Post-fontan circulation hepatocellular carcinoma:Open and laparoscopic hepatectomy

To the Editor:Fontan-associated liver disease shows increasing incidence as advances in pediatric cardiology have prolonged life expectancy in patients with single ventricle congenital heart defects[1].Their unique physiology and procedure-related sequelae present an increasingly relevant challenge in hepatic surgery.We hereby reported a series of patients suffering from hepatocellular carcinoma(HCC)who successfully underwent open and laparoscopic hepatectomy.

Laboratory scoring system to predict hepatic indocyanine green clearance ability during fluorescence imaging-guided laparoscopic hepatectomy

BACKGROUND Indocyanine green(ICG)fluorescence played an important role in tumor localization and margin delineation in hepatobiliary surgery.However,the preoperative regimen of ICG administration was still controversial.Factors associated with tumor fluorescence staining effect were unclear.AIM To investigate the preoperative laboratory indexes corelated with ICG fluorescence staining effect and establish a novel laboratory scoring system to screen specifical patients who need ICG dose adjustment.METHODS To investigate the predictive indicators of ICG fluorescence characteristics in patients undergoing laparoscopic hepatectomy from January 2018 to January 2021 were included.Blood laboratory tests were completed within 1 wk before surgery.All patients received 5 mg ICG injection 24 h before surgery for preliminary tumor imaging.ImageJ software was used to measure the fluorescence intensity values of regions of interest.Correlation analysis was used to identify risk factors.A laboratory risk model was established to identify individuals at high risk for high liver background fluorescence.RESULTS There were 110 patients who were enrolled in this study from January 2019 to January 2021.The mean values of fluorescence intensity of liver background(FI-LB),fluorescence intensity of gallbladder,and fluorescence intensity of target area were 18.87±17.06,54.84±33.29,and 68.56±36.11,respectively.The receiver operating characteristic(ROC)curve showed that FI-LB was a good indicator for liver clearance ability[area under the ROC curve(AUC)=0.984].Correlation analysis found pre-operative aspartate aminotransferase,alanine aminotransferase,gammaglutamyl transpeptidase,adenosine deaminase,and lactate dehydrogenase were positively associated with FI-LB and red blood cell,cholinesterase,and were negatively associated with FI-LB.Total laboratory risk score(TLRS)was calculated according to ROC curve(AUC=0.848,sensitivity=0.773,specificity=0.885).When TLRS was greater than 6.5,the liver clearance ability of ICG was considered as poor.CONCLUSION Preoperative laboratory blood indicators can predict hepatic ICG clearance ability.Surgeons can adjust the dose and timing of ICG preoperatively to achieve better liver fluorescent staining.

Laparoscopic left hemihepatectomy guided by indocyanine green fluorescence: A cranial-dorsal approach

BACKGROUND Advancements in laparoscopic technology and a deeper understanding of intra-hepatic anatomy have led to the establishment of more precise laparoscopic hepatectomy(LH)techniques.The indocyanine green(ICG)fluorescence navi-gation technique has emerged as the most effective method for identifying hepatic regions,potentially overcoming the limitations of LH.While laparoscopic left hemihepatectomy(LLH)is a standardized procedure,there is a need for innova-tive strategies to enhance its outcomes.important anatomical markers,surgical skills,and ICG staining methods.METHODS Thirty-seven patients who underwent ICG fluorescence-guided LLH at Qujing Second People's Hospital between January 2019 and February 2022 were retrospectively analyzed.The cranial-dorsal approach was performed which involves dissecting the left hepatic vein cephalad,isolating the Arantius ligament,exposing the middle hepatic vein,and dissecting the parenchyma from the dorsal to the foot in order to complete the anatomical LLH.The surgical methods,as well as intra-and post-surgical data,were recorded and analyzed.Our hospital’s Medical Ethics Committee approved this study(Ethical review:2022-019-01).RESULTS Intraoperative blood loss during LLH was 335.68±99.869 mL and the rates of transfusion and conversion to laparotomy were 13.5%and 0%,respectively.The overall incidence of complications throughout the follow-up(median of 18 months;range 1-36 months)was 21.6%.No mortality or severe complications(level IV)were reported.CONCLUSION LLH has the potential to become a novel,standardized approach that can effectively,safely,and simply expose the middle hepatic vein and meet the requirements of precision surgery.

Is laparoscopic hepatectomy superior to open hepatectomy for hepatocellular carcinoma?

