Operative techniques to avoid near misses during laparoscopic hepatectomy

Background The lack of a complete hepatic overview and tactile feedback during laparoscopic hepatectomymay result in near missesor fatal intraoperative complications despite the advantage of a magnified laparoscopicview. The aim of the study is to describe operative techniques and guiding principleswith which to address near missesunique to laparoscopic hepatectomyand evaluate the intraoperative complication rate overtime. Methods Data of 408 consecutive patients who underwent laparoscopic hepatectomywere reviewed. Representative operative techniques and guiding principleswith which to address near missesand pitfalls unique to laparoscopic hepatectomywere evaluated among the patients by 2 surgeons. Results Most near misseswere due to lack of understanding of both the laparoscopicview and anatomic aspects unique to laparoscopic hepatectomy. Operative techniques and/or guiding principleswith which to address these issues were demonstrated as follows: starting parenchymal transection at the declivitous parts; no ligation of the right or left portal vein before confirming the bifurcation; dissection of the short hepatic veinusing a sealing device; dissection of the root of the hepatic veinusing scissors; exposure of the middle hepatic vein, which is anatomically close to the hilar plate; and identification of V8 using intraoperative ultrasonography. The intraoperative massive bleeding due to vessel injury or surgical clip slippage occurred in 25 patients (6.1%), and its rate had a significant trend to decrease with increasing years. Conclusion We demonstrated operative techniques and guiding principleswith which to address near missesin laparoscopic hepatectomy. The intraoperative massive bleeding rate trended to decrease over time.