LETTER TO THE EDITOR Laparoscopic Hepatectomy Under Epidural Anesthesia To the Editor: lthough hepatectomy has played a pivotal role as the most radical treatment of hepatic malignancies, it usually requires large abdominal incisions, deteriorating patients’ postoperative physical and mental health. Over the last 15 years, laparoscopic hepatectomy has been rapidly spreading worldwide as a safe alternative to open surgery that can markedly improve surgical invasiveness.1 However, laparoscopic hepatectomy still has a risk of complications associated with endotracheal intubation, mechanical ventilation, and systemic narcotic/muscle relaxant agents. In the author’s (K.Y.) hospital, more than 3000 open abdominal surgical procedures for gastrointestinal malignancies have been safely performed under epidural anesthesia and conscious sedation without endotracheal general anesthesia for 50 years. This anesthetic technique has been safely applied to laparoscopic cholecystectomy since 19922 and to open hepatectomy since 2010.3 While expanding the indications for epidural anesthesia, we noticed that retraction or insufflation of the abdominal wall did not inflict intolerable discomfort on patients without general anesthesia. This led us to apply the same anesthetic policy to laparoscopic left lateral sectionectomy in a 64-year-old patient with hepatocellular carcinoma. An epidural catheter was inserted via the seventh thoracic vertebral interspace, and 10 mg of diazepam was administered orally 1 hour preoperatively.3 In the operating room, the abdominal cavity was insufflated with carbon dioxide gas at less than 8 mm Hg and 4 trocars were placed (Fig. 1A). The hepatic parenchyma was transected with a bipolar energy device. The Glissonian sheaths and the left hepatic vein were exposed on the hepatic raw surface and then divided with a surgical stapler (Fig. 1B, C). The surgical procedure was completed in 3 hours with 100 mL of blood loss under

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Disclosure: No funding was received in support of this work. The authors declare there are no conflicts of interest. The patient provided written, signed consent for her case and for images to be used in its presentation. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsofsurgery.com). C 2014 by Lippincott Williams & Wilkins Copyright  ISSN: 0003-4932/14/26002-e0001 DOI: 10.1097/SLA.0000000000000816

FIGURE 1. Laparoscopic left lateral sectionectomy for hepatocellular carcinoma under epidural anesthesia. All laparoscopic procedures were managed under epidural anesthesia with conscious sedation (A). The hepatic parenchyma was transected, and the Glissonian sheaths and the left hepatic vein were divided using conventional laparoscopic techniques (B), with no problems associated with the absence of general anesthesia. Pathological examination proved the tumor on the resected specimen to be a hepatocellular carcinoma (C). See Supplemental Digital Content Video (available at http://links.lww.com/SLA/A576). epidural anesthesia by injection of 7 mL of 2% mepivacaine hydrochloride every 40 minutes.3 Postoperatively, the patient rapidly recovered consciousness with no surgical or anesthetic complications. Laparoscopic hepatectomy solely under epidural anesthesia has possible advantages in accelerating postoperative recovery and may extend opportunities for elderly patients or those with respiratory diseases, allowing them to receive radical treatment of hepatic malignancies; both epidural anesthesia and laparoscopy potentially favor a reduction in pulmonary complications.4 Furthermore, lower intrathoracic pressure by spontaneous breathing leads to lower central venous pressure than that by mechanical positivepressure ventilation, which can reduce the amount of venous bleeding during hepatic transection. We emphasize, however, that the present anesthetic approach should be applied to laparoscopic resection of peripheral hepatic regions with a low risk of hemorrhage5 under conditions that enable conversion to general anesthesia whenever uncontrollable bleeding is encountered. Kentaroh Yamamoto, MD, PhD Department of Surgery Yamamoto Memorial Hospital, Imari City Saga, Japan

Annals of Surgery r Volume 260, Number 2, August 2014

Takeaki Ishizawa, MD, PhD Norihiro Kokudo, MD, PhD Hepato-Biliary-Pancreatic Surgery Division Department of Surgery Graduate School of Medicine The University of Tokyo Tokyo, Japan E-mail: [email protected]

REFERENCES 1. Buell JF, Cherqui D, Geller DA, et al. The international position on laparoscopic liver surgery: the Louisville Statement, 2008. Ann Surg. 2009;250: 825–830. 2. Yamamoto F, Shigemura T, Burgess W, et al. Hemodynamic changes during laparoscopic cholecystectomy under continuous epidural anesthesia. Int J Surg Sci. 1995;2:124–127. 3. Yamamoto K, Fukumori D, Yamamoto F, et al. First report of hepatectomy without endotracheal general anesthesia. J Am Coll Surg. 2013;216:908– 914. 4. Lawrence VA, Cornell JE, Smetana GW, American College of Physicians. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006;144:596–608. 5. Ishizawa T, Gumbs AA, Kokudo N, et al. Laparoscopic segmentectomy of the liver: from segment I to VIII. Ann Surg. 2012;256:959– 964.

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