Video
Liver 		  
VL02 Video Liver: Minimal Invasive Liver Surgery 
Selection of Video Presentations from Abstract Submissions
VL02-01 Totally Laparoscopic ALPPS Procedure for Colorectal Liver Metastases
Eric Herrero, Spain

E. Herrero1, J. Camps1, M.I. Garcia-Domingo1, L. Martinez1, A. Rodríguez2, E. Cugat1
1HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain, 2Anaesthesiology - HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain

Introduction: Liver resection is the only curative treatment for patients with colorectal liver metastases. The goal is to completely remove all the lesions (R0 resection) leaving enough liver remnant to avoid postoperative liver failure.
Methods: The case of a 39 year old woman with a sigmoid colon cancer KRAS mutated is presented.
Extension study was performed with CT, MRI and PET showing multiple liver mets affecting all liver segments but IV and II. Neoadjuvant chemotherapy combining Folfox-Bevacizumab during 7 cycles was appointed achieving partial response. FLRV was 23%.
A two-stage procedure was decided. The first stage inclusive a liver partition containing right segments extended to segment I, segment III resection and right portal vein ligation. Right hepatectomy extended to segment I was performed during second stage.
Results: This video shows the laparoscopic surgical technique during first and second stage of ALPPS procedure. CT volumetry after first stage showed an increase of FRLV of 30%.
Postoperative morbidity was grade II (Dindo-Clavien). Pathology accounted for 8 nodules with a cell viability ranging from 5 to 25% with negative margins. Hospital stay was 25 days.
Conclusion: ALPPS procedure can provide a rapid growth of liver remnant in patients with huge metastatic disease, leading to increased resectability. However, increased morbidity and mortality of this strategy and technical difficulties of the procedure, make that it has to be performed only in very selected cases for specialized teams both in liver surgery and laparoscopic surgery.
VL02-02 Full Robotic ALPPS for HCC
Paolo Magistri, Italy

F. Di Benedetto, P. Magistri
University of Modena and Reggio Emilia, Italy

Background: The Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) technique can induce a greater degree of hypertrophy of the future liver remnant (FLR) in a shorter time compared to other procedures. A robotic approach may reduce the complication rate, increasing the ability to perform classic ALPPS.
Methods: We report the first full robotic ALPPS (stage 1 and stage 2) for hepatocellular carcinoma (HCC). The patient was a 38 year-old man with Milan-out HCC on chronic unknown HBV infection. On CT scan he was diagnosed with a 7-cm LIRADS-5 HCC of the right lobe, with intrahepatic tumor thrombus of a branch of the portal vein for segment VIII. AFP was 1417.4 ng/dl, MELD 7, Child-Pugh A-5, ALBI score was -3,26 (Grade 1). FLR volume was 19.6% (segment 1-2-3), R15 3.7%; PDR 21.9 %/min; HVPG 2 mmHg. After multidisciplinary evaluation he was scheduled for right trisectionectomy ALPPS.
Results: Both the steps of the ALPPS procedure were completed with full robotic approach. On p.o.d. 8 after stage 1 FLR increased to 37%, therefore he underwent completion of ALPPS on p.o.d. 10. No complications occurred in the interstage period, neither after ALPPS completion. The post-operative course was uneventful, and the patient was discharged in good general conditions on p.o.d. 3. Final pathology showed a 7 cm HCC, G3, micro- and macrovascular infiltration, R0 margin (12 mm).
Conclusion: Robotic ALPPS is safe and feasible for selected patients with initially unresectable HCC or requiring extended resections, with good post-operative outcomes.
VL02-03 Ultrasound Guided Pedicle First Approach to Sg7 Laparoscopic Segmentectomy for Hepatocellular Carcinoma
Roberto Lo Tesoriere, Italy

A. Ferrero, R. Lo Tesoriere, S. Langella, F. Forchino, A. Borello, N. Russolillo
General and Oncological Surgery, Mauriziano Hospital, Italy

Laparoscopic liver resection is reported as a safe procedure with potential advantages over open surgery, albeit with inherent limitations, such as loss of spatial orientation and tactile feedback.
Anatomical segmentectomies, because of the lack of anatomic landmarks are often more challenging procedures than major hepatectomy, especially with minimally invasive approach. Ultrasound (US) is considered the best tool to identify anatomic landmarks and the transection plane during liver surgery.
The relatively superficial anatomical position on the ventral surface of the liver of the right posterior glissonean pedicle and its division branches of Sg6 and Sg7, makes these segments suitable for the “pedicle first approach”. This technique involves US identification of the course of the concerned pedicle on the liver surface. Through a US targeted hepatotomy, the pedicle is identified and isolated exactly at the level where it will be ligated. Clamping the pedicle causes ischemic demarcation of the segment. The demarcation, together with the US guidance, allows the anatomic resection.
The video shows an anatomical Sg7 segmentectomy with pedicle first approach in a 78 years old woman with 5 cm hepatocellular carcinoma. Once the ischemic demarcation of Sg7 is thus obtained, the parenchymal section is conducted with a cranio-caudal approach to the right hepatic vein. The transection begins close to the hepatocaval confluence. Right hepatic vein is reached and followed caudally, dividing the venous branches draining Sg7. At the end of the resection the RHV and a Sg6 venous branch are exposed on the cut surface.
VL02-05 Laparoscopic Right Hepatectomy for Polycystic Liver Disease
Amy Li, United States

A. Li, J. Bergquist, B. Visser
Stanford University, United States

Polycystic liver disease (PCLD) is characterized by 20 or more liver cysts, with progressive hepatomegaly. Surgery is reserved for those with medically refractory disease and severe symptomatology. This video presents the surgical technical challenges associated with the inherent pathophysiology of PCLD. We present the case of a 48-year-old otherwise healthy female who presented with abdominal pain, nausea and vomiting. CT imaging demonstrated innumerable liver cysts, with a right-lobe predominance. Based on the patient's symptomatology, the patient underwent laparoscopic right hepatectomy with fenestration of left-sided liver cysts for volume reduction. A 12 mm port was placed in the supraumbilical position and three 5 mm trocars to the left midline, right midclavicular line and right anterior axillary line. There was limited intraabdominal domain due to massive hepatomegaly. Fenestration of the left sided liver cysts was performed first to increase working room. Right hepatectomy was performed with a Glissonian approach along Cantlie's line. Due to the diffuse distribution of liver cysts, anatomical planes and vascular anatomy were distorted. Hepatic vessels may be encountered at any time during division of liver cysts and parenchyma. After the right lobe was divided and mobilized, the specimen was further decompressed with fenestration. The specimen was morcellated for extraction through the 12 mm umbilical port site. The patient tolerated the procedure well and was discharged home on postoperative day 2. Postoperatively, the patient reported symptomatic resolution. Postoperative imaging demonstrated approximately 60% volume reduction, from approximately 3,000cc to 1200cc.
VL02-06 Robotic Right Hepatectomy
Omeed Moaven, United States

O. Moaven1, C. Tschuor2, E. Baker2, D.A. Ianitti2, D. Vrochides2, J.B. Martinie2
1Section of Surgical Oncology, Department of Surgery, Wake Forest Baptist Medical Center, United States, 2Division of Hepatobiliary and Pancreatic Surgery, Carolinas Medical Center, Atrium Health, United States

Background: Despite growing interest in minimally invasive liver resection, most liver surgeons still prefer an open approach for major liver resection. Here, we present feasibility and efficiency of right hepatectomy with robotic approach in a a 71-year-old female with a 10 cm right-sided mass, confirmed to be cholangiocarcinoma after biopsy. She received neoadjuvant cisplatin/Gemcitabine (7 cycles) with radiologically stable disease.
Video case presentation: After placement of trochars and docking the robot, we started the procedure with portal lymphadenectomy, removing the tissue around porta hepatis and posterior to the duodenum en bloc. With confirmation of intraoperative ultrasound (IOUS) we identified inflow vascular pedicle for the right lobe. We dissected off and ligated right hepatic artery, and identified and ligated right posterior and right anterior portal veins with suture and hemoclips. We then mobilized the liver from its retroperitoneal attachments and inferior vena cava (IVC). The dissection was carried to identify right and left hepatic ducts. Right hepatic duct was divided and ligated. Parenchymal division was performed at the demarcation line with a vessel sealer. Multiple branches of middle hepatic vein were identified and divided with clips. We again identified the tumor with IOUS and dissected it off the IVC. We finally identified the superior and inferior branches of right hepatic vein and divided them robotic vascular load staple. The remaining attachments of liver to diaphragm were divided and specimen was removed.
Discussion: Oncologically appropriate major liver resection is feasible with robotic approach and with quicker and more favorable postoperative recovery.
VL02-07 Robotic Left Hepatectomy
Christoph Tschuor, United States

C. Tschuor1, O. Moaven2, E. Baker1, D.A. Ianitti1, D. Vrochides1, J.B. Martinie1
1Division of Hepatobiliary and Pancreatic Surgery, Carolinas Medical Center, Atrium Health, United States, 2Section of Surgical Oncology, Department of Surgery, Wake Forest Baptist Medical Center, United States

Background: Favorable results of minimally invasive major hepatic resection have been reported for malignant and benign tumor entities. While major hepatectomies are still performed mostly open up to now, the robotic approach is considered as an attractive alternative.
Video Case Presentation: Here we present a 67-year-old female with an intrahepatic cholangiocarcinoma involving segments II as well as III and significant intrahepatic biliary dilatation in these segments. The local tumor board recommended left hemihepatectomy and a robotic approach was planned. The patient was placed in the supine position and 4 daVinci Surgical Systems™ trocars were inserted as well as an assistant port. After dissection, hilar structures were isolated extrahepatically and ligated according to the extra-Glissonian approach. Intraoperative ultrasound was used to clarify the course of relevant intrahepatic vascular structures. Firefly Fluorescence Imaging - after intraoperative application of indocyanine green (Verdye®) - revealed the course of the left bile duct. Parenchymal transection was performed using the robotic vessel sealer, fenestrated forceps and clips. Pathology confirmed the diagnosis showing clear resection margins. Patient was discharged on POD 4.
Discussion: Robotic assisted left hepatectomy is feasible, safe, oncological efficient and demonstrates an attractive alternative to the conventional open approach. Patients benefit from a fast recovery for further oncologic treatment.
VL02-08 Laparoscopic Anatomic Hepatic Segmentectomy 7 for Hepatocellular Carcinoma (HCC) on Cirrhosis
Felice Giuliante, Italy

F. Giuliante, F. Ardito, M. Vellone, C. Mele, E. Panettieri, M. Bellobono
Fondazione Policlinico Universitario Agostino Gemelli IRCCS (Catholic University of the Sacred Heart), Italy

Introduction: Laparoscopic approach for liver resections is widely performed for lesions in the antero-lateral segments. Laparoscopic resections of posterior segments are more complex procedures and longer operative time often is needed. However, there is a greater advantage for minimally invasive approach for posterior segments resections, because in case of open procedures for posteriorly located lesions, wide incisions are performed to better expose operative field.
Methods: The video shows the case of a 53-years-old male patient with a 3.3 cm HCC nodule located in segment 7 (S7), on liver cirrhosis on metabolic syndrome. At liver magnetic resonance imaging (MRI), the nodule presented typical HCC features and was in contact with the portal pedicle for segment 7 (P7). The patient had a normal liver function (CHILD A5, MELD 8), without portal hypertension and alfa-fetoprotein level of 399 ng/ml. Laparoscopic anatomic resection of S7 was planned.
Result(s): The patient was placed in slight left lateral decubitus with right arm suspended. Five trocars were placed below the right subcostal margin. The right hemiliver was fully mobilized. The first step was to reach and divide the P7 to perform anatomic resection of S7. P7 was detected by ultrasound and marked on the liver surface. Parenchymal transection was performed by ultrasonic dissector, bipolar forceps and articulating energy device. Intermittent pedicle clamping (116 minutes) was used. After dividing P7, ischemic area of S7 was confirmed with Indocyanine Green fluorescence and anatomic resection was performed.
Conclusion(s): Postoperative course was uneventful and patient was discharged on post-operative day 5.
VL02-09 Laparoscopic Caudate Lobectomy for Neuroendocrine Tumor with Waterjet Parenchymal Transection
John Bergquist, United States

J. Bergquist1, J. Morris2, G. de Azevedo3, N. Shaikh3, S. Cleary1
1HPB Surgery, Mayo Clinic, United States, 2Radiology, Mayo Clinic, United States, 3Surgery, Mayo Clinic, United States

Introduction: Caudate tumors are not uncommonly encountered. Resection is complicated because of the caudate lobe's intimate relationship to the proper hepatic artery, porta hepatis, and inferior vena cava. Laparoscopic caudate lobectomy is infrequently performed because of the risk of hemorrhage and the high level of technical skill required to complete the operation safely in minimally-invasive fashion.
Methods and Results: We describe a laparoscopic caudate lobectomy in a 63 year old gentleman with pancreatic neuroendocrine tumor metastatic to the caudate lobe. Pre-operative imaging demonstrates that the proper hepatic artery, left portal pedicle, and inferior vena cava are the critical nearby structures. The ligamentum venosum and main portal vein branch supplying the lobe are visible. The patient is positioned supine with split leg table. Standard laparoscopic cholecystectomy port locations were used. The gastrohepatic ligament was incised. The caudate lobe was grasped and retracted cephalad and anteriorly. Draining hepatic veins into the IVC were carefully ligated with a laparoscopic bipolar energy device. The lobe was then retracted toward the patient's left and the ligamentum venosum was ligated. Parenchymal transection was completed with waterjet dissection. The main portal vein supply was ligated with clips. The caudate lobe was freed of remaining attachments and removed in a bag.
Conclusion: If care is taken, caudate lobectomy can be performed safely in minimally invasive fashion. Use of waterject dissection can mitigate risk of injury to the IVC with ultrasonic dissection device. Meticulous surgical planning is required to ensure successful and safe completion.
VL02-10 Laparoscopic Indocyanine Green Fluorescence Navigation Anatomical Portal Territory (Segment 7) Resection by Takasaki's Approach with Cirrhosis
Xiao Liang, China

