Keywords
liver hemangioma - laparoscopic liver resection - laparoscopic anterior approach -
preoperative embolization - anatomical liver resection - pure laparoscopic hepatectomy
Laparoscopic resection of liver lesions has been associated with a diminished stress
response resulting in an early recovery and a shorter hospital stay along with an
improved cosmetic outcome compared with open liver resection. Because of technical
difficulties and the possibility of catastrophic intraoperative bleeding, the role
of laparoscopy in the management of symptomatic giant hepatic hemangioma (GH) had
been restricted based on site and size criteria.[1] The rapid progress made in the field of laparoscopic surgery in recent years has
proffered great opportunities for resecting symptomatic liver hemangiomas in a minimally
invasive fashion. Liver hemangioma of more than 20 cm in size is generally termed
as an extremely giant hepatic hemangioma.[2] The literature on laparoscopic resection of extremely GH is scarce as these are
typically resected using the open approach.[2]
[3]
[4] Here, we describe the technical nuances of totally laparoscopic removal of an extremely
giant hepatic hemangioma of 22-cm size in craniocaudal diameter and occupying almost
the entire right lobe using modified port positions and the anterior approach.
Patient Details
A 51-year-old female was referred to our institute with a history of progressive right
upper quadrant pain of 5 months duration. Her routine blood tests were essentially
normal. Imaging of the abdomen revealed a hemangioma of 22 cm in craniocaudal diameter
involving almost the entire right lobe and extending up to the right iliac fossa ([Fig. 1]). In view of persistent symptom, the patient was planned for laparoscopic right
hepatectomy after obtaining informed consent and thorough preoperative work up. Preoperative
transarterial embolization of GH was performed but it could not reduce the size of
the GH, possibly due to the presence of collateral vessels.[3]
Fig. 1 Contrast enhanced CT scan demonstrates the huge size of hemangioma which occupies
almost the entire right lobe. CT, computed tomography. (Open black arrow shows the
medial extend and the solid white arrow shows the inferior extent of the hemangioma).
Procedure
Port Placement
The patient was placed in the supine low-lithotomy position. The surgeon was standing
in between the patient's legs, with two assistants, one on each side of the patient.
Because of the huge size of the GH, routine supraumbilical camera port and bilateral
upper quadrant working ports for standard right hepatectomy could not be placed. Hence
the pneumoperitoneum was created using a suprapubic 10-mm camera port inserted by
open method. Two 5-mm working ports, one in each iliac fossa were inserted for inflow
control which also helped in performing initial stages of the parenchymal transection.
After obtaining inflow control and performing a major part of the parenchymal transection,
the camera port was shifted to the umbilicus for outflow control and mobilization
of the liver. An additional 10-mm port was placed below the left-costal margin slightly
lateral to the midclavicular line for parenchymal transection and right hepatic vein
(RHV) stapling. Later on, a 5-mm working port was placed in the midclavicular line
in the right upper quadrant ([Video 1]; available online only).
Video 1
Demonstration of patient details and port placement.
Inflow Control
The falciform ligament was taken down, following which the suprahepatic vena cava
was also dissected. Access to the right pedicle was gained after dividing the cystic
duct and artery and lowering the hilar plate. The gall bladder was kept undissected
and it was used for traction when needed. At this stage, a few collateral vessels
in the perihilar region were clipped and divided. Following this, the right hepatic
artery (RHA) and the right portal vein (RPV) were dissected and looped. A caudate
branch from RPV was divided. The caudate lobe was freed from the inferior vena cava
(IVC). Only RPV was needed to be clipped to develop the ischemic line of demarcation
since RHA had already been embolized ([Video 2]).
Video 2
Demonstration of steps of inflow control.
Parenchymal Transection and Outflow Control:
We decided to do a right hepatectomy as the right lobe was almost entirely replaced
by the GH. The anterior approach was preferred as the huge size of the hemangioma
hampered early mobilization of the right lobe. Initial superficial transection was
done by the harmonic scalpel and in deeper planes, the ultrasonic aspirator (CUSA)
was used. The middle hepatic vein (MHV) was safe guarded and used as a guide for liver
transection plane. Draining veins from segment V and VIII were clipped or stapled
depending on the size. After partial parenchymal transection, the attention was redirected
towards the inflow vessels. Hem-o-lok clips were applied on RHA and RPV and they were
divided with an Endo GIA vascular stapler. The right hepatic duct along with its accompanying
hilar plate was divided with an Endo GIA vascular stapler. The parenchymal transection
was proceeded cephalad and deeper planes were developed carefully safeguarding IVC.
