Impact of intraoperative ultrasonography in laparoscopic liver surgery

Laparoscopic segment VI liver resection using a left lateral decubitus position: a personal modified technique

BACKGROUND

Laparoscopic technique for lesions located in the left liver is well described in the literature. On the contrary, the best laparoscopic approach for lesions located in the right liver, such as in segment VI, is still debated.

AIM

In this article, we provide a detailed description of a laparoscopic segment VI liver resection using a left lateral decubitus position with the right side up, facilitated by a personal technique. We also discuss potential advantages and disadvantages of this procedure.

Laparoscopic staged adjustable gastric banding and liver resection in morbidly obese patient

We report the case of a 34-year old morbidly obese female, with a history of polycystic ovarian syndrome and birth control pill therapy, who underwent laparoscopic gastric banding. On laparoscopic exploration, a 4-cm liver neoplasm that was missed by preoperative ultrasound was incidentally found. The intraoperative biopsy was suggestive for a benign lesion of hepatocellular origin but could not make the differential diagnosis between focal nodular hyperplasia and adenoma. The neoplasm had atypical features on postoperative magnetic resonance imaging and was suggestive of liver adenoma. Six months after laparoscopic gastric banding, the patient presented with a weight loss of 24 kg and consented to liver resection. A laparoscopic resection of liver segment 3 was performed. Atypical liver neoplasms are subject to potential degeneration, rupture, and bleeding; therefore, they should be treated surgically to allow final diagnosis and potential cure of the disease. In this case, a staged approach was effective in obtaining substantial weight loss and a lesser degree of liver steatosis to enable the performance of a laparoscopic liver resection.

The current role of laparoscopic liver resection for the treatment of liver tumors

Laparoscopic liver resection (LLR) represents a natural extension of minimally invasive surgery. Several case-control studies have demonstrated that LLR is safe and feasible in carefully selected patients. LLR is associated with reduced operative blood loss and earlier recovery when compared with open surgery. In addition, oncologic clearance achieved with LLR is comparable to that achieved with open surgery. Improved cosmesis and postoperative patient comfort also argue in favor of LLR compared with open surgery. When considering whether a patient is suitable for LLR, the size and location of the neoplasm must be taken into account. Operator experience must also be considered as LLR is technically demanding and requires experience in conventional hepatobiliary surgery and advanced laparoscopy. The main indication for LLR is limited resection of superficial or peripherally located tumors. In the case of malignant tumors, LLR should be indicated only if a safe and effective oncologic resection can be performed, and the availability of laparoscopy should not change the indications for benign lesions. Ultimately, the future application of LLR will depend on how easily liver surgeons can master the technique and whether the long-term results of LLR can match those achieved with open resection.

Early experiences of robotic-assisted laparoscopic liver resection

PURPOSE

The surgical robotic system is superior to traditional laparoscopy in regards to 3-dimensional images and better instrumentations. Robotic surgery for hepatic resection has not yet been extensively reported.

PATIENTS AND METHODS

Between March and May 2007, we performed 3 robot-assisted left lateral sectionectomies of the liver. Case 1 had a hepatocellular carcinoma (HCC), case 2 had colon cancer with liver metastasis, and case 3 had intrahepatic duct stones.

RESULTS

All patients had successful operation and recovered without complications. Shorter length of hospital stays, earlier start of oral feeding and less amount of ascites were found. However, case 1 had recurrent HCC at 3 months after operation.

CONCLUSION

Robotic-assisted liver surgery is still a new field in its developing stage. In patients with small malignant tumors and benign liver diseases, robotic-assisted laparoscopic resection is feasible and safe. Through experience, the use of robotics is expected to increase in the treatment of benign diseases and malignant neoplasms. However, careful patient selection is important and long-term outcomes need to be evaluated.

Laparoscopic liver resections for hepatocellular carcinoma. Is it a feasible option for patients with liver cirrhosis?

BACKGROUND

Laparoscopic surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver, above all for patients with hepatocellular carcinoma (HCC) and cirrhosis. This approach mainly includes diagnostic procedures and interstitial therapies. However, we believe there is room for laparoscopic liver resections in well-selected cases. The aim of this study is to assess: (a) the risk of intraoperative bleeding and postoperative complications, (b) the safety and the respect of oncological criteria, and (c) the potential benefit of laparoscopic ultrasound in guiding liver resection.

METHODS

A prospective study of laparoscopic liver resections for hepatocellular carcinoma was undertaken in patients with compensated cirrhosis. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6), and the tumor had to be 5 cm or smaller. Tumor location and its transection margins were defined by laparoscopic ultrasound.

