Author: Editorial Board of Chinese Journal of Digestive Surgery
Source: Chinese Journal of Digestive Surgery, 2024, 23(1)
summary
Laparoscopic hepatectomy has been gradually applied to the treatment of various diseases in hepatobiliary surgery. The development of laparoscopic hepatectomy is a derivative process of the surgical approach. Physician experience, tumor location, patient size, and liver anatomy are all factors influencing physicians' choice of surgical strategies and techniques. With the development of laparoscopic technology, the surgical approach of liver resection has been continuously updated and evolved. There is no consensus in China on the laparoscopic approach to liver resection. Therefore, the editorial board of the Chinese Journal of Digestive Surgery organized domestic experts in related fields to formulate the Chinese Expert Consensus on Laparoscopic Liver Resection Surgical Approaches (2023 Edition) after many discussions using the Delphi method, aiming to standardize the approach and scope of application of laparoscopic liver resection surgery.
In the past 30 years, laparoscopic hepatectomy has been gradually applied to the treatment of various diseases in hepatobiliary surgery. He has undergone open vision-guided laparoscopic hepatectomy (initial stage), laparoscopic visual field-guided laparoscopic hepatectomy (development stage), technology-guided laparoscopic hepatectomy (perfection stage) and strategy-guided laparoscopic hepatectomy (mature stage). It can be seen that the development of laparoscopic hepatectomy is a derivation of the surgical approach. Physician experience, tumor location, patient size, and liver anatomy are all factors influencing physicians' choice of surgical strategies and techniques. The volume of laparoscopic hepatectomy in some domestic high-throughput medical centers is much higher than that of open hepatectomy, but the overall minimally invasive rate of hepatectomy in China is about 20%. Therefore, the editorial board of the Chinese Journal of Digestive Surgery organized domestic experts in related fields to formulate the "Chinese Expert Consensus on Laparoscopic Liver Resection Surgical Approaches (2023 Edition)" after many discussions, aiming to standardize the approach and scope of application of laparoscopic liver resection surgery. In this consensus, the level of evidence-based medicine refers to the grading of recommenda-tions, assessment, development and evaluation (GRADE) and the Oxford Centre for Evidence-Based Medicine 2011 Edition, and the strength of expert recommendations is graded with reference to GRADE.
1. Classification according to operation space
In the tubular field of view of the laparoscope, the operating space is an important factor affecting the surgery. According to the operation space, the surgical approach was divided into abdominal approach, posterior peritoneal approach, thoracic approach or combined thoracoabdominal approach.
(1) Abdominal entrance tract
Since most of the liver and its tumors are located in the abdominal cavity, the surgical approach to laparoscopic hepatectomy is mostly taken in the abdominal approach.
The abdominal approach surgery has a wide field of view, which is in line with the traditional open surgery operation habits, and most of the liver tumors can be resected after the liver is properly freed. Due to the unique angle of the abdominal approach from the foot side to the cephalad side, the tumors in some special parts (such as the S1 segment of the liver) are more direct and have more room for operation than the open surgical approach, while for the S4a, S7 and S8 segments of the liver that are deeply located, the surgical field is difficult to be exposed, and the surgical instruments are difficult to operate, laparoscopic hepatectomy can be assisted by measures such as full liver free, suspension lift, or transthoracic and intercostal placement of Trocar.
Recommendation 1: The peritoneal approach is suitable for the vast majority of laparoscopic hepatectomy. For the deep position of the liver segment that is difficult to operate, the abdominal approach can also be completed through technical improvement and training. (Level of evidence: III.; strength of recommendation: B)
(2) Posterior peritoneal approach
There is a large anatomical gap between the visceral extraperitoneal bare hepatic area and the right adrenal gland. This space is used to establish a spatial channel, the posterior peritoneal approach. This approach can directly reach the bare liver area, and if necessary, the right posterior lobe of the liver can be appropriately free to obtain a larger area, so that the instrument can reach the ideal surgical site for easy operation. This surgical approach is usually indicated for resection of lesions located in the right posterior lobe of the liver in the S6 and S7 segments of the liver. Due to the deep presence of the tumor in this area, it is difficult to reveal and the surgical angle is inconvenient, especially for patients with severe abdominal adhesions, and the liver cannot be fully free to reveal the lesions.
In 2011, domestic scholars tried retroperitoneal approach laparoscopic resection of small and superficial tumors in the right posterior lobe of the liver. In 2021, Otsuka et al. refined the indications for this approach: the maximum diameter of the tumor was <3 cm, and the tumor was located in the posterior inferior part of the S6 or S7 segment of the liver and did not invade the inferior vena cava. Posterior peritoneal approach surgery has little interference with the patient's cardiopulmonary function, avoids the anatomical separation of abdominal organs, and has little impact on the patient's physiological function. However, the posterior peritoneal approach has a small operating space and cannot block the first hepatic hilum and is mostly non-anatomical hepatic resection, usually with the establishment of a joint urologist. Therefore, this approach requires high surgical skills and stereoscopic spatial positioning of the bare liver area.
