Overview
Definition:
Laparoscopic left lateral sectionectomy is a minimally invasive surgical procedure involving the removal of the left lateral section (segments I and II) of the liver using laparoscopic techniques
This section comprises the caudate lobe and the left lobe's anterior-most part
It is one of the simpler laparoscopic liver resections, often performed for benign lesions or small, well-demarcated malignant tumors in this specific liver territory
The procedure aims to achieve oncological clearance with minimal invasiveness, reducing postoperative pain, hospital stay, and recovery time compared to open surgery.
Epidemiology:
While specific epidemiological data for left lateral sectionectomy is limited, liver resections in general are performed for a variety of benign and malignant conditions, with hepatocellular carcinoma (HCC) being a leading indication worldwide
The incidence of liver tumors amenable to segmentectomy, particularly in the left lateral section, is influenced by factors like hepatitis B/C prevalence, alcohol consumption, and NAFLD
Laparoscopic liver surgery has seen a significant increase in adoption globally, with left lateral sectionectomies often being the first or most frequently performed segment-specific resection due to its anatomical accessibility and relatively lower complexity.
Clinical Significance:
Laparoscopic left lateral sectionectomy is significant for several reasons: 1
Minimally Invasive Approach: Offers reduced morbidity, faster recovery, and better cosmetic outcomes
2
Oncological Control: Allows for radical resection of tumors located in the left lateral segment, crucial for improving survival in primary liver cancers
3
Benign Lesions Management: Effective for symptomatic or large benign tumors (e.g., adenomas, focal nodular hyperplasia) that do not respond to conservative management
4
Training Platform: Serves as an excellent entry point for surgeons learning laparoscopic liver surgery due to its simpler anatomy and reduced risk of major vascular or biliary complications compared to more extensive resections
5
Preservation of Liver Function: By resecting only the affected segment, it maximally preserves overall liver function, vital for patients with compromised hepatic reserve.
Indications
Absolute Indications:
Resectable primary or secondary liver malignancies confined to the left lateral segment with clear margins (e.g., well-differentiated HCC, cholangiocarcinoma, colorectal metastases)
Solitary benign liver tumors (e.g., hepatocellular adenoma, hemangioma, focal nodular hyperplasia) causing symptoms, compressing vital structures, or with concerning features on imaging.
Relative Indications:
Certain early-stage intrahepatic cholangiocarcinomas, atypical hemangiomas, or lesions where non-operative management has failed or is contraindicated
Patients with adequate liver function reserve (Child-Pugh A or B) suitable for hepatic resection.
Contraindications:
Unresectable disease extending beyond the left lateral segment
Extensive multifocal liver disease
Inadequate liver function reserve (Child-Pugh C)
Significant comorbidities precluding major surgery
Uncontrolled sepsis or coagulopathy
Surgeon's lack of experience with laparoscopic liver surgery for complex cases.
Diagnostic Approach
History Taking:
Detailed history should focus on presenting symptoms such as right upper quadrant pain, abdominal fullness, early satiety, unintentional weight loss, jaundice, or signs of liver decompensation
Inquire about risk factors for liver disease (viral hepatitis, alcohol, metabolic syndrome, autoimmune disorders) and malignancy (e.g., cirrhosis, prior malignancy)
Past medical and surgical history, including prior abdominal surgeries, is crucial.
Physical Examination:
Abdominal examination may reveal a palpable mass in the left upper quadrant or epigastrium, hepatomegaly, ascites, or signs of portal hypertension (e.g., splenomegaly, caput medusae)
Jaundice, if present, indicates biliary obstruction or significant liver dysfunction
Assess for signs of nutritional deficiency.
Imaging Modalities:
Contrast-enhanced computed tomography (CECT) with arterial and portal venous phases is essential for lesion characterization, anatomical mapping, and assessment of vascularity and surrounding structures
Magnetic resonance imaging (MRI) with hepatobiliary contrast agents (e.g., gadoxetic acid) offers superior soft tissue contrast and characterization, especially for HCC
Doppler ultrasonography can assess vascularity and rule out deep venous thrombosis
Positron emission tomography (PET) scans may be used for staging of suspected malignancies to detect distant metastases.
Laboratory Investigations:
Complete blood count (CBC) to assess anemia and thrombocytopenia
Liver function tests (LFTs) including bilirubin, AST, ALT, alkaline phosphatase, GGT, albumin, and prothrombin time/INR are vital for assessing liver reserve
Tumor markers such as alpha-fetoprotein (AFP) for HCC, CA 19-9 for cholangiocarcinoma, and CEA for metastatic disease are important
Serological tests for viral hepatitis (HAV, HBV, HCV) are indicated
Coagulation profile is crucial pre-operatively.
Surgical Management
Preoperative Preparation:
Thorough patient counseling regarding the procedure, potential risks, and benefits
Optimization of nutritional status and management of ascites or coagulopathy
Prophylactic antibiotics are administered
DVT prophylaxis is initiated
Patients with cirrhosis may undergo further assessment of liver reserve (e.g., indocyanine green retention test, MELD score)
Multidisciplinary team review including radiologists and pathologists is recommended.
Instrumentation And Positioning:
The patient is typically placed in a modified lithotomy position
Four to five trocars are usually inserted: a 10-12 mm umbilical port for the camera, and 5-12 mm ports in the left upper quadrant, right subcostal region, and epigastrium for instrument manipulation
The liver is usually suspended to facilitate access.