X. Liang, J. Zheng, X. Feng, J. Cai, M. Kirih, L. Tao, Z. Shen
Department of General Surgery, Zhejiang University, School of Medicine, Sir Run Run Shaw Hospital, China

Introduction: Anatomic liver resection has shown its advantages in the treatment of hepatocellular carcinoma (HCC).[1]Pure laparoscopic hepatectomy for some deep lesions like locating in right posterior lobe still remains challenging, especially for anatomical resection.[2]Because of many variations, resection along the hepatic vein may not be real anatomical resection. We used three-dimensional visualization technique to construct a portal territory model which represent patient-specific anatomy. During the operation, we make the territory visualized by indocyanine green (ICG) navigation.
Patient: A 48-year-old man was admitted to our institution for a 4.5 cm single hepatic mass in segment 7. The patient has hepatitis B related cirrhosis and severe portal hypertension.
Methods: We make a resection plan by 3-D visualization technique before the operation (Figure 1A). The patient was placed in supine position with upper body twist to the left. Trocars were sited like Figure 2B. After removal of the gallbladder and suspecting of the G6, the G7 was dissected and ligature by Takasaki's approach (Figure 3C).[3]Then the ischemic line appeared that was consistent with the demarcation line of portal territory. (Figure 4D) Parenchyma transection was performed alongside the boundary of ICG fluorescence area.
Result: The operation time was 205 min, the estimated blood loss was 150 ml. With no postoperative complication, the patient was discharged on the fourth day. Hepatocellular carcinoma was confirmed in histopathology with a negative surgical margin.
Conclusion: Preoperative 3-D visualization technique combined with intraoperative ICG fluorescence navigation facilitate a precise and safe laparoscopic anatomical liver resection.
VL02-11 Robotic Excision of A Large Type 1 Choledochal Cyst With Roux-en-Y Hepaticojejunostomy
Iswanto Sucandy, United States

I. Sucandy1, G. Rivera2, S. Ross2, A. Rosemurgy2
1Surgery, AdventHealth Tampa, United States, 2AdventHealth Tampa, United States

Choledochal cyst is a rare premalignant cystic dilation that occurs in the biliary tree, with type 1 being the most common. The estimated incidence in Western population are 1:150,000. Transformation to cholangiocarcinoma is the most feared complication (about 20 to 30 folds). The standard management is surgical resection with Roux-en-Y hepaticojejunostomy to decrease the likelihood of malignant transformation.
We present a case of a 33-year-old man with known choledochal cyst (diagnosed 10 years prior to presentation). Initially being asymptomatic, he recently developed abdominal pain and nausea unrelated to meals. Further workup revealed a large (9cm) type 1 choledochal cyst compressing neighboring porta hepatic structures. Minimally invasive robotic biliary resection was planned. The operation started with opening of the hepatoduodenal ligament to expose the porta hepatis. The choledochal cyst was found to have inflammatory adhesions to proper hepatic artery, portal vein and head of pancreas. Cholecystectomy was undertaking, keeping the cystic duct attached to the choledochal cyst. A meticulous dissection was exercised to isolate the right hepatic artery as it crossed posterior to the choledochal cyst. Cephalad dissection was continued towards the biliary confluence, where normal caliber duct was seen. Caudal dissection was carried down toward the head of pancreas and staple transection was undertaken as distal as possible without injuring pancreatic duct. The resected specimen included extrahepatic bile duct and gallbladder enblock. A Roux-en-Y hepaticojunostomy was created for biliary reconstruction. A drain was placed. The patient had an uneventful postoperative recovery and he was discharged home on postoperative day 3.
VL02-12 Ultrasound Guided Sg8 Dorsal Segmentectomy for Colorectal Liver Metastasis
Roberto Lo Tesoriere, Italy

R. Lo Tesoriere, N. Russolillo, S. Langella, F. Fazio, M. Fracasso, A. Ferrero
General and Oncological Surgery, Mauriziano Hospital, Italy

Laparoscopic liver resection has gained widespread acceptance, albeit the difficulty identifying anatomic landmarks and the surgical transection plane makes segmentectomy and non-anatomic resection often more challenging than major hepatectomy. Ultrasound is the only tool that can overcome these limitations providing real-time feedback during all types of hepatectomy.
The video shows technical aspects of ultrasonography guided Sg8 dorsal resection in a 73-year-old man with a 4 cm colorectal metastasis.
The liver pedicle is encircled for intracorporeal Pringle maneuver, if necessary. The round and falciform ligament are sectioned and the hepatocaval confluence is dissected. The right liver is mobilized. The landmarks necessary for a Sg8 dorsal segmentectomy are identified and marked on the liver surface: the right hepatic vein (RHV); the right anterior portal branch, Sg8 dorsal pedicle that will be cut, Sg8 ventral branch that will be spared, and the most cranial Sg5 pedicle that will be spared as well. The parenchymal section is performed with ultrasonic dissector and radiofrequency sealer.
The parenchymal section follows the map sketched on the liver surface. The transection reaches Sg8d pedicle that is clamped. Ischemic demarcation of Sg8d is marked. The pedicle is clipped and cut. The parenchymal section follows the RHV hepatic vein and a Sg6 venous branch that is exposed on the cut surface. Veins draining Sg8 in the RHV are cut while a Sg7 vein is spared. The progression of the dissection is checked by LUS. When the resection is completed all the landmarks are visible on the cut surface.
VL02-13 Laparoscopic Resection of Paracaval Hepatic Colorectal Metastasis
Marco Garatti, Italy

A. Manzoni, G. Zimmitti, M. Garatti, V. Sega, A. Benedetti Cacciaguerra, B. Görgec, M. Abu Hilal
Department of General Surgery, Fondazione Poliambulanza - Istituto Ospedaliero, Italy

Background: Hepatic neoplasms in the paracaval area of the liver, such as S1 and S9 are usually difficult to approach surgically because such neoplasms often are strictly linked to hepatic veins and/or inferior vena cava (IVC). The constant development of laparoscopic liver surgery has pushed liver surgeons beyond the limits, however laparoscopic approach to paracaval lesion is still demanding and poorly described.
Methods: Herein, we describe our technique for laparoscopic liver resection of paracaval tumours. After the mobilization of the right lobe the liver has been lifted upward, allowing the section of the peritoneal reflection till the right side of the IVC. After that, IVC dissection was performed, exposing the accessory hepatic veins and interrupting them between clips. Subsequently, the right hepatic vein was slinged before starting the resection, which was performed following the posterior wall of the right hepatic vein. Finally, the S1-S9 portal branch was isolated and resected between clips as completation of the resection.
Results: The operative time was 238 minutes, estimated blood loss 100 cc. The postoperative period was uneventful and the length of stay was 4 days. Pathologic exam showed a colorectal liver metastases (CRLM) with R0 resection.
Conclusion: The laparoscopic approach for the malign lesions located in the paracaval segments (S1-S9) is still a complex procedure which place the surgeons in front of many technical difficulties, however if managed by experts hands it could be safe and feasible.
VL02-15 Pure Laparoscopic Right Trisectionectomy for Intermediate Stage HCC
Wing Chiu Dai, Hong Kong

W.C. Dai, T.T. Cheung, C.M. Lo
Surgery, University of Hong Kong, Hong Kong

The use of laparoscopy for liver surgery is gaining popularity. The difficulty of laparoscopic hepatectomy are determined by a combination of factors including the extent of liver resection, tumor location, tumor size, proximity to major vessels, and the severity of fibrosis. In the literature, most series on pure laparoscopic major hepatectomy focused on tumour of small to intermediate size. The role of laparoscopic hepatectomy for intermediate stage HCC remained uncertain.
We presented a patient with three sizable hepatitis B-related hepatocellular carcinoma up to 7.4cm who underwent pure laparoscopic right trisectionectomy. With the use of laparoscopy and careful dissection, detailed vascular and biliary structures could be identified clearly. The specimen was delivered via a 9cm Pfannenstiel incision. The operation time was 375min and blood loss was 600ml. The post-operative course was uneventful and the patient was discharged on post-operative day 6.
This demonstrated that for intermediate stage HCC, pure laparoscopic hepatectomy is a feasible and safe option for patient.
VL02-16 ICG Fluorescence Guided Laparoscopic Isolated Anatomic Caudate Lobectomy for Hepatocellular Carcinoma
Xiaoying Wang, China

X. Wang, Q. Gao, X. Zhu, K. Zhu, J. Zhou, J. Fan
Department of Liver Surgery, Zhongshan Hospital, Fudan University, China

Caudate lobe (CL) is located deeply behind the 3 hepatic veins and the hilar plate in front of the IVC. It divides into three portions: the Spigel process, the paracaval portion, and the right caudate process. There is no clear intersegmental plane between CL and right posterior segment. So laparoscopic anatomic resection of CL remains a challenging procedure. Herein, we apply ICG fluorescence injection to visualize the boundary of CL during anatomic total caudate lobectomy. The left liver was mobilized to expose the CL. The hilum was dissected. After clamping the left and right portal vein (preserve the branches of CL), 5ml ICG (0.0125mg/ml) was injection into main trunk of portal vein. The CL started to fluoresce immediately after the injection of the ICG. The short hepatic veins were divided to free the CL from IVC. The parenchyma was transected starting from right caudate process by CUSA and Harmonic scalpel along the fluorescence boundary. The intersegmental plane could be identified clearly during division. The small Glissonean branches from hilum to CL was clipped and transected. The 3 hepatic veins and IVC were presented on the ICG border. Finally, the specimen was retrieved in a bag through an extended trocar wound. Total operative time was 320 minutes with a blood loss of 50mL. The postoperative course was uneventful. The pathology confirmed the HCC and clear margin. To our knowledge, this is the first report of ICG fluorescence guided visualization of boundary of the CL and laparoscopic isolated anatomic total caudate lobectomy.
VL02-17 Laparoscopic Left Hepatectomy with Biliary Tumor Thrombectomy under Indocyanine Green Fluorescent Navigation and Choledochoscope
Sunhawit Junrungsee, Thailand

S. Junrungsee, W. Lapisatepun, A. Chotirosniramit
Hepatobiliary-Pancreas Surgery and Liver Transplantation, Chiang Mai University, Thailand

This is a 56 years old male patient who had chronic hepatitis B infection presented with abdominal pain. The CT scan revealed multiple arterial enhancing masses in the left lobe of the liver and the left intrahepatic duct. Hepatocellular carcinoma with biliary tumor thrombus was diagnosed and laparoscopic left hepatectomy with biliary tumor thrombectomy was planned. The 0.25 mg of indocyanine green was injected throgh peripheral vein before the operation was started. After cholecystectomy was performed, we then ligated the left hepatic artery and left portal vein separately. Parenchymal transection was performed with ultrasonic dissection device and cavitron ultrasonic aspirator. We then divided the left bile duct, and tumor thrombectomy was performed. The choledochoscope was inserted through the bile duct to confirm there is no residual tumor in the bile duct. The left hepatic vein was divided with the endovascular stapler, and the bile duct opening was sutured with polydioxanone 4-0. The operative time was 5 hours, and the estimated blood loss was 300 ml. There was no complication and the patient still has no recurrence for one year after surgery.
VL02-18 Laparoscopic Segmentectomy 1 for Large Adenoma
Daniel Cherqui, France

D. Cherqui
Paul Brousse Hospital - Paris South University, Villejuif, France

This video presents a 50 year old woman with a 8-cm biopsy proven adenoma in segment 1.
The video clearly shows all steps of surgery.
Surgery included:
- French position
- 5 port laparoscopy
- Exploration including ultrasound
- Left liver mobilization
- Extrahepatic control of the trunk of left and middle hepatic vein
- Complete resection of the Spiegel lobe with complete exposure of the retrohepatic IVC
- Liver transection with CUSA and energy device under intermittent inflow occlusion
- Specimen extraction in a bag through an 8 cm Pfannenstiel incision.
Postoperative course was uneventful and the patient was discharged at day 5.
VL02-19 Extended Right Hepatectomy for Management of Colorectal Cancer Liver Metastases
Jaime Arthur Pirola Kruger, Brazil

J.A.P. Kruger1,2, G.N. Namur1, B.C. Azevedo1, S.E.A. Araujo1, S. Klajner1
1Surgical Oncology, Hospital Israelita Albert Einstein, Brazil, 2Liver Surgery Unit, University of Sao Paulo - Hospital das Clinicas, Brazil

Multiple and oddly located liver tumors might be a contra-indication for minimally invasive liver surgery. Such limitations have hampered initial development of major resections and the management of multiple tumors in colorectal cancer liver metastases. Minimally invasive hepatectomy offers benefits beyond quicker recovery, as it allows lesser blood loss and quicker resuming perioperative chemotherapy. In this sense, efforts should be made to offer laparoscopic hepatectomy for metastatic patients. The case depicted in the video is multinodular (six lesions) synchronous colorectal metastases that were closely located to the middle hepatic vein, demanding an extended right hepatectomy. The procedure was carried out in a totally laparoscopic technique, with extensive surgical planning with operative ultrasound.
VL02-20 Robotic Left Hepatectomy and Biliary Resection for Hilar Cholangiocarcinoma
Christoph Tschuor, United States

C. Tschuor1, O. Moaven2, E. Baker1, D.A. Ianitti1, D. Vrochides1, J.B. Martinie1
1Division of Hepatobiliary and Pancreatic Surgery, Carolinas Medical Center, Atrium Health, United States, 2Section of Surgical Oncology, Department of Surgery, Wake Forest Baptist Medical Center, United States

