The learning curve in laparoscopic major liver resection. J Hepatobiliary Pancreat Sci. 2013;20:131-136. [PMID: 23064988 DOI: 10.1007/s00534-012-0571-1]

[Early outcomes of robot-assisted liver resection]

AIM

To assess an experience of robot-assisted liver resection using CUSUM-test.

MATERIAL AND METHODS

The results of 46 robot-assisted liver resections were retrospectively analyzed by using of CUSUM-test.

RESULTS

There were 3 periods in development of the technology. The 1st period - procedures with the lowest index of difficulty (n=16), the 2nd period - expansion of the indications for difficult resections (n=18) and the 3rd period - stabilization of the results (n=12). The dynamics of difficulty index, intraoperative blood loss, duration of procedure and morbidity (Clavien-Dindo Grade II-V) were evaluated. Five liver resections were needed to decrease blood loss and duration of the procedure. Expansion of indications was feasible after 16 procedures. Stable results were obtained after 34 liver resections.

Graduating otolaryngology resident preparedness for fellowship as assessed by fellowship faculty

OBJECTIVES/HYPOTHESIS

The purpose of this study was to evaluate fellowship program directors' perceptions of incoming clinical fellows' preparedness for subspecialty training and to thereby identify strengths and shortcomings in otolaryngology training programs' ability to prepare residents for fellowship.

STUDY DESIGN

Validated e-mail survey.

METHODS

Two hundred eleven otolaryngology subspecialty fellowship program directors and faculty directly involved with training fellows were contacted. A validated survey by the American College of Surgeons was modified and distributed to otolaryngology fellowship faculty in six otolaryngology subspecialties. The 59-item survey employed a five-response Likert scale tailored to each subspecialty. Responses were collected between November 2016 and January 2017.

RESULTS

One hundred ten otolaryngology faculty responded to the survey (52%). Respondents had worked with fellows for a mean of 12 years (standard deviation = 8). Respondents felt fellows were competent in the areas of professionalism, clinical evaluation, and management. Pediatric faculty were more likely to disagree about fellows' independence in the operating room (P = .004) and during call (P = .002) compared to other specialties. Laryngology and facial plastic and reconstructive surgery faculty felt more neutral about anatomy recognition (P = .008), tissue manipulation (P = .002), and use of energy sources (e.g., cautery, lasers) (P < .001). Fellows in all subspecialties were felt to be least prepared in research and academic interest.

CONCLUSIONS

Faculty involved in fellowship training feel that fellows are well-prepared overall upon entering fellowship. Residency programs may benefit from providing more experience with facial plastic reconstructive surgery, laryngology, and pediatrics. Regardless of specialty, residents could benefit from increased training in research design, data analysis, and basic statistics.

LEVEL OF EVIDENCE

NA Laryngoscope, E280-E286, 2018.

Comparative analysis of learning curve in complex robot-assisted and laparoscopic liver resection

BACKGROUND

There is no comparative analysis of the learning curves for robot-assisted and laparoscopic liver resection. We aimed to compare learning curves in complex robotic and conventional laparoscopic liver resections with regards to estimation of the difficulty index score.

METHODS

The results of 131 consecutive liver resections were analyzed retrospectively (40 robot-assisted and 91 laparoscopic). The learning curve evaluation was based on calculation of procedures number before significant change of the difficulty index for minimally invasive liver resection or the rate of posterosuperior segments resection. Groups of early and late experience were compared in every type of approach (robot-assisted and laparoscopic).

RESULTS

Significant increase of difficulty index (from 5.0 [3.0-7.7] to 7.3 [4.3-10.2]) of robotic procedures required 16 procedures. It was necessary to perform 29 laparoscopic resections in order to significantly increase the rate of laparoscopic posterosuperior segments resection but without significant increase of difficulty index. The implementation of minimally invasive liver resection started with the robotic approach.

CONCLUSION

The learning curve for robot-assisted liver resections is shorter in comparison with laparoscopic resections. The inclusion of robot-assisted resections in a minimally invasive liver surgery program may be useful to rapidly increase the complexity of laparoscopic liver resections.

Hand-assisted Approach as a Model to Teach Complex Laparoscopic Hepatectomies: Preliminary Results

BACKGROUND

Currently, there are limited and scarce models to teach complex liver resections by laparoscopy. The aim of this study is to present a hand-assisted technique to teach complex laparoscopic hepatectomies for fellows in liver surgery.

MATERIALS AND METHODS

Laparoscopic hand-assisted approach for resections of liver lesions located in posterosuperior segments (7, 6/7, 7/8, 8) was performed by the trainees with guidance and intermittent intervention of a senior surgeon. Data as: (1) percentage of time that the senior surgeon takes the surgery as main surgeon, (2) need for the senior surgeon to finish the procedure, (3) necessity of conversion, (4) bleeding with hemodynamic instability, (5) need for transfusion, (6) oncological surgical margins, were evaluated.

RESULTS

In total, 12 cases of complex laparoscopic liver resections were performed by the trainee. All cases included deep lesions situated on liver segments 7 or 8. The senior surgeon intervention occurred in a mean of 20% of the total surgical time (range, 0% to 50%). A senior intervention >20% was necessary in 2 cases. There was no need for conversion or reoperation. Neither major bleeding nor complications resulted from the teaching program. All surgical margins were clear.

CONCLUSIONS

This preliminary report shows that hand-assistance is a safe way to teach complex liver resections without compromising patient safety or oncological results. More cases are still necessary to draw definitive conclusions about this teaching method.

Is the Use of a Robotic Camera Holder Economically Viable? A Cost Comparison of Surgical Assistant Versus the Use of a Robotic Camera Holder in Laparoscopic Liver Resections

The laparoscopic approach has gained acceptance in the field of hepatopancreaticobiliary surgery. It offers several advantages including reduced blood loss, reduced postoperative pain, and shorter length of stay. However, long operating times can be associated with surgeon and assistant fatigue and image tremor. Robotic camera holders have been designed to overcome these drawbacks but may come with significant costs. The aim of this study was to economically evaluate their use compared with standard assistants using a single surgeon consecutive series of laparoscopic liver resections from January 2014 to May 2015. Only use of nurse assistants with no advanced training and postgraduate year 2 doctors were cheaper than utilization of the device. We suggest the use of a robotic camera holder is cost-beneficial and may have wider service and educational benefits.

Box- or Virtual-Reality Trainer: Which Tool Results in Better Transfer of Laparoscopic Basic Skills?-A Prospective Randomized Trial

OBJECTIVE

Simulation training improves laparoscopic performance. Laparoscopic basic skills can be learned in simulators as box- or virtual-reality (VR) trainers. However, there is no clear recommendation for either box or VR trainers as the most appropriate tool for the transfer of acquired laparoscopic basic skills into a surgical procedure.

DESIGN

Both training tools were compared, using validated and well-established curricula in the acquirement of basic skills, in a prospective randomized trial in a 5-day structured laparoscopic training course. Participants completed either a box- or VR-trainer curriculum and then applied the learned skills performing an ex situ laparoscopic cholecystectomy on a pig liver. The performance was recorded on video and evaluated offline by 4 blinded observers using the Global Operative Assessment of Laparoscopic Skills (GOALS) score. Learning curves of the various exercises included in the training course were compared and the improvement in each exercise was analyzed.