Recommendation 2: The posterior peritoneal approach is suitable for small and superficial lesions in the right posterior lobe of the liver, where severe adhesions are expected in the abdominal cavity. (Level of evidence: III; strength of recommendation: C)
(3) Thoracic approach
Transthoracic resection means that the diaphragm is ventilated with a single lung and the diaphragm is cut directly to establish a channel, and the liver lesions under the diaphragm are exposed, and liver resection is performed. This approach is not limited by the patient's abdominal environment and is suitable for patients with a history of upper abdominal surgery, such as recurrent liver cancer, colorectal cancer, or gastric cancer liver metastases.
In 2017, Yamashita et al. performed transthoracic resection of liver S8 metastases in patients with multiple abdominal surgeries. Aikawa et al. also proposed that the thoracic approach is suitable for patients with a history of multiple liver surgeries. Clinical reports have shown that the surgical effect of the thoracic approach is similar to that of the abdominal approach, with less intraoperative blood loss and shorter operation time, and it is also safe and feasible to remove the S8 segment lesion in patients with liver cirrhosis. In addition, for resectable lesions with simultaneous involvement of the liver and lungs, a thoracic approach can be used to perform laparoscopic hepatectomy combined with lung lesion resection. However, the transthoracic approach cannot treat or block the first hepatic hilum and it is more difficult to stop bleeding during surgery, it is difficult to perform anatomic liver resection, and single-lung ventilation is required during the operation, which has high requirements for the patient's cardiopulmonary function, and the establishment of the access can be completed with the assistance of a thoracic surgeon.
Recommendation 3: The thoracic approach can be selectively performed with the assistance of a thoracic surgeon in patients with superficial subdiaphragmatic liver lesions, a history of multiple liver surgeries, severe adhesions in the abdominal cavity, or concomitant hepatectomy combined with lung lesion resection. (Level of evidence: III; strength of recommendation: C)
(4) Thoracic and abdominal joint approach
Liver lesions located under the diaphragm are located deep and often adjacent to the hepatic vein and inferior vena cava, and have problems such as limited surgical field and difficulty in exposure, difficulty in reaching surgical instruments and difficulty in controlling bleeding. The thoracic approach has the advantage of a short path and direct exposure of the lesion. However, the thoracic approach alone cannot block the hilar blood flow and is not easy to control the intraoperative blood loss, which limits its safety and wide application. Domestic scholars have proposed a "dual approach", which can make up for the shortcomings of the simple thoracic approach that is difficult to deal with the first hilum by inserting instruments from the chest cavity and the abdominal cavity at the same time, and is more flexible than the simple abdominal approach. The results of related studies showed that the combined thoracoabdominal approach was feasible in anatomic liver S7 and S8 segment resection, and its oncological outcome may be better than that of the abdominal approach alone.
Recommendation 4: For deep subdiaphragmatic liver lesions, the combined thoracoabdominal approach can make up for the shortcomings of the first hilum that is difficult to deal with with the first liver portal with the thoracic approach alone, and is more flexible than the simple abdominal approach, which is suitable for experienced surgeons. (Level of evidence: III; strength of recommendation: C)
2. Classification according to the direction of operation
As the largest substantial organ of the human body, the liver has three dimensions: ventral, dorsal, foot and cephalic. Guided by the middle hepatic vein or the right hepatic vein, hepatic parenchymal dissection can be started from these four aspects. In the laparoscopic field of view, the surgeon can reveal the ventral, dorsal, foot, and cephalic sides of the liver and its ducts from different angles. The surgeon can quickly reach the predetermined anatomical goal from different directions of operation according to actual needs and personal habits.
(1) Ventral approach
The ventral approach is the basic hepatic resection technique and strategy in the field of open surgery, which dissects the liver parenchyma from the surface of the liver to the vena cava. This approach can achieve in-situ resection without turning the liver, reducing the squeezing of the tumor, which is in line with the principle of tumor-free surgery.
This approach is suitable for resection of the left hepatic hemigram that does not require liver dissociation, and also for resection of large tumors in the right hepatic hemiliver that is not suitable or cannot be free of the liver. For tumors adjacent to the major hepatic vein, the ventral approach avoids accidental injury to the hepatic vein. Liver resection in the field of view of the robot is not suitable for liver dissociation, so the ventral approach is usually used to complete liver parenchymal separation and duct dissection. However, the ventral approach alone greatly limits the exposure of the surgical field and the separation of vital ducts in laparoscopic surgery, and there is a greater surgical risk when dissecting the liver parenchyma at a deeper position. When this approach is adopted, the hepatic vein traction is obvious after the liver section is expanded, which can easily cause hepatic vein tearing and bleeding.