Background: Favorable results of a minimally invasive approach for major hepatic resection have been reported. While major hepatectomies for primary hepatic tumors are still performed mostly open up to now in many centers, the robotic approach is considered to be an attractive alternative.
Video Case Presentation: Here we present a 48-year-old male with a hilar cholangiocarcinoma (Bismuth-Colette 3B) and consequently significant biliary dilatation of the left hemiliver. MRI revealed a vague hypodense mass while ERCP brush was negative. The local tumor board recommended left hemihepatectomy with extrahepatic bile duct resection and a robotic approach was planned. The patient was placed in the supine position and 4 daVinci Surgical Systems™ trocars were inserted as well as an assistant port. Intraoperative ultrasound was used to clarify the course of relevant anatomic structures. Left hepatectomy together with resection of the caudate lobe, extrahepatic bile duct resection, lymphadenectomy of the hepatic hilum was performed. Intraoperative frozen-section examinations were negative for tumor. Parenchymal transection was performed using the robotic vessel sealer, fenestrated forceps and clips. Reconstruction was performed by Roux-en-Y hepaticojejunostomy. Pathology confirmed the diagnosis showing clear resection margins. Patient was discharged on POD 5.
Discussion: Robotic assisted left hepatectomy with extrahepatic bile duct resection and Roux-en-Y hepaticojejunostomy reconstruction is feasible, safe, oncological efficient and demonstrates an attractive alternative to the conventional open approach. Patients benefit from a fast recovery for further oncologic treatment.
VL02-21 Management of Potentially Fatal Bleeding during Laparoscopic Hepatectomy: Intracorporeal Suturing
Jaime Arthur Pirola Kruger, Brazil

J.A.P. Kruger, G.M. Fonseca, V.B. Jeismann, F.F. Coelho, W. Andraus, P. Herman
Liver Surgery Unit, University of Sao Paulo - Hospital das Clinicas, Brazil

Laparoscopic liver surgery has evolved from the management of benign to malignant diseases, from minor to major and complex operations. Despite the technical evolution, liver surgeons still deal with a richly vascularized organ in which blood loss is a major determinant of conversion to open operations, complications and oncological outcomes. Most videos describing technical steps are based on a “how I do it” fashion and adverse outcomes are usually not made public. Bleeding in liver surgery can be ominous and life threatening, sometimes conversion to open operation seems the best solution. The drawback of such option is that it takes time to change the surgical approach as large incisions and retractors need to be placed, and such time might not be available in major bleedings. Moreover, if a large venous defect is exposed, the patient might suffer the additional complication of an of air embolism. The video presented shows three different operations in which surgeons, with different levels of experience, had hemorrhagic complications at different steps of a hepatectomy, all managed without conversion.
VL02-22 Laparoscopic Total Caudate Lobectomy for Introhepatic Cholangiocarcinoma Invading the Middle Hepatic Vein
Jiwei Huang, China

J. Huang
West China Hospital of Sichuan University, Chengdu, China

Background: Laparoscopic partial hepatectomy has been proved to provide comparable long-term outcomes as open approach surgery while beingless invasion. In spite of the prevalence of laparoscopic hepatectomy in recent years, laparoscopic total caudate lobectomy faces challenges and difficulties. Here, we present a video on laparoscopic total caudate lobectomy for introhepatic cholangiocarcinoma located in the caudate lobe.
Method: The patient was a 61-year-old male patient with a 4.6✕3.9 cm lesion located in the caudate lobe of liver adjacent to the inferior vena cava, middle hepatic vein (MHV), right hepatic vein (RHV) as well as the bifurcation of the main trunk of the Glissonean pedicle. One of the main tributaries of the MHV was invaded by the tumor. His liver function was Child-pugh A, Carbohydrate antigen CA19-9 was 54.58 U/ml and was diagnosed as introhepatic cholangiocarcinoma. Total laparoscopic resection of the caudate lobe was performed as presented in the video.
Results: The operation time around 300 minutes. The blood loss was 180 ml. He resumed diet on postoperative day one and was discharged on postoperative day 7. Histopathological examination showed a 4.2 cm in diameter cholangiocarcinoma (T2N0M0) with a negative margin. Postoperative chemotherapy was applied in his location hospital and latest follw-up showed no recurrence at 6 months after sugery.
Conclusions: Laparoscopic resection for caudate lobe is a feasible and safe procedure. Experienced hepatobiliary surgeon could perform the procedure in selected cases even with hepatic vein invasion.
VL02-23 Laparoscopic Isolated Caudate Lobectomy for HCC by Application of Intraoperative ICG Fluorescence Imaging
Koo Jeong Kang, Korea, Republic of

K.J. Kang, K.S. Ahn, T.-S. Kim, Y.H. Kim
Division of HBP Surgery, Surgery, Keimyung University Dong-San Hospital, Korea, Republic of

Application of indocyanine green (ICG) fluorescence imaging is very useful for real-time visualization of biological structures and assessment of blood perfusion. Hepatic tumors are stained by fluorescent ICG dye accumulated in hepatic tumor that was IV injected 1-2 days prior to surgery, which is investigated by specially equipped laparoscopic unit.
In apart, isolated caudate lobectomy is a challenging procedure for the experienced liver surgery even in open surgery. Laparoscopic caudate lobectomy is one more escalating step for challenging procedure. However, it is easier with laparoscopically in some aspect. The view of retrohepatic pre-IVC space is achieved better with laparoscopy than the open. Superior area of the gastrohepatic ligament of the caudate lobe is blind spot during open surgery in particular, but very well visualized by laparoscopy. Application of ICG fluroscent dye make easier to do the procedure to identify the margin of the tumor during hepatic transection.
We underwent laparoscopic caudate lobectomy very safely of the well encapsulated HCC, 4.6cm in diamenter, confined in the caudate lobe. Interestingly, 3 cm sized colon tumor in the ascending colon that was detected in the preoperative screening PET image that was taken to rule out extrahepatic metastasis. We performed right colectomy and caudate lobectomy concomitantly. It has taken 300 minutes for entire procedure, only 2 hours for caudate lobectomy. The patient recovered without any complications.
VL02-24 Laparoscopic Anatomical Resection of Segment VIII
Lianxin Liu, China

L. Liu
The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China

Liver surgery has mostly entered the minimally invasive stage.Minimally invasive liver surgery with less trauma is conducive to the recovery of patients. However, the anatomical resection of segment VIII of the liver is more difficult than other segment resection.This operation video is an example of laparoscopic anatomical resection of segment VIII of the liver that we did and we want to share and discuss with every expert.
VL02-25 Laparoscopic Right Anterior Sectoriectomy (Sg5-8) with Extraglissonian Approach for CRLM
Andrea Ruzzenente, Italy

A. Ruzzenente, A. Ciangherotti, T. Campagnaro, E. Lombardo, E. Poletto, C. Iacono, A. Guglielmi
Department of General and Hepatobiliary Surgery, University of Verona, Italy

This video describes the clinical case of a 66-year-old male patient who underwent a laparoscopic right anterior sectoriectomy with an extraglissonian approach for a single 4 cm colorectal liver metastasis (CRLM) involving segments 5 and 8.
The patient had a history of arterial hypertension and was previously subjected to a right emicolectomy for adenocarcinoma (pT2N0/18M0 - G2). The preoperative examinations were normal and liver function was preserved (ICGr15 3,1%). This video describes the surgical technique of a laparoscopic right anterior sectoriectomy with an extraglissonian approach to che S5-8 pedicle for a parenchimal-sparing approach to centrally located liver metastases.
The definitive histology confirmed the presence of a CRLM and no involvement of the resection margins. Surgical time was 452min, the patient was discharged in 5th POD without postoperative complications.
Conclusions: Laparoscopic right anterior sectoriectomy with an extraglissonian approach to che S5-8 pedicle is an advanced technique of hepatic surgery that can provide excellent results in patients candidates to parenchimal sparing liver resections.
This video demonstrated that complex centrally located liver lesions can be safely approached with a minimally invasive approach and extraglissonial approach can be helpful for anatomical resections.
VL02-26 Laparoscopic ICG Fluorescence Navigation, Anatomical Portal Territory (Segment 5&6) Resection, by Takasaki's Approach with Cirrhosis
Xu Feng, China

X. Feng1, X. Liang1, J. Zhen2
1Zhejiang University, School of Medicine, Sir Run Run Shaw Hospital, China, 2Zhejiang University, China

Background: Anatomic liver resection has shown its advantages in the treatment of hepatocellular carcinoma (HCC). Accurate hepatectomy for some deep lesions located cross adjacent hepatic segments still remains challenging, especially for anatomical resection. We used three-dimensional visualization technique to construct a portal territory model which represent patient-specific anatomy. During the operation, we make the territory visualized by indocyanine green (ICG) navigation.
Patient: A 60-year-old man was admitted to our institution for a 4cm single hepatic mass across segment 5&6. The patient has no surgical history but HBV related cirrhosis.
Methods: We make a resection plan involving three glission pedicles by 3-D visualization technique before the operation. The patient was placed in supine position with upper body twist to the left. Three related glission pedicle were dissected and disconnected by Takasaki's approach. Then the ischemic line appeared that was consistent with the demarcation line of portal territory. Parenchyma transection was performed alongside the boundary of ICG fluorescence area.
Result: The operation time was 180 min. The estimated blood loss was 100 ml. With no postoperative complication, the patient was discharged on the sixth day. Hepatocellular carcinoma was confirmed in histopathology with a negative surgical margin.
Conclusion: Preoperative 3-D visualization technique combined with intraoperative ICG fluorescence navigation facilitate a precise and safe laparoscopic anatomical liver resection.
VL02-27 Laparoscopic Partial Hepatectomy in Segment 7 with Control of IVC and Right Hepatic Vein
Oriana Ciacio, France

O. Ciacio, D. Cherqui
Centre Hépato-Biliaire, Paul Brousse Hospital - Paris South University, Villejuif, France

This video presents a 36 year old woman with a 3-cm multilocular cystic lesion located in segment 7. She had no history of liver disease and tumor markers were normal. Imaging diagnosis was hepatobiliary cystadenoma. Surgery was scheduled due the perceived risk of eventual malignant transformation.
The video clearly shows all steps of surgery.
Surgery included:
- Full left lateral decubitus position
- 5 port laparoscopy
- Exploration including ultrasound
- Right liver mobilization
- Dissection of retrohepatic IVC
- Division of hepatocaval ligament
- Extrahepatic control of right hepatic vein
- Partial resection using CUSA and energy device using intermittent inflow occlusion
- Transection along the right hepatic vein
- Specimen extraction in a bag through an enlarged subcostal port site.
Postoperative course was uneventful and the patient was discharged at day 5. Final pathology was localized Caroli disease with no malignancy.
VL02-28 Pure Laparoscopic Donor Right Hepatectomy in Donor with Severe Portal Vein Anomaly
Young Seok Han, Korea, Republic of

Y.S. Han, J.R. Han
Hepato-Biliary-Pancreas Surgery and Liver Transplantation, Kyungpook National University School of Medicine/Kyungpook National University Hospital, Korea, Republic of

Donor operation in adult-to-adult living donor liver transplantation (AALDLT) is still associated with postoperative morbidity. But, laparoscopic donor hepatectomy is sporadically reported in a few centers with substantial experience and pure laparoscopic donor right hepatectomy (PLRH) has been gradually increased because of cosmetic satisfaction and rapid recovery, despite the controversial issues. We present PLRH in donor with severe portal vein anomaly. A 57-year-old man volunteered to living liver donation for his wife who suffered from hepatic encephalopathy related with cirrhosis. Donor's portal vein was unusual type on preoperative computed tomography; Nakamura type - single non-bifurcating portal vein variation. Right hepatic artery and hepatic duct were single. Right posterior portal vein and S5 branching portal vein were meticulously dissected and encircled with vessel loops before liver parenchymal transection, and S8 branching portal vein was identified after right hepatic duct transection. Three portal veins were reconstructed to one orifice during bench work procedure. Donor's and recipient's portal vein were patent, postoperatively.
PLRH seems to be a feasible procedure when performed by a highly experienced surgeon, but careful preoperative evaluation and preparations are essential. Laparoscopic donor hepatectomy is being tried consistently and PLRH can be cautiously expanded to donors with hepatic anatomic variations.
VL02-29 Laparoscopic Left Hepatectomy for HCC in a Cirrhotic Patient with Right-To-Left Lobe Volume Shift
Jaime Arthur Pirola Kruger, Brazil

J.A.P. Kruger, G.M. Fonseca, V.B. Jeismann, F.F. Coelho, P. Herman
Liver Surgery Unit, University of Sao Paulo - Hospital das Clinicas, Brazil

Laparoscopic surgery has evolved to safely perform operations in major resections and in chronically diseased livers. Cirrhotic patients derive benefits beyond early postoperative recovery, as liver specific complications, such as biliary fistulas and liver dysfunction, are reduced after minimally invasive operations. The video presented shows a case of a liver with a dominant left lobe (comprising 60% of total liver volume) due to cirrhotic morphologic changes, bearing a large HCC on segment 4. The patient had normal liver function and no signs of portal hypertension. Technical details are described as the operation was carried out as a complete laparoscopic resection, with classic dissection of the portal pedicle, parenchymal transection with ultrasonic scalpel and major vascular control with endovascular staplers.
VL02-30 Laparoscopic Completion Extended Cholecystectomy and Lymphadenectomy for Gallbladder Cancer
Madeline Chee, Singapore