SETTING

Surgical Skills Lab of the Department of General and Visceral Surgery, University Hospital Muenster.

PARTICIPANTS

Surgical novices without prior surgical experience (medical students, n = 36).

RESULTS

Posttraining evaluation showed significant improvement compared with baseline in both groups, indicating acquisition of laparoscopic basic skills. Learning curves showed almost the same progression with no significant differences. In simulated laparoscopic cholecystectomy, total GOALS score was significantly higher for the box-trained group than the VR-trained group (box: 15.31 ± 3.61 vs. VR: 12.92 ± 3.06; p = 0.039; Hedge׳s g* = 0.699), indicating higher technical skill levels.

CONCLUSIONS

Despite both systems having advantages and disadvantages, they can both be used for simulation training for laparoscopic skills. In the setting with 2 structured, validated and almost identical curricula, the box-trained group appears to be superior in the better transfer of basic skills into an experimental but structured surgical procedure.

Evolution of laparoscopic surgery in a high volume hepatobiliary unit: 150 consecutive pure laparoscopic hepatectomies

INTRODUCTION

Compared to other surgical areas, laparoscopic liver resection (LLR) has not been widely implemented and currently less than 20% of hepatectomies are performed laparoscopically worldwide. The aim of our study was to evaluate the feasibility, and the ratio of implementation of LLR in our department.

METHODS

We analyzed a prospectively maintained database of 749 liver resections performed during the last 10-year period in a single centre.

RESULTS

A total of 150 (20%) consecutive pure LLR were performed between 2005 and 2015. In 87% of patients the indication was the presence ofprimary or metastatic liver malignancy. We performed 30 major hepatectomies (20%) and (80%) were minor resections, performed in all liver segments. Twelve patients were operated twice and 2 patients underwent a third LLR. The proportion of LLR increased from 12% in 2011 to 62% in the last year. Conversion rate was 9%. Overall morbidity rate was 36% but only one third were classified as severe. The 90-day mortality rate was 1%. Median hospital stay was 4 days and the rate of readmissions was 6%.

CONCLUSIONS

The implementation of LLR has been fast with morbidity and mortality comparable to other published series. In the last 2 years more than half of the hepatectomies are performed laparoscopically in our centre.

Early experience with totally laparoscopic major hepatectomies: single institution experience with 31 consecutive cases

BACKGROUND

Totally laparoscopic major hepatectomy (LMH) is a technically challenging procedure with limited studies mainly from high-volume expert centers reported. In this study, we report our initial experience with totally LMH.

METHODS

A retrospective review of a prospective database of 340 consecutive patients who underwent laparoscopic liver resection at a single institution was conducted. Thirty-one consecutive patients who underwent attempted totally LMH between March 2011 to December 2016 were identified. Major hepatectomies were defined as resection of ≥3 contiguous segments which included only right/left hepatectomies, extended hepatectomies or central hepatectomies.

RESULTS

The procedures included 11 right hepatectomies, one extended right hepatectomy, nine left hepatectomies (two including middle hepatic vein), two extended left hepatectomies, two left hepatectomies with caudate lobe and six central hepatectomies. The median tumor size was 40 (range, 12-100) mm and the median operation time was 435 (range, 245-585) min. Median blood loss was 500 (range, 100-1900) mls and 10 (32.3%) patients required blood transfusion. There were three (9.7%) open conversions of which two occurred during the first five cases. There was one (3.2%) major (>grade 2) morbidity and there were no 30-day/in-hospital mortalities or reoperations. The median postoperative stay was 5 (range, 3-14) days.

CONCLUSION

Our initial experience confirms the feasibility and safety of LMH. There was an increase in the number and proportion of LMH performed at our institution over time.

Development Process and Technical Aspects of Laparoscopic Hepatectomy: Learning Curve Based on 15 Years of Experience

BACKGROUND

Laparoscopic hepatectomy continues to be a challenging operation associated with a steep learning curve. This study aimed to evaluate the learning process during 15 years of experience with laparoscopic hepatectomy and to identify approaches to standardization of this procedure.

STUDY DESIGN

Prospectively collected data of 317 consecutive laparoscopic hepatectomies performed from January 2000 to December 2014 were reviewed retrospectively. The operative procedures were classified into 4 categories (minor hepatectomy, left lateral sectionectomy [LLS], left hepatectomy, and right hepatectomy), and indications were classified into 5 categories (benign-borderline tumor, living donor, metastatic liver tumor, biliary malignancy, and hepatocellular carcinoma).

RESULTS

During the first 10 years, the procedures were limited mainly to minor hepatectomy and LLS, and the indications were limited to benign-borderline tumor and living donor. Implementation of major hepatectomy rapidly increased the proportion of malignant tumors, especially hepatocellular carcinoma, starting from 2011. Conversion rates decreased with experience for LLS (13.3% vs 3.4%; p = 0.054) and left hepatectomy (50.0% vs 15.0%; p = 0.012), but not for right hepatectomy (41.4% vs 35.7%; p = 0.661).

CONCLUSIONS

Our 15-year experience clearly demonstrates the stepwise procedural evolution from LLS through left hepatectomy to right hepatectomy, as well as the trend in indications from benign-borderline tumor/living donor to malignant tumors. In contrast to LLS and left hepatectomy, a learning curve was not observed for right hepatectomy. The ongoing development process can contribute to faster standardization necessary for future advances in laparoscopic hepatectomy.

Comparative Effectiveness of Minimally Invasive Surgery and Conventional Approaches for Major or Challenging Hepatectomy

BACKGROUND

The benefits of minimally invasive surgery (MIS) for low-risk or minor liver resection are well established. There is growing interest in MIS for major hepatectomy (MH) and other challenging resections, but there remain unanswered questions of safety that prevent broad adoption of this technique.

STUDY DESIGN

We conducted a retrospective cohort study of patients undergoing hepatectomy at 65 hospitals participating in the NSQIP Hepatopancreatobiliary Collaborative in 2014. We assessed serious morbidity or mortality (SMM; including organ/space infection and organ failure). Secondary outcomes included transfusion, bile leak, liver failure, reoperation or intervention, and 30-day readmission. We also measured factors considered to make resection more challenging (ie large tumors, cirrhosis, ≥3 concurrent resections, previous neoadjuvant chemotherapy, and morbid obesity).

RESULTS

There were 2,819 patients who underwent hepatectomy (aged 58 ± 14 years; 53% female; 25% had MIS). After adjusting for clinical and operative factors, the odds of SMM (odds ratio [OR] = 0.57; 95% CI 0.34 to 0.96; p = 0.03) and reoperation or intervention (OR = 0.52; 95% CI 0.29 to 0.93; p = 0.03) were significantly lower for patients undergoing MIS compared with open. In the MH group (n = 1,015 [13% MIS]), there was no difference in the odds of SMM after MIS (OR = 0.37; 95% CI 0.13 to 1.11; p = 0.08); however, minimally invasive MH met criteria for noninferiority. There were no differences in liver-specific complications or readmission between the groups. Odds of SMM were significantly lower after MIS among patients who had received neoadjuvant chemotherapy (OR = 0.33; 95% CI 0.15 to 0.70; p = 0.004).

