The study is self-sponsored.

The protocol follows the guidelines of Kwong Wah Hospital&#39;s human research ethics committee.
1. Pre-operative workup
<ol>
	<li>Check triphasic CT scans to evaluate the extent of disease and vascular anatomy.</li>
	<li>Perform an indocyanine green (ICG) retention test to assess liver function properly. Preferably, ICG retention of less than 15% is required for patients to undergo major liver resection13.</li>
	<li>Perform CT volumetry to ensure adequate residual liver volume (RLV). 40% RLV is required for cirrhotic liver, while 30% RLV is necessary for the normal liver14.</li>
</ol>
2. Anesthesia
<ol>
	<li>Administer pre-operative antibiotics, typically 1.2 g of amoxicillin and clavulanic acid, intravenously on induction of anesthesia.</li>
	<li>Perform deep venous thrombosis prophylaxis with a sequential compression device and compression stockings15.</li>
	<li>Place an arterial line and a central venous line.</li>
	<li>Control low central venous pressure to 3-8 mmHg16. An anesthetist performs this.</li>
</ol>
3. Patient positioning
<ol>
	<li>Position the patient in the Lloyd-Davis position on a split-leg table.</li>
	<li>Set the theatre as depicted in Figure 2, allowing the surgeon to stand between the patient&#39;s legs. 
	NOTE: This position allows the surgeon to operate while standing between the legs, providing ergonomic benefits during such a lengthy procedure and preventing early fatigue.</li>
	<li>Elevate the patient to 30&#176; left lateral position with a pillow during the operation.</li>
</ol>
4. Port site insertion and the laparoscope
<ol>
	<li>Establish access into the intraabdominal cavity with a sub-umbilical incision by open Hasson Technique17.</li>
	<li>Place the remaining ports as depicted in Figure 3.</li>
	<li>Place a 12 mm port in the right upper quadrant along the midclavicular line.</li>
	<li>Place 5 mm laparoscopic assistant port at epigastrium, right flank along the anterior axillary line, and left upper quadrant. 
	NOTE: A laparoscope with a flexible tip is preferred for a better view above the dome of the liver (Figure 4).</li>
</ol>
5. Operative steps
<ol>
	<li>Mobilization of the whole right lobe of the liver
	<ol>
		<li>Expose the root of the right hepatic vein superiorly.
		<ol>
			<li>Complete division of triangular ligament until bare area exposed.</li>
			<li>Expose the groove between the right hepatic veins and the common trunk of the middle and left hepatic veins.</li>
		</ol>
		</li>
		<li>Expose the root of IVC inferiorly.
		<ol>
			<li>Incise inferior peritoneal attachment and drop the adrenal gland to the retroperitoneum.</li>
			<li>Divide the short hepatic veins and vena cava ligament until the inferior border of the right hepatic vein is seen.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Right posterior pedicle control with intrahepatic Glissonian approach18.
	<ol>
		<li>Dissect along the superior border of the right posterior Glissonian pedicle along the Rouviere sulcus while keeping the Laennec capsule intact.</li>
		<li>Transect the caudate process to expose the inferior margin of the right posterior Glissonian pedicle.</li>
		<li>Dissect along the inferior border of the right posterior Glissonian pedicle along the Rouviere sulcus while keeping the Laennec capsule intact.</li>
		<li>Control the right posterior pedicle temporarily with a bulldog clamp.</li>
	</ol>
	</li>
	<li>Determination of the transection plane along the ischaemic line
	<ol>
		<li>Perform Intraoperative ultrasonography (USG) to identify the course of the right hepatic vein19.</li>
		<li>Open the liver capsule with an ultrasonic scalpel (Table of Materials) at the dome of the liver along the left margin of the right hepatic vein to secure a correct transection plane.</li>
		<li>Mark the rest of the transection line along the ischaemic line with diathermy.</li>
	</ol>
	</li>
	<li>Pringle maneuver
	<ol>
		<li>Prepare intracorporeal tourniquet for laparoscopic Pringle maneuver by Huang&#39;s Loop using a shortened Foley catheter20.</li>
	</ol>
	</li>
	<li>Parenchymal transection
	<ol>
		<li>Open the liver capsule with an ultrasonic scalpel along the planned transection line.</li>
		<li>Perform subsequent deep parenchymal transection with the &#39;ultrasonic scalpel mimic CUSA&#39; technique12.
		<ol>
			<li>Keep both arms of the ultrasonic scalpel open.</li>
			<li>Use the active blade of the ultrasonic scalpel to dissect the tissue.</li>
			<li>Activate maximum and move the active blade in a horizontal swinging motion parallel to the vasculobiliary structure.</li>
			<li>Dissect the parenchyma while exposing the individual intrahepatic vessels and leaving them intact.</li>
			<li>Use a suction device with the left hand constantly to keep the surgical field dry.</li>
			<li>Divide small vessels with the ultrasonic scalpel.</li>
			<li>Divide large vessels or pedicle structures between plastic clips (Table of Materials) or metal clips.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Right posterior pedicle transection
	<ol>
		<li>Encircle the right posterior pedicle with vascular tape.</li>
		<li>Transect the right posterior pedicle with a vascular stapler.</li>
	</ol>
	</li>
	<li>Right hepatic vein transection
	<ol>
		<li>Transect the right hepatic vein with a vascular stapler.</li>
	</ol>
	</li>
	<li>Bleeding control
	<ol>
		<li>The right posterior pedicle is temporarily controlled as a form of partial Pringle&#39;s maneuver during parenchymal transection. Meticulous dissection and identification of intrahepatic vessels are critical. Divide portal and hepatic venules with clips or ultrasonic scalpel.</li>
		<li>Use bipolar diathermy for bleeding with simultaneous suctioning to clear the surgical field.</li>
		<li>Increase carbon dioxide pneumoperitoneum (15-20 mmHg) to slow down the bleeding from hepatic veins and use intracorporal suture for significant bleeding, for example, bleeding from the right hepatic vein.</li>
		<li>Use a suture to secure bleeding from large veins or arteries.</li>
	</ol>
	</li>
</ol>
6. Specimen retrieval
<ol>
	<li>The specimen is put into a plastic bag and retrieved through the Pfannenstiel incision.</li>
</ol>

