Laparoscopic Total Caudate Lobectomy for Hepatocellular Carcinoma

Abstract

Background:

The caudate lobe consists of the Spigelian lobe, paracaval portion, and the caudate process. It is in proximity to the right and middle hepatic veins, the inferior vena cava (IVC) posteriorly, and the portal triad anteriorly. Torrential bleeding can occur from the IVC and the short hepatic veins during dissection. There are few small case series on laparoscopic caudate lobectomy, ^{1 –7} many of which are on limited resection or combined resection with other lobes. Isolated total caudate lobe resection is still rare and technically demanding. ^{8 –11} We herein present a video on the technical aspect of laparoscopic total caudate lobectomy.

Method:

A 61-year-old woman was admitted for recurrent hepatocellular carcinoma (HCC) detected on imaging. She had history of multifocal HCC in July 2015 and underwent open cholecystectomy, and segment 6 and segment 8 tumorectomy. Ten months later, the computed tomography (CT) scan and magnetic resonance imaging showed a 1 cm arterial enhancing lesion in segment I (S1) with no other foci of recurrence. Laparoscopic total caudate lobectomy was contemplated. The right posterior glissonian pedicle was isolated and temporarily clamped with a Bulldog clamp. The counter demarcation of the caudate process and the right posterior section was marked with electrocautery. Parenchymal transection was performed with Harmonic Scalpel^® and CUSA^®. The posterior surface of the caudate lobe was freed from the IVC and the short hepatic veins were controlled with clips and Ligasure^®. The portal branches to the caudate lobe were ligated and cut. The parenchymal dissection continued cranially to expose the right and middle hepatic veins. Bleeding from the middle hepatic vein was readily controlled by sutures.

Results:

The operative time was 270 minutes. The intraoperative blood loss was 200 mL and the patient was safely discharged on the fourth postoperative day. Pathology analysis showed a 1.6 × 1.5 × 1.2 cm HCC with a 3 mm tumor-free resection margin. CT scan at 1 month after the operation showed complete removal of the caudate lobe with no evidence of recurrence. From November 2014 to June 2016, we have performed five laparoscopic partial caudate lobectomies for patients with HCC in the Spigelian lobe. The median operative time was 135 minutes and all the resection margins were clear. Two patients had recurrence located in the other liver segments. The median disease-free and overall survivals were 5 and 11 months, respectively.

Discussion:

Comprehensive knowledge of the anatomy of the caudate lobe is paramount to the safe dissection around the glissonian pedicles and major hepatic veins. Laparoscopy offers a clear and magnified view of the area from the caudal approach. ¹² To mark the boundary of the caudate process, the right posterior glissonian pedicle is temporarily clamped. The demarcation of the caudate process and right posterior section is determined by the counter-demarcation technique. ^13,14

Conclusion:

This video presentation shows the safety and feasibility of laparoscopic total caudate lobectomy. Nonetheless, it is a technically demanding procedure. It should be performed in carefully selected patients and by experienced hepatobiliary surgeons proficient in laparoscopic liver resection.

No competing financial interests exist.

Runtime of video: 9 mins