Laparoscopic application of the hooking technique for ultrasound-guided minimally invasive liver surgery

Laparoscopic liver surgery has a wide diffusion worldwide, but the reproducibility of a parenchyma-sparing approach with a minimally invasive technique is still to explore. Intraoperative ultrasound (IOUS) is a mandatory tool to guarantee safety (transection plane) and oncological adequacy (margin) of minor but complex resections for deep-located tumors. The hooking technique has been developed exactly with this aim: once a vessel is isolated and encircled, the surgeon applies gentle traction on the tape surrounding the vessel and, under IOUS vision, "recognizes" the vessel and the adequate level of section. At present, advanced IOUS-guided maneuvers have limited application to laparoscopic liver surgery. We report the first application of the hooking maneuver during laparoscopic hepatectomy in three consecutive patients. In all cases, it was successfully performed and allowed to section the proper vessel at the right level. No procedure-related complications occurred and no ischemic areas of the remnant liver were evident. All resections had a negative surgical margin. Even if technically demanding, the laparoscopic hooking technique is a further step toward the standardization of a minimally invasive approach to advanced parenchyma-sparing liver surgery.