M. Chee, L.S. Lee
Hepatopancreatobiliary Surgery, Changi General Hospital, Singapore

Gallbladder cancer is a rare entity with poor overall prognosis, as many patients present late and only approximately 20% of patients have early stage disease. Surgical resection is the only curative treatment modality. Typically, an extended cholecystectomy (i.e. removal of gallbladder with a rim of liver tissue) with lymphadenectomy is required for the treatment of resectable gallbladder cancer (i.e. T1 and T2), with the exception of T1a disease where a simple cholecystectomy is sufficient, as cancers of stage T1b and greater (where the tumour has invaded the muscle layer or beyond) have a higher incidence of lymph node metastases. Depending on tumour location, a formal central liver resection of segments 4b and 5 may be appropriate.
Our patient is a 64 year old Chinese female who initially presented with acute gangrenous cholecystitis with sealed perforation, for which she underwent laparoscopic cholecystectomy. However, histology showed a well differentiated gallbladder adenocarcinoma with invasion into muscular layer (pT1b). As such, she was counselled for laparoscopic completion of extended cholecystectomy (wedge resection of segment 4b/5) and lymphadenectomy.
VL02-31 Laparoscopic Glissonian Approach for Right Posterior Sectionectomy and Hepatic Parenchymal Transection ICG-guided
Maria Teresa Mita, Italy

M.T. Mita, V. Barbieri, M. Gregori, A. Altamura, G. Giaracuni, F. Rubichi, M.G. Viola
Azienda Ospedaliera 'Cardinale G. Panico', Italy

In this video we perform a right posterior sectionectomy for a segment six colorectal metastasis combining the Glissonian approach and ICG fluorescence for hepatic transection.
The lesion involved the Glissonian pedicle for the right posterior segments and a right posterior sectionectomy was indicated. The ICG was first administered intravenously within twelve hours before surgery and the intraoperative ICG‐fluorescence showed the hepatic lesion.
We started with division of the segment six and segment seven arterial and portal branches. After dissection around the pedicle, the pedicle is encircled and clamped. The tertiary branches that originate from the deep portions of the secondary pedicles are approached after initially dissecting the liver parenchyma on the border between the sections.
The intravenous ICG was newly administered after standard Glissonian dissection and ligation, staining the whole liver except tumor-bearing area. The ICG fluorescence on the liver surface drived the transection plane and remained easily appreciable throughout the surgical procedure. Accurately following this fluorescent intersegmental boundary on the cut surface facilitated precise anatomical liver resection, which was the ultimate goal of our technique.
The expanding indications for the laparoscopic approach during anatomic liver resections raised specific technical difficulties, such as limited laparoscopic visual access to posterior hepatic areas, lack of palpatory feedback and difficulty in intraoperative ultrasound. The accurate visualization of the segmental planes to be transected become even more crucial in this setting. Our experience with ICG fluorescence imaging has lead the application of ICG in laparoscopic liver surgery to overcome many of these inherent challenges.
VL02-32 Full Right Laparoscopic Hepatectomy
Ignacio Miranda Castillo, Chile

I. Miranda Castillo, E. Buckel Gonzalez, F. Puelma Calvo, E. Buckel Schaffner, N. Jarufe Cassis
Clinica las Condes, Chile

This video shows an anatomic full laparoscopic right lobe resection in a 44 years old woman with diagnosis of hepatolithiasis. She underwent laparoscopic cholecystectomy in 2013. Hepatolithiasis involve both, anterior and posterior sectors of the right lobe with clear areas of stenosis and bile duct dilatation with intrahepatic stones. Patient remained asymptomatic however with moderate cholestasis on liver function test. Due to impossibility of endoscopic treatment the multidisciplinary team decided to proceed with liver resection. The surgery develops without incidents and uneventful postoperative period. She was discharge from hospital at day 4. In the video details of the hepatic mobilization as well as the dissection of the pedicle, retro-hepatic vena cava and parenchymal transection are demonstrated.
VL02-33 Laparoscopic Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS)
Sung Hoon Choi, Korea, Republic of

E.H. Chong, S.H. Choi
Surgery, CHA Univesity/Bundang CHA Medical Center, Korea, Republic of

Introduction: Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy (ALPPS) is a novel variant of two-staged hepatectomy, inducing rapid hypertrophy in future remnant liver. Laparoscopic approach for ALPPS has not been widely performed because of rare suitable indications and difficulty of surgery due to adhesion and anatomical deformations after first surgery. This video demonstrates the technique of laparoscopic ALPPS and conditions of the second operation
Methods: Between January 2017 and October 2019, four patients underwent laparoscopic ALPPS. The first operation consists with right portal vein occlusion and liver transection to induce accelerated regeneration of the putative future liver remnant and wedge resections were accompanied in case of multiple liver metastases of colon cancer. The second operation was decided after checking hypertrophied remnant liver by CT scan on postoperative 6th. or 7th. day.
Results: Two patients with colon cancer liver metastases and two patients with hepatocellular carcinoma were indicated. The total operation time of the first surgery was 190 to 230 minutes and the estimated blood loss was 150 to 230 mL without transfusion. The total operation time of the second surgery was 130 to 160 minutes and the estimated blood loss was 120 to 200 mL without transfusion. The second operation was performed on 7 to 13th days after the first operation. One patient was suffered from postoperative transient ascites, but others' postoperative courses were uneventful.
Conclusion: Laparoscopic approach for ALPPS is feasible in selected patients with general benefits of minimally invasive surgery.
VL02-35 Laparoscopic Microwave Ablation Using 3-Dimensional Electromagnetic Guidance System
Patrick Salibi, United States

P. Salibi, J. Sulzer, E. Baker, D. Vrochides, D. Iannitti, J. Martinie
Hepatobiliary and Pancreas Surgery, Carolinas Medical Center, Atrium Health, United States

Background: Microwave ablation is used in the treatment of both primary and metastatic hepatic lesions. The surgical approach can be complicated by difficulty in lesion targeting and trajectory. A novel 3-dimensional electromagnetic guidance system has been developed to improve accuracy and efficiency during surgical ablations.
Video Case Presentation: Here we present a 69-year-old female with regional recurrence of hepatocellular carcinoma after a laparoscopic microwave ablation 3 years prior. After discussing her care at the hepatocellular carcinoma tumor board surgical ablation was recommended. The patient was brought to the operating room and placed in supine position. Three trocars were used to gain access to the abdomen and then using the novel electromagnetic 3-dimensional targeting system (Medtronic EmprintTM SX Ablation Platform with ThermosphereTM Technology) the lesion was laparoscopically targeted and ablated. The patient was discharged on postoperative day 1 without complication. Follow up triphasic computed tomography at 1 month demonstrated complete ablation of the lesion.
Discussion: A novel 3-dimensional electromagnetic guidance system used for during microwave ablation of hepatic lesions improves accuracy and efficiency of targeting lesions surgically.
VL02-36 Laparoscopic Anatomical Extended Right Posterior lobectomy (Segment 6+7+5d+8d) With ICG Fluorescence Staining by Ultrasound Guided Portal Branch Puncture Approach
Qiang Yan, China

Q. Yan1, Z. Shen1, J. Mao2
1General Surgery, Zhejiang University Huzhou Hospital, Huzhou, China, 2Department of Surgery, Zhejiang University School of Medicine, Hangzhou, China

Introduction: Occasionally laparoscopic segmental anatomy liver resection faces the conflict of radical resection and remnant liver function. Sub-segmental anatomy lap liver resection with ICG fluorescence staining by ultrasound guided portal branch puncture approach is a good way to get out the dilemma.
Method: This case is a patient with a lesion located in the area between right anterior and right posterior lobes.Preoperative three-dimensional imaging of residual liver volume: FLV = 32.9% for right hepatectomy; resection of right posterior lobe (S6 / 7) and right anterior lobe dorsal segment (S5d / 8d), FLV (increase of 14.4%) = 47.3%, which meet the requirements of residual liver volume. we underwent laparoscopic ultrasound guided puncture of the portal vein S5d and S8d branches and injected indocyanine green. The subsegments started to fluoresce immediately after injection.
Result: Under the fluorescent navigation, the liver S5d / 6/7 / 8d anatomic resection was performed. The operation took 265min. The blood loss was 250ml. The patients were discharged after 11 days of ERAS management. There were no postoperative complications and no tumor recurrence during follow-up 4 months after discharge.
Conclusion: Preoperative three-dimensional imaging of residual liver volume measurement and laparoscopic radical tumor resection under ICG fluorescence staining by ultrasound guided portal branch puncture approach is a safe and effective way for preciseminimally invasive liver surgery. It should be performed by surgeons with experience in both minimally invasive liver surgery and ultrasound techniques.
VL02-37 Laparoscopic Placement of Intra-Arterial Hepatic Catheter for Chemotherapy in Unresectable Colorectal Liver Metastases: Technical Considerations
Eric Herrero, Spain

M.I. Garcia-Domingo1, J. Camps1, E. Herrero1, L. Hernandez1, L. Martinez1, A. Rodríguez2, E. Cugat1
1HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain, 2Anaesthesiology - HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain

Introduction: In patients with unresectable metastatic disease confined to the liver, hepatic intra-arterial chemotherapy (HACT) with implantable systems is an option. The rationale for delivering chemotherapy through the hepatic artery (HA) is that hepatic metastases receive their blood supply mainly from the HA, whereas liver parenchyma is primarily supplied by the portal vein. Higher concentrations of chemotherapeutic drugs can be delivered to liver metastases thereby avoiding the toxicity of equally high systemic concentrations (concentration ratio of 400:1).
Methods: HACT is infused into a subcutaneous reservoir connected to an implanted intra-arterial catheter positioned at the junction of the gastroduodenal artery (GDA) with the common and proper hepatic artery. The variations in the hepatic arterial anatomy were previously ruled out with a angioCT. Indocyanine green was injected into the port side to exclude misperfunsions and confirm complete hepatic perfusions intraoperatively. After percutaneous insertion, technetium-99 scintigraphy is recommended to ensure that the entire liver is perfused without extrahepatic diffusion.
Laparoscopic technique can offer better results in terms of less morbidity, less pain and reduces hospital stay.
Results: Laparoscopic surgical technique is described through a video.
Conclusions: Unresectable hepatic metastases from colorectal cancer without extrahepatic disease are the best indication for HACT.
Laparoscopic placement of a hepatic artery catheter is associated with a low operative morbidity, less pain and hospital stay.
VL02-38 Total Robotic Right Hepatectomy: Anterior Approach with Minimal Instrumentation in a Resource Constraint Setting
Shraddha Patkar, India

A. Gupta, S. Patkar, A. Parry, S. Patel, G. Arra, M. Goel
GI-HPB Oncology, Tata Memorial Hospital, India

Objective: We present our experience with total robotic right hepatectomy in resource constraint settings using bipolar and monopolar scissors for liver transection.
Methods: 56-year-old lady, with no co-morbidities, presented with abdominal pain of two months duration. Contrast enhanced CT scan of chest and abdomen revealed mass in the segment VI and VII of liver and a replaced right hepatic artery with no evidence of distant metastases. Liver function tests were normal and CA19-9 levels were 171876 U/ml. FLR for right hepatectomy was 47 percent. A robotic right hepatectomy with da-Vinci Xi system using 6 ports (4 robotic and 2 assistant ports) was performed after initial staging laparoscopy. Liver transection was performed using bipolar and monopolar scissors. Specimen was extracted in a bag from a small incision at assistant port.
Results: The procedure was performed in 300 minutes with a blood loss of 400 mL. Final histopathology report revealed moderately differentiated intrahepatic cholangiocarcinoma with negative margins (R0 resection).
Conclusions: Robotic right hepatectomy is an oncologically acceptable approach. However, careful selection of patients is essential. Development of cost effective instrumentation paralleling laparoscopic instrumentation is the key to its wider acceptability.
VL02-39 Caudal Approach in Laparoscopic Liver Resection for Tumors in the Segment 1
Takayuki Kawai, Japan

T. Kawai1,2, K. Iguchi1, Y. Okuda1, R. Kamimura1, H. Terajima1
1Department of Gastrointestinal Surgery, Medical Research Institute, Kitano Hospital, Japan, 2Department of Surgery, Kyoto University, Japan

Introduction: Although laparoscopic liver resection (LLR) is widely performed, LLR for tumors in the Segment 1 is still challenging due to its anatomical deep location. Caudal approach, proposed as a safe and efficient technique in laparoscopic right hepatectomy, can be also applied to overcome technical difficulties. In this study, we show our concept of LLR for tumors in the Segment 1 with caudal approach.
Video presentation: The video was laparoscopic partial liver resection for a 61-year-old female diagnosed as solitary 35 mm colorectal liver metastasis in the Segment 1. Prior to approach to the Segment 1, left-lateral section was mobilized and retracted by Nathanson liver retractor. After the isolation of left hepatic artery from left gastric artery, Arantius ligament was identified and divided at its junction with the left hepatic vein. Subsequently, the Segment 1 was mobilized from inferior vena cava with careful division of short hepatic vein. After the mobilization, liver parenchymal transection was performed using harmonic scalpel and ultrasonic dissector. Glissonean pedicles of the Segment 1 were carefully dissected free and divided with secured clips. The Pringle maneuver was systemically prepared for intermittent vascular clamping when necessary. Both the mobilization and the parenchymal transection were carried out from the caudal to cranial direction using laparoscopy-specific caudal view.