CONCLUSIONS

In this large study of minimally invasive MH, we found safety outcomes that are equivalent or superior to conventional open surgery. Although the decision to offer MIS might be influenced by factors not included in this evaluation (eg surgeon experience and other patient factors), these findings support its current use in MH.

Comparison of Upper Midline Incision With and Without Laparoscopic Assistance for Living-Donor Right Hepatectomy

BACKGROUND

Since minimally invasive procedures for living-donor right hepatectomy (LDRH) became popular in recent years, several studies comparing the outcomes of donors undergoing an upper midline incision (UMI) under laparoscopic assistance for LDRH with those undergoing the traditional open LDRH have been published. However, there are very few comparative studies of outcomes for a UMI for LDRH with and without laparoscopic-assistance. We designed the present study to compare the benefits and shortcomings of a UMI for LDRH with and without laparoscopic assistance.

METHODS

Forty-eight patients in our center were included in the study: group hybrid (n = 28) versus group UMI (n = 20). Their surgical outcomes, postoperative course, and cosmetic outcomes were studied from medical records.

RESULTS

No differences existed between the 2 groups regarding their baseline characteristics except that group Hybrid had more donors with positive hepatitis B core antibody. No difference was observed in operative time, graft weight, warm ischemia time, blood loss, incision length, liver and coagulation function test results, postoperative complications, or cosmetic parameters. No deaths occurred in both groups. The length of postoperative hospital stay was similar for both groups, but the hospital cost was significantly lower for group UMI than for group hybrid (6,906.7 ± 777.4 USD vs 7,643.3 ± 918.6 USD; P = .005).

CONCLUSIONS

An UMI without laparoscopic assistance can be considered as the first-line incision of choice for LDRH.

Local recurrence after laparoscopic radiofrequency ablation of malignant liver tumors: Results of a contemporary series

INTRODUCTION

The aims of this study were to determine the incidence of Local recurrence (LR) in patients at long-term follow-up after laparoscopic RFA (LRFA) and also to determine the risk factors for LR from a contemporary series.

METHODS

Patients undergoing LRFA between 2005 and 2014 by a single surgeon were reviewed. Demographic and perioperative data were analyzed from a prospective database.

RESULTS

LRFA was performed on 316 patients with 901 lesions. Median follow-up was 25 months, with 76% of whom completed at least one year of follow-up. The LR rate was 18.4%. The LR in patients followed for less than 12 months was 13.8%, 20.3% for 12 months, and 19.7% for 18 months (P = 0.02). One-fourth of the LRs developed after the 1st year. Morbidity was 8.9% and mortality 0.3%. Tumor type, size, ablation margin, and surgeon experience affected LR, with tumor type, size, and ablation margin being independent.

CONCLUSIONS

This study shows that 14% of malignant liver tumors will develop LR within a year after LRFA. Additional 4% of the lesions will demonstrate recurrence within 1 cm of the ablation zone, mostly as part of a multifocal recurrence. Ablation margin is the only parameter that the surgeon can manipulate to decrease LR.

A survey of current practices and barriers to expanding laparoscopic HPB surgery in Canada

BACKGROUND

The purpose of this survey was to determine the extent to which laparoscopy is used in hepatopancreatobiliary (HPB) resections in Canada, and to assess HPB surgeons' attitudes and their perceived barriers to its further adoption.

METHODS

Using an electronic questionnaire, 68 Canadian Hepatopancreatobiliary Association (CHPBA) surgical members were surveyed. The questionnaire consisted of 12 questions regarding: surgeon demographics, the use and limitations of laparoscopy in their practice, and interest in increasing the use of laparoscopic techniques.

RESULTS

The survey response rate was 75%. Of the 51 respondents, 86% reported performing minor laparoscopic resections such as hepatic wedge resections. Only 23% of surgeons reported performing laparoscopic liver lobectomies. Eighty-two percent of respondents indicated a wish to increase the use of laparoscopy in their practice. Barriers identified included operating time constraints (61%), a lack of equipment (41%) and lack of adequate training (43%).

DISCUSSION

This survey demonstrates that currently, most Canadian HPB surgeons use laparoscopy for minor HPB resections; however, there is a strong desire to expand the use of minimally invasive techniques amongst Canadian HPB surgeons. Training centered on addressing the limitations and barriers to the uptake of minimally invasive techniques in HPB surgery are needed.

Pure Laparoscopic Hepatectomy Versus Open Hepatectomy for Hepatocellular Carcinoma in 110 Patients With Liver Cirrhosis: A Propensity Analysis at a Single Center

OBJECTIVE

To investigate the long-term outcomes of pure laparoscopic hepatectomy versus open hepatectomy for hepatocellular carcinoma (HCC) with background cirrhosis.

BACKGROUND

Laparoscopic hepatectomy has been gaining popularity, but has not been widely accepted, because published data were gathered from small numbers of patients.

METHODS

Data of patients diagnosed with HCC and cirrhosis treated by hepatectomy were reviewed. The outcomes of pure laparoscopic hepatectomy were compared with those of open hepatectomy. Propensity score matching of patients in a ratio of 1:3 was conducted.

RESULTS

There were 110 patients and 330 patients in the laparoscopic group and the open group, respectively. The laparoscopic group had less blood loss (150 vs 400 mL; P < 0.001), shorter operation time (185 vs 255 minutes; P < 0.001), and shorter hospital stay (4vs 7 days; P < 0.001). The median overall survival was 136 months in the laparoscopic group and 120 months in the open group. The 1, 3, and 5-year overall survival rates were 98.9%, 89.8%, and 83.7%, respectively, in the laparoscopic group, and 94%, 79.3%, and 67.4%, respectively, in the open group (P = 0.033). The median disease-free survival was 66.37 months in the laparoscopic group and 52.4 months in the open group. The 1, 3, and 5-year disease-free survival rates were 87.7%, 65.8%, and 52.2%, respectively, in the laparoscopic group, and 75.2%, 56.3%, and 47.9%, respectively, in the open group (P = 0.141).

CONCLUSIONS

Pure laparoscopic hepatectomy for HCC can be carried out safely with favorable short-term and long-term outcomes even in cirrhotic patients at high-volume liver cancer centers.

Safely extending the indications of laparoscopic liver resection: When should we start laparoscopic major hepatectomy?

BACKGROUND

Laparoscopic major hepatectomy (LMH) is an innovative procedure that is still in the exploration phase. Although new surgical techniques have learning curves, safety should be maintained from the onset. This retrospective study was conducted to evaluate the safe introduction of LMH.

METHODS

We retrospectively reviewed data from 245 consecutive patients who underwent pure laparoscopic liver resection. Patients were divided into three groups: Phase I, the first 64 cases, all minor hepatectomies; Phase II, cases from the first LMH case to the midmost of the LMH cases (n = 69, including 22 LMHs); Phase III, the most recent 112 cases, including 22 LMHs. Patient characteristics and surgical results were evaluated, and the learning curve was analysed with the cumulative sum (CUSUM) method.

RESULTS

The first LMH was adopted after sufficient preparatory experience was gained from performing 64 minor hepatectomies. In cases of LMH, there were no significant differences in the surgical time between Phases II and III (356 vs. 309 min; P = 0.318), morbidity rate (22.7 vs. 31.8 %; P = 0.736), or major morbidity rate (18.2 vs. 9.1 %; P = 0.664); however, estimated blood loss was significantly reduced from Phase II to Phase III (236 vs. 68 mL; P = 0.018). The CUSUM for morbidity also showed similar outcomes through Phases II and III.

