Robotic Technique for Accessing Left Hepatic Vein Through Ligamentum Venosum in Left Hepatectomy: How I Do It?

Blood loss is associated with postoperative morbidity and mortality. Outflow control could be used concomitantly with inflow control for maximum reduction in blood loss during parenchymal transection. However, in left hepatectomy (LH) and left lateral sectionectomy (LLS), extrahepatic control of the left hepatic vein (LHV) is still less commonly used. Some authors reported extrahepatic LHV control technique using ligamentum venosum (LV) in open or laparoscopic surgery, but no reports of this technique in robotic surgery have been found.

The dissection of LV from the liver was performed, followed by clipping and transecting LV. The cephalad LV stump was retracted to the left inferior direction and then the dissection of the posterior part of LHV was performed until the opening space was connected to the anterior part of LHV. The LHV was encircled with the tape and vascular stapler was inserted to manage LHV stump. From 2013 to 2015, LHV was successfully encircled by using this technique in 7 out of 11 cases. The mean operative time was 244 minutes, the mean estimated blood loss was 300 mL, and the mean length of hospital stay was 4.8 days. Neither injury to LHV, nor complications related to the liver were found.

From our experiences, LHV was routinely controlled in robotic LH or LLS and the success rate was 60%. However, this technique is not recommended for the tumor that compresses or abuts LHV/LV, and in cirrhotic liver with associated hypertrophic left lateral segment.