Ultrasound liver map technique for laparoscopic liver resections: tips and tricks

Laparoscopic liver resection (LLR) is safer and more advantageous than open surgery regarding morbidity, blood loss, and length of hospital stay. Several radiological studies and liver surgical strategies confirmed that the anatomy of the liver is more complex than what Couinad described. Intraoperative ultrasound (IOUS) has become an indispensable tool to identify the “real anatomy” and to plan a tailored LLR because of wide sub-segmentary variability and lack of external indicators for small functional liver cores. We schematized our standard ultrasound guidance technique during anatomical and non-anatomical LLR as a four-step method called the Ultrasound Liver Map Technique: (1) Compose the three-dimensional mind map to study the relationships between lesions and surrounding vascular elements; (2) create a sketch on the Glissonian using cautery to help the surgeon recall the mind liver anatomy map; (3) check the section plane while proceeding with the transection; and (4) correct the direction of resection plan to ensure a healthy margin concerning the lesion and to point out the pedicle section correctly and not affected structures. Finally, IOUS-Doppler can be used to study the segmental portal flow to assess venous drainage of the remnant parenchyma, avoiding ischemia and increasing the possibility of performing parenchyma-sparing surgery

Recurrence after Curative Resection for Intrahepatic Cholangiocarcinoma: How to Predict the Chance of Repeat Hepatectomy?

(1) Background: Tumor recurrence after liver resection (LR) for intrahepatic cholangiocarcinoma (ICC) is common. Repeat liver resection (RLR) for recurrent ICC results in good survival outcomes in selected patients. The aim of this study was to investigate factors affecting the chance of resectability of recurrent ICC. (2) Methods: LR for ICC performed between January 2001 and December 2020 were retrospectively reviewed. Patients who had undergone first LR were considered for the study. Data on recurrences were analyzed. A logistic regression model was used for multivariable analysis of factors related to RLR rate. (3) Results: In total, 140 patients underwent LR for ICC. Major/extended hepatectomies were required in 105 (75%) cases. The 90-day mortality was 5.7%, Clavien–Dindo grade 3, 4 complications were 9.3%, N+ disease was observed in 32.5%, and the median OS was 38.3 months. Recurrence occurred in 91 patients (65%). The site of relapse was the liver in 53 patients (58.2%). RLR was performed in 21 (39.6%) patients. Factors that negatively affected RLR were time to recurrence ≤12 months (OR 7.4, 95% CI 1.68–33.16, p = 0.008) and major hepatectomy (OR 16.7, 95% CI 3.8–73.78, p p = 0.02). (4) Conclusions: Patients with ICC treated at first resection with major hepatectomy and those who recurred in ≤12 months had significantly lower probability to receive a second resection for recurrence