Although formal laparoscopic hepatic lobectomies are performed routinely, concerns including the risk of major intra-operative haemorrhage remain regarding such an approach.1,2
Control of the inflow vasculature prior to parenchymal transection reduces intra-operative blood loss during major hepatectomy3, and extra-hepatic dissection, ligation and division of the right hepatic artery and right portal vein (RPV) is effective in reducing intra-parenchymal haemorrhage.
Laparoscopic exposure and stapled division of the RPV is limited owing to the weight of the liver and the RPV anatomical position. Excessive tension or torque on the vein while positioning the stapler can result in catastrophic consequences. A major impediment to smooth introduction of the stapler is the caudate process posterior to the RPV. This report and accompanying video describe the author's approach to address these issues.
Specific gallbladder retraction and division of the caudate process after hepatic mobilization is crucial (Fig. 1). The approach is summarized as a checklist in Fig. 2. This method (TorCH manoeuver) is readily teachable and can be included in curricula for continuing medical education or for fellows and established surgeons learning laparoscopic techniques.
Figure 1.
Completed TorCH manoeuver with a stapler around the right portal vein. Illustrated by: Laura Maaske
Figure 2.
Checklist summarizing the steps of the TorCH manoeuver
No disclosures or conflicts of interest
References
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