Advancing LRPS: Optimal Techniques for Challenging Liver Resections

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A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+versus+open+resection+for+colorectal+liver+metastases:+The+OSLO-COMET+randomized+controlled+trial.">Laparoscopic versus open resection for colorectal liver metastases: The OSLO-COMET randomized controlled trial.</a> Annals of Surgery. 267 (2), 199-207 (2018).</li><li>Landi, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Short-term+outcomes+of+laparoscopic+vs.+open+liver+resection+for+hepatocellular+adenoma:+a+multicenter+propensity+score+adjustment+analysis+by+the+AFC-HCA-2013+study+group.">Short-term outcomes of laparoscopic vs. open liver resection for hepatocellular adenoma: a multicenter propensity score adjustment analysis by the AFC-HCA-2013 study group.</a> Surgical Endoscopy. 31 (10), 4136-4144 (2017).</li><li>Cho, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safe+and+feasible+extrahepatic+Glissonean+access+in+laparoscopic+anatomical+liver+resection.">Safe and feasible extrahepatic Glissonean access in laparoscopic anatomical liver resection.</a> Surgical Endoscopy. 25 (4), 1333-1336 (2011).</li><li>Oztas, M., Lapsekili, E., Fatih Can, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+liver+right+posterior+sectionectomies;+surgical+technique+and+clinical+results+of+a+single+surgeon+experience.">Laparoscopic liver right posterior sectionectomies; surgical technique and clinical results of a single surgeon experience.</a> Turkish Journal of Surgery. 38 (1), 18-24 (2022).</li><li>Siddiqi, N. N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+right+posterior+sectionectomy+(LRPS):+surgical+techniques+and+clinical+outcomes.">Laparoscopic right posterior sectionectomy (LRPS): surgical techniques and clinical outcomes.</a> Surgical Endoscopy. 32 (5), 2525-2532 (2018).</li><li>Machado, M. A., Makdissi, F. F., Galvao, F. H., Machado, M. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intrahepatic+Glissonian+approach+for+laparoscopic+right+segmental+liver+resections.">Intrahepatic Glissonian approach for laparoscopic right segmental liver resections.</a> The American Journal of Surgery. 196 (4), e38-e42 (2008).</li><li>Machado, M. A., Kalil, A. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Glissonian+approach+for+laparoscopic+mesohepatectomy.">Glissonian approach for laparoscopic mesohepatectomy.</a> Surgical Endoscopy. 25 (6), 2020-2022 (2011).</li><li>Topal, B., Aerts, R., Penninckx, F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+intrahepatic+Glissonian+approach+for+right+hepatectomy+is+safe,+simple,+and+reproducible.">Laparoscopic intrahepatic Glissonian approach for right hepatectomy is safe, simple, and reproducible.</a> Surgical Endoscopy. 21 (11), 2111 (2007).</li><li>Park, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safety+and+Risk+factors+of+pure+laparoscopic+living+donor+right+hepatectomy:+Comparison+to+open+technique+in+propensity+score-matched+analysis.">Safety and Risk factors of pure laparoscopic living donor right hepatectomy: Comparison to open technique in propensity score-matched analysis.</a> Transplantation. 103 (10), e308-e316 (2019).</li><li>Yang, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Laparoscopic+liver+resection+with+&amp;#34;ultrasonic+scalpel+mimic+CUSA&amp;#34;+technique.">Laparoscopic liver resection with &amp;#34;ultrasonic scalpel mimic CUSA&amp;#34; technique.</a> Surgical Endoscopy. 36 (12), 8927-8934 (2022).</li><li>Kitano, S., Kim, Y. 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Laparoscopes articulating HD 3D videoscope ENDOEYE FLEX 3D (LTF-190-10-3D) Available from: <a target="_blank" href="https://medical.olympusamerica.com/products/laparoscopes/endoeye-flex-3d">https://medical.olympusamerica.com/products/laparoscopes/endoeye-flex-3d</a> (2023)</li><li>Welling, A., Scoggins, P., Cummings, J., Clymer, J., Amaral, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Superior+dissecting+capability+of+a+new+ultrasonic+device+improves+efficiency+and+reduces+adhesion+formation.">Superior dissecting capability of a new ultrasonic device improves efficiency and reduces adhesion formation.</a> Global Surgery. 3 (1), (2017).</li><li>Lortat-Jacob, J. L., Robert, H. 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The authors have nothing to disclose.

