Thoracoscopic Liver Resection Combined with Laparoscopic Pringle Maneuver for Recurrent Tumor with Diaphragmatic Invasion and Intra-Abdominal Adhesions.

[BACKGROUND] Laparoscopic liver resection for tumors located just under the diaphragm at the right posterosuperior segments is technically challenging, especially repeat liver resection, due to severe intra-abdominal adhesions. A thoracoscopic-only transdiaphragmatic approach can enable straightforward access to subdiaphragmatic liver tumors, but the absence of hepatic inflow occlusion may lead to increased bleeding risk during liver parenchymal resection. In this video presentation, we demonstrate laparoscopy and thoracoscopy cooperative liver resection via transdiaphragmatic approach under the security of a total Pringle maneuver.

[CASE] A man in his 70s had two-time history of laparoscopic resection for liver metastases derived from sigmoid colon cancer, including segmentectomy VII. This time, a third occurrence of liver metastasis appeared around the site of previous resection at the edge of segment VII, and there was suspicion of diaphragm invasion. Severe adhesion was a concern, so we planned laparoscopy and thoracoscopy cooperative liver resection.

[SURGICAL PROCEDURE] First, only encirclement of the hepatoduodenal ligament for the total Pringle maneuver could be achieved by laparoscopy, so the thoracoscopic approach was started. The tumor could be easily identified through the diaphragm, and thoracoscopic liver resection was performed safely under the total Pringle maneuver. After liver resection, the diaphragmatic defect was repaired using barbed sutures. The amount of intraoperative bleeding was 420 mL and the operative time was 471 min. The patient was discharged on postoperative day 8 without any complications. R0 resection was pathologically confirmed.

[CONCLUSIONS] This procedure can be a safe and useful option for specific cases..