Recommendation 5: The ventral approach conforms to the traditional perspective, which can reduce liver turnover and avoid crushing the tumor, and for larger tumors adjacent to the major hepatic veins, the ventral approach can achieve in situ resection. (Level of evidence: II; strength of recommendation: A)
(2) Dorsal approach
The three main hepatic veins ride across the caudate lobe of the liver and join the inferior vena cava at the second hila. The dorsal approach is to dissect the liver parenchyma of the caudate lobe ventrally of the inferior vena cava, expose and dissect the target liver pedicle on the dorsal side, and further dissect the liver parenchyma dorsally to reveal the target hepatic vein. For right-sided hepatic resection, the preferential approach through the caudate lobe may be used as part of the dorsal approach.
When using the dorsal approach, the direction of liver parenchymal separation should be ventral, and the surgical field should be clear, which is convenient for accurate and rapid visualization of the hepatic vein and separation of the liver parenchyma. The dorsal approach was first applied to the left hemihepatectomy, and then gradually applied to the right hemiliver, right posterior lobe, and liver S7 segment resection. Compared with the laparoscopic left hemihepatectomy with the anterior approach, the operation time with Glisson liver pedicle anatomy combined with dorsal approach was shorter, the intraoperative blood loss was less, and the hospital stay was shorter. The dorsal approach is usually used in conjunction with the Glisson hepatic pedicle approach for laparoscopic anatomical hepatectomy.
Recommendation 6: According to the needs of surgery, the target liver pedicle and hepatic vein are preferentially exposed, and the dorsal approach can be used, which is usually combined with the Glisson hepatic pedicle approach, and is suitable for laparoscopic resection of the left hepatic hepaticle, the right hemiliver, the right posterior lobe of the liver, and part of the liver S7 segment. (Level of evidence: II; strength of recommendation: A)
(3) Cephalad approach
The cephalad approach is a surgical method in which the hepatic vein is gradually exposed from the root of the hepatic vein from cephalad to foot, along the main trunk of the hepatic vein. The three main trunks of the hepatic vein converge into the inferior vena cava at the second hepatic hilus, and there is no hepatic parenchymal attachment on the surface, and the whole process of the hepatic vein can be quickly exposed along the root of the main hepatic vein to ensure the correct direction and plane of hepatic parenchymal disconnection. At this time, the direction of the device operation is consistent with the direction of the hepatic vein branch, and the possibility of intraoperative tearing of the hepatic vein branch is reduced. The above two advantages are helpful for the surgeon to perform anatomical hepatectomy guided by the hepatic vein.
Domestic scholars have used cephalad approach to perform laparoscopic left hepatectomy, liver S7 or S8 segment resection, right anterior hepatic lobectomy or liver S3 segment resection, etc., and obtained good results. The use of cephalad approach to change the direction of the traditional exposed hepatic vein has high requirements for the operator's anatomical technique, operation skills, intraoperative coordination, use of liver totomy instruments and central venous pressure control.
Recommendation 7: The cephalad approach is suitable for laparoscopic hepatectomy with preferential exposure of the root of the hepatic vein, such as resection of the left hemiliver, liver S4a, S7, and S8 segments, which can reduce the incidence of hepatic vein tears and reduce the amount of intraoperative blood loss. (Level of evidence: II; strength of recommendation: A)
(4) Foot approach
The lateral approach of the foot refers to the unique foot view of the laparoscope, in which the surgeon dissects the liver parenchyma from the foot side to the cephalad side, so as to achieve a tunnel anatomy that is different from the traditional laparotomy perspective. The traditional ventral approach requires partial cleaving of the liver parenchyma to reveal the deep dorsal surface of the liver, while the foot approach can easily and quickly separate and dissect the short hepatic vein.
The foot approach is mostly used for hepatectomy in special parts, such as hepatic caudate lobe and right posterior lobe of the liver, which can obtain a better angle of view and operation space from the foot side, which is helpful to better display the dorsal region of the liver, inferior vena cava and right hepatic vein, and can broaden the surgical dimension of laparoscopic hepatectomy. This approach tends to injure the slender hepatic venous branches when dissecting the liver parenchyma, resulting in the loss of direction to the level of the hepatic severance. Due to the limited operating space, it requires high cooperation of the surgical team.
Recommendation 8: The foot approach is in line with the laparoscopic perspective and direction of operation, and the liver is resected in the need for tunneled dissection, such as hepatic caudate lobectomy and right posterior hepatic lobectomy. (Level of evidence: II; strength of recommendation: A)
3. Classification according to the priority dissected pipeline
The hepatic pedicle and hepatic vein are important ducts of the liver and important markers for anatomic liver resection. Therefore, according to the classification of the preferential dissecting pipeline, the surgical approach can be divided into hepatic venous approach, Glisson hepatic pedicle approach, and liver parenchymal priority approach.