CONCLUSION

There is a learning curve associated with laparoscopic liver resection. To maintain a low morbidity rate, 60 laparoscopic minor hepatectomies could provide adequate experience before the adoption of LMH.

Efficacy and cost of robotic hepatectomy: is the robot cost-prohibitive?

Robotic technology is being utilized in multiple hepatobiliary procedures, including hepatic resections. The benefits of minimally invasive surgical approaches have been well documented; however, there is some concern that robotic liver surgery may be prohibitively costly and therefore should be limited on this basis. A single-institution, retrospective cohort study was performed of robotic and open liver resections performed for benign and malignant pathologies. Clinical and cost outcomes were analyzed using adjusted generalized linear regression models. Clinical and cost data for 71 robotic (RH) and 88 open (OH) hepatectomies were analyzed. Operative time was significantly longer in the RH group (303 vs. 253 min; p = 0.004). Length of stay was more than 2 days shorter in the RH group (4.2 vs. 6.5 days; p < 0.001). RH perioperative costs were higher ($6026 vs. $5479; p = 0.047); however, postoperative costs were significantly lower, resulting in lower total hospital direct costs compared with OH controls ($14,754 vs. $18,998; p = 0.001). Robotic assistance is safe and effective while performing major and minor liver resections. Despite increased perioperative costs, overall RH direct costs are not greater than OH, the current standard of care.

What is the Learning Curve for Laparoscopic Major Hepatectomy?

BACKGROUND

Laparoscopic liver resection is rapidly expanding with more than 9500 cases performed worldwide. While initial series reported non-anatomic resection of benign peripheral hepatic lesions, approximately 50-65 % of laparoscopic liver resections are now being done for malignant tumors, primarily hepatocellular carcinoma (HCC) or colorectal cancer liver metastases (mCRC).

METHODS

We performed a literature review of published studies evaluating outcomes of major laparoscopic liver resection, defined as three or more Couinaud segments.

RESULTS

Initial fears of adverse oncologic outcomes or tumor seeding have not been demonstrated, and dozens of studies have reported comparable 5-year disease-free and overall survival between laparoscopic and open resection of HCC or mCRC in case-cohort and propensity score-matched analyses. Increased experience has led to laparoscopic anatomic liver resections including laparoscopic major hepatectomy. A steep learning curve of 45-60 cases is evident for laparoscopic hepatic resection.

CONCLUSION

Laparoscopic major hepatectomy is safe and effective in the treatment of benign and malignant liver tumors when performed in specialized centers with dedicated teams. Comparable to other complex laparoscopic surgeries, laparoscopic major hepatectomy has a learning curve of 45-60 cases.

Evidence supporting laparoscopic major hepatectomy

Laparoscopic liver resection (LLR) has been increasing in frequency with over 9,000 cases done worldwide. Benefits of laparoscopic resection include less blood loss, smaller incisions, decreased postoperative morbidity, and shorter length of stay compared to open liver resection. With increased experience, several centers have reported series of laparoscopic major hepatectomy, although this represents only about 25% of total LLR performed. Evidence is accumulating to support laparoscopic major hepatectomy with the understanding that there is a steep learning curve, and surgeons should begin with minor LLR before moving on to laparoscopic major hepatectomy. Controversy still remains concerning indications, techniques, learning curve, risks, and long-term cancer outcomes with laparoscopic major hepatectomy.

Laparoscopic liver resection: Experience based guidelines

Laparoscopic liver resection (LLR) has been progressively developed along the past two decades. Despite initial skepticism, improved operative results made laparoscopic approach incorporated to surgical practice and operations increased in frequency and complexity. Evidence supporting LLR comes from case-series, comparative studies and meta-analysis. Despite lack of level 1 evidence, the body of literature is stronger and existing data confirms the safety, feasibility and benefits of laparoscopic approach when compared to open resection. Indications for LLR do not differ from those for open surgery. They include benign and malignant (both primary and metastatic) tumors and living donor liver harvesting. Currently, resection of lesions located on anterolateral segments and left lateral sectionectomy are performed systematically by laparoscopy in hepatobiliary specialized centers. Resection of lesions located on posterosuperior segments (1, 4a, 7, 8) and major liver resections were shown to be feasible but remain technically demanding procedures, which should be reserved to experienced surgeons. Hand-assisted and laparoscopy-assisted procedures appeared to increase the indications of minimally invasive liver surgery and are useful strategies applied to difficult and major resections. LLR proved to be safe for malignant lesions and offers some short-term advantages over open resection. Oncological results including resection margin status and long-term survival were not inferior to open resection. At present, surgical community expects high quality studies to base the already perceived better outcomes achieved by laparoscopy in major centers’ practice. Continuous surgical training, as well as new technologies should augment the application of laparoscopic liver surgery. Future applicability of new technologies such as robot assistance and image-guided surgery is still under investigation.

Pure Laparoscopic Versus Open Left Lateral Sectionectomy for Hepatocellular Carcinoma: A Single-Center Experience

INTRODUCTION

Laparoscopic left lateral sectionectomy has been proven to be a safe and effective treatment for liver lesions. However, most of the literatures only reported this treatment method on benign lesion or colorectal metastases. The data on long-term outcome of laparoscopic left lateral section resection in patients with HCC and cirrhosis are still limited. The aim of this study is to analyze the survival outcome of laparoscopic left lateral sectionectomy when compared to open approach in patients with HCCs.

METHOD

Between January 2004 and September 2014, 967 patients had primary HCC with hepatectomy performed. Twenty-four patients had undergone pure laparoscopic left lateral sectionectomy for hepatocellular carcinoma (HCC). Twenty-nine patients with case-matched tumor characteristics and liver functions but received open left lateral sectionectomy for HCC were included for comparison.

RESULTS

Comparing laparoscopic group to open resection group, the median operation time was 190.5 versus 195 min (P = 0.734); the median blood loss was 100 versus 300 ml (P < 0.001). Hospital stay was 5 days in laparoscopic group versus 6 days in the open group (P = 0.057). There was no difference between the two groups in terms of complications (P = 0.495). The median survival in laparoscopic group was >115 months versus >125 months in the open group (P = 0.853).

CONCLUSION

Laparoscopic left lateral sectionectomy for HCC is a safe and simple procedure associated with less blood loss. The survival outcome is comparable with conventional open approach. It is becoming a more favorable treatment option even for patients with HCC and cirrhosis.

The superficial precoagulation, sealing, and transection method: a "bloodless" and "ecofriendly" laparoscopic liver transection technique

Supplemental Digital Content is available in the text.

Background:

Minimizing blood loss is an important aspect of laparoscopic liver resection. Liver transection is the most challenging part of liver resection, but no standard method is available for this step at present. Herein, we have introduced the superficial precoagulation, sealing, and transection (SPST) method, a potentially “bloodless” and “ecofriendly” laparoscopic liver transection technique involving reusable devices: the VIO soft-coagulation system; VIO BiClamp (bipolar electrosurgical coagulation); Olympus SonoSurg (ultrasonic surgical system); and CUSA (ultrasonic aspirator). Furthermore, we have reported the short-term outcomes of laparoscopic liver transection with the SPST method.

