laparoscopic liver surgery is now being performed by select groups worldwide . the louisville consensus conference on laparoscopic liver surgery suggested a role for laparoscopic liver resections for lesions in segment 2 to 6 .
we herein report a male patient undergoing laparoscopic liver resection for a giant right lobe liver hemangioma .
a 45-year - old male patient with no known medical risk factors presented to the outpatient department with complaints of right upper quadrant pain restricting his regular activity .
a multidetector computerized tomography ( mdct ) of the abdomen showed a giant hemangioma ( 18 cm in greatest diameter ) arising from segments 5 and 6 of the liver [ figure 1 ] .
the feeding vessel to the hemangioma was from the anterior branch of right hepatic artery ( rha ) .
the right anterior portal pedicle ( rapp ) was seen abutting the hemangioma supero - medially .
( a ) computerized tomography showing the giant hemangioma arising from segment 5 and 6 of the liver , ( a  reconstructed image showing extent of hemangioma . ) ( b ) arterial phase showing the main feeding artery from the anterior branch of the right hepatic artery , ( c ) portal venous phase showing relation of the anterior portal pedicle to the hemangioma an open entry was achieved with a 10-mm port at the umbilicus for laparoscopic vision and four additional ports were placed [ figure 2 ] . at laparoscopy ,
a giant hemangioma of 18 cm  12 cm was seen to arise from segments 5 and 6 of the liver , reaching up to the iliac fossa on the right side with displacement of the gall bladder medially to midline , in line with the falciform ligament [ figure 3a ] .
the gall bladder fundal retraction was achieved using a grasper through a port in the right midclavicular port .
c , camera port ( 10 mm ) ; rhw , right hand working port ( 12 mm ) ; left hand working port ( 5 mm ) ; lr , liver retractor port ( 10 mm ) ; gbf , gall bladder fundal retraction port ( 5 mm ) ( a ) laparoscopic view of the giant hemangioma , ( b ) laparoscopic image showing the bulldog clamp across the anterior branch of the right hepatic artery , ( c ) line of demarcation on the liver after clamping the anterior branch of the right hepatic artery , ( d ) laparoscopic view of the enucleation plane the calot 's triangle was dissected and the cystic artery was clipped and divided .
the right anterior branch was selectively dissected , looped and occluded with a bulldog clamp [ figure 3b ] .
the line of demarcation of the anterior segment became clearly evident and was associated with shrinkage of the hemangioma by one - third of its size [ figure 3c ] .
resection was initially performed in the plane of enucleation medially [ figure 3d ] . during the course of this dissection ,
cranially , a transverse line of transection was marked at the summit level of the hemangioma .
the transverse transection plane thus chosen was based on pre - operative planning from the reconstruction from mdct evaluation and intraoperative ultrasound ( ious ) .
the hepatic venous tributary running from segment 6 crossed this line as confirmed by ious .
the 5-mm port in the epigastrium was exchanged for a 12-mm port to facilitate the use of the 4 habib laparoscopic probe .
california , usa ) , 60 watts setting , was used during liver parenchymal transection with the laparoscopic 4 habib probe by choosing a 2 cm depth of application of rf prongs along the line of transection with parenchymal division performed with straight scissors [ figure 4a ] . to prevent injury to the retroperitoneal structures ,
the posterior 1 cm depth of the parenchymal division was achieved by two firings of an endo gia stapler with 60 mm , white reloads ( autosuture ) [ figure 4b ] .
( a ) laparoscopic 4 habib probe  transection in progress , ( b ) final transaction surface , ( c ) morselled specimen an indigenously prepared endobag ( urobag ) cut to appropriate size with a prolene 2 - 0 suture placed as a pursestring along its open end was then passed into the abdomen through the 12 port .
the bag was placed in the right upper abdomen and two 2 - 0 prolene , interrupted sutures were placed on the anterior leaf of the open end of the bag and sutured to the anterior wall of the abdomen .
one grasping foreceps held the posterior leaf of the open end of the bag . this suturing technique facilitated in bagging the large specimen comfortably .
the cystic duct was clipped , the gallbladder was dissected off from the liver bed , placed in the same endobag and the pursestring suture at the mouth of the bag was tightened . under laparoscopic guidance ,
the pursestring suture was held and the mouth of the bag was delivered through the umbilical port site .
re - laparoscopy was performed , hemostasis was ensured , a subhepatic 24 f tube drain was placed and ports were withdrawn .
the patient was started orally the same evening and discharged from hospital on the third post - operative day .
an open entry was achieved with a 10-mm port at the umbilicus for laparoscopic vision and four additional ports were placed [ figure 2 ] . at laparoscopy ,
a giant hemangioma of 18 cm  12 cm was seen to arise from segments 5 and 6 of the liver , reaching up to the iliac fossa on the right side with displacement of the gall bladder medially to midline , in line with the falciform ligament [ figure 3a ] .
the gall bladder fundal retraction was achieved using a grasper through a port in the right midclavicular port .
c , camera port ( 10 mm ) ; rhw , right hand working port ( 12 mm ) ; left hand working port ( 5 mm ) ; lr , liver retractor port ( 10 mm ) ; gbf , gall bladder fundal retraction port ( 5 mm ) ( a ) laparoscopic view of the giant hemangioma , ( b ) laparoscopic image showing the bulldog clamp across the anterior branch of the right hepatic artery ,
( c ) line of demarcation on the liver after clamping the anterior branch of the right hepatic artery , ( d ) laparoscopic view of the enucleation plane
the right anterior branch was selectively dissected , looped and occluded with a bulldog clamp [ figure 3b ] .
