Laparoscopic Segment 1 with Partial IVC Resection in Advanced Cirrhosis: How to Do It Safely

Laparoscopic versus open hepatocellular carcinoma (HCC) resection reduces morbidity without a compromise in oncologic safety.1^-4 Moreover, in the subgroup of cirrhotic patients, a decreased risk of prolonged postoperative ascites and liver decompensation has been reported.5^-7 METHODS: A 54-year-old homeless, deaf male with chronic alcoholism, hepatitis C, and advanced cirrhosis was referred with a caudate tumor from a critical access hospital. Imaging showed a 3.6-cm HCC in the caudate lobe compressing the inferior vena cava (IVC). With the patient in reversed, modified French position, the liver was mobilized, and the hepatocaval space dissected. Portal and short hepatic vein branches were individually controlled, and the caudate lobe was dissected off the IVC. At the superior portion of the Spiegel process, the tumor was inseparable from the IVC, necessitating en bloc segment 1 with partial IVC resection. The IVC was reconstructed laparoscopically following a preplanned approach. The pathology report confirmed R0 resection of a moderately differentiated hepatocellular carcinoma without microvascular or perineural invasion (pT1bN0M0).

Laparoscopic caudate lobectomy for cirrhotic patients with partial IVC resection is technically demanding. It therefore requires a strategic and preplanned approach with dedicated instrumentation and laparoscopic skills available. Although the caudal view along the axis of the IVC facilitates dissection, a laparoscopic approach necessitates particular attention to central venous pressure management (intravenous fluid and respiratory tidal volume), meticulous control of portal and short hepatic vein branches, and availability of specialty laparoscopic instrumentation to ensure procedural safety.