Conclusion
Caudal approach would facilitate safe and efficient execution of LLR for tumors in the Segment 1.
VL02-40 Laparoscopic Posterior Sectionectomy Using Inside-out Transection
Osamu Itano, Japan

O. Itano, S. Imai, T. Minagawa, S. Hoshimoto, M. Yoshida, A. Kato, T. Hatori, M. Miyazaki
Department of Hepato-Biliary-Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Japan

Background: In anatomical liver resection, transection line is confirmed using dye-injection method or extrahepatic glissonian approach as a demarcation line. Disorientation during liver parenchymal transection sometimes occurs and is modified by intraoperative ultrasonography. However those are too complicated and technical-demanding procedures for laparoscopic approach. In open liver resection, liver parenchymal transection from the peripheral part to the hilum because of restricted surgical view. However, considering the directions of branched Glissonian pedicles and hepatic veins, the transection of intersegmental plane in anatomical liver resection should be done from the hilum to the the peripheral, in other words, 'inside-out'. We recently perform laparoscopic anatomical 'inside-out' liver resection utilizing laparoscopic caudal view.
Video: Laparoscopic posterior sectionectomy was performed using 'inside-out' transection. The operation started from parenchyma transection around the root of the posterior Glissonian pedicle and a tip of CUSA was moved inside-out in the direction with low resistance between the anterior and posterior glissonian pedicles, which leads to the precise intersegmental transection plane. The direction of transection could also be corrected by visually checking the ramification of branched vessels that were clearly recognizable in the laparoscopic view. The posterior Glissonian pedicle was dissected on the way of paremchymal transection when surgical space was made for safe procesures. The right hepatic vein was naturally exposed during 'inside-out' transection. Liver parenchyma near the surface was dissected in the end.
Conclusion: Laparoscopic posterior sectionectomy using 'inside-out' transection was performed simply and safely utilizing the advantages of laparoscopic approach.
VL02-42 Laparoscopic Left Hemihepatectomy with Limphadenectomy for Intrahepatic Cholangiocellular Carcinoma
Alessandro Anselmo, Italy

A. Anselmo, G. Pisani, B.M. Pirozzi, G. Tisone
Hepatobiliary and Transplant Surgery Unit, Policlinico Tor Vergata, Italy

Laparoscopic liver resection (LLR) has become an essential method for treating malignant liver tumors but there are still few reports of LLR for intrahepatic cholangiocarcinoma (IHCC).
We present a video of a laparoscopic left hemihepatectomy with lymphadenectomy for the treatment of an IHCC. Case presentation: A 67 year old asymptomatic man underwent a routine abdominal ultrasound that revealed a 15x9 mm solid nodular, iso-hyperhecoic lesion, located in SIII with dilation of SII/III biliary ducts. An MRI confirmed a 32x22 mm lesion in SII/III, with mild hyperintensity on T2 weighted images and strong hypointensity on T1 weighted images. After administration of contrast medium the lesion showed light peripheral enhancement on portal and delayed phases and hypointensity on hepatospecific phase. Dilation of SII/III bile ducts. No relevant comorbidities, KPS 100. Lab tests showed normal liver function and normal Ca 19.9 levels. A laparoscopic left hemihepatectomy was planned.
Operative time was 330 minutes. Four intermittent cycles of pringle manouvre were applied, no blood transfusions. Postoperative course was uneventful and patient was discharged on 3d POD. Pathology report: cholangiocellular carcinoma pT1b, No.
According to recent reports in the literature and our experience laparoscopic surgery for intrahepatic cholangiocellular carcinoma should be considered in selected patients.
VL02-43 Laparoscopic Resection of Caudate Lobe Giant Liver Hemangioma, with 3d Preoperative Reconstruction
Alessandro Anselmo, Italy

A. Anselmo, G. Pisani, M. Pellicciaro, G. Tisone
Hepatobiliary and Transplant Surgery Unit, Policlinico Tor Vergata, Italy

Caudate lobe is still considered a difficult segment for laparoscopic liver surgery. Its deep location and proximity with major vascular structures such as IVC and left portal and suprahepatic vein are the main concerns for laparoscopic approach.
We present a video of a laparoscopic resection of caudate lobe in a patient with giant (10 cm diameter) liver hemangioma. Case presentation: a 51 year old man after an episode of postprandial right upper quadrant colic pain underwent an abdominal ultrasound that showed lithiasis of gallbladder and some incidental multiple hyperechoic liver lesions compatible with hemangiomas. The biggest hemangioma (max diameter 10 cm) was located in segment I.
A CT Scan confirmed the presence of a 83x59x104 mm lesion located in segment I compressing IVC. A laparoscopic cholecystectomy was initially planned but when the patient was informed about the potential risk of rupture of the hemangioma in case of trauma, being a professional martial art player, asked the removal of the lesion during the same laparoscopic session. A 3D reconstruction of the lesion was used as preoperative planning and a laparoscopic caudate lobe resection was planned together with the cholecystectomy.
Postoperative course was uneventful and no blood transfusion were administered. Patient was discharged on 3 POD. Pathology report confirmed the diagnosis of cavernous hemangioma of the liver and lithiasis.
According to recent reports in the literature and our experience laparoscopic surgery of caudate lobe is safe in selected patients and in experienced centers.
VL02-44 Laparoscopic Right Hepatectomy with the Laparoscopic Liver Hanging Maneuver
Wanguang Zhang, China

W. Zhang
Hepatic Surgical Center, Tongji Hospital of Huazhong University of Science and Technology, Wuhan, China

This video presents laparoscopic right hepatectomy using laparoscopic liver hanging maneuver. A 51-year-old man was referred to treat hepatic hemangioma. The preoperative enhancement CT scan showed a 14 cm x 10 cm mass in right hepatic lobe adjacent to middle hepatic vein.We performed right hepatectomy using laparoscopic liver hanging maneuver.The right hepatic artery was visualized and then clamped with Hem-o-loks. The portal trunk was then cautiously dissected until there was clear identification of the portal bifurcation and the right portal branch. Short hepatic veins were then exposed, clamped and divided. The Goldfinger dissector was inserted through the tunnel for blunt dissection thus establishing a retrohepatic tunnel. The fossa of the second porta hepatis was exposed by dissecting the space adjacent to the right hepatic vein. The hanging tape was successfully and completely placed through the retrohepatic tunnel. Liver parenchyma transection was performed using harmonic scalper along the ischemia line. Th inferior part of the median hepatic vein was exposed, clamped and divided. The technique of curettage was used to the middle hepatic vein. The hanging tape was then tensioned and the transection line was even more accurate with the guide from the tape. With this lifting tension effect, minor bleeding can be immediately coagulated and the right hepatic vein was transected. The operation time was 210 minutes. The estimated blood loss was 100 ml. The final pathological diagnosis was hepatic hemangioma. The patient was discharged on postoperative day 8 with no complication.
VL02-45 Robotic Partial Segment VIII Resection
Michael White, United States

M. White, N. Ikoma, C.-W. Tzeng, T. Aloia, Y.S. Chun, J.-N. Vauthey, H. Tran Cao
Surgical Oncology, MD Anderson Cancer Center, United States

Here we demonstrate successful hepatic resection of a single focus of metastatic colonic adenocarcinoma from segment VIII using a robotic approach. This video exemplifies the utility of preoperative imaging and intraoperative ultrasound in guiding these resections. Moreover, the robotic platform's unique ability to control wristed instruments allows for safe and precise dissection, as well as, suture repair of bile ducts. Use of this and other minimally invasive platforms have shown early equivalency in oncologic outcomes and decreased length of stay. As these techniques become more widely adapted we hope to see continued improvements for patients.
VL02-46 Minimal Invasive Approach for a Radical Surgery Due to Gallbladder Carcinoma
Pablo Barros Schelotto, Argentina

S. Almanzo, M.F. Fernandez, F. Pattin, F. Lobos, P. Barros Schelotto, E. Varela, L. Montes, G. Gondolesi
Cirugia HPB y Trasplante Multiorganico, Hospital Universitario Fundacion Favaloro, Argentina

Gallbladder cancer is a relatively rare but highly aggressive malignancy and the only effective treatment is the surgical resection. Unlike elsewhere in the intestinal tract, the gallbladder does not have a muscularis mucosae but also due to the fact that half of gallbladder`s body is attached to the liver, separated only from it by the cystic plate (connective tissue). For this reason, gallbladder cancers located in the liver-side of the gallbladder and that invades into the muscularis, have a propensity to invade the liver. Thus to achieve negative margins, in tumors T1b-T4 an hepatic resection of segments 4b and 5 is mandatory.
The aim of this video is to present the case of a 60-year-old female patient, who underwent a laparoscopic cholecystectomy due to symptomatic gallstone disease and whose anatomopathologic analysis (AP) informed adenocarcinoma that reached the subserosal layer (Stage II), located in the gallbladder`s liver side. The case was presented in a multidisciplinary committee and laparoscopic radical surgery was planned. An anatomic resection of segments 4b/5 of the liver associated to a lymphadectomy of the hepatic pedicle were performed. Operative time was 360 minutes. There were no complications. Patient was discharged on the third postoperative day. Postoperative AP: no residual tumor cells in the hepatectomy and lymphadenectomy: T2 N0 M0. Patient is alive, and has 5 month of disease-free survival.
VL02-47 Minimizing Blood Loss during Robotic Hepatectomy: Technical Description and Initial Experience
Jason Hawksworth, United States

J. Hawksworth, P. Radkani, E. Winslow, T. Fishbein
MedStar Georgetown Transplant Institute, MedStar Georgetown University Hospital, United States

Introduction: Minimally invasive techniques in liver surgery continue to evolve and robotic surgery technology has increased the capability of hepatobiliary surgeons to perform safe liver resections.
Methods: Initial experience on 20 consecutive robotic hepatectomies from September 2018 to September 2019 at 2 institutions were analyzed. Extrahepatic inflow control and CUSA application during parenchymal transection were utilized to minimize blood loss during hepatectomy. Clinical characteristics and surgical outcomes were maintained in a prospective database.
Results: There were 10 major hepatectomies and 4 bisegmentectomies and 6 segmentectomies performed robotically. Extrahepatic inflow control was achieved in 12 cases. The laparoscopic CUSA was used in all cases and median blood loss was 275 mL (50-700). No patient required conversion to open procedure. One patient required blood transfusion. Median OR time was 383min (213-622). Median length of stay was 3 days (1-6). Major morbidity included 1 Clavian dindo IIIa bile leak requiring ERCP. There was no 90-day mortality.
Conclusions: Advanced techniques to reduce blood loss in robotic hepatectomy may optimize safety and minimize morbidity in these complex minimally invasive procedures.
Age, median (range)57 (20-82)
BMI, median (range)27 (16-40)
Major lobectomy10
Conversions0
Malignancy, n (%)12 (60)
Operative time, median (range)383min (213-622)
Estimated blood loss, median (range)275 mL (50-700)
Major morbidity (grade III-V) Bile leak, n (%)1 (5)
Length of stay, median (range)3 days (1-6)
Mortality, 90 day0
[Table: Clinical characteristics and surgical outcomes]
VL02-48 Laparoscopic Left Hepatectomy for Hilar Cholangiocarcinoma
Safi Dokmak, France

S. Dokmak, B. Aussilhou, F. Cauchy, O. Soubrane
HBP Departement and Liver Transplantation, Beaujon Hospital, France

Introduction: Hilar cholangiocarcioma is considered as contraindication to the laparoscopic approach related mainly to the necessity of vascular dissection and a bilioenteric anastomosis. However with the development of minimally invasive pancreatoduodenctomy, we become more familiar with hepatic pedicle dissection, biliary anastomosis and even vascular resection-anastomosis. We present a video of laparoscopic left hepatectomy for hilar cholangiocarcinoma.
Methods: Hilar cholangiocarcinoma was discovered on jaundice in a 72 year old male and treated efficiently by endoscopic drainage. Lesion was located on the biliary confluence with left extension and no vascular invasion. The laparoscopic approach was decided and five trocars were used.
Results: The operative duration was 360 minutes; the blood loss was 200 ml, with isolated clampage of the portal vein of 30 minutes. The postoperative stay was marked by biliary fistula with spontaneous healing at POD 5 and the patient was discharged home at POD 14. Histology confirmed the diagnosis of a well differentiated cholangiocarcinoma of 3 cm with perineural invasion and no vascular invasion, 15 harvested negative lymph nodes and R0 resection (T2bN0R0).
Conclusion: The development and experience with laparoscopic pancreatoduodenctomy will increase the feasibility of some difficult liver resections by the laparoscopic approach including hilar cholangiocarcinoma.
VL02-49 Laparoscopic Anatomical Resection of S4 and S8 by Clamp Crush Method: Preserving More Parenchyma for Cirrhotic Liver
Ying Chin Yang, Taiwan, Republic of China

Y.C. Yang
Department of Surgery, Buddhist Tzu Chi General Hospital, Hualien, Taiwan, Republic of China

For a primary tumour in the midline of the liver and the middle hepatic vein(MHV) will be excised, a central hepatectomy can preserve more parenchyma than an extended right or left trisectionectomy. Sometimes, we want to go further to preserve more parenchymal reserve, but also want to keep an anatomical resection for cancer in cirrhotic liver.
This patient had a history of non-anatomical resection for a single subcapsular small hepatocellular carcinoma of S8. Recurrence happened at the midline near the middle hepatic vein in 2 years. Anatomical resection of S4 and S8 was then chosen for this recurrent HCC. Caudal to cranial and left to right approach was used in this video. After exploring the middle hepatic vein central tract and the S5 hepatic veins ( tributaries of MHV) inside the liver, the S8 pedicles were transected one by one by intraparenchymal exploration. S8 hepatic vein was transected from the main tract of the right hepatic vein (RHV), and the main tract of MHV was transected later. The S5 was preserved when its inflow from liver hilum and outflow to RHV were not interrupted. Only a small part of the central coronary ligament was dissected at last. There was not a complication of ascites after this operation.
VL02-50 Laparoscopic Resection of the Posterior Sector Plus the Dorsal Part of the Anterior Sector by Clamp-Crush Method: Emphasizing the "Anterior Fissure"
Ying Chin Yang, Taiwan, Republic of China

Y.C. Yang
Department of Surgery, Buddhist Tzu Chi General Hospital, Hualien, Taiwan, Republic of China

