Liver laparoscopy surgery technique:

Laparascopic liver surgery is more easily performed with the patient in the left-side semidecubitus position in order to expose the lateral and posterior side of the right lobe. A gastric tube is placed before surgery. The patient is also closely monitored for vital parameters, end tidal carbon dioxide throughout the entire operation. The abdominal carbon dioxide pressure is premanently evaluated and kept below 15 mmHg. In order to minimize the risk of gaz embolism, insuffation pressure should be kept as low as possible, preferably below 10mmHg. Special precautions need to be taken using argon plasma coagulator because it may lead to increased abdominal pressure and gas embolism.
For the exploration 3 trocars are usually used. One 10mm and two 5mm trocars. The 10mm trocar used fro video inspection is placed taking into consideration the morphology of the patientm immediately or a few centimeters above the umbilicus. The other two 5mm trocars are placed on the sides of the video port being used for palpation grasping, retracting or coagulation. The operating table can balance from a horizontal position to 20-25 degrees anti-Trendelenburg position in order to lower the liver parenchyma and to facilitate the exploration of the hepatic dome.
The liver size morphology and surface regularity are assessed during the exploration. At the same time it is also possible to obtain tissue samples and products. A laparoscope-guided liver biopsy is performed whenever necessary.
If a resection is required, more trocars are placed in order to use the dissecting instruments (electric scalpel, ultrasonic scalpel, endo-GIA etc), retractors and to allow access to the hepatic pedicle or to the vena cava above or below the liver.

Reference: Popescu I, Tomulescu V, Hrehoret D, Boeti-Sarbu P, Stanciulea O, Kosa A.Laparoscopic liver surgery. Analysis of a series of 61 patients. Rom J Gastroenterol. 2005 Dec;14(4):343-9.