Minimally invasive liver resection for metastatic colorectal cancer: a multi-institutional, international report of safety, feasibility, and early outcomes. Ann Surg. 2009;250:842-848. [PMID: 19806058 DOI: 10.1097/sla.0b013e3181bc789c]

Meta-analysis of laparoscopic versus open liver resection for colorectal liver metastases

Background

To compare surgical and oncological outcomes of laparoscopic versus open liver resection for colorectal liver metastases.

Results

A total of 14 retrospective studies with 1679 colorectal liver metastases patients were analyzed: 683 patients treated with laparoscopic liver resection and 996 patients with open liver resection. With respect to surgical outcomes, laparoscopic compared with open liver resection was associated with lower blood loss (MD, -216.7, 95% CI, -309.4 to -124.1; P < 0.00001), less requiring blood transfusion (OR, 0.36; 95% CI, 0.23 to 0.55; P < 0.00001), lower postoperative complication morbidity (OR, 0.61; 95% CI, 0.47 to 0.80; P = 0.003), and shorter hospitalization time (MD, -3.85, 95% CI, -5.00 to -2.71; P < 0.00001). However, operation time and postoperative mortality were no significant difference between the two approaches. With respect to oncological outcomes, laparoscopic liver resection group was prone to lower recurrence rate (OR, 0.78; 95% CI, 0.61−0.99; P = 0.04), but surgical margins R0, overall survival and disease-free survival were no significant difference.

Materials and Methods

We performed a systematic search in MEDLINE, EMBASE, and CENTRAL for all relevant studies. All statistical analysis was performed using Review Manager version 5.3. Dichotomous data were calculated by odds ratio (OR) and continuous data were calculated by mean difference (MD) with 95% confidence intervals (CI).

Conclusions

Laparoscopic and open liver resection for colorectal liver metastases have the same effect on oncological outcomes, but laparoscopic liver resection achieves better surgical outcomes.

Laparoscopic liver resection for colorectal liver metastasis patients allows patients to start adjuvant chemotherapy without delay: a propensity score analysis

BACKGROUND

Although adjuvant chemotherapy (AC) is widely used after liver resection (LR) for colorectal liver metastasis (CRLM), surgical invasiveness may lead to delay in starting AC, which is preferably started within 8 weeks postoperative. We investigated whether laparoscopic liver resection (LLR) for CRLM facilitates AC start without delay.

METHODS

Between November 2014 and December 2016, 117 consecutive CRLM patients underwent LR followed by AC. LLR and OLR were performed in 30 and 87 patients, respectively. After propensity score matching on clinical characteristics, oncologic features, and type of resection, the time interval between liver resection and AC start was compared between LLR (n = 22) and OLR (n = 44) groups.

RESULTS

After propensity score matching, major LR was performed in 8/22 (36%) and 15/44 (34%) cases of LLR and OLR groups, respectively (P = 1.0). Clinical-pathological characteristic and intraoperative findings were comparable between two groups. There was no significant difference in postoperative complications between the two groups. The time interval between liver resection and AC start was significantly shorter in LLR than in OLR group (43 ± 10 versus 55 ± 18 days, P = 0.012). While 15/44 (34%) patients started AC after 8 weeks postoperative in OLR group, all patients in LLR group started AC within 8 weeks.

CONCLUSIONS

LLR for CRLM is associated with quicker return to AC when compared to OLR. The delivery of AC without delay allows CRLM patients to optimize the oncologic treatment sequence.

Advances and challenges in laparoscopic surgery in the management of hepatocellular carcinoma

Hepatocellular carcinoma is the fifth most common malignancy and the third most common cause of cancer-related mortality worldwide. From the wide variety of treatment options, surgical resection and liver transplantation are the only therapeutic ones. However, due to shortage of liver grafts, surgical resection is the most common therapeutic modality implemented. Owing to rapid technological development, minimally invasive approaches have been incorporated in liver surgery. Liver laparoscopic resection has been evaluated in comparison to the open technique and has been shown to be superior because of the reported decrease in surgical incision length and trauma, blood loss, operating theatre time, postsurgical pain and complications, R0 resection, length of stay, time to recovery and oral intake. It has been reported that laparoscopic excision is a safe and feasible approach with near zero mortality and oncologic outcomes similar to open resection. Nevertheless, current indications include solid tumors in the periphery < 5 cm, especially in segments II through VI, while according to the consensus laparoscopic major hepatectomy should only be performed by surgeons with high expertise in laparoscopic and hepatobiliary surgery in tertiary centers. It is necessary for a surgeon to surpass the 60-cases learning curve observed in order to accomplish the desirable outcomes and preserve patient safety. In this review, our aim is to thoroughly describe the general principles and current status of laparoscopic liver resection for hepatocellular carcinoma, as well as future prospects.

