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“ Combined Laparoscopic and Trans-Thoracic Approach ” for Limited Liver Resections

Salceda Juan, Laurent Alexis, Cherqui Daniel, Azoulay Daniel and Tayar Claude

Background: Since the very first report and through to the last two decades, laparoscopy has demonstrated to be an effective tool for liver surgery, especially limited resections. Despite increasing experience worldwide and the multitude of instruments and energy based devices for parenchymal transection, some locations remain difficult for limited laparoscopic resections. Posterior and upper right segments of the liver (segments 7 and 8) are still tricky to be exposed properly while using a standard laparoscopic approach. We present a new technique with a Combined Laparoscopic and Trans-Thoracic Approach (CLTTA) to reach difficult locations in the liver enabling limited resections while conserving the advantages of minimally invasive surgery. Methods: Three patients underwent limited liver resection through a CLTTA. The first patient had liver metastasis of colonic cancer, the second an inflammatory liver adenoma and the third a liver nodule suspected to be a HCC with underlying cirrhosis. All lesions were located between segments 7 and 8. Results: All procedures were performed using CLTTA. Four ports were placed in the abdomen and two supplementary 5 mm ports were placed through the right pleural cavity. Parenchymal transection was done in every case using either harmonic scalpel (Ultracision, Ethicon Endosurgery, Cincinnati, OH) or vessel sealing device (Ligasure, Covidien-Valleylab, Boulder, CO) for the first two superficial centimetres and then Ultrasonic Surgical Aspirator (Sonosurg, Olympus, Tokyo, Japan) for deeper transection. Haemostasis was achieved using bipolar coagulator and clips when necessary. Chest tube was left in place for two days after surgery. No patient was transfused. No conversion, morbidity or mortality was observed. Conclusions: We report our early experience with this new technique that seems to be feasible and safe for the laparoscopic limited resections of upper and posterior right segments of the liver. Further experience is needed in order to confirm these data.