Methods:

The study included 14 consecutive patients who underwent laparoscopic partial liver resection with the SPST method at a single institution between August 2008 and June 2010.

Results:

The median operative time was 201 minutes (range, 97 to 332 min) and the median blood loss was 5 mL (range, 5 to 250 mL). There was no requirement for blood transfusion, no intraoperative complications, and no cases of conversion to open laparotomy. There were no liver transection-related complications such as postoperative bile leakage, bleeding, or infection. All surgical margins were negative, with a mean margin of 4.6 mm, and no local recurrence was observed at an average follow-up of 37.6 months.

Conclusions:

The SPST method is a simple, efficient, and cost-effective surgical technique for laparoscopic liver resection. It is associated with low intraoperative blood loss and good short-term outcomes. We recommend that the SPST method should be used as a standard technique for laparoscopic liver transection (Supplemental Digital Content 1, http://links.lww.com/SLE/A103).

Laparoscopic liver mobilization: tricks of the trade to avoid complications

Supplemental Digital Content is available in the text.

Laparoscopic liver resection is gaining popularity because of the availability of new laparoscopic instruments and advanced techniques. Laparoscopic liver mobilization is not only necessary for pure laparoscopic liver resection but also for laparoscopy-assisted hepatectomy. Laparoscopy-assisted hepatectomy significantly reduces the length of the laparotomy incision, and it is a good educational transition to the more advanced laparoscopic liver resection. Laparoscopic liver mobilization is a simple and easy procedure if surgeons know what challenges to expect. Here, the technique of liver mobilization is summarized, along with those challenges.

Learning curve of self-taught laparoscopic liver surgeons in left lateral sectionectomy: results from an international multi-institutional analysis on 245 cases

BACKGROUND

Laparoscopy was suggested as gold standard for left lateral sectionectomy (LLS), thanks to recognized benefits compared to open approach. Aim of this study was to define learning curve (LC) of laparoscopic LLS (LLLS) using operative time (OT) as tool to analyze outcome of procedures performed by four experienced surgeons. Reproducibility and safety of LC in LLLS among independent surgeons were also analyzed as essential features of "standard procedure" concept.

METHODS

LLLS performed by four experienced surgeons was collected. Multivariate analysis was carried out to screen factors affecting OT. A cumulative LC was created calculating median OT. Skewness of OT was analyzed, and ROC curve was carried out to identify the cutoff for LC. The impact of LC on outcomes (morbidity and mortality, blood loss, conversions, surgical margins and length of stay) was determined.

RESULTS

A total of 245 LLLSs were collected. Conversion rate was 1.2 %. Median OT was 141 min, blood loss 100 mL, morbidity 11.4 % and mortality 0.4 %. "Associated procedures" was the only independent factor affecting OT. The skewness of the OT was calculated, and the cutoff point for LC was determined after 15 LLLSs. LLLS performed during and after LC period had similar outcomes.

CONCLUSION

LLLS is feasible with low morbidity, mortality and conversion rate. LC in LLLS is shorter compared to minor liver resections. Furthermore, it is reproducible and safe since it does not negatively affect clinical outcome. A reproducible, safe and short LC contributes to considering laparoscopy as the gold standard approach to perform LLS.

Minimally invasive liver surgery in a hepato-biliary unit: learning curve and indications

Operative indications and type of resection represent a crucial issue of minimally invasive liver surgery (MILS), and they should not be modified by the increased experience of laparoscopic liver surgeons. The aim of this study was to define the indications for MILS and the learning curve in a high-volume hepatobiliary surgery Unit. Between 2009 and 2014, 993 liver resections were performed in our unit, and MILS was performed in 81 of these (8.2%). The proportion of MILS significantly increased over the study period of time and was significantly higher during the last 2 years than during the first 2 years (10.8 vs. 6.4%; p = 0.042). Rate of liver resections for benign disease between the first 2 years and the last 2 years of the study period was not significantly different (14.7 vs. 10.5%; p = 0.098). Rate of MILS for malignant disease significantly increased from the first 2 years to the last 2 years: 3.2 vs. 7.5% (p < 0.001). Indication for left lateral sectionectomy in the whole series was rare. It was performed in 37 cases as the only liver surgical procedure, on 993 liver resections (3.7%). In 25 (67.6%) of these, a minimally invasive approach was used. Rate of left lateral sectionectomies between the first 2 years and the last 2 years of the study period was not significantly different: 4.5 vs. 3.8% (p = 0.645). This study shows that the proportion of MILS significantly increased over the study period of time in our high-volume hepatobiliary surgery Unit without changing surgical indications for benign disease and type of resections.

Laparoscopic versus open major hepatectomy for hepatocellular carcinoma: a matched pair analysis

BACKGROUND

Laparoscopic major hepatectomy (LMH) for hepatocellular carcinoma (HCC) is currently perceived a complex and challenging laparoscopic procedure and is limited to a few expert teams. This study analyzed the short- and long-term outcomes of LMH for HCC compared with open hepatectomy.

METHODS

From January 2006 to May 2014, 38 patients underwent LMH for HCC (10 left and 28 right hepatectomy). They were matched and compared to 38 patients (10 left and 28 right hepatectomy) who underwent a conventional open approach. Short-term operative and postoperative outcomes as well as long-term outcomes, including disease-free survival and overall survival rates, were evaluated.

RESULTS

Patients were well matched for several preoperative factors. Overall complication rates were significantly higher for the open group. No significant difference was seen in 3-year overall survival between the open and laparoscopic groups (69.2 vs. 73.4 %; p = 0.951). A trend toward better 3-year disease-free survival after laparoscopy was observed (29.7 vs. 50.3 %; p = 0.219), even though the difference did not reach statistical significance. The same trend was seen in subgroup analyses of right and left hepatectomy.

CONCLUSIONS

This study shows the feasibility of LMH for HCC compared to open hepatectomy in regard to both short- and long-term outcomes. LMH offers many advantages commonly attributed to laparoscopy and is well suited for HCC with cirrhosis when performed by experienced surgeons.

Laparoscopic versus open major hepatectomy for hepatocellular carcinoma: a matched pair analysis

BACKGROUND

Laparoscopic major hepatectomy (LMH) for hepatocellular carcinoma (HCC) is currently perceived a complex and challenging laparoscopic procedure and is limited to a few expert teams. This study analyzed the short- and long-term outcomes of LMH for HCC compared with open hepatectomy.

METHODS

From January 2006 to May 2014, 38 patients underwent LMH for HCC (10 left and 28 right hepatectomy). They were matched and compared to 38 patients (10 left and 28 right hepatectomy) who underwent a conventional open approach. Short-term operative and postoperative outcomes as well as long-term outcomes, including disease-free survival and overall survival rates, were evaluated.

RESULTS

Patients were well matched for several preoperative factors. Overall complication rates were significantly higher for the open group. No significant difference was seen in 3-year overall survival between the open and laparoscopic groups (69.2 vs. 73.4 %; p = 0.951). A trend toward better 3-year disease-free survival after laparoscopy was observed (29.7 vs. 50.3 %; p = 0.219), even though the difference did not reach statistical significance. The same trend was seen in subgroup analyses of right and left hepatectomy.

