Usefulness of Pure Laparoscopic Hepatectomy for Hepatocellular Carcinoma in a Severely Cirrhotic Patient
A 55-year-old Japanese woman had been observed at a local hospital for 10 years for liver cirrhosis of unknown cause. A 20-mm tumor was found in liver segment III (S3), and she was referred to our hospital for surgery. Her laboratory data on admission were as follows: platelet count 7.8 × 104/dl (normal 13.0-36.0), total bilirubin 1.4 mg/dl (normal 0.2-1.1), albumin 3.3 g/dl (normal 3.8-5.3), prothrombin time 88% (normal 70-140), and ammonia 95 μg/dl (normal 30-86). Her hepatic functional reserve was as follows: indocyanine green retention rate at 15 min 72.7% (normal 0-10) and galactose tolerance test 40 min (normal ≤20 min). Abdominal enhanced computed tomography (CT) showed a 20-mm tumor that was heterogeneously enhanced during the early phase (fig. ) and washed out during the late phase (fig. ) on the surface of S3. Gd-EOB-DTPA-enhanced magnetic resonance imaging showed a hypointense region in S3 as seen on CT in the hepatocyte phase (fig. ). Although the patient's hepatic functional reserve was poor, the tumor was located in the edge of the liver and we thus considered percutaneous ablation therapy, such as radiofrequency ablation, to be unsuitable because of concern about hemorrhage, tumor dissemination and injury to adjacent organs. Therefore, we performed pure laparoscopic partial hepatectomy of S3.\nThe patient was placed supine, in the head-up tilt position, with the primary surgeon on the right side of the patient. Five ports were placed including 12-mm ports for the camera and intraoperative ultrasonography (fig. ). Intra-abdominal pressure was maintained at 10-12 mm Hg. Operative findings revealed that a 20-mm white tumor protruding outside the liver was present in S3 (fig. ). A Cavitron ultrasonic surgical aspirator and saline-enhanced coagulation were used to perform partial hepatectomy of S3 with a margin of 1 cm without vascular inflow occlusion. Operative time was 170 min and operative blood loss was 350 ml. A 20-mm, comparatively well-demarcated, septate white tumor was present in the resected specimen (fig. ). Histopathologically, the lesion was identified as moderately differentiated HCC without vascular invasion, and the surgical margin was negative for cancer (fig. ).\nThe patient's postoperative course was extremely uneventful. Her drain discharge was serous, with a volume of around 100 ml until postoperative day 3; the drainage decreased to 30 ml on day 4. The drain was therefore removed on day 5. There was no subsequent ascites retention, edema or weight gain. Her serum liver enzyme levels were transiently elevated postoperatively, but rapidly decreased again. There was no rise in total bilirubin or ammonia levels postoperatively. The patient was discharged on postoperative day 8 with no other complications (fig. ). As of the time of this writing (10 months postoperatively), the patient is doing well clinically with no signs of recurrence.