Utility of Left Lateral Liver Lobectomy in Removing Retrohepatic Lesions During Cytoreductive Surgery for Low-Grade Mucinous Carcinoma Peritonei.

Abstract

Complete cytoreduction (CC) during cytoreductive surgery (CRS) is essential for favorable outcomes in appendix neoplasms.^1-5 However, achieving CC is particularly challenging and may require non-trivial maneuvers when the tumor grows in the left retrohepatic space and along the ligamentum venosum (LV).^6-8 MATERIALS AND METHODS: This multimedia article features a step-by-step video of CRS with left lateral liver lobectomy (LLLL) in a patient with a low-grade appendiceal mucinous neoplasm (LAMN) and extensive peritoneal dissemination. After initial systemic chemotherapy resulted in toxicity and no disease response, the patient sought CRS and hyperthermic intraperitoneal chemotherapy (HIPEC) at our center. The preoperative PCI was 34.⁹ Surgery started with greater omentectomy, left diaphragmatic peritonectomy, and splenectomy. During right diaphragmatic peritonectomy and porta hepatis dissection, we found peri- and retrohepatic implants extending to the left hepatic vein. To remove these difficult-to-reach lesions completely and safely, we performed LLLL using a "predissected" plane along LV. We then resected segment 1 due to bulky disease between it and inferior vena cava (IVC), which provided a direct view of the retrohepatic IVC, allowing for safe tumor removal. After completing CRS in other areas (CC-0), a 90-min HIPEC perfusion (mitomycin-C) was performed.⁹ The patient had no major complications.¹⁰ At 24 months post-CRS/HIPEC, he remained symptom- and disease-free. Removing lesions around the left liver and segment 1 is challenging yet essential to ensure CC in LAMN. While not a routine maneuver, in such cases, LLLL can be utilized to access retrohepatic lesions safely and expeditiously, allowing for their removal.