Procedure Steps:
The falciform ligament and umbilical fissure are divided to expose the left lobe
The liver parenchyma is dissected using ultrasonic devices (e.g., harmonic scalpel) or bipolar electrocautery, carefully controlling small vessels and bile ducts
The left hepatic vein is identified, ligated, and divided
The portal vein and hepatic artery branches supplying the left lateral section are identified, ligated, and divided
Careful attention is paid to the extrahepatic dissection of the portal pedicle and hepatic vein for adequate margins
Hemostasis is meticulously achieved
The resected specimen is retrieved in an endoscopic bag to prevent tumor spillage
Intraoperative ultrasound may be used for precise tumor localization and assessment of vascular structures.
Intraoperative Monitoring:
Continuous monitoring of vital signs, oxygen saturation, and end-tidal CO2 is essential
Careful fluid management is maintained
Estimated blood loss is meticulously recorded
If any ambiguity regarding margins or vascular control, intraoperative frozen section analysis may be considered.
Postoperative Care
Initial Management:
Patients are transferred to a post-anesthesia care unit for close monitoring of vital signs, pain control, and fluid balance
Nasogastric tube decompression may be continued initially
Adequate intravenous hydration is provided
Routine laboratory monitoring includes CBC and LFTs.
Pain Management:
Multimodal analgesia is crucial, including intravenous opioids, NSAIDs (if no contraindications), and patient-controlled analgesia (PCA)
Thoracic epidural analgesia can provide excellent pain relief in select patients
Early mobilization is encouraged to prevent pulmonary complications.
Nursing Care:
Monitoring for signs of bleeding (e.g., increasing abdominal girth, falling hemoglobin), bile leak (e.g., bile-stained drain output, increasing bilirubin), infection, and respiratory complications
Strict input-output charting
Early ambulation and deep breathing exercises are promoted
Wound care is provided as per protocol.
Nutritional Support:
Oral intake is gradually resumed as tolerated, starting with clear liquids and advancing to a regular diet
Patients with significant liver resection or compromised liver function may require specialized nutritional support, including protein-rich and calorie-dense meals
Parenteral nutrition may be considered if oral intake is insufficient.
Complications
Early Complications:
Bleeding (intraoperative or postoperative), bile leak (biloma, biliary peritonitis), liver failure (acute or decompensated chronic), wound infection, port-site hernia, pancreatitis, pneumonia, atelectasis, deep vein thrombosis (DVT), pulmonary embolism (PE).
Late Complications:
Bile duct strictures, intra-abdominal abscess, recurrence of malignancy, incisional hernia, adhesions leading to bowel obstruction, chronic liver dysfunction, secondary biliary cirrhosis.
Prevention Strategies:
Meticulous surgical technique with careful handling of liver parenchyma, precise identification and management of vascular and biliary structures
Use of energy devices for hemostasis and dissection
Adequate drainage to monitor for bile leaks
Thorough preoperative assessment of liver function
Aggressive postoperative mobilization and respiratory physiotherapy
DVT prophylaxis
Careful tumor margin assessment during surgery.
Prognosis
Factors Affecting Prognosis:
The prognosis depends heavily on the underlying pathology
For benign lesions, prognosis is generally excellent with complete resolution of symptoms and no long-term sequelae
For malignant tumors, factors include the type and grade of cancer, stage at diagnosis, adequacy of surgical margins, presence of lymph node metastasis, and underlying liver health (e.g., cirrhosis).
Outcomes For Benign Lesions:
Excellent outcomes with high cure rates and minimal morbidity
Patients typically return to normal activities within a few weeks.
Outcomes For Malignant Lesions:
Prognosis for malignant lesions is more guarded
For HCC, disease-free survival rates vary widely but adequate resection with negative margins is crucial for long-term survival
For metastatic disease, prognosis depends on the primary cancer and extent of disease.
Follow Up:
Patients require regular follow-up with clinical examination and imaging
For benign lesions, follow-up may be short-term
For malignant lesions, long-term surveillance with serial AFP, cross-sectional imaging (CT/MRI), and abdominal ultrasound is essential to detect recurrence or new primary lesions
Follow-up intervals are guided by specific oncological guidelines.
Key Points
Exam Focus:
Understand the anatomical boundaries of the left lateral section (segments I and II)
Recognize indications for laparoscopic versus open approach
Be aware of the critical steps: identifying and controlling the left hepatic vein, portal vein branch, and hepatic artery branch to the segment
Know potential complications specific to liver resection and laparoscopic surgery.
Clinical Pearls:
The umbilical fissure is a key landmark for dissection
Careful control of the glissonean pedicle is paramount
Use of intraoperative ultrasound can be invaluable for precise tumor localization and vascular mapping
Retrieval of the specimen in a bag is essential to prevent peritoneal dissemination of malignant cells.
Common Mistakes:
Inadequate dissection of the falciform ligament leading to poor exposure
Insufficient control of vascular or biliary structures leading to hemorrhage or bile leak
Failure to achieve negative surgical margins for malignant lesions
Inadvertent injury to major vessels or bile ducts
Retraction of the liver too forcefully leading to diaphragmatic injury.