Double cone-unit laparoscopic hepatic resection for tumors adjacent to the hepatic vein

In recent years, with the widespread of laparoscopic hepatectomy, the procedure has been performed worldwide [1]. In anatomical hepatic resection, “sub-segmentectomy” was introduced for small hepatocellular carcinoma, which is a systematic removal of the liver area confined by tumor-bearing portal tributaries [2]. On the other hand, the anatomy of the liver has many of its abnormalities, and the branches of the tertiary Glissonean pedicles run in a complex pattern [3, 4].

Furthermore, with the evolution of preoperative imaging such as CT and MRI, the usefulness of preoperative simulation has been reported [5]. Preoperative simulation is important to select the most appropriate technique for the anatomical variations of liver. Takasaki et al. advocated that each segment is separated into smaller areas by the pattern of the tertiary branches, and the area supplied by each of the tertiary branches is cone-shaped [6] (Fig. 1). In particular, for tumors adjacent to the hepatic vein, it is important to dissect the two tertiary Glissonean branches that straddle to the hepatic vein and resect two cone-units dominated by the Glissonean pedicle in order to eliminate the tumor with a negative margin. In small tumor adjacent to the veins, the anatomical resection of the smallest unit is considered to be the resection of the double cone-unit. The recognition of cone-unit could be more significant in laparoscopic hepatectomy more than open approach, because surgical orientation during parenchymal resection is more difficult in laparoscopic approach [7]. We herein report the laparoscopic double cone unit (DCU) hepatic resection performed at our hospital.

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