RESULTS

From January 1997, 22 out of 250 patients with HCC (9%) underwent laparoscopic liver resections. The mean patient age was 61.4 years (range, 50-79 years). In three patients, conversion to laparotomy was necessary. The laparoscopic resections included five bisegmentectoies (2 and 3), nine segmentectomies, two subsegmentectomies and three nonanatomical resections for extrahepatic growing lesions. The mean operative time, including laparoscopic ultrasonography, was 199 +/- 69 min (median, 220; range, 80-300). Perioperative blood loss was 183 +/- 72 ml (median, 160; range, 80-400 ml). There was no mortality. Postoperative complications occurred in two out of 19 patients: an abdominal wall hematoma occurred in one patient and a bleeding from a trocar access in the other patient requiring a laparoscopic re-exploration. Mean hospital stay of the whole series was 6.5 +/- 4.3 days (median, 5; range, 4-25), while the mean hospital stay of the 19 laparoscopic patients was 5.4 +/- 1 (median, 5; range, 4-8).

CONCLUSION

Laparoscopic treatment should be considered in selected patients with HCC and liver cirrhosis in the left lobe or segments 5 and 6 of the liver. It is clear that certain types of laparoscopic resection are feasible and safe when carried out by adequately skilled surgeons with appropriate instruments.

Feasibility of laparoscopic liver resection for tumors located in the posterosuperior segments of the liver, with a special reference to overcoming current limitations on tumor location

BACKGROUND

Laparoscopic liver resection is usually limited to the anterolateral segments of the liver (AL; Segments II, III, V, VI, and the inferior part of IV). We evaluated the feasibility of laparoscopic liver resection in the posterosuperior segments (PS; Segments I, VII, VIII, and the superior part of IV).

METHOD

We analyzed retrospectively the clinical data of 82 patients who underwent laparoscopic liver resection for tumors from September 2003 to September 2007. Patients were classified into 2 groups according to tumor location: group AL (n=54) and group PS (n=28).

RESULTS

There was no mortality, reoperation, or major complications. Four (5%) conversions to open procedures were necessary. There were no differences in tumor characteristics, including mean tumor size and number of tumors between 2 groups (P = .427 and .611); however, there was a greater proportion of deeply seated tumors in group PS than group AL (P < .001). The predominant type of resection was a minor liver resection (left lateral sectionectomy, segmentectomy, or tumorectomy) in group AL, and a major liver resection (hemihepatectomy or right posterior sectionectomy) in group PS (P < .001). The median operative time in group PS was greater than that in group AL (320 vs 210 min; P < .001). There were no differences in the conversion rate (P = .113), median blood loss (P = .214), rate of intraoperative transfusion (P = .061), median tumor-free margin (P = .613), median hospital stay (P = .166), and rate of complications (P = .148) between the 2 groups.

CONCLUSION

Laparoscopic liver resection for tumors located in PS is more difficult than in AL but is feasible in selected patients.

Laparoscopic liver surgery for patients with hepatocellular carcinoma

BACKGROUND

Laparoscopic hepatectomy is feasible for hepatocellular carcinoma (HCC) today. This is a retrospective study of the patients with HCC treated by liver resection with a totally laparoscopic approach.

METHODS

This study recruited 116 patients (92 male, 24 female) that underwent laparoscopic liver resection (LR) for HCC. Patients were divided into two groups: group I: (n = 97, 78 male,19 female) those with a volume of resection less than two segments; group II: (n = 19, 14 male, 5 female) those with a volume of resection of more than two segments. The distribution of the tumor-node-metastasis (TNM) stage of patients in the two groups was not significantly different.

RESULTS

Patients resumed full diet on the second or third day after the operation, and the average length of hospital stay was 6 days. The operation time was 152.4 +/- 336.3 min and 175.8 +/- 57.4 min, while blood loss was 101.6 +/- 324.4 mL and 329.2 +/- 338.0 ml, for groups I and II, respectively. Five patients (5.2%) in group I and three patients (15.8%) in group II required blood transfusion (p = 0.122). The mortality rate was zero among our patients and complication rates were 6.2% and 5.2% for groups I and II, respectively. The 1-year, 3-year, and 5-year survival rates were 85.4%, 66.4%, and 59.4% for group I, and 94.7%, 74.2%, and 61.7% for group II, respectively, with no significant difference between two groups (p = 0.1237).

CONCLUSION

Laparoscopic liver resection is a procedure of significant risk and is more technically demanding in comparison with traditional open method. There was no significant difference in survival rates, based on the volume of resection. Laparoscopic surgery should be performed in selected patients as the postoperative quality of life of patients is better than that with open resection.