The critical components of the surgery include the intrahepatic Glissonian approach for inflow control, a &#39;ultrasonic scalpel mimic CUSA&#39; parenchymal transection technique, early identification of right hepatic vein and meticulous bleeding control by bipolar diathermy.
The first critical step in this protocol is identifying and controlling the right posterior pedicle. The Glissonian approach was first introduced as extrahepatic Glissonian pedicle control in open liver surgery23 and has been associated with reduced blood loss and faster than intra-fascial approach24,25,26. With the advancement of laparoscopic liver surgery, the laparoscopic Glissonian approach has become a safe and effective alternative to traditional inflow control. Cho et al. demonstrated that the laparoscopic extrahepatic Glissonian approach is feasible and safe in hepatectomy5. Machado et al. and Topal et al. also reported the feasibility and safety of the laparoscopic intrahepatic Glissonian approach8,9,10. This intrahepatic Glissonian approach, also known as the extra-fascial approach with minor hepatotomy27, involves making a hepatotomy on the right edge of the gallbladder bed and a vertical incision on the segment seven perpendicular to the hepatic hilum. Rouviere&#39;s sulcus is a reliable anatomical landmark housing the right posterior pedicle28. After making the hepatotomies, blunt dissection around the Rouviere&#39;s sulcus readily exposes the right posterior pedicle, which can be temporarily controlled with a vascular clamp, serving as a partial Pringle&#39;s maneuver. Ultrasonographic confirmation of normal vascular flow in other segments and the appearance of a demarcation line indicates the correct placement of the vascular clamp.
This approach can allow anatomical segmental resection, which is shown to be associated with a lower recurrence rate than non-anatomical resection29. It also provides rapid and direct access to the right posterior pedicle, avoiding the time-consuming and tedious hilar dissection. Compared with the extrahepatic approach, which, as proposed by the Korean group, is not always feasible, especially for right posterior sectionectomy, as the extrahepatic course for the right pedicle is short5. However, aberrant vascular and biliary anatomy may pose potential difficulties and danger in the intrahepatic Glissonian approach. Pre-operative studying of any imaging and liberal use of intra-operative cholangiogram and ultrasonography are essential. Laparoscopic encircling of the Glissonian pedicle may be difficult due to the constraint of movement of the laparoscopic instrument. The approach used in this case temporarily controls the pedicle with a Bulldog clamp, leaving the encircling part until the parenchymal transection is completed. This modification to Machado et al.&#39;s proposed method is a safe and easier way of performing major hepatectomy30. One limitation of this technique is that when the tumor is closed to the liver hilum, the intrahepatic Glissonian approach may cause the tumor to rupture, compromising the resection margins.
The current consensus on the best practice for laparoscopic liver parenchymal transection is still lacking29. Several surgical devices are most commonly used, including the ultrasonic scalpel, vessel sealer, CUSA, diathermy, monopolar sealer (saline drip), argon beam coagulator, radiofrequency pre-coagulator, microwave pre-coagulator and water-jet31,32. Mechanical methods include the crush-clamp approach and stapler31,32. The choice of liver parenchymal transection technique ultimately depends on the surgeon&#39;s preference. Professor Kwon introduced a novel technique called the &#39;ultrasonic scalpel mimic CUSA&#39; technique in 201911. This technique was initially used only for superficial parenchymal transection, while CUSA was used for deeper tissue. However, another study used this technique for the entire parenchymal transection12. The retrospective series by Yang et al. showed promising results. Their study showed that the &#39;ultrasonic scalpel mimic CUSA&#39; group resulted in less intraoperative blood loss and shorter operative time when compared to the CUSA group. This technique is best for the cirrhotic liver because CUSA would inadvertently damage vessels and bile ducts easily in such a situation.
The model of the ultrasonic scalpel affects the accuracy of tissue dissection. We prefer the specific model stated in Table of Materials (Figure 5) because of a blunter and shorter active blade that will cause less inadvertent tissue, bile duct, or vessel injury.
Identification and constant visualization of a clear transection plane are crucial for safe parenchymal transection when operating in this anatomically challenging location where visibility may be limited. The success of our surgery relies on two essential tips. Firstly, early identification of the right hepatic vein is vital. Anatomical resection should always follow the plane along the hepatic veins. However, bleeding from veins may occur during the parenchymal transection. Low central venous pressure should be maintained during the dissection along the hepatic veins. Minor bleeding can usually be controlled by gauze packing and bipolar diathermy, with the surgeon&#39;s assisting hand maintaining suction to keep the field clear. However, in case of significant bleeding from the right hepatic vein and even IVC, the surgeon should be familiar with intracorporal suturing techniques to control the bleeding effectively. Secondly, we used a flexible tip laparoscope. A skillful camera operator should be able to manipulate the laparoscope smoothly and accurately to provide a clear view of the field around the corners and in tight spaces, improving the surgeons&#39; ability to identify and maintain a correct transection plane.
The intrahepatic Glissonian approach and the &#39;ultrasonic scalpel mimic CUSA&#39; parenchymal transection method are promising techniques in helping surgeons overcome the difficulties in this challenging operation. Early identification of hepatic veins and meticulous hemostasis by bipolar diathermy minimize blood loss. Laparoscopic right posterior sectionectomy is safe and feasible in preserving the liver parenchymal while achieving anatomical resection for hepatic tumors.