Robotic-Assisted Versus Laparoscopic Left Lateral Sectionectomy: Analysis of Surgical Outcomes and Costs by a Propensity Score Matched Cohort Study

BACKGROUND

After comparing with open approach, left lateral sectionectomy (LLS) has become standard in terms of short-term outcomes without jeopardizing long-term survival when performed for malignancy. The aim of this study was to compare the short-term and economic outcomes of laparoscopic (L-LLS) and robotic (R-LLS) LLS.

METHODS

All consecutive patients who underwent L-LLS or R-LLS from 1997 to 2014 were analyzed. Short-term and economic outcomes were compared between the two groups using a propensity score matching (PSM).

RESULTS

Ninety-six consecutive cases of LLS were performed using the laparoscopic (80 cases; 83 %) or robotic (16 cases; 17 %) approach. The two groups were similar for operative and surgical outcomes. Operation time was similar in the R-LLS compared to the L-LLS group (190 vs. 162 min; p = 0.10). Perioperative costs were higher (1457 € vs. 576 €; p < 0.0001) in the R-LLS group than in the L-LLS group; however, postoperative costs were similar between the two groups (4065 € in the R-LLS group vs. 5459 € in the L-LLS group; p = 0.30). Total costs were similar between the two groups (5522 € in the R-LLS group vs. 6035€ in the L-LLS group; p = 0.70). The PSM included 14 patients for each group. Surgical and economic outcomes remained similar after PSM, except for total operating time which was significantly longer in the R-LLS group than in the L-LLS group.

CONCLUSIONS

Even if feasible and safe, the robotic approach does not seem so far to offer additional benefit in terms of intra- and postoperative outcomes over the laparoscopic approach in patients requiring LLS. Total costs associated with the R-LLS group are not greater than that associated with the L-LLS group, which is the standard of care so far.

Predictors and implications of unplanned conversion during minimally invasive hepatectomy: an analysis of the ACS-NSQIP database

BACKGROUND

Minimally-invasive hepatectomy (MIH) is increasingly utilized; however, predictors and outcomes for patients requiring conversion to an open procedure have not been adequately studied.

METHODS

The 2014-15 ACS-NSQIP database was analyzed. Unplanned conversion was compared to successful MIH and elective open hepatectomy.

RESULTS

Among 6918 hepatectomies, 1062 (15.4%) underwent attempted MIH: 989 laparoscopic, 73 robotic. Conversion occurred in 203 (19.1%). Compared to successful MIH, patients requiring unplanned conversion experienced higher rates of complications (34.5% vs 14.6%, p<0.001), including bile leaks (7.4% vs 2.8%, p=0.002), organ space infection (6.4% vs 2.9%, p=0.016), UTI (4.9% vs 1.2%, p=0.002), perioperative bleeding (21.2% vs 6.1%, p<0.001), DVT (3.0% vs 0.8%, p=0.024), and sepsis (5.9% vs 1.9%, p=0.001). Conversion led to greater LOS (5 days vs 3 days, p<0.001) and 30-day mortality (3.0% vs 0.5%, p=0.005). Compared to elective open hepatectomy, conversion was associated with greater perioperative bleeding (21.2% vs 15.3%, p = 0.037). On multivariate analysis, major hepatectomy (OR 2.21, p<0.001), concurrent ablation (OR 1.79, p=0.020), and laparoscopic approach (vs. robotic) (OR 3.22, p=0.014) were associated with conversion.

CONCLUSION

Analysis of this national database revealed unplanned conversion during MIH is associated with greater morbidity and mortality. MIH should be approached cautiously in patients requiring major hepatectomy.

Laparoscopic parenchymal sparing resections in segment 8: techniques for a demanding and infrequent procedure

BACKGROUND

Laparoscopic liver resections for lesions in the postero-superior segments are technically demanding due their deep location and relation with the vena cava. However, previous reports have demonstrated the feasibility and safety of these resections in centres with advanced experience in laparoscopic liver surgery. In this case series, we present our results and experience of laparoscopic parenchymal sparing liver resections of lesions in segment 8.