CONCLUSIONS

This study shows the feasibility of LMH for HCC compared to open hepatectomy in regard to both short- and long-term outcomes. LMH offers many advantages commonly attributed to laparoscopy and is well suited for HCC with cirrhosis when performed by experienced surgeons.

Hepatocellular carcinoma: Surgeon's view on latest findings and future perspectives

Hepatocellular carcinoma (HCC) is the most common liver-derived malignancy with a high fatality rate. Risk factors for the development of HCC have been identified and are clearly described. However, due to the lack of tumor-specific symptoms, HCC are diagnosed at progressed tumor stages in most patients, and thus curative therapeutic options are limited. The focus of this review is on surgical therapeutic options which can be offered to patients with HCC with special regard to recent findings, not exclusively focused on surgical therapy, but also to other treatment modalities. Further, potential promising future perspectives for the treatment of HCC are discussed.

Minimally invasive resection of choledochal cyst: a feasible and safe surgical option

BACKGROUND

The use of minimally invasive surgery (MIS) for choledochal cyst (CC) has not been well documented. We sought to define the overall utilization and outcomes associated with the use of the open versus MIS approach for CC. We examined the factors associated with receipt of MIS for CC, as well as characterized perioperative and long-term outcomes following open versus MIS for CC.

METHODS

Between 1972 and 2014, a total of 368 patients who underwent resection for CC were identified from an international, multicenter database. A 2:1 propensity score matching was used to create comparable cohorts of patients to assess the effect of MIS on short-term outcomes.

RESULTS

Three hundred thirty-two patients had an open procedure, whereas 36 patients underwent an MIS approach. Children were more likely to be treated with a MIS approach (children, 24.0 % vs. adults, 2.1 %; P<0.001). Conversely, patients who had any medical comorbidity were less likely to undergo MIS surgery (open, 26.2 % vs. MIS, 2.8 %; P=0.002). In the propensity-matched cohort, MIS resection was associated with decreased length of stay (open, 7 days vs. MIS, 5 days), lower estimated blood loss (open, 50 mL vs. MIS, 17.5 mL), and longer operative time (open, 237 min vs. MIS, 301 min) compared with open surgery (all P<0.05). The overall and degree of complication did not differ between the open (grades I-II, n=13; grades III-IV, n=15) versus MIS (grades I-II, n=5; grades III-IV, n=5) cohorts (P=0.85). Five-year overall survival was 98.6 % (open, 98.0 % vs. MIS, 100.0 %; P=0.45); no patient who underwent MIS developed a subsequent cholangiocarcinoma.

CONCLUSIONS

MIS resection of CC was demonstrated to be a feasible and safe approach with acceptable short-term outcomes in the pediatric population. MIS for benign CC disease was associated with similar perioperative morbidity but a shorter length of stay and a lower blood loss when compared with open resection.

Preparedness of neurosurgery graduates for neuroendovascular fellowship: a national survey of fellowship programs

OBJECT

Endovascular interventions have become an essential part of a neurosurgeon's practice. Whether endovascular procedures have been effectively integrated into residency curricula, however, remains uncertain. The purpose of this study was to assess the preparedness of US neurosurgery graduate trainees for neuroendovascular fellowship.

METHODS

A multidomain, global assessment survey was sent to all directors/faculty of neuroendovascular fellowship programs involved in training of US neurosurgery graduates. Surveyees were asked to assess trainees as they entered fellowship.

RESULTS

The response rate was 78% (25/32). Of respondent program directors, 38% reported that new fellows did not know the history and imaging of the patient and 50% were unable to formulate an appropriate treatment plan. As many as 79% of fellows were unfamiliar with endovascular devices and 75% were unfamiliar with angiographic equipment. Furthermore, 58% of fellows were unable to perform femoral access, 54% were unable to perform femoral closure, 79% were unable to catheterize a major vessel, 86% were unable to perform a 4-vessel angiogram, and 100% were unable to catheterize an aneurysm. Additionally, program directors reported that over 50% of fellows could not recognize neurovascular anatomy and 54% could not recognize/classify vascular abnormalities. There was an overall agreement that fellows demonstrated professionalism and interest in research and had good communication/clinical skills.

CONCLUSIONS

The results of this study suggest potential gaps in the training of neurosurgery residents with regard to endovascular neurosurgery. In an era of minimally invasive therapies, changes in residency curricula may be needed to keep pace with the ever-changing field of neurosurgery.

Long-term outcomes of laparoscopic versus open liver resection for liver metastases from colorectal cancer: A comparative analysis of 168 consecutive cases at a single center

BACKGROUND

Laparoscopic liver resection for liver metastases from colorectal cancer (CRLM) is performed in a relatively small number of institutions. Its operative results have been reported to be comparable with that of open laparotomy; however, information on its oncologic outcomes is scarce. This study aimed to compare the long-term outcomes of laparoscopic hepatectomy (LH) and open hepatectomy (OH) to treat CRLM at a single institution.

METHODS

We retrospectively reviewed data from 168 consecutive patients who underwent LH (n = 100) or OH (n = 68) for CRLM. The tumor characteristics, operative results, overall survival (OS) rate, recurrence-free survival (RFS) rate, and recurrence patterns were analyzed and compared. A previously published survival-predicting nomogram was applied to compare OS and RFS between the 2 patient groups.

RESULTS

The largest tumor diameter and the number of tumors were significantly larger in the OH group than in the LH group; however, no differences in other tumor factors were observed between the 2 groups. When matched by the nomogram, OS and RFS remained comparable between the 2 groups in every examined stratum, not only for low-risk patients but also for those with high risk. The recurrence patterns also were similar (liver: 30.2% vs 26.8%, P = .72; lung: 22.6% vs 34.1%, P = .22; peritoneum: 7.6% vs 4.9%, P = .45).

CONCLUSION

The long-term outcomes of laparoscopic liver resection for CRLM were comparable with those of the open procedure in not only low-risk but also high-risk patients.

Are general surgery residents adequately prepared for hepatopancreatobiliary fellowships? A questionnaire-based study

BACKGROUND

The present study was conducted to assess the preparedness of hepatopancreatobiliary (HPB) fellows upon entering fellowship, identify challenges encountered by HPB fellows during the initial part of their HPB training, and identify potential solutions to these challenges that can be applied during residency training.

METHODS

A questionnaire was distributed to all HPB fellows in accredited HPB fellowship programmes in two consecutive academic years (n = 42). Reponses were then analysed.

RESULTS

A total of 19 (45%) fellows responded. Prior to their fellowship, 10 (53%) were in surgical residency and the rest were in other surgical fellowships or surgical practice. Thirteen (68%) were graduates of university-based residency programmes. All fellows felt comfortable in performing basic laparoscopic procedures independently at the completion of residency and less comfortable in performing advanced laparoscopy. Eight (42%) fellows cited a combination of inadequate case volume and lack of autonomy during residency as the reasons for this lack of comfort. Thirteen (68%) identified inadequate preoperative workup and management as their biggest fear upon entering practice after general surgery training. A total of 17 (89%) fellows felt they were adequately prepared to enter HPB fellowship. Extra rotations in transplant, vascular or minimally invasive surgery were believed to be most helpful in preparing general surgery residents pursing HPB fellowships.