Laparoscopic liver surgery has been shown to have several advantages over open liver resection, including reduced blood loss, decreased wound pain, and shorter hospital stay while maintaining comparable oncological outcomes1,2,3,4. Although LRPS was previously considered a relative contraindication due to its deep-seated anatomic location and challenges in bleeding control, recent advancements have proven its safety and feasibility2,5,6,7. Various strategies and surgical devices have been developed to overcome these challenges. However, no consensus exists on the best surgical technique and devices for LRPS.
In this article, we aim to provide a detailed description of the steps involved in LRPS at our centre, with a specific focus on the intrahepatic Glissonian approach for inflow control, a novel technique called the &#39;ultrasonic scalpel mimic Cavitron ultrasonic surgical aspirator (CUSA)&#39; for parenchymal transection, early identification of the right hepatic vein, and meticulous bleeding control using bipolar diathermy. Machado et al. and Topal et al. reported the feasibility and safety of the laparoscopic intrahepatic Glissonian approach8,9,10. Laparoscopic techniques offer improved visualization and precision in dissecting the Glissonian pedicle. The approach maintains the blood flow to the remnant liver, reducing the risk of ischaemic injury. Additionally, this approach allows for the exact demarcation of liver segments that are being resected, making the surgery more precise and reducing the risk of bleeding. Professor Kwon introduced the &#39;ultrasonic scalpel mimic CUSA&#39; technique in 201911, which has been shown to reduce intraoperative blood loss and operative time11,12.
A representative case is discussed in this study to detail the steps performed in the protocol. The patient is a 54-year-old man who is a chronic carrier of hepatitis B. During screening ultrasonography, a liver mass was identified in segment 6. A pre-operative triphasic computed tomography (CT) scan was performed, which revealed a 5.7 cm hypervascular tumor with arterial enhancement and portovenous washout in segment 7 (Figure 1).&#160;The alpha-fetoprotein (AFP) level was 2 ng/ml. The Child-Pugh score was 5 (Grade A). The indocyanine green retention at 15 min was 7.5%. The residual liver volume (RLV) was 45%. Based on the patient&#39;s hepatitis status and the radiological features of the tumor, the mass was treated as hepatocellular carcinoma. The patient was offered a laparoscopic right posterior sectionectomy, including the right hepatic vein.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>3D ENDOEYE Flex</td>
			<td>Olympus&#160;</td>
			<td>LTF-S190-10-3D</td>
			<td>Flexible tip laparoscopic camera</td>
		</tr>
		<tr>
			<td>5 mm ROBI Bipolar Grasping Forceps</td>
			<td>KARL STORZ</td>
			<td>38851 ON</td>
			<td>atraumatic, fenestrated forceps</td>
		</tr>
		<tr>
			<td>AESCULAP Challenger Ti-P</td>
			<td>Barun</td>
			<td>PL520L</td>
			<td>Pneumatic driven multi-fire clip applicator. 5 mm metal clips</td>
		</tr>
		<tr>
			<td>Endo GIA Reloads with Tri-Staple Technology, 30 mm, Tan colour</td>
			<td>Medtronic&#160;</td>
			<td>SIG30AVM</td>
			<td>Tristaple system that has stepped cartridge face that delivers graduated compression and three rows of varied height staples. Staple height 2 mm, 2.5 mm, 3 mm.</td>
		</tr>
		<tr>
			<td>Endo GIA Ultra Universal Stapler</td>
			<td>Medtronic&#160;</td>
			<td>EGIAUSTND</td>
			<td>Manual stapler that compresses tissue while it simultaneously lays down a staple line and transects the tissue</td>
		</tr>
		<tr>
			<td>HARMONIC ACE+7 Shears</td>
			<td>Ethicon</td>
			<td>HARH36</td>
			<td>Curved tip, energy sealing and dissecting, diameter 5 mm, length 36 cm</td>
		</tr>
		<tr>
			<td>Hem-o-lok Clips L</td>
			<td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td>
			<td>544240</td>
			<td>Vascular clip 5&#8211;13 mm Size Range</td>
		</tr>
		<tr>
			<td>Hem-o-lok Clips ML</td>
			<td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td>
			<td>544230</td>
			<td>Vascular clip 3&#8211;10 mm Size Range</td>
		</tr>
		<tr>
			<td>Hem-o-Lok Polymer Ligation System</td>
			<td>Weck Surgical Instruments, Teleflex Medical, Durham, NC</td>
			<td>544965</td>
			<td></td>
		</tr>
		<tr>
			<td>Profocus 2202 Ultraview 800</td>
			<td>BK Medical&#160;</td>
			<td>N/A</td>
			<td>Intraoperative Ultrasonography</td>
		</tr>
	</tbody>
</table>

techniques of laparoscopic right posterior sectionectomy: glissonian approach and a parenchymal transection technique

Laparoscopic liver resections (LLR) have been widely accepted as a treatment option for liver tumors. They offer several advantages over open liver resections, including less blood loss, reduced wound pain, and shorter hospital stays with a comparable oncological outcome. However, laparoscopic resection of lesions in the right posterior section of the liver is challenging due to difficulties in bleeding control and visualizing the surgical field. In the past, laparoscopic right posterior sectionectomy (LRPS) was still in the exploration phase, with undefined risks in the Second International Consensus Conference on LLR in 2014. However, recent technological advancements and increased surgical experience have shown that LRPS can be safe and feasible. It has been found to reduce hospital stay and blood loss compared to open surgery. This manuscript aims to provide a detailed description of the steps involved in LRPS. The key factors contributing to our success in this challenging procedure include proper liver retraction and exposure, the use of an intrahepatic Glissonian approach for inflow control, a technique called the 'ultrasonic scalpel mimic Cavitron ultrasonic surgical aspirator (CUSA)' for parenchymal transection, early identification of the right hepatic vein, and meticulous bleeding control using bipolar diathermy.

