benign liver tumors such as hepatic hemangioma , focal nodular hyperplasia , and hepatic adenoma are thought to be good indications of lh .
however , there are still technical difficulties with lh related to liver mobilization , hemorrhage controlling , and unexpected vessels injuries . among them
, hepatic vein injury ( hvi ) during lh is especially dangerous , because it may cause conversion , air embolization , fatal hemorrhage , or even death .
we here present a case of a 78-year - old female patient who was initially admitted to our department due to fever and jaundice for 2 days .
preoperative abdominal enhanced computed tomography scan showed intrahepatic and extrahepatic bile duct dilatation with liver atrophy of left lobe .
tumor markers including alpha fetoprotein , carcinoembryonic antigen , and ca19 - 9 were normal .
a laparoscopic left hepatectomy and bile duct exploration were performed for this patient due to its left lobe atrophy and bile duct dilation .
this patient was placed in the reversed trendelenburg position , with the surgeon standing by the patient 's right side .
three 12  mm and two 5  mm trocars ( ethicon endo - surgery , cincinnati , oh ) were usually inserted .
after cholecystectomy was completed , the left bile duct , left hepatic artery , and left portal vein were meticulously dissected and transected .
the hepatic vein branches of segment ii and iii were dissected and clamped by hem - o - lok .
a 5 - 0 prolene running suturing was used to fix the middle hepatic vein hemorrhage .
the left hepatic pedicle tissue and left hepatic vein were transected by laparoscopic linear stapler ( endopath endocutter ; ethicon endosurgery ) with 60  mm white cartridge .
the common bile duct was explored and a # 26 t tube was placed from the distal of left bile duct .
all clinical investigations were in accordance with the ethical guidelines of the declaration of helsinki .
ethical approval was obtained from the committee of ethics in west china hospital of sichuan university .
this patient was placed in the reversed trendelenburg position , with the surgeon standing by the patient 's right side .
three 12  mm and two 5  mm trocars ( ethicon endo - surgery , cincinnati , oh ) were usually inserted .
after cholecystectomy was completed , the left bile duct , left hepatic artery , and left portal vein were meticulously dissected and transected .
the hepatic vein branches of segment ii and iii were dissected and clamped by hem - o - lok .
a 5 - 0 prolene running suturing was used to fix the middle hepatic vein hemorrhage .
the left hepatic pedicle tissue and left hepatic vein were transected by laparoscopic linear stapler ( endopath endocutter ; ethicon endosurgery ) with 60  mm white cartridge .
the common bile duct was explored and a # 26 t tube was placed from the distal of left bile duct .
all clinical investigations were in accordance with the ethical guidelines of the declaration of helsinki .
ethical approval was obtained from the committee of ethics in west china hospital of sichuan university .
during operation , a lot of mucus was seen within the common bile duct and left intrahepatic bile duct .
parenchymal transection , intraoperative hemorrhage from middle hepatic vein was met , and we repaired middle hepatic vein by laparoscopic suture ( 5 - 0 prolene ) no complication including air embolization , hypotension , or oxygen saturation decreasing was met during and after surgery .
postoperative ultrasonography indicated a normal outflow of middle hepatic vein and there was no stricture .
the patient 's postoperative course was uneventful , and was discharged on the 6th day after surgery .
although control of the hepatic vein can be laparoscopically obtained , this is not always possible . as a result ,
intraoperative hemorrhage is extremely dangerous . in this case , the patient who underwent lh suffered intraoperative hvi .
however , the lack of complete view on surgical field always mistook local structures from their right anatomy . a good camera manipulating and general observation were very important to identify the right anatomy of hepatic vein . in this case , when intraoperative hepatic vein bleeding occurred , the first assistant used a forceps to retract the left lobe to the left side by one hand and used an aspirator to clean the surgical site bleeding by the other hand .
the scopist changed the camera angle ( zoom out ) and showed a complete view of surgical site to identify where the bleeding came from .
then , the scopist zoomed in the camera when the precise stitching and hvi repairing were performed .
no air embolization , hypotension , or oxygen saturation decreasing was met during and after lh .
three factors might contribute to it : good exposure of bleeding site by an experienced first assistant ; skillful stitching for hvi ; and good communications among surgeon , anesthetist , and nurse .
, it was thought that air embolism could possibly occur due to the pneumoperitoneum . however , because of the higher solubility rate of carbon dioxide in the blood than in the air , although carbon dioxide gas embolism frequently occurs throughout laparoscopic liver surgery , it is not clinically significant . as a result , the risk of air embolism may be less with the laparoscopic approach than with the open approach because pneumoperitoneum is obtained with carbon dioxide gas rather than air . in conclusion , this is the first case about laparoscopic anatomical left hepatectomy for intrahepatic bile duct papillary mucinous cystadenoma . and
we should pay more attention to the details when performing lh , to avoid hvi .
 abstractlaparoscopic hepatectomy has been widely performed for patients with benign liver tumors such as hepatic hemangioma , focal nodular hyperplasia , and hepatic adenoma.we here present a case of a 78-year - old female patient who was initially admitted to our department due to fever and jaundice for 2 days . abdominal enhanced computed tomography scan showed intrahepatic and extrahepatic bile duct dilatation with liver atrophy of left lobe . 
 unenhanced nodules were seen within the left intrahepatic bile duct . 
 ultrasonography revealed intrahepatic and extrahepatic bile duct dilatation with viscous fluid , tubular adenoma ? 
 tumor markers including alpha fetoprotein , carcinoembryonic antigen , and ca19 - 9 were normal . 
 preoperative total bilirubin was 64.4  mmol / l.laparoscopic anatomical left hepatectomy and common bile duct exploration were performed . in this procedure , a lot of mucus was seen within the common bile duct and left intrahepatic bile duct . 
 no bile duct stones were found after the exploration . during parenchymal transection , intraoperative hemorrhage from middle hepatic vein 
 was met , and we repaired middle hepatic vein by laparoscopic suture ( 5 - 0 prolene ) . 
 no air embolism and hypotension were met . 
 this operation took 232 minutes and estimated blood loss was 300  ml . 
 postoperative ultrasonography indicated a normal outflow of middle hepatic vein and there was no stricture . 
 the patient 's postoperative course was uneventful and was discharged on the 6th day after surgery . 
 postoperative pathological diagnosis was intrahepatic bile duct papillary mucinous cystadenoma . 
INTRODUCTION
PATIENTS AND METHODS
Surgical Procedure
Ethics Statement
RESULTS
DISCUSSION