CONCLUSIONS

Overall, HPB fellows felt themselves to be adequately prepared for fellowship. Advanced laparoscopic procedures and the perioperative management of complex patients are two of the challenges facing HPB fellows. General surgery residents who plan to pursue an HPB fellowship may benefit from spending extra rotations on certain subspecialties. Focus on perioperative workup and management should be an integral part of residency and fellowship training.

Influence of cumulative surgical experience on the outcome of poor-grade patients with ruptured intracranial aneurysm

BACKGROUND

The expansion of endovascular techniques for intracranial aneurysms has led to a global decrease in vascular neurosurgery activity. This situation might impact neurosurgeons' level of expertise, even though they all might have to deal with this surgically challenging pathology. In that context, we wanted to assess the impact of cumulative surgical experience on the outcome of patients with poor-grade subarachnoid haemorrhage (SAH) and intracerebral haemorrhage (ICH) treated by microsurgery.

METHODS

Sixty-seven patients who underwent surgery for a ruptured aneurysm with SAH and ICH, and a WFNS scale of IV/V, were included. Surgeries were performed by five surgeons, whose experience was judged by the total number of aneurysm surgeries performed. The outcome was assessed by three indicators: intraoperative rupture (IOR), early mortality, and the modified Rankin Scale at last follow-up. The time of IOR was reported on an IOR score. The correlation between surgical experience and outcome was assessed by linear regression. Nonlinear regression was used to assess the correlation of the data with a learning curve model.

RESULTS

The analysis showed an influence of surgical experience on intraoperative rupture, with no effect on long-term outcome. No influence was found on early mortality. Increased surgical experience seems to reduce IOR during aneurysm dissection and clip repositioning. Intraoperative rupture data fit Wright's learning curve model.

CONCLUSION

This study suggests a direct impact of cumulative experience on the course of ruptured aneurysm surgery and pleads for the use of training and simulation programmes dedicated to neurovascular surgery.

Laparoscopic liver resection for living donation: Where do we stand?

In Western countries, living donor liver transplantation (LDLT) may represent a valuable alternative to deceased donor liver transplantation. Yet, after an initial peak of enthusiasm, reports of high rates of complications and of fatalities have led to a certain degree of reluctance towards this procedure especially in Western countries. As for living donor kidney transplantation, the laparoscopic approach could improve patient’s tolerance in order to rehabilitate this strategy and reverse the current trend. In this setting however, initial concerns regarding patient’s safety and graft integrity, need for acquiring surgical expertise in both laparoscopic liver surgery and living donor transplantation and lack of evidence supporting the benefits of laparoscopy have delayed the development of this approach. Similarly to what is performed in classical resectional liver surgery, initial experiences of laparoscopy have therefore begun with left lateral sectionectomy, which is performed for adult to child living donation. In this setting, the laparoscopic technique is now well standardized, is associated with decreased donor blood loss and hospital stays and provides graft of similar quality compared to the open approach. On the other hand laparoscopic major right or left hepatectomies for adult-adult LDLT currently lack standardization and various techniques such as the full laparoscopic approach, the hand assisted approach and the hybrid approach have been reported. Hence, even-though several reports highlight the feasibility of these procedures, the true benefits of laparoscopy over laparotomy remain to be fully assessed. This could be achieved through standardization of the procedures and creation of international registries especially in Eastern countries where LDLT keeps on flourishing.

[Laparoscopic liver surgery]

Liver resection remains the method of choice for curative treatment for liver tumors. Development in diagnostic and surgical techniques has improved operative results as well as long-term outcomes. In the last decade minimally invasive laparoscopic (LAP) surgery has been increasingly adopted by liver units. The trend in LAP liver resection has been moving from limited resections towards major hepatectomy. This process, however, is relatively slow, which can be due to technical difficulties of the procedure and fear of haemorrhage. Despite having a hard time at the start, major resections become more common. Up to now approximately 6000 LAP liver resections were performed worldwide, number of major hepatectomies is estimated between 700-800. LAP liver resections are feasible with significant benefits for patients consisting of less blood loss, less narcotic requirements, and shorter hospital stay with comparable postoperative morbidity and mortality to open liver resections. It is an accepted management of both benign and malignant liver lesions. There is no difference between LAP and open surgery in late survival after resection for colorectal liver metastases. Overall survival of LAP resected hepatocellular carcinoma cases seems to be superior compared with open surgery.

A comparison of open and minimally invasive surgery for hepatic and pancreatic resections using the Nationwide Inpatient Sample

BACKGROUND

The use of minimally invasive surgery (MIS) techniques for pancreatic and liver operations remains ill defined. We sought to compare inpatient outcomes among patients undergoing open versus MIS pancreas and liver operations using a nationally representative cohort.

METHODS

We queried the Nationwide Inpatient Sample database for all major pancreatic and hepatic resections performed between 2000 and 2011. Appropriate International Classification of Diseases, 9th Revision (ICD-9) coding modifiers for laparoscopy and robotic assist were used to categorize procedures as MIS. Demographics, comorbidities, and inpatient outcomes were compared between the open and MIS groups.

RESULTS

A total of 65,033 resections were identified (pancreas, n = 36,195 [55.7%]; liver, n = 28,035 [43.1%]; combined pancreas and liver, n = 803 [1.2%]). The overwhelming majority of operations were performed open (n = 62,192, 95.6%), whereas 4.4% (n = 2,841) were MIS. The overall use of MIS increased from 2.3% in 2000 to 7.5% in 2011. Compared with patients undergoing an open operation, MIS patients were older and had a greater incidence of multiple comorbid conditions. After operation, the incidence of complications for MIS (pancreas, 35.4%; liver, 29.5%) was lower than for open (pancreas, 41.6%; liver, 33%) procedures (all P < .05) resulting in a shorter median length of stay (8 vs 7 days; P = .001) as well as a lower in-hospital mortality (5.1% vs 2.8%; P = .001).

CONCLUSION

During the last decade, the number of MIS pancreatic and hepatic operations has increased, with nearly 1 in 13 HPB cases now being performed via an MIS approach. Despite MIS patients tending to have more preoperative medical comorbidities, postoperative morbidity, mortality, and duration of stay compared favorably with open surgery.

Laparoscopic liver resection: basic skills for peripheral lesions

An evaluation of the literature demonstrates atypical wedge or single segment resections to be the most commonly performed laparoscopic liver procedures. Lesions that are both visible on the surface of segments 2-6 and ≤2-3 cm can be resected by most surgeons holding a fundamental understanding of liver anatomy. These criteria are based on the anatomical circumstance that sectoral and segmental pedicles should not course through depths necessary to obtain negative margins for these sized and positioned lesions. Videos of laparoscopic liver resections referenced in PubMed demonstrate complex procedures that are rarely performed and assume an advanced skill set for laparoscopic dissection and transection of parenchyma and management of vascular and biliary structures. Herein is demonstrated basic skill for peripheral resections via two cases in one video, so that these procedures can be safely performed by surgeons with commonly available laparoscopic equipment.

Laparoscopic left lateral sectionectomy as a training procedure for surgeons learning laparoscopic hepatectomy

BACKGROUND

Laparoscopic liver resection remains limited to a relatively small number of institutions because of insufficient hepatic and laparoscopic surgical experience and few training opportunities. The aim of this study was to assess the feasibility and safety of an improved laparoscopic left lateral sectionectomy technique as a training procedure for new surgeons.