In the representative case, the total operative time was 738 min, with an estimated blood loss of 400 mL. The patient was nursed in the intensive care unit for 2 days. The recovery was uneventful, and the patient was discharged on postoperative day 5. Histopathological examination of the specimen revealed moderately differentiated cholangiocarcinoma measured 8.0 cm x 5.5 cm x 4.5 cm. There was no perineural or lymphovascular permeation. The resection margin was 14 mm. The American Joint Committee on Cancer (AJCC) staging (8th edition) was pT1bN0M0. He was regularly followed up after the operation. The follow-up protocol is a 3-monthly follow-up in the first 2 years and then 6-monthly subsequently. The follow-up included clinical examination, liver function test and serum alpha-fetoprotein, and 6-monthly chest X-ray and contrast-enhanced computed tomography. All these details are listed in Table 1. The patient&#39;s first postoperative imaging is depicted in Figure 1C. It has been 2 years and 7 months post operation with no signs of recurrence and a normal serum alpha-fetoprotein level.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/65668/65668fig01.jpg" /> 
Figure 1: Pre-operative and postoperative triphasic computed tomography scan. (A)&#160;Arterial enhancing mass at segment 7 of the liver. The red arrow points at the tumor, and the yellow arrow points at the right hepatic vein. (B)&#160;The segment 7 tumor showed portovenous washout. The red arrow points at the tumor, and the yellow arrow points at the right hepatic vein. (C)&#160;Postoperative computed tomography scan. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65668/65668fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/65668/65668fig02.jpg" /> 
Figure 2. Patient positioning and theatre setup. The patient is placed in the Lloyd-Davis position on a split-leg table with the surgeon standing between the patient&#39;s leg. The first assistant stands on the patient&#39;s left side while the second assistant, responsible for holding the camera, stands between the surgeon and the first assistant. The instrumental table is placed on the right side while the scrub nurse standing next to the surgeon passes instruments to the surgeon. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65668/65668fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/65668/65668fig03.jpg" /> 
Figure 3. Port placement. 12 mm sub-umbilical port (camera port). (A) 5 mm port at the right flank along the anterior axillary line. (B) 12 mm port at the right upper quadrant along the mid-clavicular line. (C) 5 mm port at the left upper quadrant (liver retractor/assistant). (D) 5 mm port at epigastrium. Abbreviations: MCL = mid clavicular line; AAL = anterior axillary line. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65668/65668fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/65668/65668fig04.jpg" /> 
Figure 4. Flexible tip laparoscope. Its flexible tip (up-down and left-right) facilitates visualization of the anatomically obscured area, i.e., the dome. However, it requires a skillful and trained camera holder to operate this laparoscope21. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65668/65668fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/65668/65668fig05.jpg" /> 
Figure 5. Difference between the two models of the ultrasonic scalpel. This figure has been modified with permission from Welling et al.22. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65668/65668fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Total Operative Time&#160;</td>
			<td colspan="3">738 min</td>
		</tr>
		<tr>
			<td>Estimated blood loss</td>
			<td colspan="3">400 mL</td>
		</tr>
		<tr>
			<td>Day of discharge&#160;</td>
			<td colspan="3">Post-operative day 5</td>
		</tr>
		<tr>
			<td rowspan="5">Histopathological examination&#160;</td>
			<td colspan="3">Moderately differentiated cholangiocarcinoma&#160;</td>
		</tr>
		<tr>
			<td colspan="3">Size of tumour: 8.0 cm x 5.5 cm x 4.5 cm</td>
		</tr>
		<tr>
			<td colspan="3">Resection margin: 14 mm</td>
		</tr>
		<tr>
			<td colspan="3">No perineural or lymphovascular permeation&#160;</td>
		</tr>
		<tr>
			<td colspan="3">(American Joint Committee on Cancer (AJCC) staging (8th edition): pT1bN0M0)</td>
		</tr>
		<tr>
			<td>First post-operative CT</td>
			<td colspan="3">See Figure 1C</td>
		</tr>
		<tr>
			<td rowspan="5">Follow-up&#160;</td>
			<td colspan="3">Total follow-up period: 2 years 7 months</td>
		</tr>
		<tr>
			<td colspan="3">Status: No recurrence, normal serum alpha-fetoprotein level</td>
		</tr>
		<tr>
			<td colspan="3">Follow up protocol</td>
		</tr>
		<tr>
			<td colspan="3">&#183; 3-monthly follow-up in first two years, then 6-monthly subsequently</td>
		</tr>
		<tr>
			<td colspan="3">&#183; Clinical examination, liver function test and serum alpha-fetoprotein level, chest X-ray and contrast-enhanced computed tomography 6-monthly&#160;</td>
		</tr>
	</tbody>
</table>
Table 1: Surgical outcomes and post operative details of the patient.

Watch this Scientific Journal Video about Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique at JoVE.com

Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique

Here, we present a protocol to perform laparoscopic right posterior sectionectomy, focusing on two key aspects: the intrahepatic Glissonian approach for inflow control and a parenchymal transection technique using an ultrasonic surgical aspirator.

Laparoscopic liver resections (LLR) have been widely accepted as a treatment option for liver tumors. They offer several advantages over open liver ...

techniques-laparoscopic-right-posterior-sectionectomy-glissonian

Nanyang Technological University

Research

JoVE Journal

Medicine

741 Views.  Kwong Wah Hospital. Here, we present a protocol to perform laparoscopic right posterior sectionectomy, focusing on two key aspects: the intrahepatic Glissonian approach for inflow control and a parenchymal transection technique using an ultrasonic surgical aspirator.

