A Procedure for the Masses: Why Laparoscopic Left Lateral Sectionectomies are the new gold standard

by Brie Eteson, Digital Surgery

Laparoscopic Left Lateral Sectionectomy is becoming the gold standard method for removing tumors in the left lobe of the liver. The early 1990s saw the beginnings of laparoscopic liver resections, with the first reports of a laparoscopic left lateral sectionectomy in 1996.1,2 The approach has been shown to have decreased blood loss, shorter hospital stays, and comparable survival rates with its open surgery equivalent.3,4 Although it is becoming the approach for the resection of tumors in segments 2 and 3, variation in the procedure still exists, and it is predominantly confined to specialized teams and centers with a wealth of experience.5 This latest simulation by Touch Surgery takes you through a resection of segments 2 and 3 of the liver, along the second and third portal pedicles, and the left hepatic vein. 

Understanding liver anatomy is an essential requirement to successfully performing this procedure, so we’ve got a quick and easily accessible rundown of things to know before attempting this simulation. If you want a more in-depth guide to liver anatomy, check out our simulation and blog post on this topic in Liver Surgical Anatomy.

Biliary Drainage

Liver cells secrete bile. This bile is collected by a system of ducts flowing from the liver to the right and left hepatic ducts that then drain into the common hepatic duct. The common hepatic duct merges with the cystic duct of the gallbladder and forms the common bile duct.6

Major Hepatic Vessels

There are three large intrahepatic veins that drain venous blood into the inferior vena cava. They are the right hepatic vein, middle hepatic vein, and left hepatic vein. These major vessels are important landmarks that run between and define the four sections of the liver, listed below.7

Additionally, there are the highly variable caudate lobe veins that contribute to the venous drainage of the liver.8

Functional Divisions of the Liver9

There are two functional lobes; right and left. These are subsequently divided into four sectors; the left medial and lateral sectors, and the right anterior and posterior sectors.

Each sector is subsequently divided into two, with a total of eight hepatic segments. This is known as the third order of division and is marked by the bifurcation of the portal vein. The left portal vein bifurcates further to form the second and third portal pedicles, supplying segments 2 and 3.

Segment 1 is known as the caudate lobe and lies posterior to segment 4.

Segment 2 forms the superior segment of the left lateral sector.

Segment 3 forms the inferior segment of the left lateral sector.

Segment 4 encompasses the entire left medial lobe anteriorly. It is subdivided into segments 4a, superiorly, and 4b, inferiorly.

Segment 5 is the inferior part of the right medial sector.

Segment 6 is the inferior part of the right lateral sector.

Segment 7 is the superior aspect of the right lateral sector.

Segment 8 is the superior aspect of the right medial sector.

First order of division

First order of division

Second order of division

Second over of division

Third order of division

This simulation demonstrates a case of a lesion in the left lateral section of the liver, found on investigation to be consistent with metastatic adenocarcinoma. The patient had chemotherapy with an excellent clinical response.

Preoperative imaging and liver function tests were performed in preparation for surgery.

Key Surgical Objectives

Patient Positioning and Port Insertion

The patient is positioned in the French position. This position is a variation of lithotomy, which can also be used. Legs should be placed in either lithotomy or on a split table. This allows the operating surgeon to stand between the legs of the patient.

The below animations demonstrate the location of all port insertions used in the simulation.

  1. Midline
  2. Left clavicular line
  3. T1: Palmer’s point
  4. T2: where the 30° laparoscope is inserted (camera port)
  5. T3: surgeon’s left working port
  6. T4: assistant’s port

Locations of the port insertions vary based on the patient’s size and the surgeon’s preferences.

The abdomen is insufflated at 14 mmHg through the Palmer’s point port. The author’s preference is to use a 5 mm optical trocar (T1) to ensure safe entry. An abdominal sweep is performed to check for signs of metastasis or abdominal adhesions. After all ports are inserted, an ultrasound scan of the liver is performed.

T1

T2

T3

T4

Mobilization of the Left Lateral Liver

To begin mobilization, the falciform ligament is taken down toward the diaphragm, stopping at the bifurcation of the coronary ligaments. Staying close to the liver, the round ligament is transected. It is then possible to retract the liver superiorly and remove any adhesions to the left lateral section.

Preparing the Pringle maneuver

Preparation for Parenchymal Transection

A shallow parenchymal incision is made, defining the transection margin. The Pringle maneuver is prepared by dividing the hepatogastric ligament so tape can be passed through the foramen of Winslow. The surgeon gains temporary control of blood flow to the liver via tape secured around the hepatoduodenal ligament. This is the technique demonstrated in the simulation, but note there are many alternative ways of performing the Pringle maneuver.

Parenchymal and Portal Pedicle Dissection

The parenchymal transection of segment 3 is deepened, any crossing veins superficial to the third portal pedicle are sealed and divided, and the dissection is extended posteriorly. 