The low perioperative morbidity and shorter hospital stay associated with laparoscopic hepatectomy have made it an often-used option at many liver centers, despite the fact that many patients with hepatocellular carcinoma have cirrhosis, which makes the procedure more difficult and dangerous. Type of surgical procedure proves not to be a primary risk factor for poor outcomes after hepatic resection for hepatocellular carcinoma, the available evidence clearly shows that laparoscopic hepatectomy is an effective alternative to the open procedure for patients with early-stage hepatocellular carcinoma, even in the presence of cirrhosis. Whether the same is true for patients with intermediate or advanced disease is less clear, since laparoscopic major hepatectomy remains a technically demanding procedure.

Expert Consensus on Laparoscopic Hepatectomy(2013 Version)

Background： Laparoscopic hepatectomy has many advantages over open surgery, including minimiza- tion of local injury, reduced systemic reactions, and faster postoperative recovery. The aim of this ＂Consensus＂ is to provide guidance and reference to surgeons who perform, or are interested in per- forming laparoscopic liver surgeries. Methods： The National Hepatic Surgery Group of the Society of Surgery, a professional society of the Chinese Medical Association, gathered 60 expert hepatic surgeons in Wuhan, China in December 2012, and an ＂Expert Consensus on Laparoseopic Hepatectomy＂ was developed. Results： The types of hepatectomy, indications and contraindications, preoperative preparation, anes- thesia, patient position, insuffiation pressure, port position, control of hepatic inflow and outflow, indi- cations for conversion to open surgery, and surgical devices and equipment are reviewed. Techniques and procedures of various laparoscopic hepatectomies are also discussed.

Expanding the selection criteria of laparoscopic hepatectomy for hepatocellular carcinoma

The introduction of laparoscopic procedures is one of the milestones of surgical innovation over the past few decades. The advantages of minimally invasive approach have been gradually accepted owing to its less postoperative pain, reduced morbidity and faster recovery. Also, since the introduction of laparoscopic approach of liver surgery in 1955 （1）, the benefit of the procedure had long been questioned but expected.

Pure laparoscopic hepatectomy as repeat surgery and repeat hepatectomy

AIM:To assess clinical outcomes of laparoscopic hepatectomy(LH) in patients with a history of upper abdominal surgery and repeat hepatectomy.METHODS:This study compared the perioperative courses of patients receiving LH at our institution that had or had not previously undergone upper abdominal surgery.Of the 80 patients who underwent LH,22 had prior abdominal surgeries,including hepatectomy(n = 12),pancreatectomy(n = 3),cholecystectomy and common bile duct excision(n = 1),splenectomy(n = 1),total gastrectomy(n = 1),colectomy with the involvement of transverse colon(n = 3),and extended hysterectomy with extensive lymph-node dissection up to the upper abdomen(n = 1).Clinical indicators including operating time,blood loss,hospital stay,and morbidity were compared among the groups.RESULTS:Eighteen of the 22 patients who had undergone previous surgery had severe adhesions in the area around the liver.However,there were no conversions to laparotomy in this group.In the 58 patients without a history of upper abdominal surgery,the median operative time was 301 min and blood loss was 150 m L.In patients with upper abdominal surgical history or repeat hepatectomy,the operative times were 351 and 301 min,and blood loss was 100 and 50 m L,respectively.The median postoperative stay was 17,13 and 12 d for patients with no history of upper abdominal surgery,patients with a history,and patients with repeat hepatectomy,respectively.There were five cases with complications in the group with no surgical history,compared to only one case in the group with a prior history.There were no statistically significant differences in the perioperative results between the groups with and without upper abdominal surgical history,or with repeat hepatectomy.CONCLUSION:LH is feasible and safe in patients with a history of upper abdominal surgery or repeat hepatectomy.