METHODS

All patients undergoing laparoscopic liver resections of segment 8 lesions, alone or combined with other liver resections, between August 2003 and July 2016 were included. Analysis of baseline characteristics and perioperative results was performed for the whole cohort. A separate subgroup analysis was performed for isolated segment 8 resections. Long-term results were analyzed in patients with colorectal liver metastases. A video is attached for thorough explanation of surgical technique.

RESULTS

A total of 30 patients were included. Among them, 13 patients had isolated segment 8 resections. Operative time for the whole cohort and isolated segment 8 resections were 210 min (range 180-247 min) and 200 min (range 90-300 min), respectively. The conversion rate was 3.4% for the entire cohort and 0 for isolated segment 8 resections. Major morbidity was 7 and 0%, respectively. R0 rates were 96% for the entire cohort and 92% for isolated segment 8 resections. Recurrence free survival in the colorectal liver metastasis subgroup was 82, 71 and 54% at 1, 3 and 5 years. Overall survival was 94, 82 and 65% at 1, 3 and 5 years.

CONCLUSIONS

Laparoscopic resection of lesions in segment 8 is feasible and offers the benefits of minimally invasive surgery with parenchyma sparing resections. However, advanced experience in LLR is essential to ensure safety and oncological results.

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.

First quarter century of laparoscopic liver resection

The beginnings of laparoscopic liver resection (LLR) were at the start of the 1990s, with the initial reports being published in 1991 and 1992. These were followed by reports of left lateral sectionectomy in 1996. In the years following, the procedures of LLR were expanded to hemi-hepatectomy, sectionectomy, segmentectomy and partial resection of posterosuperior segments, as well as the parenchymal preserving limited anatomical resection and modified anatomical (extended and/or combining limited) resection procedures. This expanded range of LLR procedures, mimicking the expansion of open liver resection in the past, was related to advances in both technology (instrumentation) and technical skill with conceptual changes. During this period of remarkable development, two international consensus conferences were held (2008 in Louisville, KY, United States, and 2014 in Morioka, Japan), providing up-to-date summarizations of the status and perspective of LLR. The advantages of LLR have become clear, and include reduced intraoperative bleeding, shorter hospital stay, and - especially for cirrhotic patients-lower incidence of complications (e.g., postoperative ascites and liver failure). In this paper, we review and discuss the developments of LLR in operative procedures (extent and style of liver resections) during the first quarter century since its inception, from the aspect of relationships with technological/technical developments with conceptual changes.

Laparoscopic Versus Open Liver Resection for Colorectal Liver Metastases: A Comprehensive Systematic Review and Meta-analysis

The effects of laparoscopic liver resection (LLR) and open liver resection (OLR) on oncological outcomes for colorectal cancer liver metastases (CCLM) remain inconclusive. Major databases were searched from January 1992 to October 2016. Effects of LLR vs OLR were determined. The primary endpoints were oncological outcomes. In total, 32 eligible non-randomized studies with 4697 patients (LLR: 1809, OLR: 2888) were analyzed. There were higher rates of clear surgical margins (OR: 1.64, 95%CI: 1.32 to 2.05, p < 0.00001) in the LLR group, without significant differences in disease recurrence, 3- or 5-year overall survival(OS) and disease free survival(DFS) between the two approaches. LLR was associated with less intraoperative blood loss (WMD: −147.46 [−195.78 to −99.15] mL, P < 0.00001) and fewer blood transfusions (OR: 0.41 [0.30–0.58], P < 0.00001), but with longer operation time (WMD:14.44 [1.01 to 27.88] min, P < 0.00001) compared to OLR. Less overall morbidity (OR: 0.64 [0.55 to 0.75], p < 0.00001) and shorter postoperative hospital stay (WMD: −2.36 [−3.06 to −1.66] d, p < 0.00001) were observed for patients undergoing LLR, while there was no statistical difference in mortality. LLR appears to be a safe and feasible alternative to OLR in the treatment of CCLM in selected patients.

Robotic Liver Resection: A Case-Matched Comparison

BACKGROUND

In recent years, increasingly sophisticated tools have allowed for more complex robotic surgery. Robotic hepatectomy, however, is still in its infancy. Our goals were to examine the adoption of robotic hepatectomy and to compare outcomes between open and robotic liver resections.

