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Extrafascial Laparoscopic Radical Prostatectomy

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Laparoscopic Left Hepatectomy With Direct Glissonian Approach

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Do Rego Monteiro Filho Jose Julio,
Rio De Janeiro

PERSONAL COMMENTS:
I've used this kind of approach successfully in laparoscopic left hepatic resections( also in segments II and III resection). It is very objective, with minor bleeding, but requires experience in either laparoscopic and hepatic surgery.

ABSTRACT:
The patient is a 43 years old female that 3 years before was operated on for a microinvasive breast cancer. An ultra sound revealed a suspicious liver segment IV lesion that is confirmed by an MRI. A laparoscopic left hepatectomy with direct glissonian approach is proposed. The MRI shows the relationship of the lesion and the segment IV pedicule, preventing an isolated segment IV resection. It also shows the right deep limit of resection, the middle hepatic vein, showing also the anatomy of the liver pedicule.
The patient is placed in a supine position, the surgeon between the legs. Adhesions from previous surgery(laparoscopic cholecistectomy) are taken down. The main left glissonian pedicule is identified, as is the pedicule of segments II and III. A small hepatotomy is made in segment IV just anterior to the left main pedicule. The lesser sac is opened and a small hepatotomy is made just posterior to the left main pedicule. A linear stapler with a vascular load is placed envolving the whole left main pedicule. It is closed and the liver observed for isquemic delimitation. The stapler is fired, the delimitation is clearly seen. The hepatotomy line is made with monopolar cautery. The hepatotomy is made with ultrasonic scissors with hemostasis being complemented with bipolar cautery. Greater vessels are either clipped or ligated with ligasure. As expected, we encountered the middle hepatic vein and a branch of it needed to be suture ligated. The left hepatic vein is treated with a vascular stapler. The specimen is placed in a bag and removed through a lower abdominal transverse incision. The liver is coagulated and an absorbable hemostatic agent is used together with a biological glue. A tubular closed suction drain is used and the greater omentum covers the raw surface of the liver
fluoroscopically-guided laparoscopic choledochotomy for impacted CBD stone
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