Video: Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique

Rat Model of Photochemically-Induced Posterior Ischemic Optic Neuropathy

Posterior Ischemic optic neuropathy (PION) is a sight-devastating disease in clinical practice. However, its pathogenesis and natural history have&#160;remained poorly understood. Recently, we developed a reliable, reproducible animal model of PION and tested the treatment effect of some neurotrophic factors in this model1. The purpose of this video is to demonstrate our photochemically induced model of posterior ischemic optic neuropathy, and to evaluate its effects with retrograde labeling of retinal ganglion cells. Following surgical exposure of the posterior optic nerve, a photosensitizing dye, erythrosin B, is intravenously injected and a laser beam is focused onto the optic nerve surface. Photochemical interaction of erythrosin B and the laser during irradiation damages the vascular endothelium, prompting microvascular occlusion mediated by platelet thrombosis and edematous compression. The resulting ischemic injury yields a gradual but pronounced retinal ganglion cell dieback, owing to a loss of axonal input - a remote, injury-induced and clinically relevant outcome. Thus, this model provides a novel platform to study the pathophysiologic course of PION,&#160;and can be further optimized for testing therapeutic approaches for optic neuropathies as well as other CNS ischemic diseases.

The goal of this protocol is to photochemically induce ischemic injury to the posterior optic nerve in rat. This model is critical to studies of the pathophysiology of posterior ischemic optic neuropathy, and therapeutic approaches for this and other optic neuropathies, as well as of other CNS ischemic diseases.

Posterior Ischemic optic neuropathy (PION) is a sight-devastating disease in clinical practice. However, its pathogenesis and natural history ...

Laparoscopic Technique for Serial Collection of Liver and Mesenteric Lymph Nodes in Macaques

The mesenteric lymph nodes (MLN) and the liver are exposed to microbes and microbial products from the gastrointestinal (GI) tract, making them immunologically unique. The GI tract and associated MLN are sites of early viral replication in human immunodeficiency virus (HIV) infection and the MLN are likely important reservoir sites that harbor latently-infected cells even after prolonged antiretroviral therapy (ART). The liver has been shown to play a significant role in immune responses to lentiviruses and appears to play a significant role in clearance of virus from circulation. Nonhuman primate (NHP) models for HIV and Acquired Immunodeficiency Syndrome (AIDS) closely mimic these aspects of HIV infection and serial longitudinal sampling of primary sites of viral replication and the associated immune responses in this model will help to elucidate critical events in infection, pathogenesis, and the impact of various intervention strategies on these events. Current published techniques to sample liver and MLN together involve major surgery and/or necropsy, which limits the ability to investigate these important sites in a serial fashion in the same animal. We have previously described a laparoscopic technique for collection of MLN. Here, we describe a minimally invasive laparoscopic technique for serial longitudinal sampling of liver and MLN through the same two port locations required for the collection of MLN. The use of the same two ports minimizes the impact to the animals as no additional incisions are required. This technique can be used with increased sampling frequency compared to major abdominal surgery and reduces the potential for surgical complications and associated local and systemic inflammatory responses that could complicate interpretation of results. This procedure has potential to facilitate studies involving NHP models while improving animal welfare.

Here, we describe a minimally invasive laparoscopic technique for serial sampling of liver and mesenteric lymph nodes (MLN) in macaques that allows for increased sampling frequency, and reduces the potential for surgical complications when compared to performing a laparotomy.

The mesenteric lymph nodes (MLN) and the liver are exposed to microbes and microbial products from the gastrointestinal (GI) tract, making them ...

Posterior Semicircular Canal Approach for Inner Ear Gene Delivery in Neonatal Mouse

Inner ear gene therapy offers great promise as a potential treatment for hearing loss and dizziness. One of the critical determinants of the success of inner ear gene therapy is to find a delivery method which results in consistent transduction efficiency of targeted cell types while minimizing hearing loss. In this study, we describe the posterior semicircular canal approach as a viable method for inner ear gene delivery in neonatal mice. We show that gene delivery through the posterior semicircular canal is able to perfuse the entire inner ear. The easy anatomic identification of the posterior semicircular canal, as well as minimal manipulation of the temporal bone required, make this surgical approach an attractive option for inner ear gene delivery.

In this study, we describe the posterior semicircular canal approach as a reliable method for inner ear gene delivery in neonatal mice. We show that gene delivery through the posterior semicircular canal is able to perfuse the entire inner ear.

Inner ear gene therapy offers great promise as a potential treatment for hearing loss and dizziness. One of the critical determinants of the success of ...

Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The incidence of the pathology increases with growing age after 65 years. Conventional surgical aortic valve replacement through median sternotomy has been the gold standard of patient care for symptomatic aortic valve stenosis. However, as the risk profile of patients worsens, other therapeutic strategies have been introduced in an attempt to maintain the excellent results obtained by the established surgical treatment. One of these approaches is represented by transcatheter aortic valve implantation. Although the outcomes of high-risk patients undergoing treatment for symptomatic aortic valve stenosis have improved with transcatheter aortic valve replacement, many patients with this condition remain candidates for surgical aortic valve replacement. In order to reduce the surgical trauma in patients who are candidates for surgical aortic valve replacement, minimally invasive approaches have garnered interest during the past decade. Since the introduction of right anterior thoracotomy for aortic valve replacement in 1993, right anterior mini-thoracotomy and upper hemi-sternotomy have become the predominant incisional approaches among cardiac surgeons performing minimal access aortic valve replacement. Beside the location of the incision, the arterial cannulation site represents the second major landmark of minimal access techniques for aortic valve replacement. The two most frequently used arterial cannulation sites include central aortic and peripheral femoral approaches. With the purpose of reducing surgical trauma in these patients, we have opted for a right anterior mini-thoracotomy approach with a central aortic cannulation site. This protocol describes in detail a technique for minimally invasive aortic valve replacement and provides recommendations for patient selection criteria, including cardiac computer tomography measurements. The indications and limitations of this technique, as well as its alternatives, are discussed.

