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Golhar et al. Mini-invasive Surg 2019;3:9 I http://dx.doi.org/10.20517/2574-1225.2018.58 Page 3 of 8

towards the tumor and about 4 to 5 working ports for graspers, suction, ultrasonic or sealing energy
devices, cavitron ultrasonic surgical aspirator (CUSA) and others are placed on either side of the camera
[7]
port at a reasonable distance . In hand-assisted technique, in addition to the regular ports a hand-port is
[7]
used to help mobilize the liver and retract both cut surfaces during the transection . The hybrid technique
involves mobilization laparoscopically followed by parenchymal transection and specimen extraction
[8]
through a small open incision and may combine the benefits of both techniques . Robot assisted LLR
offers the advantage of a 3 dimensional vision and dexterity of robotic arms whereas parenchymal
transection is performed laparoscopically with access to better retractors and CUSA. Robot assisted LLR
[4]
may be more suited for postero-superior segment tumors .

LLR involves the following steps, not necessarily in the same order:
• Hilar dissection followed by inflow control is obtained fairly early during the LLR. Inflow control
may be obtained by intra-fascial or Glissonian approach depending on tumor factors and surgeon’s
preferences, as both are safe [3,6,9] . Biliary anatomy can be deciphered using fluorescence, conventional
[10]
contrast or combined cholangiography . Either intrabiliary injection of 0.025-0.5 mg/mL indocyanine
green (ICG) or intravenous injection of 2.5 mg ICG fifteen minutes before fluoroscopy can be used to
[10]
identify biliary anatomy and plan division of the bile ducts .
• Approach for laparoscopic right hepatectomy may be by anterior approach or conventional approach
after mobilisation of liver [3,11,12] .
• The transection plane is identified for left or right hepatic resection by unilateral clamping vascular
[10]
inflow of same side at the hilum or by fluorescence imaging with ICG . After clamping the portal
pedicle supplying segment to be removed, boundaries of hepatic segments can be visualized following
[10]
injection of 0.25-2.5 mg/mL ICG into the portal veins or by intravenous injection of 2.5 mg ICG . For
segmental or non-anatomical resection, the transection plane may be identified using the Glissonian
approach or intra-operative Doppler Ultrasonography [3,13] .
• Cholecystectomy: some surgeons although disconnect the cystic artery and duct, retain the gall bladder
for retraction until later in the case.
• Pringle’s maneuver, the practice is variable with few centers not using it at all and others using it in all
cases [3,11] . Parenchymal transection is the most challenging part of the surgery with large variations
in technique, instruments, equipment used between different surgeons also depending on the tumor
size, location and nature of background liver [3,14] . Various transection techniques have been described
including the use of the modern dissectors/ aspirators [laparoscopic CUSA, WaterJet (Helix Hydro-Jet
Erbe Elektromedizin GmbH, Tuebingen, Germany), etc.], sealing devices [Harmonic scalpel (Ethicon
Endo Surgery INC - Johnson & Johnson Medical SPA, Somerville, NJ), Ligasure (Valleylab Inc.,
Boulder, Colorado, USA), bipolar sealing devices, etc.], and vascular staplers [3,14] . Superficial transection
can be performed with any energy device, but deeper transection should be performed with an
[3]
appropriate device to identify deep vascular structures . While large vessels should be secured with
vascular staplers or Hem-o-lok clips (Weck Closure Systems, Research Triangle Park, Durham, NC,
USA Manufacturer), smaller vessels can be divided using metal or Hem-o-lok clips or sealed with an
energy device [3,14] . Staplers for parenchymal transection should be used with caution because it lacks
[3]
precision and identification of the underlying structures . Argon Plasma Coagulator (APC) should be
[3]
used for haemostasis with extreme caution due to the potential risk of gas embolism . More recently,
a novel technique has been described, called “superficial pre-coagulation, sealing and transection
method”, which utilizes a soft coagulation system to create a 5 mm zone of pre-coagulation causing
shrinkage and blockage of micro-vessels and bile ducts smaller than 1 mm without causing sparks
[15]
and tissue desiccation . This is followed by liver parenchymal dissection using CUSA in a bloodless
[15]
plane created by pre-coagulation . Use of the laparoscopic hanging maneuver is also reported by few
surgeons [3,16] . Intra-operative Doppler Ultrasonography (IOUS) is used for confirming adequate tumor
[11]
margin from the cut surface .
• The specimen may be extracted using an appropriate retrieval bag generally through a midline or
pfannenstiel incision.