The Pringle maneuver is released accordingly and reapplied if needed at specific intervals. To learn about how intervals are safely implemented in this particular case, search in the Touch Surgery™ app for the full simulation.

Extending the parenchymal dissection posteriorly

The dissection of the liver parenchyma continues posteriorly from superficial to deep up to the inferior surface of the liver, and extending past the hepatic inflow to the left lateral segment. The locations of the left hepatic vein (LHV), portal pedicles 3 and 2 (in order of visualization), and the tumor margins are subsequently confirmed. Dissection continues until the portal pedicles are visualized. They are then divided en masse. The left main pedicle should not be included within the jaws of the stapler.

Extraction of specimen via a Pfannenstiel incision

Left Hepatic Vein Division

The deep parenchyma is dissected until the LHV is exposed. Confirmation of safety of the proximal stomach and the esophagus is now possible. The left anterior coronary ligament is then dissected and divided along with the division of the LHV en masse, taking down the posterior coronary and left triangular ligaments.

Specimen Removal

Any bleeding from the remnant liver is suctioned, and hemostasis confirmed. The Pringle maneuver is then released. The specimen is placed in a specimen retrieval bag and extracted via a Pfannenstiel incision.

Closure

The fascia and skin of the extraction site are closed using subcuticular sutures. Reinsufflation should occur prior to the closure of the remaining port sites, to perform a final check for bleeding. Fascial closure sutures are placed for all 12 mm port sites and all ports are removed under direct vision, before closing the skin of all port sites, using subcuticular sutures.

Fascial closure suture for 12 mm port sites

This simulation was authored by David A Kooby and Yuman Fong.

For a detailed breakdown of all the objectives and alternatives, or to learn more about this complicated and highly specialized procedure, search in the Touch Surgery™ app today for Laparoscopic Left Lateral Sectionectomy.

Launch in App

or scan the QR code below.

How to cite this simulation: Kooby DA, Fong Y. Laparoscopic Left Lateral Sectionectomy. Touch Surgery Simulations. http://dx.doi.org/10.18556/touchsurgery/2021.s0183. Published May. 7, 2021.

References

1. Morise Z, Wakabayashi G. First quarter century of laparoscopic liver resection. World J Gastroenterol. 2017;23(20):3581.

2. Liu Z, Ding H, Xiong X, Huang Y. Laparoscopic left lateral hepatic sectionectomy was expected to be the standard for the treatment of left hepatic lobe lesions: a meta-analysis. Med. 2018;97(7).

3. Rong L. Laparoscopic Liver Resection Theory and Techniques. Beijing, China: Springer Science+Business Media; 2017.

4. Geller DA, Khreiss M. Laparoscopic Liver Resection. Clin Liver Dis. 2015;5(1):1-4.

5. Goumard C, Farges O, Laurent A, et al. An update on laparoscopic liver resection: the French Hepato-Bilio-Pancreatic Surgery Association statement. J. Visc. Surg. 2015;152(2):107-12.

6. Hopkins Medicine. Biliary System Anatomy and Functions. Website. https://www.hopkinsmedicine.org/health/conditions-and-diseases/biliary-system-anatomy-and-functions. Updated 2021. Accessed Apr. 21, 2021.

7. Bell DJ, and Bashir O, et al. Hepatic Veins. Radiopaedia Website. https://radiopaedia.org/articles/hepatic-veins. Accessed Apr. 21, 2021.

8. Sendic G. Hepatic veins. Kenhub. https://www.kenhub.com/en/library/anatomy/hepatic-veins. Updated Apr. 8, 2021. Accessed Apr. 21, 2021.

9. Crumbie L. Functional Division of the Liver. Kenhub Website. https://www.kenhub.com/en/library/anatomy/functional-division-of-the-liver. Updated Apr. 8, 2021. Accessed May. 6, 2021.

10. Aragon RJ, Solomon NL. Techniques of hepatic resection. J Gastrointestl Oncol. 2012;3(1):28-40.

11. Lee BH, Yun SS, Kim MK, Jung HK, Lee DS, Kim HJ. Rationale and surgical technique of laparoscopic left lateral sectionectomy using endoscopic staples. Ann Surg Treat Res. 2014;87(2):66-71.

12. Man K, Fan ST, Ng IOL, et al. Tolerance of the Liver to Intermittent Pringle Maneuver in Hepatectomy for Liver Tumors. Arch Surg. 1999;134(5):533-539.

13. TVASurg – The Toronto Video Atlas of Surgery. Laparoscopic left lateral sectionectomy. http://pie.med.utoronto.ca/TVASurg/project/lap-leftlateralsectionectomy/. Accessed Nov. 2, 2020.

14. Sarkar M, Prabhu V. Basics of cardiopulmonary bypass. Indian J Anaesth. 2017;61(9):760-767.