Pure laparoscopic hepatectomy for hepatocellular carcinoma with chronic liver disease

Pure laparoscopic hepatectomy is a less invasive procedure than conventional open hepatectomy for the resection of hepatic lesions. Increases in experiences with the technique, in combination with advances in technology, have promoted the popularity of pure laparoscopic hepatectomy. However, indications for usage and potential contraindications of the procedure remain unresolved. The characteristics and specific advantages of the procedure, especially for hepatocellular carcinoma(HCC) patients with chronic liver diseases,are reviewed and discussed in this paper. For cirrhotic patients with liver tumors, pure laparoscopic hepatectomy minimizes destruction of the collateral blood and lymphatic flow from laparotomy and mobilization, and mesenchymal injury from compression. Therefore, pure laparoscopic hepatectomy has the specific advantage of minimal postoperative ascites production that leads to lowering the risk of disturbance in water or electrolyte balance and hypoproteinemia. It minimizes complications that routinely trigger postoperative serious liver failure. Under adequate patient positioning and port arrangement, the partial resection of the liver in the area of subphrenic space, peri-inferior vena cava area or next to the attachment of retro-peritoneum is facilitated in pure laparoscopic surgery by providing good vision and manipulation in the small operative field.Furthermore, the features of reduced post-operative adhesion, good vision, and manipulation within the small area between the adhesions make this procedure safer in the context of repeat hepatectomy procedures.These improved features are especially advantageous for patients with liver cirrhosis and multicentric and/or metachronous HCCs.

Overlay of a sponge soaked with ropivacaine and multisite infiltration analgesia result in faster recovery after laparoscopic hepatectomy

BACKGROUND Compared with traditional open surgery,laparoscopic surgery is preferred due to the advantages of less trauma,less pain,and faster recovery.Nevertheless,many patients still suffer from postoperative pain resulting from the surgical incision and associated tissue injury.Many researchers have reported methods to improve postoperative pain control,but there is not a simple and effective method that can be clinically adopted in a widespread manner.We designed this study to prove the hypothesis that application of ropivacaine in the port site and operative site in patients is an effective and convenient method which can decrease postoperative pain and accelerate recovery.AIM To evaluate the effects of ropivacaine on pain control after laparoscopic hepatectomy and its contribution to patient recovery.METHODS From May 2017 to November 2018,146 patients undergoing laparoscopic hepatectomy were randomized to receive infiltration of either 7.5 mg/mL ropivacaine around the trocar insertions,incision,and cutting surface of the liver(with a gelatin sponge soaked with ropivacaine)at the end of surgery(ropivacaine group),or normal saline(5 mL)at the same sites at the end of surgery(control group).The degree of pain,nausea,vomiting,heart rate(HR),and blood pressure were collected.The length of postoperative hospitalization,complications,and the levels of stress hormones were also compared between the two groups.RESULTS Compared with the control group,the ropivacaine group showed reduced postoperative pain at rest within 12 h(P<0.05),and pain on movement was reduced within 48 h.The levels of epinephrine,norepinephrine,and cortisol at 24 and 48 h,HR,blood pressure,and cumulative sufentanil consumption in the ropivacaine group were significantly lower than those in the control group(P<0.05).In the ropivacaine group,hospitalization after operation was shorter,but the difference was not statistically significant.There were no significant differences in postoperative nausea,vomiting,or other complications,including hydrothorax,ascites,peritonitis,flatulence,and venous thrombus(P>0.05),although fewer patients in the ropivacaine group experienced these situations.CONCLUSION Infiltration with ropivacaine in the abdominal wound and covering the cutting surface of the liver with a gelatin sponge soaked with ropivacaine significantly reduce postoperative pain and the consumption of sufentanil.

Hydrogen-rich saline protects against hepatic injury induced by ischemia-reperfusion and laparoscopic hepatectomy in swine

Background: Hydrogen-rich saline(HRS) has antioxidative, anti-inflammatory and anti-apoptotic properties. We investigated the effects of hydrogen on hepatic ischemia-reperfusion(I/R) and laparoscopic hepatectomy in swine. Methods: Twenty-one healthy Bama miniature pigs were randomly divided into the sham group, ischemia-reperfusion injury(IRI) group, HRS-5(5 m L/kg) group, and HRS-10(10 m L/kg) group. HRS was injected through the portal vein 10 min before reperfusion and at postoperative day 1, 2 and 3. The roles of HRS on oxidative stress, inflammatory response and liver regeneration were studied. Results: Compared with the IRI group, HRS treatment attenuated oxidative stress by increasing catalase activity and reducing myeloperoxidase. White blood cells in the HRS-10 group were reduced compared with the IRI group( P < 0.01). In the HRS-10 group, interleukin-1 beta, interleukin-6 and tumor necrosis factor alpha, C-reactive protein and cortisol were downregulated, whereas interleukin-10 was upregulated. In addition, HRS attenuated endothelial cell injury and promoted the secretion of angiogenic cytokines, including vascular endothelial growth factor, angiopoietin-1 and angiopoietin-2. HRS elevated the levels of hepatocyte growth factor, Cyclin D1, proliferating cell nuclear antigen, Ki-67 and reduced the secretion of transforming growth factor-beta. Conclusions: HRS treatment may exert a protective effect against I/R and hepatectomy-induced hepatic damage by reducing oxidative stress, suppressing the inflammatory response and promoting liver regeneration.