The goal of this protocol is to describe in detail the technique of minimally invasive aortic valve replacement through a right anterior mini-thoracotomy and central aortic cannulation. This technique can potentially enhance patients&#39; comfort and, by reducing post-operative morbidity, promote lowering the length of stay and global costs.

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The ...

Laparoscopic Radical Left Pancreatectomy for Pancreatic Cancer: Surgical Strategy and Technique Video

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological resection of left-sided pancreatic cancer. Several surgical techniques have been described in recent years, but few were specifically designed for minimally invasive approaches. This study describes and demonstrates a standardized and reproducible technique for an adequate oncological resection of pancreatic cancer: laparoscopic radical left pancreatectomy (LRLP).
A 61-year-old woman presented with an incidental finding of a 3 cm mass in the left pancreas suspect for malignancy. Imaging did not reveal distant metastases, central vascular involvement, or morbid obesity, hence the patient was suitable for LRLP. This study describes the main steps of LRLP for pancreatic cancer. First, the lesser sac is opened by transecting the gastrocolic ligament. The splenic flexure of the colon is mobilized and the inferior border of the pancreas including Gerota&#39;s fascia is dissected down to the inferior border of the spleen. The pancreas is tunneled and hung, including Gerota&#8217;s fascia with a vessel loop. At the pancreatic neck, a tunnel is created between the pancreas and the portal vein, likewise a vessel loop is passed. The pancreas is then transected using the graded compression technique with an endostapler. Both the splenic vein and artery are transected before completing the resection. The entire specimen is extracted in a retrieval bag via a small Pfannenstiel incision.
Duration of the surgery was 210 min with 250 mL blood loss. Pathology revealed a R0-resection (&#62;1 mm) of a well-to-moderately differentiated adenocarcinoma originating from an intraductal papillary mucinous neoplasm. A total of 15 tumor-negative lymph nodes were resected. This is a detailed description of LRLP for left-sided pancreatic cancer as is currently being used within the international, multicenter randomized DIPLOMA (Distal Pancreatectomy Minimally Invasive or Open for PDAC) trial.

Oncologically safe left pancreatectomy requires radical resection (R0), Gerota&#8217;s (perirenal) fascia resection, and adequate lymph node dissection. This study describes the technical details of laparoscopic radical left pancreatectomy (LRLP), used in the first international multicenter randomized trial comparing minimally invasive with open left pancreatectomy for pancreatic cancer, the DIPLOMA trial.

Radical resection margins, resection of Gerota&#8217;s (perirenal) fascia, and adequate lymph node dissection are crucial for an adequate oncological ...

Posterior Approach for Debridement of the Psoas Abscess

This method focuses on outlining a safe zone for irrigation and debridement of a psoas abscess through a posterior approach. Initially, an anterior approach to the spine was performed to ensure that the anterior longitudinal ligament and the psoas muscle could be visualized. All the abdominal organs were removed. Subsequently, a posterior approach was performed to remove the paraspinal muscles from L1&#8211;L5. The transverse processes, pars interarticularis and lamina of L1&#8211;L5 were identified. The exiting nerve root was identified between the transverse processes and followed into the substance of the psoas muscle. Using the anterior and posterior approach, the lumbar plexus was isolated from the substance of the psoas muscle. Before and after various steps of dissection, digital photographs were obtained. These images were uploaded into ImageJ and multiple measurements, including the distance between the lateral superior and inferior tip of each TP to the most lateral region of the plexus, the distance between the lateral superior and inferior tip of the TP to the lateral edge of the psoas, and the width of the lumbar plexus were recorded. The safe zone for entering the substance of the psoas muscle was defined between the lateral edge of the psoas muscle and the lateral edge of the lumbar plexus. The relationship of this interval to the tip of the transverse process at each level was measured and reported.

This is a cadaveric study investigating the landmarks for the posterior approach for irrigation and debridement of the psoas abscess. The interval between the transverse processes (TP) was used to access the substance of the psoas muscle.

This method focuses on outlining a safe zone for irrigation and debridement of a psoas abscess through a posterior approach. Initially, an anterior ...

Surgical Techniques to Optimize Ovarian Reserve during Laparoscopic Cystectomy for Ovarian Endometrioma

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts to spare normal ovarian cortex. Optimization of tubal anatomy is another frequent consideration. Fertility-sparing laparoscopic techniques at the time of cystectomy for ovarian endometrioma seek to limit iatrogenic surgical damage to the ovarian cortex and strategically assess and respond to genital tract patency. Surgical candidates frequently desire relief from endometriosis-associated pain while also seeking to optimize spontaneous or assisted conception rates. Operative benefits include potential for surgical and histopathologic diagnosis of endometriosis, evaluation of genital tract patency, and treatment of visualized lesions. Resection of ovarian endometrioma nonetheless poses significant risks, including surgical injury, blood loss, post-surgical decline in ovarian reserve and post-operative inflammation with adhesion formation, both of which may impair folliculogenesis.
We present the case of a 32-year-old woman with known endometriosis and continued pain refractory to medical management who opted for surgical management of her disease tailored toward optimizing her chances at future conception. Using this case as an example, we describe techniques and considerations for diagnostic laparoscopy, adhesiolysis, ovarian cystectomy, chromopertubation, and salpingectomy with a focus on maintaining a fertility-preserving approach.

