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INDICATIONS

Laparoscopic liver resection is usually performed to remove a cyst or a tumor. It is recommended that initial experience in liver resection be gained with small peripheral lesions, hepatic cysts, liver biopsies, and the use of radiofrequency ablation. Facility with laparoscopic ultrasonography is imperative. As technical expertise grows, most resections that can be performed using open techniques can be approached laparoscopically. Many patients with liver masses are cirrhotic; therefore, evaluation for portal hypertension and careful patient selection is required. For cancers, oncologic principles must be maintained.

PREOPERATIVE PREPARATION

Tumors are preoperatively studied to establish resectability using triphasic abdominal and pelvic computed tomography (CT) scans or contrast-enhanced magnetic resonance imaging (MRI). The boundaries of the tumor are established with respect to Couinaud segments to develop an operative strategy. If intraoperative localization of the lesion is to be performed using ultrasound, a preoperative ultrasound should be obtained to ensure that the lesion is visible sonographically.

Laparoscopic liver resections are challenging cases dependent on complex equipment. Rapid performance of certain tasks may be required. Therefore it is recommended that a dedicated operative team be present throughout the case, a team knowledgeable in all aspects of the surgery and the equipment.

Patients should be evaluated with appropriate cardiovascular and pulmonary screening to identify individuals with excessive surgical risk. At minimum, two units of packed red blood cells are typed and cross-matched in preparation for the surgery.

ANESTHESIA

General anesthesia with endotracheal intubation is required for laparoscopic liver surgery. Complete neuromuscular blockade is necessary. Intravenous antibiotics with broad coverage (including Enterococcus) are given prior to skin incision. To minimize the risk of deep vein thrombosis, compression stockings and sequential compression devices must be in place and working before the induction of anesthesia. The systolic blood pressure should be maintained at 90 to 120 mm Hg. A central line should be placed to enable monitoring and adjustment of the central venous pressure to between 3 and 5 mm Hg to minimize bleeding from hepatic veins.

POSITIONING AND OPERATIVE PREPARATION

The patient is placed in the supine position to permit safe induction of anesthesia and line placement. An operating table that allows the surgeon to stand in between the patient’s legs is often advantageous (Figure 1). Adequate access for rapid large-volume resuscitation is assured with at least two large-bore (≤18 gauge) infusion lines. An orogastric tube and a Foley catheter are placed after induction. If the tumor is in the posterior right lobe, the patient may be placed in the left lateral decubitus (right side up) position; otherwise, the supine, split-leg position is maintained. The entire abdomen of the patient, from the nipples to the pubis, is shaved and sterilely prepped. An open hepatic surgery setup with vascular clamps and suctioning equipment should be in the room, open, and ...

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