Laparoscopic resection of giant liver hemangioma using laparoscopic Habib probe for parenchymal transection.

Experience with laparoscopic liver resections is limited. Laparoscopic resection of a variety of liver lesions has been reported and is considered appropriate for lesions in the left lateral segment and inferior segments of the right lobe. Herein, we report a 52-year-old male patient who underwent a laparoscopic resection of giant liver hemangioma with the use of a laparoscopic 4× Habib probe.

INTRODUCTION

Laparoscopic liver surgery is now being performed by select groups worldwide. The Louisville consensus conference on laparoscopic liver surgery suggested a role for laparoscopic liver resections for lesions in segment 2 to 6.[1] We herein report a male patient undergoing laparoscopic liver resection for a giant right lobe liver hemangioma.

CASE REPORT

A 45-year-old male patient with no known medical risk factors presented to the outpatient department with complaints of right upper quadrant pain restricting his regular activity. A multidetector computerized tomography (MDCT) of the abdomen showed a giant hemangioma (18 cm in greatest diameter) arising from segments 5 and 6 of the liver [Figure 1]. The feeding vessel to the hemangioma was from the anterior branch of right hepatic artery (RHA). The RHA was prominent with a long extrahepatic course. The right anterior portal pedicle (RAPP) was seen abutting the hemangioma supero-medially. The patient was planned for a laparoscopic resection of the liver hemangioma. The operation was planned in five steps.

Figure 1

(a) Computerized tomography showing the giant hemangioma arising from segment 5 and 6 of the liver, (A – Reconstructed image showing extent of hemangioma.) (b) Arterial phase showing the main feeding artery from the anterior branch of the right hepatic artery, (c) Portal venous phase showing relation of the anterior portal pedicle to the hemangioma

Step 1: Port placement and retraction

An open entry was achieved with a 10-mm port at the umbilicus for laparoscopic vision and four additional ports were placed [Figure 2]. At laparoscopy, a giant hemangioma of 18 cm × 12 cm was seen to arise from segments 5 and 6 of the liver, reaching up to the iliac fossa on the right side with displacement of the gall bladder medially to midline, in line with the falciform ligament [Figure 3a]. The operative port position had to be modified keeping in mind the distorted anatomy. The gall bladder fundal retraction was achieved using a grasper through a port in the right midclavicular port.

Figure 2

Frontal view of the abdomen at 1 month follow-up showing port sites. C, camera port (10 mm); RHW, right hand working port (12 mm); Left hand working port (5 mm); LR, liver retractor port (10 mm); GBF, gall bladder fundal retraction port (5 mm)

Figure 3

(a) Laparoscopic view of the giant hemangioma, (b) Laparoscopic image showing the bulldog clamp across the anterior branch of the right hepatic artery, (c) Line of demarcation on the liver after clamping the anterior branch of the right hepatic artery, (d) Laparoscopic view of the enucleation plane

Step 2: Taking control of the anterior branch of the right hepatic artery

The Calot's triangle was dissected and the cystic artery was clipped and divided. Posterior to the gall bladder neck, the RHA was looped. The right anterior branch was selectively dissected, looped and occluded with a bulldog clamp [Figure 3b]. The line of demarcation of the anterior segment became clearly evident and was associated with shrinkage of the hemangioma by one-third of its size [Figure 3c].

Step 3: Dissection of the medial part of the hemangioma in an enucleation plane

Resection was initially performed in the plane of enucleation medially [Figure 3d]. During the course of this dissection, the branches entering the hemangioma from the RAPP were clipped and divided.

Step 4: Transverse line of transection (cranially) using a laparoscopic Habib probe

Cranially, a transverse line of transection was marked at the summit level of the hemangioma. The transverse transection plane thus chosen was based on pre-operative planning from the reconstruction from MDCT evaluation and intraoperative ultrasound (IOUS). This plane was away from the hilum. The hepatic venous tributary running from segment 6 crossed this line as confirmed by IOUS. The 5-mm port in the epigastrium was exchanged for a 12-mm port to facilitate the use of the 4× Habib laparoscopic probe. RF generator (Habib™ 4X, Generator 1500X, RITA Medical Systems, Inc. California, USA), 60 Watts setting, was used during liver parenchymal transection with the laparoscopic 4× Habib probe by choosing a 2 cm depth of application of RF prongs along the line of transection with parenchymal division performed with straight scissors [Figure 4a]. To prevent injury to the retroperitoneal structures, the hemangioma was lifted in an anterior direction with a 10 mm fan retractor. The posterior 1 cm depth of the parenchymal division was achieved by two firings of an endo GIA stapler with 60 mm, white reloads (Autosuture) [Figure 4b]. Hemostasis was ensured with bipolar cautery. The bulldog clamp on the anterior RHA was released.

