Robotic Right Hepatectomy with Portal Vein Thrombectomy for Colorectal Liver Metastasis (with Video)

• Published in: Journal of gastrointestinal surgery 2021-07, Vol.25 (7), p.1932-1935
• Main Authors: Machado, Marcel A., Mattos, Bruno H., Lobo Filho, Murillo M., Makdissi, Fabio F.
• Format: Article
• Language: English
• Subjects: Blood clots; Colonic Neoplasms; Female; Gastroenterology; Hepatectomy; Humans; Laparoscopy; Liver; Liver Neoplasms - surgery; Medicine; Medicine & Public Health; Metastasis; Middle Aged; Multimedia Article; Portal Vein - surgery; Robotic Surgical Procedures; Robotics; Surgery; Thrombectomy; Veins & arteries
• ISSN: 1091-255X; 1873-4626
• DOI: 10.1007/s11605-021-04954-x

Background Hepatectomy is the standard treatment for colorectal liver metastases. However, the high recurrence rate is a persistent problem that occurs in up to 65% of patients. Repeat hepatectomy is a feasible treatment and may offer favorable surviva but is technically demanding so minimally invasive repeat hepatectomy has been used in a few patients. Colorectal liver metastases are different from hepatocellular carcinoma and rarely present with macroscopic portal vein tumoral thrombus. To the best of our knowledge, minimally invasive approaches for this rare condition have not yet been reported. Method We present here a video of a robotic right hepatectomy in a patient with single colorectal liver metastasis and macroscopic tumor thrombi in the right portal vein. A 61-year-old woman underwent open resection of a transverse colon cancer (T3N0M0) in December 2015. In March 2019, she underwent nonanatomical resection of a liver metastases located in segment 6 also via an open approach. She then underwent adjuvant chemotherapy. However, in September 2020, she presented with a local recurrence and a tumor thrombus in the right portal vein. She was then referred to us for treatment and a multidisciplinary team decided on upfront liver resection due to the risk of left portal vein progression. Liver volumetry showed future liver remnant of 52.5%. Right hepatectomy with portal vein thrombectomy was indicated. A robotic approach was proposed, and consent was obtained. Results The Da Vinci system was used. The operation began with the division of adhesions from previous laparotomies. Intraoperative ultrasound was performed to locate the tumor and to confirm the portal vein invasion. Hepatic hilum was carefully dissected. The replaced right hepatic artery from the superior mesenteric artery was ligated and divided. The common bile duct was dissected and encircled with a vessel loop. The portal vein was dissected, and an enlarged right portal vein with a protruding tumoral thrombus was seen. The left portal vein and portal vein trunk were then temporarily clamped. The right portal vein was carefully transected with robotic scissors being careful not to displace the thrombus. A minimum stump was left to safely suture the portal vein. The portal vein was then closed with a running 5-0 prolene suture. The portal vein clamping was then released, and a patent anastomosis with no leakage was observed. Right liver ischemic discoloration was seen and confirmed with fluores