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Otsuka et al.                                                                                                                                   Indications and technique for LLR in HCC with liver cirrhosis

            A                                B                               C















           Figure 1: Laparoscopic limited anatomical resection in segment 6 in a patient with hepatocellular carcinoma (HCC) and Child-Pugh class B
           cirrhosis. (A) HCC and liver cirrhosis in segment 6; (B) illumination by indocyanine green fluorescence imaging shows the inflow preserved area
           after occlusion of the Glissonean pedicle of segment 6. Dotted line shows liver transection line; (C) liver resection plane


           three Couinaud’s segments), at high-volume centers.  and ultrasonically activated devices are placed on the
                                                              right or left.  An ultrasound diagnostic system is also
           In patients with cirrhosis, parenchyma-preserving limited   positioned to the left of the patient.
           anatomical resection along a demarcation line on the
           liver surface (formed by division of the Glissonean sheath   Trocar placement
           at the hepatic hilus) is now achievable using laparoscopic   After pneumoperitoneum is achieved by means of
           technique. A recent modality, laparoscopic near-infrared   an umbilical incision, the laparoscope is inserted. For
           fluorescence  imaging,  allows for precise anatomic   operative manipulation in partial hepatectomy, three or
                               [30]
           resection [Figure 1].                              four trocars are placed in a concentric circle radiating
                                                              from the tumor. In left lateral sectionectomy, three
           LLR has a steep learning curve; therefore, the technical   trocars are placed at the right hypochondrium and
           ability of a particular surgical team should be considered   bilateral abdomen. For anatomical hepatectomies other
           when assessing the applicability of LLR. A recent study   than left lateral sectionectomy, four trocars are usually
           proposed  a  difficulty  scoring  system  for  stepwise   necessary: at the epigastrium, right hypochondrium,
           application of LLR, which was based on experience at   and bilateral abdomen. Intercostally inserted trocars are
           high-volume Japanese centers.  The proposed system   useful for manipulation during resection of the superior
                                      [31]
           predicts surgical difficulty by considering tumor location,   region of the liver. A 5-mm trocar is placed in the upper
           extent of liver resection, tumor size, proximity to major   abdomen for Pringle’s maneuver, when it is needed.
           vessels, and existing chronic liver damage.
                                                              During trocar insertion, surgeons should attempt to
           SURGICAL TECHNIQUE FOR LLR                         preserve collaterals on the abdominal wall in patients with
                                                              liver cirrhosis. This may require use of ultrasonography to
           Patient position and setting                       identify collateral vessels. [32]
           Under general anesthesia, the patient is positioned
           depending  on the location  of the tumor. In general,   Hepatic parenchymal transection
           resection of the left hemi-liver or right anterior region of   For this procedure, laparoscopic ultrasound is performed
           the liver is performed with the patient in conventional   using  a  flexible-angle  ultrasound  probe,  to  confirm  the
           supine position. Resection of the right posterosuperior   location of the tumor in relation to the vascular anatomy
           region  of the liver is performed  with the patient in a   and identify other lesions in the liver. Although surface
           left hemilateral  decubitus  position, especially  for   roughness from cirrhosis may impede ultrasound
           resections requiring mobilization of the right liver from   inspection,  use  of  a  water  drip  around  the  ultrasound
           the retroperitoneum. In the left hemilateral position, the   probe can improve penetration of the ultrasound signal
           patient’s body is fixed using a negative pressure bag   into the liver parenchyma.
           packed with plastic beads, which is placed under the
           patient, and several support arms to prevent slipping   Because of the risk of CO  gas embolism caused by
                                                                                      2
           during abrupt position changes.                    pneumoperitoneum, [33,34]  intra-abdominal pressure should
                                                              be maintained below 8-12 mmHg during the procedure. [35]
           The laparoscopic tower contains the light source,
           camera,  and  insufflators  and  is  positioned  to  the  right   Chronic  liver  disease  is  characterized  by  significant
           of  the  patient.  Monopolar  and  bipolar  generators  for   alterations in the intra- and extrahepatic vasculature.
           electrocautery devices, a microwave tissue coagulator,   Division of collaterals within the falciform ligament or
                           Hepatoma Research ¦ Volume 2 ¦ September 19, 2016                              243
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