the line of demarcation of the anterior segment became clearly evident and was associated with shrinkage of the hemangioma by one - third of its size [ figure 3c ] .
resection was initially performed in the plane of enucleation medially [ figure 3d ] . during the course of this dissection ,
cranially , a transverse line of transection was marked at the summit level of the hemangioma .
the transverse transection plane thus chosen was based on pre - operative planning from the reconstruction from mdct evaluation and intraoperative ultrasound ( ious ) .
the hepatic venous tributary running from segment 6 crossed this line as confirmed by ious .
the 5-mm port in the epigastrium was exchanged for a 12-mm port to facilitate the use of the 4 habib laparoscopic probe .
california , usa ) , 60 watts setting , was used during liver parenchymal transection with the laparoscopic 4 habib probe by choosing a 2 cm depth of application of rf prongs along the line of transection with parenchymal division performed with straight scissors [ figure 4a ] . to prevent injury to the retroperitoneal structures ,
the posterior 1 cm depth of the parenchymal division was achieved by two firings of an endo gia stapler with 60 mm , white reloads ( autosuture ) [ figure 4b ] .
( a ) laparoscopic 4 habib probe  transection in progress , ( b ) final transaction surface , ( c ) morselled specimen
an indigenously prepared endobag ( urobag ) cut to appropriate size with a prolene 2 - 0 suture placed as a pursestring along its open end was then passed into the abdomen through the 12 port .
the bag was placed in the right upper abdomen and two 2 - 0 prolene , interrupted sutures were placed on the anterior leaf of the open end of the bag and sutured to the anterior wall of the abdomen .
one grasping foreceps held the posterior leaf of the open end of the bag . this suturing technique facilitated in bagging the large specimen comfortably .
the cystic duct was clipped , the gallbladder was dissected off from the liver bed , placed in the same endobag and the pursestring suture at the mouth of the bag was tightened . under laparoscopic guidance ,
the pursestring suture was held and the mouth of the bag was delivered through the umbilical port site . the umbilical port was extended to 3 cm .
re - laparoscopy was performed , hemostasis was ensured , a subhepatic 24 f tube drain was placed and ports were withdrawn .
the patient was started orally the same evening and discharged from hospital on the third post - operative day .
the role of laparoscopic liver resection for liver tumors is unclear at present.[25 ] the louisville consensus statement suggests laparoscopic liver resection as an option for lesions in the left lateral and inferior segments of the right lobe . the concerns with regard to laparoscopic liver resections are many .
thirdly , there is a lack of tactile feedback , which is critical in evaluating the margin of resection , particularly in malignant tumorus .
fourthly , the ideal technique for parenchymal transection during laparoscopic liver resection is not yet standardized .
lastly , retrieval of a large specimen may require a large incision , which defeats the primary objective of keeping the procedure minimally invasive .
lesions reaching the hilar structures , in particular , pose technical problems with the laparoscopic approach .
we elected to perform the resection laparoscopically in our patient because of a suitable location of the tumour , namely segment 5 and 6 , with a large exophytic component . also , a good triphasic mdct with reconstruction provided excellent anatomical delineation , facilitating appropriate planning of vascular control and line of parenchymal transection .
enucleation has been reported for smaller hemangiomas . in giant hemangioms such as in this report
, the cross - sectional area for enucleation is likely to be large and visualization of the entire enucleation plane and achieving blood - less dissection could pose problems .
although control of the feeding vessel with subsequent shrinkage of the tumour could facilitate enucleation , choosing , a transverse line of transection cranially in our patient kept the transection surface to the minimum .
a blood - less transection was achieved medially in the enucleation plane and cranio - laterally with the laparoscopic 4 habib probe in our patient .
others have reported on the use of a laparoscopic habib probe for blood - less liver parenchymal transection .
our technique of bagging the specimen is very suitable for solid organs , particularly large specimens .
we have used the same technique for laparoscopic retrieval of other solid organs such as spleen or distal pancreas before . in our present report , because there was no concern of studying margins during histopathological examination , the specimen could be morselled and retrieved . in conclusion ,
laparoscopic resection is feasible in giant liver hemangiomas located in the inferior segments of the right lobe of the liver .
laparoscopic 4 habib probe is an important tool in the armamentarium of liver transection methods .
 experience with laparoscopic liver resections is limited . 
 laparoscopic resection of a variety of liver lesions has been reported and is considered appropriate for lesions in the left lateral segment and inferior segments of the right lobe . 
 herein , we report a 52-year - old male patient who underwent a laparoscopic resection of giant liver hemangioma with the use of a laparoscopic 4 habib probe . 
INTRODUCTION
CASE REPORT
Step 1: Port placement and retraction
Step 2: Taking control of the anterior branch of the right hepatic artery
Step 3: Dissection of the medial part of the hemangioma in an enucleation plane
Step 4: Transverse line of transection (cranially) using a laparoscopic Habib probe
Step 5: Bagging the specimen, morsellation and retrieval
DISCUSSION