Laparoscopic Caudate Resection: How to Safely Manage the Spiegel/IVC Interface

Area of Science:

• Hepatobiliary surgery
• Minimally invasive liver resection
• Colorectal cancer metastasis

Background:

• Minimally invasive caudate lobectomy carries significant bleeding risks due to proximity to the inferior vena cava (IVC) and major vessels.
• Cirrhosis and neoadjuvant therapy can exacerbate these risks by causing fusion of the hepato-caval space.
• A patient with stage IVa colorectal adenocarcinoma presented with a liver metastasis in the paracaval caudate lobe, complicated by neoadjuvant chemotherapy-induced hepato-caval space fusion.

Observation:

• Three-dimensional modeling was used for precise surgical planning, visualizing the tumor's relationship with the IVC and portal-hepatic veins.
• The fused hepato-caval space was carefully dissected using sharp dissection with scissors to avoid thermal injury to the IVC.
• Inflow control of portal veinous branches was crucial before dissecting adhesions.

Findings:

• Laparoscopic Spiegel process resection was safely performed despite the fused hepato-caval space.
• Judicious management of short hepatic vein branches and maintaining low central venous pressure were key to successful dissection.
• Sharp dissection with scissors proved effective in managing adhesions without causing inadvertent thermal injury.

Implications:

• Preoperative virtual hepatectomy enhances surgical planning and understanding of complex anatomical relationships.
• Anticipating and strategically managing a fused hepato-caval space is critical for successful minimally invasive caudate resections.
• This approach offers a safe alternative for complex liver resections in challenging oncological cases.