This protocol presents techniques to laparoscopically excise ovarian endometrioma, to perform adhesiolysis with sparing electrosurgical application, and to employ intraoperative chromopertubation to assess for genital tract patency. This systematic approach will facilitate optimal endometriosis management, guide concomitant adnexal surgeries, and enhance post-surgical fertility outcomes.

Surgical management of ovarian endometrioma in patients desiring fertility is complicated by the need to balance maximal resection of disease with efforts ...

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who have had neoadjuvant chemotherapy. Here, we present a technique to perform laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) using the dorsal-caudal artery approach by making full use of the high-definition vision and operation modes of the laparoscope.
The innovation and optimization of this operation are provided in the protocol. Priority should be given to the dorsal resection plane, including the dorsal side of the superior mesenteric artery (SMA), the dorsal side of the pancreatic head, the root of the celiac artery (CeA), the ventral side of the left renal vessels, and the renal hilum. On the condition that the operation for pancreatic neck-body cancer is feasible and safe, the second step is to perform tumor resection en bloc surrounding the SMA and CeA from the caudal to the cephalic side to increase the rate of R0 (radical zero) resection and further prognosis.

Laparoscopic Radical Antegrade Modular Pancreatosplenectomy via Dorsal-Caudal Artery Approach for Pancreatic Neck-Body Cancer

With advancements in laparoscopic techniques, laparoscopic radical antegrade modular pancreatosplenectomy (L-RAMPS) has been widely recognized. However, owing to several technical difficulties in this procedure, the artery-first approach in L-RAMPS still remains uncommon. Here, we developed the dorsal-caudal artery approach for L-RAMPS, which might be safe and beneficial for pancreatic neck tumors.

Laparoscopic radical resection of the pancreatic neck is one of the most complicated radical operations for pancreatic cancer, especially for patients who ...

Chronic Ovine Model of Right Ventricular Failure and Functional Tricuspid Regurgitation

The pathophysiology of severe functional tricuspid regurgitation (FTR) associated with right ventricular dysfunction is poorly understood, leading to suboptimal clinical results. We set out to establish a chronic ovine model of FTR and right heart failure to investigate the mechanisms of FTR. Twenty adult male sheep (6-12 months old, 62 &#177; 7 kg) underwent a left thoracotomy and baseline echocardiography. A pulmonary artery band (PAB) was placed and cinched around the main pulmonary artery (PA) to at least double the systolic pulmonary artery pressure (SPAP), inducing right ventricular (RV) pressure overload and signs of RV dilatation. PAB acutely increased the SPAP from 21 &#177; 2 mmHg to 62 &#177; 2 mmHg. The animals were followed for 8 weeks, symptoms of heart failure were treated with diuretics, and surveillance echocardiography was used to assess for pleural and abdominal fluid collection. Three animals died during the follow-up period due to stroke, hemorrhage, and acute heart failure. After 2 months, a median sternotomy and epicardial echocardiography were performed. Of the surviving 17 animals, 3 developed mild tricuspid regurgitation, 3 developed moderate tricuspid regurgitation, and 11 developed severe tricuspid regurgitation. Eight weeks of pulmonary artery banding resulted in a stable chronic ovine model of right ventricular dysfunction and significant FTR. This large animal platform can be used to further investigate the structural and molecular basis of RV failure and functional tricuspid regurgitation.

Right ventricular failure and functional tricuspid regurgitation are associated with left-sided heart disease and pulmonary hypertension, which contribute significantly to morbidity and mortality in patients. Establishing a chronic ovine model to study right ventricular failure and functional tricuspid regurgitation will help in understanding their mechanisms, progression, and possible treatments.

The pathophysiology of severe functional tricuspid regurgitation (FTR) associated with right ventricular dysfunction is poorly understood, leading to ...

Modified Arteriovenous Fistula Surgery to Establish the RV Volume Overload Mouse Model

Establishment and Confirmation of a Postnatal Right Ventricular Volume Overload Mouse Model

Right ventricular (RV) volume overload (VO) is common in children with congenital heart disease. In view of distinct developmental stages,the RV myocardium may respond differently to VO in children compared to adults. The present study aims to establish a postnatal RV VO model in mice using a modified abdominal arteriovenous fistula. To confirm the creation of VO and the following morphological and hemodynamic changes of the RV, abdominal ultrasound, echocardiography, and histochemical staining were performed for 3 months. As a result, the procedure in postnatal mice showed an acceptable survival and fistula success rate. In VO mice, the RV cavity was enlarged with a thickened free wall, and the stroke volume was increased by about 30%-40% within 2 months after surgery. Thereafter, the RV systolic pressure increased, corresponding pulmonary valve regurgitation was observed, and small pulmonary artery remodeling appeared. In conclusion, modified arteriovenous fistula (AVF) surgery is feasible to establish the RV VO model in postnatal mice. Considering the probability of fistula closure and elevated pulmonary artery resistance, abdominal ultrasound and echocardiography must be performed to confirm the model status before application.

Author Spotlight: Establishment and Confirmation of a Postnatal Right Ventricular Volume Overload Mouse Model  

This protocol presents the establishment and confirmation of a postnatal right ventricular volume overload (VO) model in mice with abdominal arteriovenous fistula (AVF), which can be applied to investigate how VO contributes to postnatal heart development.

Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique

Summary

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Chapters in this video

Rat Model of Photochemically-Induced Posterior Ischemic Optic Neuropathy

Laparoscopic Technique for Serial Collection of Liver and Mesenteric Lymph Nodes in Macaques

Posterior Semicircular Canal Approach for Inner Ear Gene Delivery in Neonatal Mouse

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