METHODS

Twenty-four laparoscopic left lateral sectionectomies (LLLSs) were retrospectively reviewed. Patients were divided into 3 groups with 8 patients in each: those undergoing surgery by expert surgeons prior to 2008 (Group A); those undergoing surgery by expert surgeons after 2008, when a standardized LLLS technique was adopted (Group B); and those undergoing LLLS by junior surgeons being trained (Group C).

RESULTS

The median operative time was significantly shorter for Group B (103 min; range, 99-109 min) and C (107 min; range, 85-135 min) patients than for Group A (153 min; range, 95-210 min) patients. There were no significant differences in blood loss or hospital stay. In Groups B and C, no conversions to open laparotomy or complications occurred.

CONCLUSION

The standardized LLLS procedure was both safe and feasible as a technique for training surgeons in laparoscopic hepatectomy.

General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors

OBJECTIVE

To assess readiness of general surgery graduate trainees entering accredited surgical subspecialty fellowships in North America.

METHODS

A multidomain, global assessment survey designed by the Fellowship Council research committee was electronically sent to all subspecialty program directors. Respondents spanned minimally invasive surgery, bariatric, colorectal, hepatobiliary, and thoracic specialties. There were 46 quantitative questions distributed across 5 domains and 1 or more reflective qualitative questions/domains.

RESULTS

There was a 63% response rate (n = 91/145). Of respondent program directors, 21% felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications. Finally, it was felt that the majority of new fellows were unable to conceive, design, and conduct research/academic projects. Thematic clustering of qualitative data revealed deficits in domains of operative autonomy, progressive responsibility, longitudinal follow-up, and scholarly focus after general surgery education.

Laparoscopic liver resection: 5-year experience at a single center

Background

Hepatocellular carcinoma (HCC) is a common cancer, especially in the Association of Southeast Asian Nations (ASEAN) region, where the prevalence of hepatitis virus infection is high. Liver resection is a potentially curative and popular therapy for HCC. Laparoscopic surgery using minimally invasive techniques potentially brings benefits to patients who need liver resection for HCC. This study aimed to evaluate the effectiveness, safety, and benefits of laparoscopic liver resection for HCC with long-term follow-up evaluation.

Methods

This cohort study with 5-year results of total laparoscopic hepatectomy for HCC was conducted in one center. Patients with HCC were selected for laparoscopic liver resection by the same team. The operation also was performed by one team of surgeons. The follow-up protocol was similar to that for open surgery. The patients were scheduled to return for examination every 2 months after the operation. The data for the patients were collected and analyzed using SPSS software.

Results

From January 2008 to December 2012, 173 enrolled patients with HCC underwent laparoscopic liver resection. The male-to-female ratio was 3:1. The mean age of the patients was 56 years (range 16–83 years). The follow-up period for 130 patients was 21.6 ± 16.0 months (range 0–60 months). The mean tumor size was 3.73 cm (range 2–10 cm). The stages of HCC according to the Barcelona Clinic Liver Cancer (BCLC) categorization were as follows: 0 (6 %), A1 (59.5 %), A2 (6.9 %), A4 (2.9 %), and B (27.2 %). Four patients required conversion to other techniques (2.3 %) because of the potential for major bleeding and tumor perforation. The types of resection were resection of one segment (segments 2, 3, 4, 5, 6, 7, and 8; 43.8 %), resection of two segments (posterior sector, anterior sector, segments 5 and 6, and left lateral sector; 47.9 %), resection of three segments (left and central liver; 4.7 %), and four segments (right liver; 3.6 %). The mean operation time was 112 ± 56 min (range 30–345 min), and the median blood loss was 100 ml (range 20–1,200 ml). The mean hospital stay was 6.5 ± 2.0 days (range, 3–19 days). No perioperative mortality occurred. The overall survival rates were 94.2 % at 1 year, 87 % at 2 years, 72.9 % at 3 years, 72.9 % at 4 years, and 72.9 % at 5 years. The mean overall survival time was 49.7 ± 2.1 months (range 45.5–53.9 months). The disease-free survival rates were 79.1 % at 1 year, 60 % at 2 years, 57 % at 3 years, 52 % at 4 years, and 26.3 % at 5 years. The mean disease-free survival time was 38.9 ± 2.6 months (range 33.9–44.0 months).

Conclusion

Laparoscopic liver resection for HCC is feasible, safe, and effective, with good oncologic results. Major and anatomic hepatectomy are possible with improved skill and experience. Laparoscopic liver resection is a promising treatment option with minimally invasive benefits for HCC patients.

Laparoscopic robot-assisted major hepatectomy

BACKGROUND

We herein present a systematic review of English literature on robot-assisted major hepatectomy (MH).

METHODS

Major hepatectomy was defined as resection of three or more liver segments. A literature search was performed using the Pubmed database. Articles containing more than five robotic MH were selected. In case of multiple publications from the same institution, only the most recent article was considered in order to avoid double counting of patients between series.

RESULTS

Five articles were included in this review. A total of 68 robotic MH were analyzed, including 38 right hepatectomies and 30 left hepatectomies. There were no deaths. Two right hepatectomies (5.2%) and one left hepatectomy (3.3%) were converted to open surgery. Weighted average of operative time and intraoperative blood loss were 418.6 min and 411.4 ml, respectively. Four patients received blood transfusions (6.3%) and 17 developed postoperative complications (26.9%). Information on tumor type were available for 57 patients of whom 42 were diagnosed with malignant tumors (73.6%) and 15 with benign diseases (26.3%). No port site metastasis, peritoneal carcinomatosis, or intrahepatic recurrence were reported. Three patients had microscopic margin positivity.

CONCLUSIONS

Major hepatectomy can be performed under robotic assistance. Further experience is needed before final conclusions can be drawn.

Laparoscopic Hepatectomy is a Safe and Effective Approach for Resecting Large Colorectal Liver Metastases

Hepatectomy is an accepted treatment modality for large (greater than 5 cm) colorectal liver metastases (CLM). Recently, laparoscopic hepatectomy has emerged as a viable option; however, its use for patients with large CLM is undefined. A retrospective analysis of a single institution's prospective database was performed for patients with large CLM resected between 1995 and 2010. Patients were stratified by operative approach. Patient characteristics, tumor burden, operative factors, hospital course, and long-term outcomes were compared using nonparametric, Fisher's exact, and Kaplan-Meier testing. Eighty-four patients were identified. Eight patients (9.5%) underwent laparoscopic resection. Age (59.5 vs 60 years), body mass index (26.8 vs 27.5 kg/m2), size of largest tumor (6.8 vs 7.5 cm), R0 resection (100 vs 89.5%), hepatic recurrence (25 vs 43.4%), and transfusion rate (14.3 vs 30.9%) of laparoscopic compared with open resection were similar. However, complication rate (12.5 vs 60.5%; P = 0.0192), blood loss (225 vs 400 mL; P = 0.0427), and length of stay (3.5 vs 7.0 days; P = 0.0005) were significantly higher in the open resection cohort. Median disease-free survival was 14.4 and 13.2 months for laparoscopic and open patients, respectively. Laparoscopic resection appears to be a safe approach for resecting large CLM. Tumor size does not preclude laparoscopic hepatectomy.