Clinical study of laparoscopic versus open hepatectomy for malignant liver tumors

BACKGROUND

The number of reported laparoscopic hepatectomies for liver malignancy is increasing, but comparative data on the survival outcomes between the patients who have undergone laparoscopic hepatectomy versus open surgery are still lacking.

METHODS

We compared 31 laparoscopic liver resections with 31 open liver resections in a pair-matched retrospective analysis with the aim of evaluating the intraoperative hazards, recovery, and survival outcomes of these procedures for liver cancer. The laparoscopic group and the open group were matched for age, sex, the size and location of the tumor, and the presence or absence of cirrhosis.

RESULTS

Thirty cases in the laparoscopic group were performed successfully while one case was converted to open surgery due to intraoperative hemorrhage. The length of hospital stay was 7.5 (5-15) days, which was significantly shorter than those in open group (p < 0.01). The mean operative time and blood loss in the laparoscopic group were 140.1 (60-380) min and 502.9 (50-2000) ml, respectively, which were lower than those in open group but without significant difference. There were no operative complications and no deaths in the laparoscopic group. The mean and median survival times of laparoscopic group were 59.3 and 70 months, compared with 49.4 and 60 months in the open group, respectively. The 1-, 3-, 5-year survival rates in the laparoscopic group were, respectively, 96.55%, 60.47%, and 50.40%, and 96.77%, 68.36%, and 50.64% in the open group. By log-rank test, these two survival curves were not significantly different (p = 0.8535).

CONCLUSION

This study shows that laparoscopic hepatectomy for liver malignancy in selected patients is a safe, effective, and oncologically efficient procedure with better short-term results and similar survival outcomes to open hepatectomy for liver malignancy after midterm follow-up.

Laparoscopic versus open liver resection for hepatocellular carcinoma in patients with histologically proven cirrhosis: short- and middle-term results

BACKGROUND

Liver surgery, especially for cirrhotic patients, is one of the last areas of resistance to progress in laparoscopic surgery. This study compares the postoperative results and the 2-year patient outcomes between laparoscopic and open resection for hepatocellular carcinoma in patients with histologically proven cirrhosis.

METHODS

From May 2000 to October 2004, 23 consecutive cirrhotic patients who underwent laparoscopic hepatectomy (LH) for HCC were compared in a retrospective analysis with a historic group of 23 patients who underwent open hepatectomy (OH). The two groups were well matched for age, gender, American Society of Anesthesiology (ASA) class, tumor location and size, type of liver resection, and severity of cirrhosis. The selection criteria for both groups specified a small (size < 5 cm), exophytic, or subcapsular tumor located in the left or peripheral right segments of the liver (II-VI segments, Couinaud); a well-compensated cirrhosis (Child-Pugh A); and an ASA score lower than 3. In the LH group, 15 subsegmentectomies, 3 segmentectomies, and 5 left lateral sectionectomies were performed, as compared with 12 subsegmentectomies, 5 segmentectomies, and 6 left lateral sectionectomies in the OH group.

RESULTS

One patient in the LH group (4.3%) underwent conversion to laparotomy for inadequate exposition. The mean operative time was statistically longer for the LH group (LH, 148 min; OH, 125 min; p = 0.016), whereas blood transfusions (LH, 0%; OH, 17.3%; p = 0.036), Pringle maneuver (LH, 0%; OH, 21.73%; p = 0.017), mean hospital stay (LH, 8.3 days; OH, 12 days; p = 0.047), and postoperative complications (LH, 13%; OH, 47.8%; p = 0.010) were significantly greater in OH group. There was no statistically significant difference in mortality and 2-year survival rates between the two groups.

CONCLUSION

This study shows that LH for HCC in properly selected cirrhotic patients results in fewer early postoperative complications and a shorter hospital stay than the traditional OH. The 2-year survival rate was the same for LH and OH.

Der laparoskopische Ultraschall

Laparoscopic ultrasound exploration has significantly augmented the range of minimally invasive surgery. In particular it is essential for 3D exploration of the abdomen for staging. Beyond its diagnostic, purposes laparoscopic ultrasound is gaining importance for intraoperative therapeutic support, e. g. imaging of the biliary tree during laparoscopic surgery of the bile duct and for navigation during radio-frequency ablative or resective interventions on the liver and other parenchymatous organs. Compared to other imaging procedures, sonography has still the highest potential for further development. The most progress can be expected in navigated ultrasound.