Intercostal Trocar Facilitates Difficult Liver Resections : Ann Hepatobiliary Pancreat Surg | May 2026

Introduction:

Laparoscopic liver resection (LLR) has become an established approach for the management of selected hepatic lesions, offering benefits such as reduced postoperative pain, shorter hospital stay, and faster recovery. However, lesions located in the posterosuperior (PS) liver segments remain technically challenging because of their deep anatomical location, limited visualization, and restricted instrument maneuverability. Various technical modifications have been proposed to overcome these limitations, including the use of intercostal (IC) trocars.

Problem Statement:

Despite increasing interest in IC trocar-assisted LLR, evidence supporting its safety and effectiveness remains limited. Concerns persist regarding potential thoracic complications, optimal port placement, and whether improved access can be achieved without compromising patient safety or oncological outcomes.

Summary:

This single-center study evaluated the feasibility and safety of incorporating a small intercostal trocar during laparoscopic resection of lesions located in the posterosuperior liver segments. The technique involved placement of an accessory 5-mm right intercostal port to improve surgical exposure and instrument access in anatomically difficult regions of the liver. The approach was successfully applied across a range of benign and malignant hepatic conditions, including liver adenomas, colorectal liver metastases, neuroendocrine metastasis, and hepatolithiasis. Outcomes were highly favorable, with no intraoperative complications, no conversions to open surgery, and no requirement for blood transfusion. All resections achieved negative margins, indicating satisfactory oncologic clearance, while postoperative recovery was rapid with short hospital stays. Importantly, no postoperative morbidity or mortality was observed during follow-up. These findings suggest that the addition of a small intercostal trocar may provide enhanced visualization and access to challenging posterosuperior liver segments without increasing operative risk. Although the study is limited by its small sample size and retrospective design, it supports IC trocar-assisted LLR as a practical technical adjunct for complex minimally invasive liver surgery. Larger prospective multicenter studies are needed to establish standardized indications and validate its broader clinical applicability.