Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Dec 21, 2016; 22(47): 10267-10274
Published online Dec 21, 2016. doi: 10.3748/wjg.v22.i47.10267
Laparoscopic liver resection for posterosuperior tumors using caudal approach and postural changes: A new technical approach
Zenichi Morise
Zenichi Morise, Department of Surgery, Fujita Health University School of Medicine, Toyoake 470-1192, Japan
Author contributions: Morise Z performed the study and wrote the article.
Conflict-of-interest statement: The author declares no conflict of interest related to this publication.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Zenichi Morise, MD, PhD, FACS, AGAF, Department of Surgery, Fujita Health University School of Medicine, 1-98 Kutsukakecho, Toyoake 470-1192, Japan. zmorise@fujita-hu.ac.jp
Telephone: +81-562-939246 Fax: +81-562-935125
Received: August 11, 2016
Peer-review started: August 12, 2016
First decision: September 12, 2016
Revised: September 27, 2016
Accepted: October 31, 2016
Article in press: October 31, 2016
Published online: December 21, 2016

Laparoscopic liver resection (LLR) for tumors in the posterosuperior liver [segment (S) 7 and deep S6] is a challenging clinical procedure. This area is located in the bottom of the small subphrenic space (rib cage), with the large and heavy right liver on it when the patient is in the supine position. Thus, LLR of this area is technically demanding because of the handling of the right liver which is necessary to obtain a fine surgical view, secure hemostasis and conduct the resection so as to achieve an appropriate surgical margin in the cage. Handling of the right liver may be performed by the hand-assisted approach, robotic liver resection or by using spacers, such as a sterile glove pouch. In addition, the operative field of posterosuperior resection is in the deep bottom area of the subphrenic cage, with the liver S6 obstructing the laparoscopic caudal view of lesions. The use of intercostal ports facilitates the direct lateral approach into the cage and to the target area, with the combination of mobilization of the liver. Postural changes during the LLR procedure have also been reported to facilitate the LLR for this area, such as left lateral positioning for posterior sectionectomy and semi-prone positioning for tumors in the posterosuperior segments. In our hospital, LLR procedures for posterosuperior tumors are performed via the caudal approach with postural changes. The left lateral position is used for posterior sectionectomy and the semi-prone position is used for S7 segmentectomy and partial resections of S7 and deep S6 without combined intercostal ports insertion. Although the movement of instruments is restricted in the caudal approach, compared to the lateral approach, port placement in the para-vertebra area makes the manipulation feasible and stable, with minimum damage to the environment around the liver.

Keywords: Hepatectomy, Laparoscopic surgery, Liver cancer, Posture, Prone position

Core tip: Laparoscopic liver resection for posterosuperior tumors is technically challenging because this area is located in the bottom of the small subphrenic cage, overlaid by the right liver. Thus, obtaining a fine surgical view is difficult and manipulation of the right liver is required to ensure hemostasis and obtainment of an appropriate surgical margin. The right liver may be handled by the hand-assisted approach, robotic liver resection, or a spacer-based approach. Intercostal ports can facilitate a direct lateral approach into the cage and postural changes may help. We successfully apply semi-prone positioning in the caudal approach without intercostal ports.