Left jackknife position:a novel position for laparoscopic hepatectomy

Background: Laparoscopic hepatectomy for hepatocellular carcinoma(HCC) located in segment Ⅵ, Ⅶ, or Ⅷ of the liver is usually difficult because of poor operative exposure, due to the unique anatomical structure. In this study, we evaluated the practice of laparoscopic hepatectomy with the left jackknife position for patients with HCC located in segment Ⅵ, Ⅶ, or Ⅷ.Methods: A total of 10 patients were enrolled to undergo laparoscopic hepatectomy with the left jackknife position.Tumors located in segment Ⅵ, Ⅶ, or Ⅷ were assessed by preoperative dynamic computed tomography or magnetic resonance imaging. Operation time, intraoperative blood loss, postoperative fasting time, postoperative drainage time, major postoperative complications, and duration of postoperative hospital stay were recorded.Results: All surgeries were successfully completed. None of the patients required conversion to open surgery during the procedure, and no serious postoperative complications were observed.The median tumor size was 31 mm(range 23-41 mm) in diameter, the mean operation time was 166 ± 38 min, the mean intraoperative blood loss was220 ± 135 mL, and the median postoperative hospital stay was 4 days(range 2-7 days).Conclusions: For HCC located in segment Ⅵ, Ⅶ, or Ⅷ, laparoscopic hepatectomy with this novel position—the left jackknife position—is safe and effective during tumor resection by exposing a sufficient operating field.Trial registration ClinicalTrials.gov ID:

Analgesic effect of parecoxib combined with ropivacaine in patients undergoing laparoscopic hepatectomy

BACKGROUND Currently, there is no uniform standard for analgesia during laparoscopic hepatectomy. Most of the analgesia schemes adopt epidural analgesia after laparotomy. Although the analgesia is effective, it has a great impact on the recovery of patients after laparoscopic hepatectomy and is not completely suitable for analgesia after laparoscopic hepatectomy. Although multimodal perioperative analgesia can significantly relieve postoperative pain, there is no relevant study of parecoxib combined with ropivacaine for post-laparoscopic hepatectomy analgesia. AIM To study the analgesic effect of the preoperative intravenous injection of parecoxib combined with long-acting local anesthetic ropivacaine for incision infiltration in patients undergoing laparoscopic hepatectomy. METHODS Forty-eight patients undergoing laparoscopic hepatectomy were randomly divided into a combined group (parecoxib combined with ropivacaine) and a control group. The visual analogue scale (VAS) at rest and during movement was used to compare the analgesic effect of the two groups. Meanwhile, the cumulative sufentanil, the recovery time for enterokinesia, the length of postoperative hospital stay, and the adverse reactions (nausea and vomiting) were recorded and compared between the two groups.The change tendency in VAS scores for both groups was similar after operation. At rest, the VAS scores of the combined group were significantly lower than those of the control group at 0, 6, 12, 24 and 36 h, and during movement, the VAS scores of the combined group were significantly lower than those of the control group at 0, 6, 12, and 24 h. The recovery time for enterokinesia in the combined group was 2.9 d, which was significantly shorter than that in the control group. The cumulative sufentanil in the combined group decreased significantly at 24, 36, and 48 h after operation. CONCLUSION Preoperative intravenous injection of parecoxib combined with ropivacaine for incision infiltration is a simple and effective method for postoperative analgesia in laparoscopic hepatectomy, which could relieve pain and promote recovery.

A case of laparoscopic hepatectomy for recurrent hepatocellular carcinoma

Conventional hepatectomy is an effective way to treat hepatocellular carcinoma.However,it is invasive and stressful.The use of laparoscopy in hepatectomy,while technically demanding,reduces surgical invasiveness and stressfulness but still achieves complete resection with adequate margins.Compared with conventional hepatectomy,laparoscopic hepatectomy provides a better chance and situation for further surgery in the case of recurrence of hepatocellular carcinoma.Even aged patients can successfully endure repeated hepatectomy using laparoscopy,as shown in the present report.This report presents a case of repeated laparoscopic hepatectomy treating hepatocellular carcinoma and its recurrence in an aged patient having cirrhosis,a disease causing extra difficulty for performing laparoscopic hepatectomy.The report also describes techniques of the operation and displays characteristic results of laparoscopic hepatectomy such as smaller wounds,less blood loss,less pain,less scars and adhesion,shorter postoperative hospital stay,and faster recovery.