METHODS

The robotic hepatectomy experience of 64 patients was compared to a modern case-matched series of 64 open hepatectomy patients at the same center. Matching was according to benign/malignant diagnosis and number of segments resected. Patient data were obtained retrospectively. The main outcomes and measures were operative time, estimated blood loss, conversion rate (robotic to open), Pringle maneuver use, single non-anatomic wedge resection rate, resection margin size, complication rates (infectious, hepatic, pulmonary, cardiac), hospital stay length, ICU stay length, readmission rate, and 90-day mortality rate.

RESULTS

Sixty-four robotic hepatectomies were performed in 2010-2014. Forty-one percent were segmental and 34 % were wedge resections. There was a 6 % conversion rate, a 3 % 90-day mortality rate, and an 11 % morbidity rate. Compared to 64 matched patients who underwent open hepatectomy (2004-2012), there was a shorter median OR time (p = 0.02), lower median estimated blood loss (p < 0.001), and shorter median hospital stay (p < 0.001). Eleven of the robotic cases were isolated resections of tumors in segments 2, 7, and 8.

CONCLUSIONS

Robotic hepatectomy is safe and effective. Increasing experience in more centers will allow definition of which hepatectomies can be performed robotically, and will enable optimization of outcomes and prospective examination of the economic cost of each approach.

Is Laparoscopic Hepatectomy a Safe, Feasible Procedure in Patients with a Previous Upper Abdominal Surgery?

Background:

Laparoscopic liver resection has become an accepted treatment for liver tumors or intrahepatic bile duct stones, but its application in patients with previous upper abdominal surgery is controversial. The aim of this study was to evaluate the feasibility and safety of laparoscopic hepatectomy in these patients.

Methods:

Three hundred and thirty-six patients who underwent laparoscopic hepatectomy at our hospital from March 2012 to June 2015 were enrolled in the retrospective study. They were divided into two groups: Those with previous upper abdominal surgery (PS group, n = 42) and a control group with no previous upper abdominal surgery (NS group, n = 294). Short-term outcomes including operating time, blood loss, hospital stay, morbidity, and mortality were compared among the groups.

Results:

There was no significant difference in median operative duration between the PS group and the NS group (180 min vs. 160 min, P = 0.869). Median intraoperative blood loss was same between the PS group and the control group (200 ml vs. 200 ml, P = 0.907). The overall complication rate was significantly lower in the NS group than in the PS group (17.0% vs. 31.0%, P = 0.030). Mortality and other short-term outcomes did not differ significantly between groups.

Conclusions:

Our study showed no significant difference between the PS group and NS group in term of short-term outcomes. Laparoscopic hepatectomy is a feasible and safe procedure for patients with previous upper abdominal surgery.

Surgical resection of localized hepatocellular carcinoma: patient selection and special consideration

Localized hepatocellular carcinoma (HCC) refers to a solitary or few tumors located within either the left or right hemiliver without evidence of bilobar or extrahepatic spread. This term encompasses a heterogeneous morphology with no regard to stage of prognosis of the disease. Surgical resection remains the mainstay of curative treatment for the localized HCC. Various biochemical and radiological tests constitute an indispensible part of preoperative assessment. Emergence of laparoscopic hepatectomy has brought liver resection into a new era. Improved understanding of the pathophysiology of HCC allows more aggressive surgical resection without compromising outcomes. New insights into the management of special situations, such as ruptured HCC, pyogenic transformation of HCC, and HCC with portal vein tumor thrombus, rekindle the hopes of curative resection in these terminal events. Amalgamating salvage liver transplantation into the surgical management of resectable HCC has revolutionized the treatment paradigm of this deadly disease.

Laparoscopic liver resection for posterosuperior tumors using caudal approach and postural changes: A new technical approach

Laparoscopic liver resection (LLR) for tumors in the posterosuperior liver [segment (S) 7 and deep S6] is a challenging clinical procedure. This area is located in the bottom of the small subphrenic space (rib cage), with the large and heavy right liver on it when the patient is in the supine position. Thus, LLR of this area is technically demanding because of the handling of the right liver which is necessary to obtain a fine surgical view, secure hemostasis and conduct the resection so as to achieve an appropriate surgical margin in the cage. Handling of the right liver may be performed by the hand-assisted approach, robotic liver resection or by using spacers, such as a sterile glove pouch. In addition, the operative field of posterosuperior resection is in the deep bottom area of the subphrenic cage, with the liver S6 obstructing the laparoscopic caudal view of lesions. The use of intercostal ports facilitates the direct lateral approach into the cage and to the target area, with the combination of mobilization of the liver. Postural changes during the LLR procedure have also been reported to facilitate the LLR for this area, such as left lateral positioning for posterior sectionectomy and semi-prone positioning for tumors in the posterosuperior segments. In our hospital, LLR procedures for posterosuperior tumors are performed via the caudal approach with postural changes. The left lateral position is used for posterior sectionectomy and the semi-prone position is used for S7 segmentectomy and partial resections of S7 and deep S6 without combined intercostal ports insertion. Although the movement of instruments is restricted in the caudal approach, compared to the lateral approach, port placement in the para-vertebra area makes the manipulation feasible and stable, with minimum damage to the environment around the liver.

