Patients with metastatic colorectal cancer limited to the liver are candidates for regional chemotherapy with implantable hepatic artery infusion (HAI) pumps. The poor prognosis of these patients, and the requirement of a laparotomy for placement, has deterred many oncologists from referral for HAI pump implantation. Minimally invasive surgical techniques are particularly well suited for the task of HAI pump placement in patients who may not tolerate the additional physiologic stress of a major surgical intervention. Advances in laparoscopic techniques allow pumps to be implanted safely and effectively, replicating the well-described tenets of open pump placement. The principal steps of the operation include a thorough laparoscopic evaluation to exclude extrahepatic disease, complete vascular isolation of the hepatic and gastroduodenal arteries, ligation of aberrant hepatic vessels, secure cannulation of the gastroduodenal artery, and confirmation of complete hepatic perfusion without extrahepatic perfusion. We describe the procedure and briefly review our clinical experience. We believe that the benefits typically derived from minimally invasive approaches (less pain, fewer perioperative complications, shorter hospitalization, faster recovery, and potentially less immune suppression) will be seen in these patients as well. If so, a completely laparoscopic approach to regional treatment of the liver may extend survival and improve the quality of life of patients whose prognosis is poor regardless of treatment. Controlled trials will be required to evaluate the added value of a laparoscopic approach to the placement of the hepatic artery pump.
Placement of port and pump incisions.
Laparoscopic ultrasound image of a suspicious portal lymph node (LN) anterior to the common hepatic artery (CHA) and portal vein (PV).
Dissected porta hepatis. In this patient, the gastroduodenal artery (GDA) originates from the right hepatic artery (RHA). The common hepatic artery (CHA) bifurcates into the left hepatic artery (LHA) and RHA.
Insertion of the catheter into the gastroduodenal artery. Two ligatures are positioned around the artery prior to inserting the catheter and are tied after the catheter is correctly positioned.
Securing the catheter in the gastroduodenal artery with a tie on each side of the bead.
Completed insertion of the catheter. The catheter is secured to the gastroduodenal artery (GDA) by 3 ligatures, 2 on either side of the distal bead in the GDA, and a third on the ligated end of the GDA at the superior border of the duodenum. The common hepatic artery (CHA) and proper hepatic artery (PHA) are dissected free of any vascular communications in the porta hepatis.
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