Totally laparoscopic left hepatectomy using the Torsional Ultrasonic Scalpel

Minimal invasive techniques have allowed for major surgical advances.We report our initial experience of performing total laparoscopic left hepatectomy(segmentsⅡ-Ⅳ)with the Lotus(laparoscopic operation by torsional ultrasound)Ultrasonic Scalpel.The perioperative and postoperative courses of the young female patient were uneventful and she is in a good general condition without complaints 18 mo after surgery.To the best of our knowledge,this is the first total laparoscopic hemihepatectomy to be performed in Greece,as well as the first laparoscopic liver resection using Lotus shears.

Glissonian approach combined with major hepatic vein first for laparoscopic anatomic hepatectomy

Background: Laparoscopic anatomic hepatectomy remains challenging because of the complex interior structures of the liver. Our novel strategy includes the Glissonian approach and the major hepatic vein first, which serves to define the external and internal landmarks for laparoscopic anatomic hepatectomy.Methods: Eleven cases underwent laparoscopic anatomic hepatectomy, including three right hepatectomies, three left hepatectomies, three right posterior hepatectomies, and two mesohepatectomies. The Glissonian approach was used to transect the hepatic pedicles as external demarcation. The major hepatic vein near the hepatic portal was exposed and served as the internal landmark for parenchymal transection. The liver parenchyma below and above the major hepatic vein was transected along the major hepatic vein. Fifty-nine subjects were used to compare the distance between the major hepatic vein and secondary Glisson pedicles among different liver diseases.Results: The average operative time was 327 min with an estimated blood loss of 554.55 m L. Only two patients received three units of packed red blood cells. The others recovered normally and were discharged on postoperative day 7. The distance between right posterior Glissonian pedicle and right hepatic vein was shorter in the patients with cirrhosis than that without cirrhosis, and this distance was even shorter in patients with hepatocellular carcinoma.Conclusion: The Glissonian approach with the major hepatic vein first is easy and feasible for laparoscopic anatomic hepatectomy, especially in patients with hepatocellular carcinoma and cirrhosis.

Clinical advantages of single port laparoscopic hepatectomy

AIM To evaluate the clinical advantages of single-port laparoscopic hepatectomy(SPLH) compare to multiport laparoscopic hepatectomy(MPLH).METHODS We retrospectively reviewed the medical records of 246 patients who underwent laparoscopic liver resection between January 2008 and December 2015 at our hospital. We divided the surgical technique into two groups; SPLH and MPLH. We performed laparoscopic liver resection for both benign and malignant disease. Major hepatectomy such as right and left hepatectomy was also done with sufficient disease-free margin. The operative time, the volume of blood loss, transfusion rate, and the conversion rate to MPLH or open surgery was evaluated. The post-operative parameters included the meal start date after operation, the number of postoperative days spent in the hospital, and surgical complications was also evaluated.RESULTS Of the 246 patients, 155 patients underwent SPLH and 91 patients underwent MPLH. Conversion rate was 22.6% in SPLH and 19.8% in MPLH(P = 0.358). We performed major hepatectomy, which was defined as resection of more than 2 sections, in 13.5% of patients in the SPLH group and in 13.3% of patients in the MPLH group(P = 0.962). Mean operative timewas 136.9 ± 89.2 min in the SPLH group and 231.2 ± 149.7 min in the MPLH group(P < 0.001). The amount of blood loss was 385.1 ± 409.3 m L in the SPLH group and 559.9 ± 624.9 m L in the MPLH group(P = 0.016). The safety resection margin did not show a significant difference(0.84 ± 0.84 cm in SPLH vs 1.04 ± 1.22 cm in MPLH, P = 0.704). Enteral feeding was started earlier in the SPLH group(1.06 ± 0.27 d after operation) than in the MPLH group(1.63 ± 1.27 d)(P < 0.001). The mean hospital stay after operation was non-significantly shorter in the SPLH group than in the MPLH group(7.82 ± 2.79 d vs 7.97 ± 3.69 d, P = 0.744). The complication rate was not significantly different(P = 0.397) and there was no major perioperative complication or mortality case in both groups. CONCLUSION Single-port laparoscopic liver surgery seems to be a feasible approach for various kinds of liver diseases.

