3
18
Barros Scheloꢀo P. Editorial acerca de: “Resecciones hepáꢁcas videolaparoscópicas”. Rev Argent Cir. 2023;115(4):316-319
tumor locaꢀon, tumor size, proximity to major blood bleeding is the main reason for conversion to
1
2
vessels, presence of cirrhosis, type of approach, and convenꢀonal surgery , which can occur during
extent of liver resecꢀon. The total score ranges from dissecꢀon of the portal pedicle, suprahepaꢀc veins or
0
to 12. The difficulty level of LLRs is classiꢂed as low if parenchymal transecꢀon. A meꢀculous dissecꢀon of
the score is 0-3, intermediate if it is 4-6, advanced when each element is the best means to prevent bleeding.
it is 7-9, and expert at 10-12. The use of the Pringle Some authors recommend using the Pringle maneuver
maneuver, the conversion rate and the presence to dissect the portal pedicle. Oher authors, as Machado
of morbidity are higher as the level of complexity M. suggest the intrahepaꢀc Glissonian approach and
1
3
increases. As a criꢀque, the score fails to consider stapling of the pedicle without hilar dissecꢀon .
factors such as whether it is a repeat liver resecꢀon, This approach is ꢀmesaving but demands thorough
the paꢀent’s history of chemotherapy, or obesity, all understanding of liver anatomy and poses a risk for
of which add complexity to any hepatectomy. It does injury to the contralateral hilar structures. Many
neither provide informaꢀon on what to consider when authors recommend the use of energy devices to avoid
performing mulꢀple resecꢀons. Should we consider all bleeding during parenchymal transecꢀon. Ultrasonic
lesions individually, the largest, the most complex to surgical aspirator enables the idenꢀꢂcaꢀon of the
resect? As the authors suggest, the recommendaꢀon vascular and biliary elements to ensure their effecꢀve
is to start performing minor resecꢀons of the anterior control. We are decreasing our use of mechanical
segments of the liver (segments 2, 3 4b, 5 and 6) which sutures for parenchymal transecꢀon, leaving their use
9
are considered easier and less complex .
for portal pedicle or suprahepaꢀc vein transecꢀon.
Beyond the technical difficulꢀes, one of the When the ultrasonic aspirator is not available, we can
major limitaꢀons of LLR is the need for technological use the jaws of the energy devices to perform the Kelly
1
4
equipment. We do not only need a good laparoscopy clamp crushing technique . The authors show that
tower but also speciꢂc instruments, as laparoscopic as the complexity of hepatectomies increases, they
ultrasound probe, energy devices, special clip perform the Pringle maneuver more oꢅen. The same
applicators and mechanical stapler. Unfortunately, not occurs with most of the published series. The authors
all surgical centers count with these instruments, which use extracorporeal Pringle maneuver, but or group
remains a primary obstacle to the widespread adopꢀon prefers the extracorporeal maneuver. Both opꢀons
of this approach. In the absence of instruments or are highly effecꢀve in achieving their intended goals,
equipment, we must not forget the possibility of hand- therefore it is advisable to uꢀlize the one that best
assisted or hybrid approaches which are alternaꢀves suits the surgeon’s preferences. Other methods to
to the totally laparoscopic approach while maintaining reduce blood loss during parenchymal transecꢀon are
the advantages of minimally invasive surgery. They are to increase pneumoperitoneum pressure, lower central
recommendedforsurgicalteamswithlimitedexperience, venous pressure, ask the anesthesiologist to minimize
in cases of large tumors located in posterosuperior ꢀdal volume, and posiꢀon the paꢀent in the inverted
segments, and for repeat hepatectomies. The Trendelenburg posiꢀon.
increased costs associated with the technology needed
In summary, over the past few years, LLRs
for the procedure are offset by the reduced risk of have become more prevalent in available treatment
complicaꢀons, shorter length of hospital stay, lower opꢀons for liver diseases. At present, we have sufficient
rate of readmissions, and fewer reoperaꢀons1
0-11
.
scienꢀꢂc evidence to support its use and reassure us it
As it happens in most published series, is a safe procedure for paꢀents.
Referencias bibliográficas /References
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