There is a suggestion that the anterior section of (S8+S5) can be divided into the dorsal and ventral part, according to the Glissonian pedicles and the concept of the anterior fissure (Cho A. et al. 2004).
In this video, laparoscopic liver resection was performed for a huge liver tumour involving most of the posterior sector, the right hepatic vein, and dorsal part of anterior sector ventral to the main tract of the right hepatic vein. Such huge liver tumour was initially a single small tumour in the posterior sector, treated by percutaneous radiofrequency ablation before but progressed quickly after that.
Liver parenchyma was transected according to the concept of "anterior fissure of the right liver". By intraparenchymal exploration, dorsal branches of the anterior sector were transected along the surface of anterior sectoral Glissonean pedicle, when the ventral branches were preserved.
By this approach, a right hemihepatectomy is not always necessary for a large or huge tumour involving the posterior sector plus dorsal part of the anterior sector, and more viable parenchyma can be preserved in the remnant liver.
VL02-51 Selective Preservation of Segment 5 Lateral Pedicle in Laparoscopic Central Hepatectomy: A Video Presentation
Suet Yan Ong, Singapore

S.Y. Ong, N. Thiruchelvam, L.S. Lee, S.S. Tan, A.K.H. Chiow
General Surgery, Changi General Hospital, Singapore

Introduction: Central hepatectomy is an alternative to extended hemi-hepatectomy for centrally located hepatocellular carcinoma (HCC) for oncological resection while minimizing risk of post-hepatectomy liver failure (PLF). With selective glissonian approach to inflow, preservation of hepatic parenchyma maybe possible while ensuring adequate oncological anatomical resection. This video demonstrates the technique of preserving lateral pedicle to segment 5(S5) in laparoscopic central hepatectomy.
Method: A 58-year-old lady with S8/4 HCC with Child'sA5, Non-Alcoholic Steato-Hepatitis cirrhosis. Preoperative MRI Liver showed a 6.2x5.7x5.8cm mass at S8 and another 2.6x1.8cm mass at S4/8 close to the origin of the middle hepatic vein (MHV). Pre-operative ICG was not done due to renal impairment. She underwent a laparoscopic central hepatectomy, cholecystectomy with selective preservation of the lateral branch of S5 pedicle. Margins of S4/8 lesion was delineated via intraoperative ultrasound and transection of the liver from left to right was done with Cavitron Ultrasonic Surgical Aspirator (CUSA). This was followed by isolation of the anterior pedicle which was dissected to individual segmental pedicles to S5 and S8. The lateral branch to S5 was preserved while the medial branch to S5 and the branch to S8 was ligated. The tumour was removed en-bloc at the root of the MHV with preservation of the right and left hepatic veins.
Results: Post-operatively, patient was well and was discharged on POD 6. Final histology confirmed HCC with clear margins.
Conclusion: Central hepatectomy with selective pedicle preservation is possible for large central tumours with good oncological outcome while minimizing risk of PLF.
VL02-52 Laparoscopic Anatomical Liver Resections with Glissonian Approach (Segment V and VI)
Kohei Mishima, Japan

K. Mishima, K. Igarashi, T. Ozaki, M. Honda, N. Funamizu, G. Wakabayashi
Surgery, Ageo Central General Hospital, Japan

Background: Anatomical liver resections (ARs) have been shown to improve oncological outcomes in patients with liver malignancies. Our policy in laparoscopic ARs (Lap-ARs) is to precede Glissonian approach and to remove an anatomical area that is defined by the vascular supply of the Glissonian branches.
Method: A total of 111 patients underwent Lap-ARs in Ageo Central General Hospital from April 2016 to December 2019. We performed a retrospective analysis of 10 patients with segment V/VI lesions in this video presentation.
Surgical techniques: Standardized procedures are as follows: (1) to start with 5+1-port technique, (2) to mobilize the liver, (3) to remove the gallbladder and encircle the hepatoduodenal ligament for Pringle's maneuver, (4) to clamp the targeted Glissonian pedicles (Glissonian approach) and intravenously administer 0.5 mg/body of ICG , and (6) parenchymal transection.
Results: Median age was 73. Five patients had hepatocellular carcinoma while three had colorectal liver metastasis and two had others. Difficulty score (IWATE criteria) was 7 (6-8). No patients were converted. Operative time was 270 min (240-355) and blood was 94 ml (30-257). Resected liver volume was 110 g (47-303) and R0 resection rate was 90%. One patient experienced postoperative morbidity.
Conclusions: Lap-ARs with Glissonian approach for segment V/VI integrate curability and safety. Precise preoperative simulation and standardized techniques permit to pursue the quality of this procedure.
VL02-53 ICG-Enhanced Fluorescence-Guided Laparoscopic Rehepatectomy (Left Hepatectomy and Segment I)
Eric Herrero, Spain

E. Herrero1, M.I. Garcia-Domingo1, J. Camps1, L. Martinez1, A. Rodríguez2, F. Pardo3, M. Cremades3, E. Cugat1,3
1HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain, 2Anaesthesiology - HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain, 3HPB Surgery Unit, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain

Introduction: Liver resection is the only curative treatment for patients with colorectal liver metastases, even in cases of relapse of the disease in the liver.
Rehepatectomies are usually challenging procedures but can be achieved with feasibility and safety by laparoscopic approach. The use of ICG-enhanced guidance can be useful to avoid injuries to the remnant liver.
Method: 78 year old male presented with sigmoid colon cancer and giant vellous adenoma in right colon and possible small liver met in segment IV. Underwent laparoscopic subtotal colectomy and then US guided clip insertion to mark segment IV liver met prior to start chemotherapy (capecitabine 4 cycles). Four months later underwent laparoscopic segment IV limited resection of a 0.8 cm metastatic adenocarcinoma with free margin (10 mm). Adjuvant chemotherapy (FOLFOX6m 12 cycles) was scheduled. Two years after first hepatectomy the patient relapsed with a 20 mm CRLM between segments IV, I and VIII.
Results: In this video is showed the dissection and identification of liver hilum structures and the use of ICG fluorescence to determine the trasection line and to perform a left hepatectomy extended to segment I. Postoperative course was uneventful without any complication.
Conclusion: Laparoscopy is feasible and useful to perform repeat hepatectomies achieving good short and long term results. However, are challenging surgeries and must be performed in centers with huge experience both in laparoscopy and liver surgery.
VL02-55 Laparoscopic Isolated Caudate Lobectomy Using Anterior Transhepatic Approach
In Seok Choi, Korea, Republic of

I.S. Choi, J.I. Moon, S.J. Lee
Surgery, Konyang University, Korea, Republic of

Introduction: The caudate lobe is a distinct liver lobe and surgical resection requires expertise and precise anatomic knowledge owing to its location between the inferior vena cava and the portal bifurcation and its relationship to the hepatic veins. The aim of this report is to present laparoscopic isolated resection of caudate lobe with anterior transhepatic approach.
Methods: A 65-year-old man was admitted with liver metastases during follow-up for sigmoid colon cancer after had a laparoscopic assisted anterior resection and twelve times of adjuvant chemotherapy with FOLFOX. Magnetic resonance imaging showed 18mm metastatic cancer in caudate lobe. We performed laparoscopic isolated caudate lobectomy by anterior approach and wedge resection of segment 8. Laparoscopic surgery was performed in the lithotomy position and six trocars were inserted. After mobilization of the liver, the caudate branch of portal vein and short hepatic vein were ligated and dissected. Liver resection was performed, exposing the right side of middle hepatic vein. And posterior segment of the right lobe and the right edge of the caudate lobe was resected with enough resection margin from tumor. Finally, the paracaval portion of the caudate lobe was resected.
Results: The operative time was 675minutes and estimated blood loss was 50ml. There were no major intraoperative complications. There was minor bile leakage, however after ENBD insertion, the postoperative course was uneventful.
Conclusion: Considering that laparoscopic surgery is difficult to bleeding control, anterior transhepatic approach may be a good choice when performing the laparoscopic isolated caudate lobectomy.
VL02-56 Liver Hemangioma Enucleation
Ignacio Miranda Castillo, Chile

I. Miranda Castillo1, E. Buckel Gonzalez2, E. Buckel Schaffner2, F. Puelma Calvo2, N. Jarufe Cassis2
1Surgery, Clinica las Condes, Chile, 2Clinica las Condes, Chile

This video shows a liver hemangioma enucleation in a 49 years old man. The hemangioma had a fast growth in the last three years to reach a size of 15 cm, became symptomatic with abdominal pain.
He underwent laparoscopic sleeve gastrectomy and cholecystectomy 2017. The liver function test was normal.
The surgery develops without incidents and uneventful postoperative period. He was discharge from hospital at day 2. In the video details of the liver hemangioma enucleation are demonstrated using harmonic scalpel, laparoscopic CUSA and bipolar hemostasis.
VL02-57 Laparoscopic Cystopericystectomy for Hydatid Cyst of Liver
Pravin Suryawanshi, India

P. Suryawanshi
Surgery, MGM Medical College & Hospital, Aurangabad, India

Introduction: Laparoscopic Cystopericystectomy offers a radical cure for treatment of liver hydatid disease. This surgery aims to remove the cyst completely, decreasing the chances of recurrence and residual cavity related complications with a minimally invasive approach. We present a case of liver hydatid cyst managed successfully by Laparoscopic Cystopericystectomy.
Methods: A 51 year old female presented with upper abdominal pain since 1 month associated with abdominal fullness post meals. No h/o fever, altered bowel habits or jaundice . Examination findings were non specific. CECT scan revealed a large peripherally enhancing exophytic cystic lesion with thick internal septations in left lobe of liver measuring 8 cm craniocaudally, abutting and compressing IVC, portal vein and pancreas posteriorly, with no evidence of calcification s/o liver hydatid cyst. Patient underwent Laparoscopic Cystopericystectomy. Cyst wall was identified and decompression done with no spillage technique, followed by dissection of the cyst wall from the liver parenchyma. Stretched out vessels, and biliary radicles encountered were carefully clipped. Left hepatic pedicle and left hepatic vein were also ligated, and the cyst was excised completely. Total Operative duration was 2 hrs with minimal blood loss, and no intraoperative spillage of cyst fluid, or anaphylaxis.
Results: Post operative period was uneventful, with no complications. With a follow up of 3 years, no recurrent symptoms or recurrent cysts noted.
Conclusion: Laparoscopic Cystopericystectomy is feasible radical management option for hydatid cyst with less intraoperative spillage, blood loss and residual cavity related complications, when performed by experienced laparoscopic surgeon.
VL02-58 Laparoscopic Left Hepatectomy with Right Sided Round Ligament
Laurence Webber, Australia

L. Webber1,2, D. Cavallucci2
1Fiona Stanley Hospital, Australia, 2Royal Brisbane and Women's Hospital, Australia

We present a video of a laparoscopic left hepatectomy and sub-segmental wedge resection for metastatic colorectal cancer in a 54 year old man who had been treated with neoadjuvant chemotherapy. During his clinic appointment we noted an abnormal vascular branching pattern in his liver which was subsequently classified as right sided round ligament - bifurcation type.
At laparoscopy the gallbladder was positioned to the left of the round ligament, which inserted into the right anterior pedicle. The architecture of the left lateral segment was preserved, without the presence of the falciform etc.
We were able to divide the left inflow extrahepatically, including an accessory left hepatic artery arising from the left gastric, and transect the liver to gain a clear margin and preserve the right anterior inflow and round ligament. A second wedge resection was performed from the surface of segment 5. The patient made an uneventful recovery.
Right sided round ligament is a rare anomaly in biliary architecture. Preoperative identification and planning allowed a safe laparoscopic approach in this case.
VL02-59 Laparoscopic Right Hepatectomy for Colorectal Liver Metastases
Daniel Cherqui, France

D. Cherqui
Paul Brousse Hospital - Paris South University, Villejuif, France

This video presents a 60 year old woman with history of right hemicolectomy pT3N1 followed by 12 cycles of Folfox. 14 months after surgery she was diagnosed 4 liver metastases located in the right liver. She received 4 cycles of Fofiri chemotherapy with mild response. PET CT showed no extrahepatic disease.
The video clearly shows all steps of surgery.
Surgery included:
- French position
- 5 port laparoscopy
- Exploration including ultrasound
- Right liver mobilization
- Cholecystectomy
- Extrahepatic dissection of the right hepatic artery and portal vein
- RHA division using hemolocks
- RPV division using a linear stapler
- Liver transection under intermittent inflow occlusion and using CUSA with monopolar, energy device, bipolar cautery and clips on V5 and V8
- Intraparenchymal right bile duct division using a linear stapler
- Specimen extraction in a bag through an 8 cm Pfannenstiel incision.
Postoperative course was uneventful and the patient was discharged at day 4
VL02-60 Laparoscopic Right Hemihepatectomy by Dorsal Approach Using Two-Tunnel Technique
Richard Bryant, Australia

R. Bryant, D. Cavallucci, N. O'Rourke
Royal Brisbane and Women's Hospital, Australia

This new technique, a posterior to anterior right hemihepatectomy, is a modification of the caudal approach of Soubrane, and has enabled us to perform right hemihepatectomies more easily, via a standardised technique, for larger tumours, and for anatomical variations at the porta. The initial manoeuvre is to create the retrohepatic tunnel that ultimately passes between the right and middle hepatic veins as described by Belghiti in 2007, as well as the O'Rourke-Fielding tunnel that ultimately passes lateral to the right hepatic vein as described in the initial reported series of laparoscopic right hemihepatectomy by O'Rourke in 2004. The caudate process is then divided and the posterior aspect of the right hepatic inflow cleared of parenchyma, which assists in the dissection and division of the right hepatic inflow. The Belghiti and O'Rourke-Fielding tunnels are then developed to the level of the right hepatic vein, before the liver parenchyma is then divided. The exposed right hepatic vein is then divided, followed by the hepatocaval ligament, and finally the right hemiliver is mobilised from its peritoneal attachments. We find that this approach assists maintaining anatomical orientation and helps minimise venous bleeding.
VL02-61 Minimally Invasive Repair of Right-sided Bochdalek Hernia with Mesh
John Stauffer, United States