Short-term Outcomes of Laparoscopic vs.Open Hepatectomy for Primary Hepatocellular Carcinoma:A Prospective Comparative Study

Laparoscopic hepatectomy(LH)is a newly developed technique associated with advantages as open surgery,but the study on outcome of liver function recovery was scarce.This preliminary report was aimed to comparatively assess the short?term outcomes between LH and open hepatectomy(OH)for primary hepatocellular carcinoma(PHC).This study retrospectively analyzed the demographic data and short-term outcomes of 81 patients who underwent LH or OH for the primary treatment of PHC between Oct.2017 and May 2018 at Union Hospital,Tongji Medical College,Huazhong University of Science and Technology(China).A total of 81 PHC patients who received major liver resection were enrolled.There were 38(47%)patients in the LH group and 43(53%)patients in the OH group.The operative time was significantly longer(373.53±173.38 vs.225.43±55.08,P<0.01),and hospital stay(17.34±5.93 vs.21.70±6.89,P=0.003),exhaust time(2.32±0.62 vs.3.07±0.59,P<0.01)and defecation time(2.92±0.78 vs.3.63±0.58,P<0.01)were significantly shorter in LH group than in OH group.The recovery of liver function was significantly faster in LH group,including higher serum albumin(P=0.002),higher ratio of albumin/globulin(P=0.029)and lower direct bilirubin(P=0.001)than in OH group.It is suggested that LH can serve as a fast recovery and cheap surgical procedure in the treatment of PHC,which is safe and feasible.

Successful outcome of massive carbon dioxide embolism during laparoscopic hepatectomy

Carbon dioxide embolism is a rare but severe complication of laparoscopic hepatectomy.We reported a case of massive carbon dioxide embolism that developed into a rare paradoxical gas embolism during laparoscopic hepatectomy and resulted in reduced muscular power of the left upper extremity,severe pleural effusion and hypoalbuminemia after surgery.Fortunately,the patient fully recovered with positive prevention and postoperative treatment.This case report highlights that the surgeon and anaesthesiologist must be aware of the risks and the importance for prompt treatment when massive carbon dioxide embolism occurs.

Effect of positive end-expiratory pressure ventilation on central venous pressure and intraoperative blood loss in patients undergoing laparoscopic hepatectomy

Objective:Tto investigate the effects of positive end-expiratory pressure(PEEP)ventilation on central venous pressure(CVP)and intraoperative blood loss in patients undergoing laparoscopic hepatectomy.Methods:46 cases of patients undergoing laparoscopic hepatectomy,25 cases of male,female 21 cases,ASAⅠ~Ⅲlevel,were randomly divided into two groups.In group A tidal volume was set to 6 ml/kg(Predicted Body Weight,PBW)and PEEP was set to 0 cmH2O.The tidal volume of group B was set as group A,PEEP was set to 8 cmH2O.CVP,MAP,and Ppeak were recorded in the supine position after intubation(T0),supine position after pneumoperitoneal(T1),anti-trendelenberg position after pneumoperitoneal(T2),supine position after surgery(T3),and Ddyn was calculated.The amount of nitroglycerin and the amount of blood loss were recorded.Results:Compared with group A,the CVP of group B was significantly increased at T1 and T2(P<0.05).Compared to T2 with T1 in group A and group B,CVP was decreased significantly(P<0.05).At T3,Cdyn in group B was significantly higher than that in group A(P<0.05).The amount of nitroglycerin in group B was significantly higher than that in group A(P<0.05).There was no significant difference in intraoperative fluid rehydration and blood loss between the two groups(P>0.05).Conclusion:PEEP with 8cmH2O can improve Ddyn in patients undergoing laparoscopic hepatectomy,but increased CVP.It requires more use of controlled low central venous pressure techniques to reduce intraoperative blood loss.

Arantius' ligament approach for the laparoscopic left hemihepatectomy

In recent years, the technique of laparoscopic hepatectomy has been developed rapidly, and its indications are approximately equal to open surgery [1,2]. Laparoscopic left hemihepatectomy(LLH) has become a mature and standardized operation [3,4], and there are many reports on the relevant surgical paths and norms [5-7]. Herein, the Arantius' ligament approach for the LLH is proposed, which provides a reference for the standardized path of LLH.