Difficult PS-segments: laparoscopic PS segments

Mo Abu Hilal

Laparoscopic liver surgery is in expanding and previous reports have confirmed its feasibility, safety and oncological. (1-4)

When compared to open surgery few studies has reported multiple advantages to the laparoscopic approach when compared to open surgery at least when considering minor resections. However laparoscopic major and complex resections are still limited to centres with wide experience, due to technical difficulties and to doubts about the reported advantages.

Whilst major resections have been traditionally defined as those including 3 or more liver segments (5), laparoscopic resections of lesions located in the posterior segments has been defined a technically major complex resections. (6 , 7) These difficulties are caused by the limited access and exposure of the posterior part of the liver in proximity to the diaphragm [8]. Laparoscopic right posterior sectionectomy (RPS) has been considered as one of the most complex procedures to complete laparoscopically. Ban et al have assigned a score of 9 and 10 to LRPS putting it in the most complex category. Similarly lesion’s location in the posterior segments is defined as one of 5 factors that can affect surgical difficulty. (9, 10, 11) In fact the difficult access of seg 7 , the possible close relation of the lesions with the right hepatic vein, the difficult anatomical delineation of the right posterior section, the difficult inflow control and the need to deal with a very large area of resection margin, makes it one of the most difficult laproscopic procedure to complete.

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In Southampton, we started laparoscopic liver surgery in 2004 and with growing experience laparoscopic major and complex resections, including LRPS has been completed. We herein discuss our experience, results and techniques, highlighting a variety of tips and tricks we developed during our experience and we believe they would be of help for a safe and continuous expansion of the laparoscopic approach.

Methods: Retrospective review of prospectively maintained databases from June 2006 to June 2016. Three different techniques were used: resection following hilar inflow control, inflow control at Rouviere’s sulcus and resection with intra parenchymal control.

Results: 29 LRPS were performed over a 10-year period. Median operative time was 240 min (150–480). Pringle’s manoeuvre was performed in 19 (65.5%) with a median total duration of 35 (20–75) min. Median perioperative blood loss was 600 (100–2500) ml. Additional liver resections were performed in 16 (55.1%). There were two(6.9%) laparoscopic to open conversions. Median postoperative hospital stay was 5 (2–30) days. The median size of the tumour resected was 25 (10–54) mm with median number of resected lesions were 2 (1–4), median free resection margin was 9.5 (1–45) mm, margins were infiltrated (R1) in two (6.7%) cases. There was one death within 30-days (3.4%).

Surgical technique

Three different surgical techniques were adopted according to the lesions location, lesions nature, surgical preference and intraoperative findings, the variations in each technique will be discussed for each surgical step as needed. In patients with clear roviers, solcus , a vascular control at this level is preferred leaving the hilum intact to reduce the risk on major injuries and to keep the Hilar tissue virgin in case of future need of liver resection.

1- No vascular controlled is performed and the resection line was delineated 5-10 mm from the right hepatic vein while ensuring clear margin from the tumor.

2- Inflow control was obtained after hilar dissection and identification of the RPS vessels.

3- Inflow control was performed at the level of the Rovier’s solcus

Pure laparoscopic resections were performed in all patients. Patient are placed with right side up if no hilar control is planned, otherwise a supine position with the approximately 30 degree right side elevation with a later table tilt during the transection phase is preferred. In our experience, this offers better access to the hilum. During the procedure the surgeon moves from the left to right of the patient as needed. A pneumoperitoneum was established by 12 mm trocar placed by open technique in right upper quadrant, the intraabdominal pressure is maintained between 13 and 14 mm Hg. Two working 5-mm trocars were placed in the lateral right and left upper quadrant of the costal arch line, two 10-mm trocars placed just next to the xiphoid process, and right upper quadrant.
Laparoscopic ultrasonography was routinely performed to establish the lesion and vascular proximity, and to define the resection borders. A 5-mm nylon tape for intermittent Pringle maneuver was routinely placed.

Liver mobilizzation

A full mobilization of the right liver is needed to permit a good access to this deep and central segments, especially when the lesion is located in the posterior aspect. This achieved after dividing the falciform, anterior leaf of the coronary ligament , the retroperitoneal reflection, and after dissection of the tissue around the right hepatic vein and appropriate exposure of the inferior vena cava. The round ligament was not divided if the lesion was a known or suspected HCC. In our technique the liver is pulled in a cranio- caudal direction using the falciform ligament and the gallbladder for traction, there is no need for any major rotation as we do with for lesions in segment 7, we aim is to place the lesion in the topographic initial location of seg5/8, this can be facilitated by an anti trandulenberg position.

Parenchymal approach: In those cases no inflow control was performed and the resection was performed following the course of the right hepatic vein under uss guidance

Marking the resection margin

In all cases an intraoperative ultrasound (IOUS) is perform to identifiy he right hepatic vein (RHV) and the lesion ,The resection line is marked with diathermy hook at 2-10 mm from the RHV/ ischemia line if vascular control was performed, ensuring enough free resection margin.

Parenchymal dissection

Superficial Parenchymal transection can be achieved using a harmonic scalpel. The scalpel surface itself cuts through tissue by high frequency vibration. This technique causes minimal energy transfer to surrounding tissue, potentially limiting collateral damage . The hole length of the resection line is opened from front to back from superfical to deep avoiding the creation of deep tunnels. For deeper parenchymal transection ( this is normally after the first 2 cms from the surface) Cavitron Ultrasonic Surgical Aspirator (CUSA) (Integra Lifesciences, New Jersey, USA) was used to identify and dissect vasculature and biliary structures. Low central venous pressure was routinely maintained by the anesthetist. Titanium clips were used to controll small vessels and Hem-o-Lock clips (Weck Closure Systems, Research Triangle Park, USA) or vascular staplers were used to divide major vasculatures. Prior to completion of the operation, hemostasis was checked again under the restored central venous pressure and Valsalva maneuver. Hemostatic products such as fibrillar snow (Johnson & Johnson Wound Management) evicel; Johnson & Johnson Wound Management) were routinely used to the cut surface. The specimen was removed in a plastic endoscopic bag from a Pfannenstiel incision.


Laparoscopic right posterior sectionectomy (LRPS) in a different studies was confirmed to be a major surgery in consideration of the operation time, blood lost and post-operative hospital stay. (9, 10, 11) LRPS has long represented a challenge to laparoscopic liver surgeons. It is a demanding operation which combines several maneuver, including; mobilization of the largest and deepest part of the liver, dissection of veins (portal and hepatic vein), ligature of a RP pedicle, Parenchyma transection and treatment of a wide hepatic stump. In addition the multiple curvilinear resection surfaces, make this laparoscopic resections seriously challangin . However, a number of studies from our center and other groups have reported on the management of lesions in posterior liver segments demonstrating the feasibility of this approach. (8,12-15) However we continue to emphasise the recommendations of the Southampton guidelines consensus that certain procedures should be only performed by surgeons who have gained sufficient experience in minor and non-complex major resections. (16) The Southampton difficulty score have been recently published and it may be a good help for surgeons in undersatanding which procedures they may be able to complete safely based on their position on the learning curve. (11)


LRPS is a feasible and efficient, safe. However, they are technically challenging and requires advance skills in liver and laparoscopic surgery. Few approaches are available and surgeons should be familiar with the different approaches to utilize accordingly.