Lateral approach toward hepatoduodenal ligament during laparoscopic radical cholecystectomy for Gallbladder cancer.

Background: The common approach of Lymph node dissection (LND) during laparoscopic radical cholecystectomy (LRC) is an anterior approach [1,2], which emulates the view of open surgery. However, isolating the post-pancreatic nodes and retro-portal nodes completely without any damage to neighboring organs can be difficult in laparoscopic surgery because the dorsal structures of hepatoduodenal ligament are embedded and it is difficult for a surgeon to expose them [3]. On the other hand, the lateral approach offers the better way to expose and dissect dorsal part of hepatoduodenal ligament and it can be useful for dissecting hilar during laparoscopic right hepatectomy without injury of left side vascular structures.

Methods: We performed retrospective analysis of consecutive 10 patients submitted to LRC for Gallbladder (GB) cancer and described a technical aspect regarding LND for those series of cases. Among them, we introduced a patient with 71 years old man in a surgical video clip. He had no symptom and was his lesion was detected during a regular health care screening. The preoperative computed tomography showed T2 cancer with suspicious involvement in liver. His liver function was normal and tumor marker level was in normal range. LRC with liver wedge resection were contemplated for his treatment.

Results: In the video clip, the patient was laid on an operating table in supine position. A zero degrees flexible laparoscope was used through the port on right subcostal angle. After identifying the common hepatic artery, #8 nodes were dissected and a 360-degree surrounding loop was applied to it for gentle retraction. Then gastroduodenal artery was identified with same manner. Cystic duct was isolated and frozen biopsy of its stump was done. After completing the isolation of common bile duct, another 360-degree loop was placed around it. The main trunk of the portal vein was exposed and followed superiorly up to the area of its bifurcation. Camera moved to lateral side of patient, to provide the better view of posterior and dorsal part of hepatoduodenal ligament. Careful dissection of retro-portal area with node dissection was then performed and portal vein was surrounded in 360°. Then, surgeon paid attention to dissecting retro-pancreatic #13 nodes, which was clearly identified and dissected. LRC was performed successfully by using lateral laparoscopic approach. Then liver wedge resection under laparoscopy was performed without any problem. This approach was not a great invention or innovation. Rather, this approach is commonly used technique in "liver and pancreatic minimally invasive procedures" including robotic procedures. However, this simple procedure can be useful for a surgeon to perform LRC. During last 20 years, we performed radical cholecystectomy for treating GB cancer in our institution. Since 2014, we changed the policy to treat early GB cancer (in the stage of T1b and T2) with "minimally invasive procedure". We performed only LND without liver resection for peritoneal side tumor. Most of all patients were diagnosed in preoperative manner. Only two cases of incidental cancer underwent additional operation of LND and liver resection. Half of cases went through the process of dissection of lymph nodes only and 5 liver resections were done. None of patients undergoing LRC required conversion to another view during hilar dissection. The retro-portal vein and pancreas head LND could be reached expeditiously and safely prior to parenchymal transection. Majority of them revealed T2 and T1b finally. Number of retrieved nodes were in between 1 and 17 and median was 7. There was one complication of small bowel perforation during adhesiolysis.

Conclusion: Lateral approach during LRC appears to offer better way to visualize, expose and dissect the dorsal part of hepatoduodenal ligament and LND #12,13s.