N. Del Piccolo, J. Stauffer, H. Saleem, I. Makey
Mayo Clinic, United States

Background and objectives: Bochdalek hernias are congenital diaphragmatic defects resulting from the failure of posterolateral diaphragmatic foramina to fuse in utero. Diagnosis of a Bochdalek hernia in an adult is rare and is typically observed on the left side of the diaphragm. Even more rare is the diagnosis of a symptomatic right-sided Bochdalek hernia in an adult, which generally presents with concurrent visceral involvement. We describe a case from our institution involving this rare defect.
Methods: A retrospective chart review was performed on a single patient for data collection purposes.
Results: The patient is a 77-year-old female with a history of symptomatic right posterior diaphragmatic hernia with incarcerated kidney causing hydronephrosis, as well as incarcerated colon and right posterior basilar atelectasis of the lung. Laboratory work up and imaging revealed no other findings. She has no other significant past medical or surgical history.
Laparoscopic, hand-assisted repair of the Bochdalek hernia was done via abdominal approach with GoreTex mesh and V-Loc sutures. The patient has had significant clinical improvement and continues to do well 8 weeks post-operatively.
Conclusion: Laparoscopic, hand assisted repair of symptomatic adult right-sided Bochdalek hernias with Mesh can be performed successfully despite an extensive requirement of right hepatic mobilization, and the operation may result in significant clinical improvement.
VL02-62 Laparoscopic Left Hepatectomy for a Giant Symptomatic Hemangioma
Jaime Arthur Pirola Kruger, Brazil

J. Kruger1,2, G.N. Namur1, B.C. Azevedo1, E.T. Bianchi1, S.E.A. Araujo1, S. Klajner1
1Surgical Oncology, Hospital Israelita Albert Einstein, Brazil, 2Liver Surgery Unit, University of Sao Paulo - Hospital das Clinicas, Brazil

Hepatic hemangiomas are not a surgical disease. In extremely uncommon cases this hypervascular tumor might grow and result in symptoms related to mass effect. In such cases clinical treatment of the symptoms is mandatory and surgical treatment remains exceptional. This video presents a case of a 14 centimeters hemangioma, located closely to the middle hepatic vein, with gastric compression and persistent symptoms. Surgery was successfully performed as a total laparoscopic approach in which technical steps of the operation are described. Of most importance, previous vascular control allowed for tumor shrinkage and operative ultrasound aided safe transection. The patient experienced prolonged symptomatic relief and benefited of the minimally invasive management of this usually non surgical disease.
VL02-65 Robot-assisted Resection of the Extrahepatic Bile Ducts and a Left Hemihepatectomy for Bile Duct Cystic Transformation, Todani Type IV
Mikhail Efanov, Russian Federation

M. Efanov
HPB, Moscow Clinical Scientific Center, Moscow, Russian Federation

A case of successful surgical treatment of cystic transformation of extrahepatic bile ducts using robotic technologies is presented. Technical difficulties were presented due to the primary operation of cystoeunostomy in childhood and the spread of cystic transformation to the intrapancreatic part of the choledochus. The postoperative period was complicated by pancreatic fistula and bile leakage, but was successfully cured.
VL02-66 Caudate Lobe Adenoma: Totally Laparoscopic Segment I Isolated Resection
Cristian Jarry, Chile

C. Jarry1, M. Inzunza2, E. Briceño1, M. Dib1, J. Martinez1, N. Jarufe3
1Cirugia Digestiva, Pontificia Universidad Catolica de Chile, Chile, 2Pontificia Universidad Catolica de Chile, Chile, 3Cirugia Digestiva, Clinica las Condes, Chile

Introduction: Hepatic adenomas are uncommon solid benign lesions, mostly isolated and predominantly found in the right hepatic lobe. These adenomas are usually diagnosed in young women, and the incidence and growth of these lesions have been associated with contraceptive use. Radiological follow up is reasonable and surgical resection is indicated under specific circumstances. Hepatic adenomas found in the segment I are rare, and its laparoscopic resection is technically complex.
Aim: We aim to show a totally laparoscopic segment I isolated resection, as treatment of a hepatic adenoma in the caudate lobe.
Content of the video: A brief summary of the clinical case. A 28-year-old woman with a 2-year previous follow-up of a hepatic adenoma in the caudate lobe. Due to patient's planning for pregnancy, the HPB surgical team offered to her a totally laparoscopic isolated resection of the lesion. The pre-operative imaging study is presented, including an abdomen Primovist MRI in which one hepatic adenoma can be seen right next to the inferior vena cava. Intraoperatively, two adenomas are found in the caudate lobe. The totally laparoscopic segment I isolated resection is shown, exposing the key steps of both the dissection and parenchymal transection of the liver.
VL02-67 ICG-Enhanced Fluorescence-Guided Laparoscopic Central Hepatectomy for Colorectal Liver Metastases
Eric Herrero, Spain

E. Herrero1, L. Martinez1, M.I. Garcia-Domingo1, J. Camps1, F. Pardo2, F. Espín2, A. Rodríguez3, E. Cugat1,2
1HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain, 2HPB Surgery Unit, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain, 3Anaesthesiology - HPB Surgery Unit, Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain

Introduction: Liver resection is the only curative treatment for patients with colorectal liver metastases. Laparoscopic liver resection has been widely adopted. However, performing a total laparoscopic central hepatectomy remains a challenging and technically demanding procedure because it requires two transection planes.
Method: 80 year-old male patient with prior resection of sigmoid colon cancer 2 years before. During follow-up liver mets in segment IV and VIII were detected by CT scan. Other liver lesions and extrahepatic disease were excluded with MRI and PET. Neoadjuvant chemotherapy resulted in partial response of the liver lesions, although it persisted involvement of middle hepatic vein and segments IV,V and VIII. A central hepatectomy was planned. Glissonian approach of portal pedicles for segments V and VIII, and segment IV is showed. ICG-enhanced fluorescence guidance allowed a complete resection of those segments.
Results: The technique was successfully performed without intraoperative complications. The pathological report was colorectal adenocarcinoma and free surgical margins. Morbidity was II and IIIa (Dindo Clavien). The length of hospital stay was 20 days.
Conclusion: Laparoscopic central hepatectomy using a Glissonian approach is feasible and safe. The use of ICG fluorescence may provide better transection plane and is very useful in this type of resection with 2 transections planes.
VL02-68 Application of Intraoperative Fluorescence Imaging in Laparoscopic Hepatectomy for the HCC: Detect the Cancer, Guide for Anatomical Resection and Identify the Bile Duct
Koo Jeong Kang, Korea, Republic of

K.J. Kang, K.S. Ahn, T.-S. Kim, J.W. Lee, Y.H. Kim
Division of HBP Surgery, Surgery, Keimyung University Dong-San Hospital, Korea, Republic of

Recently, intraoperative fluorescence imaging using indocyanine green (ICG) has widely been used to open or laparoscopic HPB surgery, for real-time visualization of biological structures and assessment of blood perfusion. Identification of hepatic tumors IV injected ICG accumulated in the cholangiocarcinoma or hepatocellular carcinoma, hepatic segmentation by intraoperative injection of ICG and fluorescence cholangiography excreted into the biliary tract that was injection for identification of hepatic segmentation.
Sixty eight-years old male patient who have 3.5cm sized hepatic tumor located in the hepatic segment 4 underwent laparoscopic left hepatectomy. Of note, a small 7mm sized satellite tumor located in the segment 8 that was detected in the ICG fluorescent image during laparoscopic exploration, which was not detectable by intraoperative ultrasonography. The satellite nodule was removed by laparoscopy simultaneously. We herein demonstrate four kinds of application of ICG-fluorescence imaging, detection of tumor, hepatic segmentation, fluorescent cholangiography in a time with video and assessment of hepatic blood perfusion arterial followed by portal.
VL02-69 Robotic Liver Wedge Resection
Richard Xavier Sousa Da Silva, Switzerland

R.X. Sousa Da Silva, H. Petrowsky, M. De Oliveira, P.-A. Clavien, C.E. Oberkofler
Visceral and Transplantation Surgery, University Hospital Zurich, Switzerland

This video case presentation shows a robotic liver wedge resection at the posterior liver segment VII. Since laparoscopic as well as open wedge resection of the posterior liver segments show known difficulty in access, we opt for robotic liver wedge resection. In November 2019 we performed at the University Hospital Zurich Switzerland a robotic liver wedge resection in a 55 year old obese female with invasive ductal breast cancer that metastasized solitary into liver segment VII. In order to improve exposition we placed the patient in left side position. First resection size was defined with 1 to 2 centimeter safety margin. Then laparoscopic ultrasound was used to display tumor expansion into depth as well as its relationship to the vessels. Initial parenchyma dissection was done with the monopolar hook. Deeper dissection was carried out with the DaVinci Vessel Sealer. This device allows safe sealing and cutting of bigger vessels as well as bile ducts. To seal off the resection area Aquamantys sealer was used. This device combines radiofrequency energy and saline to keep temperature low. Postoperative Situs showed small incision sites and the patient was discharged after 3 days. Robotic liver wedge resection allows safe and oncologically correct resection while reducing surgical burden, especially in obese patients. Our experience shows that a great benefit of robotic liver surgery lies in better access to the posterior liver segments.
VL02-70 Laparoscopic Right Anterior Sectionectomy for HCC
Gabriella Pittau, France

G. Pittau, D. Cherqui
Paul Brousse Hospital - Paris South University, Villejuif, France

This video presents an 80 year old woman with a 6-cm HCC in segment 8. She had no history of liver disease and AFP was normal.
The video clearly shows all steps of surgery.
Surgery included:
  • French position
  • 5 port laparoscopy
  • Exploration including ultrasound
  • Right liver mobilization
  • Cholecystectomy
  • Extrahepatic Glissonian control of the right anterior pedicle and clamping to delineate ischemic margins
  • Liver transection along the middle and right hepatic veins, respectively.
  • Intermittent inflow occlusion
  • CUSA with monopolar, energy device and bipolar cautery for transection
  • Intraparenchymal division of the right anterior pedicle
  • Specimen extraction in a bag through an 8 cm Pfannenstiel incision.
    Postoperative course was uneventful and the patient was discharged at day 8. She is alive and disease free at 18 months
VL02-71 Robotic Segment 4-5 Subsegmentectomy for Hepatocellular Carcinoma
Emanuele Felli, France

E. Felli1,2,3, E.M. Muttillo4, D. Mutter2,3,4, P. Pessaux2,3,4
1HPB Unit, Nouvel Hôpital Civil, University of Strasbourg, France, 2IHU Strasbourg, France, 3IRCAD, France, 4Nouvel Hôpital Civil, University of Strasbourg, France

We present a robotic segment 4-5 subsegmentectomy with en bloc cholecystectomy for an hepatocellular carcinoma secondary to NASH . A 80-year-old patient affected by a 40mm centimeters subcapsular lesion between segments 4 and 5 on the gallbladder bed discovered fortuitously. In his past medical history we notice obesity, diabetes, blood hypertension and dislypidemia. Biology was normal, alphafoetoprotein was 8kU/L. As the lesion was diagnosed on a non cirrhotic liver a biopsy was performed showing a well differentiated hepatocarcinoma. No extrahepatic disease was present at thoracic CT scan. Indication to resection was decided after multidisciplinary meeting. Intraoperatively, strong adhesions were initially sectioned with scissors in order to make an operative field and to dock the robot. The lesion was visible on the liver surface, an intraoperative ultrasound was then performed. The hepatic pedicle clamping was prepared. After exposure and opening of the Calot triangle , isolation and section of cystic duct and cystic artery is performed associating partial mobilization of the gallbladder. The transection line is marked with the hook on the liver surface. Hepatotectomy is performed with bipolar and scissors with crush clamping technique. Hemostasis and biliostasis with robotic metallic and hem-o-lock clips. Sous-segmental branches for the V segment are selectively sectioned, together with the venous branches. An hemostatic patch is finally applied after hemostasis and biliostasis. Pathologic analysis showed a pT2 well differentiated HCC on healthy liver. Postoperative course was uneventful and the patient was discharged at POD 5.
VL02-72 Laparoscopic S4a,8 Subsegmentectomy in a Pediatric Patient
Dmitry Akhaladze, Russian Federation

D. Akhaladze, N. Merkulov, G. Rabaev, E. Chechev
Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology, Russian Federation

The presented video describes a rare case of minimally invasive liver resection in pediatric patient, suffering from mesenchymal hamartoma.
17 y.o. female was admitted to the hospital with upper abdominal pain.
The initial abdominal CT revealed a lesion in Couinaud liver segment 8 without distant metastasis. The pure laparoscopic segment 8 resection was planned. An intraoperative ultrasonography revealed the tumor spread on the segment 4a in front of middle hepatic vein so decision was made to carry out the segments 8 and 4a resection. The procedure was accomplished totally laparoscopically with good outcome. The Patient was discharged on postoperative day 5.
To the best of our knowledge, this is the first description of minimally invasive hepatic segments 8 and 4a resection in pediatric patient.
VL02-73 Laparoscopic Left Hepatectomy
Vimalakar Reddy, India

V. Reddy, D. Reddy
Surgical Gastroenterology, Sunshine Hospital, India

Laparoscopic hepatectomy is the pinnacle in the field of minimally invasive surgery.
Anatomical hepatectomy is more difficult compared to non anatomical hepatectomy.
Achieving inflow/outflow control in laparoscopy is a difficult task due to
-Risk of massive air embolism during vascular dissection
- Difficult Ergonomics
- Accessibility
In experienced hands laparoscopic liver resections are safe with acceptable morbidity.
Patient Details:
62 year old gentlemen with complaints of pain abdomen since 3 months.
On evaluation ,he found to have a large cystic lesion in left lobe of the liver (4a,4b,3)with a probable diagnosis of biliary cystadenoma.
Underwent laparoscopic left hepatectomy.
Post operative course was uneventfull.
Discharged on fourth POD.
Further follow -up was done for 2 months which was uneventful.
VL02-74 Laparoscopic Segmentectomy for Hepatic Adenoma SEG 5
M Srinivasan, India

