneal surfaces if it was previously mobilised.

In the event that the surgeon’s preference is an extracorporeal Pringle manoeuvre, a short profile 5 mm
trocar is often utilised for convenience, such that it will not interfere with the resection and also allow