Minimally Invasive Anatomic Liver Resection

In laparoscopic anatomic liver resection (LALR), correct dissection of the Glissonean pedicles and careful exposure of the hepatic veins are essential. Therefore, LALR requires not only basic knowledge and procedures but also advanced techniques. In laparoscopic liver resection (LLR), it is essential to control bleeding. The Pringle maneuver, which suppresses bleeding from both the inflow and outflow systems, should be usually prepared before initiating liver parenchymal dissection. To prevent venous bleeding, we have to understand the relationship among the central venous pressure, airway pressure, and pneumoperitoneal pressure, and adjust those pressures appropriately. The direction of approach to the hepatic veins is also important to avoid a split injury, which may cause critical bleeding. The hepatic veins should be approached from the central to the peripheral side. The secondary or tertiary branches of the Glissonean pedicles are dissected in LALR. In open liver resection (OLR), the secondary branches are comparatively easy to dissect extrahepatically from the hepatic hilum. However, the correct dissection of these branches by laparoscopic surgery is sometimes difficult owing to restrictions in the manipulation of laparoscopic instruments. As for the tertiary branches, it is more difficult to dissect correctly even in OLR because the tertiary branches often ramify in the deep portions inside the liver. We have developed various approaches to isolate secondary and tertiary branches safely, taking advantage of laparoscopic surgery. The Arantius-first approach in left hemihepatectomy, caudate lobe-first approach in right hemihepatectomy or right posterior sectionectomy, and intrahepatic Glissonean approach to G7 or G8 are useful procedures, and described here in detail.