M. Srinivasan, S. Srivatsan Gurumurthy, P. Senthilnathan, C. Palanivelu
Division of HPB, Minimal Access Surgery and Liver Transplant, Gem Hospital, India

A 38 year old female with vague upper abdominal pain was found to have a space occupying lesion of size 3x3 cm in segment 5 of liver which was hypointense on T2W MRI. AFP and CEA were normal. FNAC was inconclusive and suspicious of malignancy. Hence, the patient was taken up for Laparoscopic segmentectomy. Under GA, Patient in supine position, ports placed. Lesion of size 3 x 3 cm found in seg - 5 close to Gall bladder. Calot's delineated. Cystic duct and artery doubly clipped and divided. Suface marking of seg - 5 done. Rubber band traction applied. Using CUSA +Harmonic + Bipolar, Liver parenchymal transection done. Segmental veins and Pedicle to segment 5 clipped and divided. Complete Haemostasis achieved. Specimen removed through pfannenstiel incision. 24 Fr DT placed. Port sites closed. HPE was reported as hepatic adenoma. Pt had an uneventful recovery.
VL02-75 Laparoscopic Complex Liver Cyst Resection
Marcelo Enrique Lenz Virreira, Argentina

M.E. Lenz Virreira, J.P.S. Durán Azurduy, J.G. Cervantes, M.L. Del Bueno, M. Poupard, M. Chahdi Beltrame, E.G. Quiñonez, F.J. Mattera
Hospital el Cruce, Argentina

Background: Liver cysts are the most benign common focal liver lessions, but on the other hand, biliary cystadenomas are uncommon benign cystic neoplasms, that may be either unilocular or multilocular. Only rarely are they found in the extrahepatic biliary tree and gallbladder.
Methods: Video of a Case report
Results: 28 years old female, with diagnosis of liver cyst who experimented a four months history of abdominal pain. Ultrasound was practiced and it shown a liver cyst with thickened wall and mixed content, she was treated with albendazol by 30 days. Hospital discharge on the fourth day with no complication. Patological anatomy diagnosis was biliary cystadenoma.
Conclusion: Complete Laparoscopic resolution of liver complex cyst is a feasible and acceptable approach nowadays. Although rare, physicians need to keep this diagnosis in mind, especially in symptomatic patient with a liver cyst with mixed content.
VL02-79 Negative Staining of Hepatic Segments Using Indocyanine Green during Laparoscopic and Robotic Hepatectomy
Fernando Pardo, Spain

F. Pardo1, E. Herrero2, F. Espin1, M. Cremades1, M. García2, J. Navines1, J. Camps2, A. Zarate1, E. Cugat1
1Hospital Universitario Germans Trias i Pujol, Spain, 2Hospital Universitari Mutua Terrassa, Universitat de Barcelona, Spain

Indocyanine green fluoresecent imaging is a usefull tool with many advantages in hepatic surgery. We present some different scenarios (laparoscopic major hepatectomy, laparoscopic segmentectomy and robotic segmentectomy) of laparoscopic and robotic hepatic surgery due to metastases and hepatocellular carcinoma using indocyanine green dye intravenously after isolating and clamping the portal branch of the segment or tumor we are resecting. This negative staining technique is a feasibility and reproducibility technique with potential benefits, enabling the surgeon to assess surgical boundaries of the resection before the hepatectomy and ischemia margins at the end of the procedure..
VL02-80 Laparoscopic Right Hemihepatectomy for Primary VIPoma of the Liver
Lin Chen, China

L. Chen, Z. Zhang, X. Chen
Hepatic Surgery Center, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology (HUST), China

Vasoactive intestinal polypeptide tumor (VIPoma) is a very rare neuroendocrine tumor that produces the vasoactive intestinal polypeptide (VIP) hormone, which is mainly secreted by gastrointestinal tract and pancreas. The clinical manifestations of VIPoma are watery diarrhea, hypokalemia and achlorhydria or hypochlorhydria. 90% of these tumors in adults arise from the pancreas, although they have also been reported to be in the colon, bronchus, adrenals and sympathetic ganglia. Primary hepatic VIPoma is rare and few literatures had reported. Here we present a case of primary hepatic VIPoma: a 32-year-old patient who suffered severe watery diarrhea and hypokalemia with Liver lesions which were found by CT scan. No lesions were found in pancreas, gastrointestinal tract or elsewhere. The diagnosis of VIPoma was confirmed. Thus, laparoscopic right hemihepatectomy and microwave ablation of left lateral lobe tumor were performed. During the operation, Chen's occlusion method (infrahepatic inferior venacava clamping plus pringle maneuver was implemented to reduce the risk of bleeding; Chen's hanging maneuver through the retrohepatic avascular tunnel on the right of the inferior vena cava was used to facilitate the exposure of the operative and guide the plane of parenchymal transection. The operation takes 4 hours and intraoperative bleeding is less than 100ml. Diarrhea did not reoccur and serum K+ rose to normal after operation. Histological examination revealed a G2 neuroendocrine tumor (NET)(Ki-67 index 30%).
VL02-82 Laparoscopic Right Posterior Sectionectomy in Left Decubitus Position for a Patient with Hepatocellular Carcinoma
Nicole Miu Yee Cheng, Hong Kong

N.M.Y. Cheng, K.K.C. Ng
Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong

Laparoscopic right posterior sectionectomy is technically challenging due to the difficulty in tumor access and bleeding control. It is graded as high difficulty (higher conversion rate, longer operation time, more intra-operative blood loss and post-operative complications) according to the laparoscopic liver resection “difficulty scoring system” by the endoscopic liver surgery group. Nevertheless, better surgical planning and meticulous intraoperative measures helps to alleviate the hurdle of this procedure.
We describe a case of laparoscopic right posterior sectionectomy for a 63-year-old hepatitis B carrier with a 5.5cm hepatocellular carcinoma (HCC) in segment VII. He had Child's A liver function and indocyanine green (ICG) at 15min was 7.5%. The patient was placed in left decubitus position on a bridging table, which helped to open up right rib cage. Following cholecystectomy, right liver was mobilized. Glissonian right posterior pedicle control (Takasaki approach) was adopted. ICG was administered systemically. Negative counterstaining of right posterior section allowed precise anatomical resection under near-infrared vision. Patient in French position, low central venous pressure, pneumoperitoneum (15mm Hg) and meticulous laparoscopic techniques (combined laparoscopic ultrasound dissector and harmonic scalpel) were applied during liver transection. The operation time was 7 hours with 300 ml blood loss. The patient recovered uneventfully after surgery. Pathology showed moderately differentiated hepatocellular carcinoma with clear margin.
With left decubitus position on bridging table, early right posterior pedicle control, negative counterstaining using ICG and skilful laparoscopic techniques, laparoscopic right posterior sectionectomy can be performed safely with excellent outcome, despite its high difficulty score.
VL02-83 Laparoscopic Left Hepatectomy, Cholecystectomy, Common Bile Duct Exploration, Excision of Bile Duct and Roux En Y Hepaticojejunostomy for Recurrent Pyogenic Cholangitis
Madeline Chee, Singapore

M. Chee, L.S. Lee
Hepatopancreatobiliary Surgery, Changi General Hospital, Singapore

Recurrent pyogenic cholangitis is a rare disease entity found almost exclusively in the Southeast Asian population. It is characterised by recurrent cholangitis due to biliary stasis and denovo intrahepatic stone formation proximal to biliary strictures. Its pathogenesis remains a mystery, but is postulated to be related to bacterial infection and secondary stone formation, with organisms such as E coli, Klebsiella, Pseudomonas and Proteus. The biliary tree is characterised by intra and extrahepatic ductal dilatation with focal areas of structuring and fibrosis from chronic inflammation. The left hepatic ducts tend to be affected earlier and more commonly, possibly due to their anatomical course where they branch off more acutely as compared to the right hepatic ducts, hence predisposing to stasis and stricture formation.
Our patient is a 70 year old Malay male who has a known history of recurrent pyogenic cholangitis complicated by choledochoduodenal fistula, with multiple admissions previously for cholangitis, for which he had undergone multiple endoscopic retrograde cholangiopancreatography (ERCP) and stenting. However, he defaulted follow up and presented 7 years later to our department with cholangitis. A computed tomography scan of the abdomen and pelvis was performed which showed that a previously inserted biliary stent was still in situ, with a calculus at the left proximal hepatic duct and upstream dilated left intrahepatic ducts. ERCP was attempted but failed. As such, he underwent laparoscopic left hepatectomy, cholecystectomy, common bile duct exploration, excision of bile duct and Roux en Y hepaticojejunostomy.
VL02-84 Robotic Recurrent Hepatocellular Carcinoma Resection of Liver Segment 3
Iswanto Sucandy, United States

I. Sucandy, S. Ross, J.-K. Dolce, K. Luberice, A. Rosemurgy
AdventHealth Tampa, United States

This video depicts a partial liver resection of a segment 3 liver tumor followed by hernia repair, in an 80-year-old man. The patient required IR right portal vein embolization followed by a 2ndstage hepatectomy with extended right hepatectomy for a large tumor, 19 months prior.
Vasculature of the liver lead to bleeding. 4-0 Polypropylene suture was used to complete the repair of the left hepatic artery to stop bleeding. This video illustrates complex liver resection of a recurrent hepatocellular carcinoma. Using an open approach with the assistance of a robot, this operation can be undertaken safely and efficaciously, as the patient responded well without any intraoperative complications.
VL02-85 Laparoscopic Left Lateral Sectionectomy for a Hypergiant Liver Hemangioma
Jose-Luis Beristain-Hernandez, Mexico

J.-L. Beristain-Hernandez1, M. Garcia-Sanchez1, V.-S. Mora-Muñoz2
1General Surgery, La Raza National Medical Center, Mexico, 2La Raza National Medical Center, Mexico

We present the case of a 65 years old female referred to our Unit for a giant liver hypergiant liver hemangioma.
She had a previous history of cholecystectomy and hysterectomy.
She had a history of colicky abdominal pain on upper quadrants, becoming more important during the last few months.
A CT scan showed a 15 cm hemangioma on segments II and III.
Due to the presence of a symptomatic hemangioma she had a laparoscopic left lateral sectionectomy performed.
Surgery lasted 140 minutes, without Pringle manœuvre and had 300 mL hemorrhage.
Postoperative course was uneventful and patient was discharged on PO day 3.
Hypergiant hemangiomas are rare indications of laparoscpic liver resection; should only be resected when proved to be symptomatic. It may pose a complex surgical scenario when trying to resect laparoscopically and should ideally be treated in high volume HPB centers.
VL02-87 Totally Robotic ALPPS Assisted with Radiofrequency for Major Liver Resection (TR-RALPPS)
Tamara Gall, United Kingdom

T. Gall, A. Fajardo, Z. Jawad, L. Jiao
Imperial College, United Kingdom

Background: To avoid liver insufficiency following major hepatic resection, associating liver partition with portal vein ligation for staged hepatectomy (ALPPS)was introduced as an alternative method to conventional portal vein embolization (PVE). ALPPS assisted with radiofrequency (RALPPS) has been described as a variant of ALPPS.
Aims: To present a video showing a two-stage robotic liver resection. Stage 1: radiofrequency assisted liver partition with portal vein ligation (RALPP). Stage 2: Extended right hepatectomy.
Methods: Both stages completed with the Da Vinci Robot Xi.
Results: A 72 year old female with primary sclerosing cholangitis developed a 13cm hepatocellular carcinoma in the right lobe of the liver. The future liver remnant (FLR) was estimated to be 29% liver volume but with multiple liver nodules this was not thought to be sufficient following an extended right hepatectomy. Stage I involved ligation of the right portal vein and radiofrequency ablation with the Habib 4 x along the line of future dissection. It took 55 minutes. Liver biopsy of the FLR confirmed no cirrhosis. After two weeks, there was an increase in the FLR of 56.9%. Stage II involved completion extended right hepatectomy and took 330 minutes, 290 minutes console time. There was no morbidity or 90 day mortality.
Conclusions: RALPP is a good technique for increasing the FLR in a shorter time period than portal vein embolization (PVE). The technique is feasible with a totally robotic approach.
VL02-88 Fluorescence-Guided Surgery for Liver Tumors
Deng Yong Zhang, China

D.Y. Zhang, Z. Lu
The First Affiliated Hospital of Bengbu Medical College, China

A 81-year-old male was admitted to our hospital due to epigastric pain during the past two weeks. The AFP value was 55083 ng/ml. The liver function evaluated as Child-Pugh grade A. He has no history of hepatitis. Abdominal computed tomography (CT) revealed a 7-cm low attenuating mass in the left liver, with mild enhancement after being contrast enhanced. Preoperative diagnosis was hepatocellular carcinoma. Indocyanine green (ICG) fluorescence-guided laparoscopic left hemihepatectomy was performed. 20mg (at a dose of 0.25mg/kg body weight) of indocyanine green was injected intravenously 72 hours before the operation. The fluorescing areas indicates tumor and the non-fluorescing areas indicates normal liver tissue which identified by the ICG-fluorescence imaging system. The operation lasted for 4 hours and the intraoperative blood loss was 200 ml. The left hepatic pedicle was blocked (intrathecal method). Hepatectomy is performed based on the ischaemic demarcation line between the left and right of the liver. The Anatomical left hemihepatectomy plus cholecystectomy was performed. He was discharged on the 6th day postoperative. The postoperative pathology is hepatocellular carcinoma.