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. Apr-Jun 2018;22(2):e2018.00017.
doi: 10.4293/JSLS.2018.00017.

A Sling Technique for Laparoscopic Resection of Segment Seven of the Liver

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Free PMC article
Case Reports

A Sling Technique for Laparoscopic Resection of Segment Seven of the Liver

Igor Mashchenko et al. JSLS. .
Free PMC article

Abstract

Introduction: As the incidence of liver cancer continues to increase in the setting of cirrhosis, parenchyma-sparing liver resection is increasingly necessary. A technique is described that involves using a sling made from 1-inch-wide packing gauze to retract and rotate the liver to divide the right triangular and coronary ligaments and mobilize segment 7. The right lobe is rotated anteriorly and counterclockwise, allowing access and parenchymal transection of segment 7 under ultrasonographic guidance.

Case presentation: Seven patients with tumors in segment 7 underwent resection with the technique described above: 4 had Child's A cirrhosis and hepatocellular carcinoma (HCC), 1 had metastatic colon cancer, 1 had an adenoma, and 1 had a symptomatic hemangioma. Tumor size ranged between 2.5 and 7.7 cm. Blood loss during resection was between 150 and 500 mL. No patients required transfusion as a result of surgery. With the exception of 1 patient with Clostridium difficile colitis, the average hospital stay was 3.8 days.

Management and outcome: Parenchyma-sparing laparoscopic resection of segment 7 is feasible and can be safely performed using a sling for intracorporal hepatic retraction, manipulation, and positioning. Given the risk of HCC recurrence, laparoscopic liver resection may also be better suited for subsequent salvage liver transplant because of less perihepatic adhesions.

Keywords: Cirrhosis; Laparoscopy; Liver cancer; Liver resection; Segment 7.

Figures

Figure 1.
Figure 1.
3D MIP reconstruction of tumor rendered as a volume for surgical planning. The tumor is rendered as a volume within reconstructed 3D MIP DICOM of the liver in the venous phase: axial (A), coronal (B), and right sagittal (C) views. DICOMs were read with the Horos open-source medical image viewer. Axial (D), coronal (E), and right sagittal (F) arterial phase images are of a segment 7 hepatoma.
Figure 2.
Figure 2.
Port and sling placement to expose right triangular ligament. (A) The blue line represents sling placement and direction of tension to initiate exposure of the right triangular ligament. The red arrows represent the anticipated rotation of the liver. (B) The sling after being slid over the dome of the liver. This maneuver allows the liver to be pulled away from the diaphragm, enabling access to the dorsal hepatic ligament and release of segment 7. Sites of 5- and 12-mm ports are shown as horizontal lines.
Figure 3.
Figure 3.
Use of the sling to retract the liver and expose the right triangular ligament. (A) Sling exposing the posterior lateral aspect of the right triangular ligament. (B) Division of the posterior superior right triangular ligament. (C) Sling pulling the dome of the liver away from the diaphragm, exposing the right coronary ligament anteriorly and laterally. Note the right phrenic vein draining into the vena cava or right hepatic vein.
Figure 4.
Figure 4.
Release of the dorsal hepatic ligament and rotation of the liver. (A) Right liver mobilized after division of short hepatic vein with exposure of dorsal hepatic ligament. (B) Liver released after division of dorsal hepatic ligament. (C) Natural position of the liver. (D) Rotation of the liver using 1-inch packing wrapped around the dome of the liver.
Figure 5.
Figure 5.
Use of umbilical tape for laparoscopic inflow control of hepatoduodenal ligament (Pringle maneuver). (A) Umbilical tape around the hepatoduodenal ligament. (B) The hepatoduodenal ligament with bulldog clamp cinched down to limit inflow to the liver.
Figure 6.
Figure 6.
Rotated liver and tissue transection for hepatoma. (A) Sling being used to rotate liver and segment 7 inferiorly and anteriorly. The harmonic scalpel is used to transect liver after lesion is identified and the borders are marked using laparoscopic ultrasonography. (B) Hepatic transection plane. (C) Resected specimen in segment 7, which is then removed through an infraumbilical incision.
Figure 7.
Figure 7.
Construction of suture for quick control of hepatic parenchymal bleeding. A 2.0 silk suture with an SH needle is used. The anchor is made by wrapping the 2.0 suture around 1 of the arms of a large hemoclip. The hemoclip is then compressed and the anchor is secured.

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