After completion of hepatic parenchymal transection, the outflow control was achieved
by exposing RHV and transecting it by an Endo GIA vascular stapler ([Video 3]).
Video 3
Demonstration of parenchymal transection, outflow control, and specimen delivery.
Mobilization of the Right Liver
This part of the surgery was time consuming due to engorged GH. Few small retroperitoneal
collateral vessels were clipped and divided by minimal lifting of the GH from the
diaphragm. The right lobe containing GH was mobilized meticulously from the retroperitoneum
and the specimen was completely freed from the IVC. Special attention was paid to
attain complete hemostasis. Finally, the contents of the hemangioma were aspirated
and the specimen was retrieved in a bag through a pfannenstiel incision. The left
lobe was then fixed to the remnant falciform ligament to prevent the spontaneous rotation
into the right subphrenic space. A right flank drain was kept in the surgical field
which was removed on the 1st postoperative day ([Video 3]).
The operative duration was 320 minutes and the blood loss was 200 mL. Patient had
an uneventful recovery and was discharged on the 4th postoperative day.
Discussion
Hepatic hemangioma can generally be observed and requires intervention only if it
is symptomatic. Hepatic hemangiomas of more than 5 to 10 cm are called giant hepatic
hemangiomas. Symptomatic GH is traditionally treated surgically either by enucleation
or resection depending on the location and size of the tumor. Enucleation is favored
over resection, if feasible. We adopted the right hepatectomy because the hemangioma
had replaced almost the entire right lobe.
The Louisville Statement, 2008, considered hemangioma of more than 5 cm as a relative
contraindication for laparoscopic resection.[1] With the advent of better sophisticated devices, like laparoscopic harmonic/CUSA
probes and Endo GIA staplers, complex laparoscopic liver resections can be safely
performed by experienced surgeons. Kim and Kwon retrospectively evaluated the feasibility
of laparoscopic removal of hepatic GH greater than 6 cm in diameter (6–18 cm) in nine
patients.[5] All, except one of nine, patients underwent anatomical resection. There was no major
morbidity or mortality in their series. It was followed by the description of a handful
of different techniques for the resection of GH, mostly between 10 and 18 cm. Lanthaler
et al reported laparoscopic resection of a 20-cm pedunculated hemangioma after reducing
its size by preoperative embolization.[4] Preoperative embolization may not always reduce the size of the hemangioma. In a
series of GH more than 20-cm operated by open technique, the mean size of the tumor
did not show any significant change on follow-up imaging studies after preoperative
embolization.[3] Zhang et al showed that a combination of infrahepatic IVC clamping and the Pringle's
maneuver with laparoscopic extracapsular enucleation of GH can significantly reduce
the intraoperative blood loss and transfusion rates compared with the Pringle's maneuver
alone.[6] But these vascular exclusion procedures are not always needed during laparoscopic
resection of GH.[4]
Our case is one of the largest GHs reported to be resected laparoscopically.[4]
[5] We did not use the Pringle's maneuver or IVC clamping. We planned the anterior approach,
as an early forceful retraction during mobilization of the GH in the conventional
approach might result in serious complications like rupture of GH leading to massive
hemorrhage and even exsanguination of the patient. In the anterior approach, after
the inflow control, the parenchymal transection is performed from the anterior surface
of the liver until the anterior surface of the IVC is exposed and then all venous
tributaries, including RHV, are controlled before the mobilization of the right lobe
of liver and the tumor.[7] Besides the technique of preoperative embolization and the application of early
inflow control, adoption of the anterior approach and anatomical resection enabled
us to curtail intraoperative hemorrhage and mitigate the need for transfusion.
To conclude, laparoscopic resection of extremely GH can be safely accomplished by
experienced hepatobiliary surgeons with proper preoperative and intraoperative planning,
and appropriate use of modern gadgets. The laparoscopic anterior approach is a safe
and effective method to restrict blood loss during minimally invasive resection of
GH.
