Laparoscopic anatomical segment III resection for a giant focal nodular hyperplasia (FNH): advantages of the extraglissonean approach—a case report

Introduction

Focal nodular hyperplasia (FNH) is the second most common benign tumor of the liver and mainly affects young people (1). Despite surgical resection is currently accepted in symptomatic patients, laparoscopic approach is sometimes challenging depending on the size and location of the tumor due to the inherent aberrant vessels surrounding the FNH. In this regard, the preoperative identification in the imaging of the arterial inflow might help in the vascular control achieving a very significant decrease in the tumor size before starting the resection. Furthermore, an extraglissonean approach favors the identification of the intrahepatic portal pedicle (2), which supplies the correspondent liver segment without any need of further dissection of the hepatoduodenal ligament. We present the following article in accordance with the CARE reporting checklist (available at http://dx.doi.org/10.21037/ls-20-132).

Case presentation

We present the case of a 24-year-old male patient with no relevant medical-surgical history, who presented with upper-right abdominal pain. In the work-up hepatocyte-specific liver magnetic resonance it was identified a 10×8×7 cm mass arising from the segment III of the liver, suggestive of FNH, with a central nutrient vessel. Given the large size of the lesion, it was decided to perform a laparoscopic anatomical segmentectomy.

The patient is placed in French position, with the main surgeon located between the legs and two assistants on each side of the patient. The first 12 mm trocar is placed supra-umbilically using an open laparoscopy technique, and then pneumoperitoneum performed. Firstly, the external Pringle maneuver is placed using a tape around the hepatoduodenal ligament and extracted through a 5 mm trocar to stop the inflow in case a hemorrhage occurs. The umbilical fissure is addressed after dividing the falciform ligament and the view facilitated by grasping upwards from the round ligament. Before starting the transection a nutritive vessel of the lesion arising from the left hepatic artery is identified and selectively clamped to reduce the blood flow into the FNH and avoid a total Pringle maneuver. According to the extraglissonean approach, liver parenchyma transection is carried out following the umbilical fissure, which enables a direct access to the targeted subsegmentary pedicle of segment III (Video 1) and the division of the same with stapler without invading the tumor capsule and thus respecting the portal pedicles for other hepatic segments. At this point of the operation to complete the resection it remains only the liver parenchyma beyond the glissonean pedicle, which is transected with an ultrasonic dissector. The patient had no postoperative complications and was discharged home on the third postoperative day. The definitive pathology confirmed the diagnosis of FNH.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committees and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient.

Discussion

FNH is currently a rare indication for liver resection however when necessary it might require a major liver resection in up to 33% of the cases (3). From a surgical point of view, the resection could be as hazardous as the location of the HNF is and the most frequent postoperative complication is described to be postoperative abscesses secondary to bile leak (4). By implementing the selective transfisural glissonean approach, the targeted pedicle is directly addressed and stapled, therefore the liver hilum is not exposed preventing thus a bile leak (2). The detailed preoperative study of the liver anatomy allows a better planning of liver surgeries. In patients with FNH, the identification and dissection of the typical central nutrient artery allows selective clamping of the problem region, reducing the risk of hemorrhage and avoiding the clamping of the entire hepatic hilium (5).

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Nadia Russolillo) for the series “Amplifying the voices of women surgeon scientists” published in Laparoscopic Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at http://dx.doi.org/10.21037/ls-20-132

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/ls-20-132). The series “Amplifying the voices of women surgeon scientists” was commissioned by the editorial office without any funding or sponsorship. BI serves as an unpaid editorial board member of Laparoscopic Surgery from November 2020 to October 2022 and PSV serves as an unpaid editorial board member of Laparoscopic Surgery from February 2020 to January 2022. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committees and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Pinotti E, Ratti F, Cipriani F, et al. Focal nodular hyperplasia. In: Aldrighetti L, Cetta F, Ferla G. editors. Benign tumors of the liver. Cham: Springer, 2015:159-68.
2. Kim JH. Laparoscopic anatomical segmentectomy using the transfissural Glissonean approach. Langenbecks Arch Surg 2020;405:365-72. [Crossref] [PubMed]
3. Navarro AP, Gomez D, Lamb CM, et al. Focal nodular hyperplasia: a review of current indications for and outcomes of hepatic resection. HPB (Oxford) 2014;16:503-11. [Crossref] [PubMed]
4. Perrakis A, Vassos N, Grützmann R, et al. What is changing in indications and treatment of focal nodular hyperplasia of the liver. Is there any place for surgery? Ann Hepatol 2017;16:333-41. [Crossref] [PubMed]
5. Wang Y, Ji W, Zhang X, et al. Laparoscopic liver resection and enucleation of liver hemangioma with selective hepatic vascular occlusion: technique and indications. J Laparoendosc Adv Surg Tech A 2017;27:944-50. [Crossref] [PubMed]