Figure 4

(a) Laparoscopic 4× Habib probe – transection in progress, (b) Final transaction surface, (c) Morselled specimen

Step 5: Bagging the specimen, morsellation and retrieval

An indigenously prepared endobag (urobag) cut to appropriate size with a prolene 2-0 suture placed as a pursestring along its open end was then passed into the abdomen through the 12 port. The bag was placed in the right upper abdomen and two 2-0 prolene, interrupted sutures were placed on the anterior leaf of the open end of the bag and sutured to the anterior wall of the abdomen. One grasping foreceps held the posterior leaf of the open end of the bag. This suturing technique facilitated in bagging the large specimen comfortably. The cystic duct was clipped, the gallbladder was dissected off from the liver bed, placed in the same endobag and the pursestring suture at the mouth of the bag was tightened. Under laparoscopic guidance, the pursestring suture was held and the mouth of the bag was delivered through the umbilical port site. The umbilical port was extended to 3 cm. The hemangioma was morselled within the bag and retrieved [Figure 4c]. The retrieval bag with the gall bladder was finally removed. Re-laparoscopy was performed, hemostasis was ensured, a subhepatic 24 F tube drain was placed and ports were withdrawn.

The operative time was 220 min and the blood loss was around 50 cc. The patient was started orally the same evening and discharged from hospital on the third post-operative day. He had no post-operative complications. At 3 months follow-up, he was asymptomatic.

DISCUSSION

The role of laparoscopic liver resection for liver tumors is unclear at present.[2-5] The Louisville consensus statement suggests laparoscopic liver resection as an option for lesions in the left lateral and inferior segments of the right lobe.[1] The concerns with regard to laparoscopic liver resections are many. Firstly, localizing lesions at surgery can be a challenge. Secondly, precise vascular control can be difficult to achieve. Thirdly, there is a lack of tactile feedback, which is critical in evaluating the margin of resection, particularly in malignant tumorus. Fourthly, the ideal technique for parenchymal transection during laparoscopic liver resection is not yet standardized. Lastly, retrieval of a large specimen may require a large incision, which defeats the primary objective of keeping the procedure minimally invasive.

Lesions reaching the hilar structures, in particular, pose technical problems with the laparoscopic approach.[1] There is a real risk of major haemorrhage. We elected to perform the resection laparoscopically in our patient because of a suitable location of the tumour, namely segment 5 and 6, with a large exophytic component. Also, a good triphasic MDCT with reconstruction provided excellent anatomical delineation, facilitating appropriate planning of vascular control and line of parenchymal transection.

Enucleation has been reported for smaller hemangiomas. In giant hemangioms such as in this report, the cross-sectional area for enucleation is likely to be large and visualization of the entire enucleation plane and achieving blood-less dissection could pose problems. Although control of the feeding vessel with subsequent shrinkage of the tumour could facilitate enucleation, choosing, a transverse line of transection cranially in our patient kept the transection surface to the minimum. A blood-less transection was achieved medially in the enucleation plane and cranio-laterally with the laparoscopic 4× Habib probe in our patient. Others have reported on the use of a laparoscopic Habib probe for blood-less liver parenchymal transection.[67]

Our technique of bagging the specimen is very suitable for solid organs, particularly large specimens. We have used the same technique for laparoscopic retrieval of other solid organs such as spleen or distal pancreas before. In our present report, because there was no concern of studying margins during histopathological examination, the specimen could be morselled and retrieved.

In conclusion, laparoscopic resection is feasible in giant liver hemangiomas located in the inferior segments of the right lobe of the liver. Careful pre-operative planning with MDCT imaging facilitated intraoperative dissection. Laparoscopic 4× Habib probe is an important tool in the armamentarium of liver transection methods.