ASO Author Reflections: Laparoscopic Caudate Lobectomy: A Feasible and Safe Approach for Cholangiocarcinoma of the Cauda
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Laparoscopic Caudate Lobectomy: A Feasible and Safe Approach for Cholangiocarcinoma of the Caudate Lobe Invading the Middle Hepatic Vein Guo-Teng Qiu, MD, Kun-Lin Xie, MD, Hong Wu, MD, and Ji-Wei Huang, MD Department of Liver Surgery and Liver Transplantation, West China Hospital, Sichuan University, Chengdu, Sichuan, China
PAST The caudate lobe is in a complicated anatomic area that was once called ‘no-man’s land’. This segment of the liver is technically demanding to approach because of its deep location in the hepatic parenchyma and its proximity to major hepatic vessels. The first isolated caudate lobectomy was reported by Lerut et al.1, but it is more commonly performed in association with resection of other segments of the liver. After the first introduction of laparoscopic liver resection (LLR) by Reich et al.2, the minimally invasive technique has been widely used in the treatment of hepatic tumors. However, the reported LRRs were confined to peripheral, benign tumors resected by non-anatomical wedge resections, and few have been mentioned in ‘dangerous’ locations such as the caudate lobe. PRESENT During the last decade, LRR has evolved dramatically with the great progress in minimally invasive techniques and equipment, the developed understanding of the liver anatomy, and the improvements in perioperative care. At
Guo-Teng Qiu and Kun-Lin Xie have contributed equally to this work. Ó Society of Surgical Oncology 2020 First Received: 8 May 2020 H. Wu, MD e-mail: [email protected] J.-W. Huang, MD e-mail: [email protected]
present, a laparoscopic hepatectomy is indicated to the right hepatectomy, left hepatectomy, and central hepatectomy, and is considered to be the standard for left lateral lobectomy.3 Increasing evidence has shown that diseasefree survival and overall survival are comparable between LLR and open hepatectomy. Although LLR has gained popularity in the treatment of liver cancer, an isolated caudate lobectomy remains rare, with very few reports on this procedure. To date, there is still no strong evidence demonstrating the superiority of the laparoscopic approach versus the open approach. Furthermore, the standard surgical flow has also not been established. To some extent, laparoscopy offers a magnified view of, and access to, the caudate lobe using the caudal approach.4 Complete mobilization of both lobes of the liver helps in achieving a stable retraction to expose the paracaval portion, which allows meticulous dissection of the short hepatic veins for subsequent control. The pneumoperitoneum in LRR and a low central venous pressure (\ 5 cm H2O) helps to decrease bleeding from the hepatic vein branches and the inferior vena cava (IVC). The intermittent Pringle maneuver serves as the inflow control to minimize bleeding during the parenchymal transection. Anatomical resection along the intersegmental plane allows complete removal of the parenchyma supplied by the portal pedicles without much residual ischemic tissue. Based on careful pat
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