(1) Hepatic venous approach
The hepatic vein is the intrahepatic boundary of anatomical hepatic resection. The hepatic venous approach is a strategy or pathway that prioritizes the exposure of the target hepatic vein. Anatomical hepatectomy with hepatic vein as the disconnection plane can not only be used as an anatomical landmark for liver resection, but also ensure the resection margin, preserve the liver tissue with normal function to the greatest extent, reduce the residual liver tissue with congestion, and reduce the risk of tumor recurrence after surgery.
The hepatic vein approach is divided into foot, cephalad, and dorsal approaches, revealing the terminals, roots, and trunks of the target hepatic vein, respectively. The caudal approach is retrograde from the terminal of the hepatic vein to the root through the liver parenchymal approach, and the cephalad approach is to dissect the second hepatic portal first, and dissect antegrade from the root of the hepatic vein to the terminal. Because the secondary hepatic pedicle and the main trunk of the hepatic vein intersect at the hepatic hila, the middle or right vein of the liver is easily exposed dorsally after the secondary hepatic pedicle is dissected. Therefore, intrahepatic hepatic venous guidance combined with extrahepatic ischemia line is more conducive to the implementation of hepatic parenchymal dissection.
Recommendation 9: Select a specific hepatic venous approach strategy according to the operator's habits and the difficulty of intraoperative anatomy. Hepatic vein approach is suitable for hepatic vein resection that requires preferential guidance of hepatic vein, such as S8 segment hepatectomy, living donor liver acquisition, and tumor adjacent to hepatic vein. (Level of evidence: II; strength of recommendation: A)
(二)循Glisson肝蒂入路
Hepatic pedicle control is an important part of hepatectomy. Following the Glisson hepatic pedicle approach, the hepatic capsule is opened at the hilum of the liver into the Laennec space, and according to the direction of the target hepatic pedicle, it is vertically separated and disconnected as a whole. Simplification of the hilar canal separation by the Glisson pedicle approach allows for rapid identification of a well-defined ischemic plane and fluorescent staining if necessary.
In 1998, the Glisson hepatic pedicle approach was first applied to laparoscopic left lateral hepatic pedicle resection, in 2002, it was applied to laparoscopic left hepatic pedicle separation, and then gradually applied to the right posterior lobe, right hepatic lobe, middle hepatic lobe, and hepatic trilobe resection, and in 2007, Cho et al. reported the Glisson hepatic pedicle approach for liver segment resection of various parts, and gradually took laparoscopic Glisson sheath hepatic pedicle dissection as a routine clinical step of liver resection.
Recommendation 10: The Glisson hepatic pedicle approach can be used as a routine approach for anatomical lobes or partial hepatic hepatic resection. It is suitable for hepatocellular carcinoma, localized intrahepatic bile duct stones and other liver resections. (Level of evidence: II; strength of recommendation: A)
(3) Preferential approach to the liver parenchyma
In the process of anatomical liver resection, the dissection of the target liver pedicle and liver parenchyma are the two main steps. The liver parenchyma priority approach was first determined according to the intrinsic anatomical landmarks of the liver (such as sickle ligament, left and right liver pedicle roots, etc.), laparoscopic ultrasound (LUS) examination to determine the landmark anatomical structure (such as the middle hepatic vein), ischemic line (such as clamping the left and right liver pedicles), intraoperative indocyanine green staining to assist in determining the hepatic resection plane, preferentially split the liver parenchyma, and gradually fully expose the target liver pedicle before dissection or blocking. The advantage is that the preemptive liver parenchymal dissection can help to fully expose and treat the liver pedicle, which can simplify the operation, save time, and reduce the risk of intraoperative bleeding and bile leakage in the cramped space to prioritize the target liver pedicle.
LUS examination is an important tool for laparoscopic hepatectomy, which is routinely used to mark important duct structures, determine resection margins, and guide puncture, which can make up for the limited palpation and exploration of laparoscopic surgery, as well as the identification of important anatomical structures in the liver, and guide the separation of liver parenchyma. At the same time, indocyanine green fluorescence detection guidance can display the interparenchymal plane in real time, which is complementary to LUS examination guidance.
Recommendation 11: The preferential approach to liver parenchyma is suitable for anatomical hepatectomy of the left and inner lobes of the liver, left and right hemilivers, and dissected resection of the middle hepatic region. LUS examination and indocyanine green fluorescence detection can be used as adjuncts to this approach to guide liver parenchymal dissociation. (Level of evidence: II; strength of recommendation: A)
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Chinese Expert Consensus on Laparoscopic Liver Resection Surgical Approach (2023 Edition)
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