Parenchymal-sparing laparoscopic liver resections for multiple and ill-located colorectal metastases

The video shows a case of a 75 years old woman with 7 liver metastases (LM) synchronous to left colon adenocarcinoma. After 6 cycles of oxaliplatin-based chemotherapy with partial response, patient was scheduled for surgery as a part of a “Liver first” strategy. Pre-operative MRI showed 6 LMs: 15mm in Sg3 infiltrating left hepatic vein (LHV), 20mm in Sg4a in contact with middle hepatic vein (MHV), 22mm in Sg7-8d in contact with glissonian pedicle of Sg7 (G7) and right hepatic vein (RHV), 10mm in Sg6, 11mm in Spiegel Lobe (SL). One LM in Sg1 (caudate lobe - CL) disappeared after chemotherapy (DLM). Intraoperative laparoscopic ultrasound (LUS) assessed the site and vascular relationship of LMs and found DLM (5mm) in CL. After right liver mobilization and extrahepatic control of RHV, color-Doppler LUS flow analysis revealed a hepatofugal inflow in the veno-occlusive segment Sg8 lateral (Sg8l) under RHV clamping. Basing on LUS findings we planned 5 resections: an upper transversal resection (Sg4a, Sg8 and Sg7) sparing RHV, MHV and Sg8l and comprising 3 LMs; resection of SL; subsegmentectomy Sg3; atypical resection Sg6 and CL. Inflow and outflow were controlled. A LUS-guided pedicle first approach was performed to isolate G7 from the dorsal side of the liver. MHV and RHV were dissected from cranio to caudal. MHV was freed from LM. Finally, LHV, MHV and RHV were exposed on the cut surface. Blood loss: 400cc. Transection time 298 min, Clamping time 203’. Postoperative course uneventful. Patient discharged in 4 th POD.