Laparoscopic repeat hepatectomy after right hepatopancreaticoduodenectomy

Although laparoscopic hepatectomy is widely accepted for primary hepatectomy, the clinical value of laparoscopic hepatectomy for repeat hepatectomy is still challenging. We herein describe our experience with laparoscopic repeat hepatectomy after right hepatopancreaticoduodenectomy. A 72-year-old woman who had undergone right hepatopancreaticoduodenectomy for perihilar cholangiocarcinoma 31 months prior was diagnosed with liver metastasis in segment 3. We performed laparoscopic repeat hepatectomy. Because mild adhesions in the left side of the abdominal cavity were detected by laparoscopy, the planned procedure was accomplished. The operative time and intraoperative blood loss were 139 min and less than 1 mL, respectively. The patient was discharged at 6 days after surgery and was healthy with no evidence of recurrence at 21 months after laparoscopic repeat hepatectomy. Laparoscopic repeat hepatectomy is a suitable and safe procedure for minor hepatectomy, provided that careful technique is used after the working space is secured under pneumoperitoneum.

Invention of Two Instruments Fitted with SECUREA™ Useful for Laparoscopic Liver Resection

Laparoscopic liver resection (LLR) became common in Japan when advanced techniques and instruments for the procedure became available and the national medical insurance began covering partial resection and lateral segmentectomy. A successful LLR requires a gentle and powerful hold on the specimens, a steady operating field, and fast and rapid compression of the bleeding point to achieve hemostasis. In this paper we describe two instruments developed in our department by attaching the SECUREA™ endoscopic surgical spacer to the forceps and suction tube used for LLR. The instruments are useful and practical for any type of LLR, even in the hands of less experienced surgeons.

Comparative Short-term Benefits of Laparoscopic Liver Resection: 9000 Cases and Climbing

OBJECTIVE

To perform a systematic review of worldwide literature on laparoscopic liver resections (LLR) and compare short-term outcomes against open liver resections (OLR) by meta-analyses.

SUMMARY BACKGROUND DATA

There are no updated pooled data since 2009 about the current status and short-term outcomes of LLR worldwide.

PATIENTS AND METHODS

All English language publications on LLR were screened. Descriptive worldwide data and short-term outcomes were obtained. Separate analyses were performed for minor-only and major-only resection series, and series in which minor/major resections were not differentiated. Apparent case duplications were excluded.

RESULTS

A set of 463 published manuscripts were reviewed. One hundred seventy-nine single-center series were identified that accounted for 9527 LLR cases worldwide. Minor-only, major-only, and combined major-minor series were 61, 18, and 100, respectively, including 32, 8, and 43 comparative series, respectively. Of the total 9527 LLR cases reported, 6190 (65%) were for malignancy and 3337 (35%) were for benign indications. There were 37 deaths reported (mortality rate = 0.4%). From the meta-analysis comparing case-matched LLR to OLR (N = 2900 cases), there was no increased mortality and significantly less complications, transfusions, blood loss, and hospital stay observed in LLR vs OLR.

CONCLUSIONS

This is the largest review of LLR available to date with over 9000 cases published. It confirms growing safety when performed in selected patients and by trained surgeons, and suggests that LLR may offer improved patient short-term outcomes compared with OLR. Improved levels of evidence, standardized reporting of outcomes, and assuring proper training are the next challenges of laparoscopic liver surgery.

"Idealized" vs. "True" learning curves: the case of laparoscopic liver resection

BACKGROUND

Learning curves are believed to resemble an "idealized" model, in which continuous improvement occurs until a plateau is reached. We hypothesized that this "idealized" model would not adequately describe the learning process for a complex surgical technique, specifically laparoscopic liver resection (LLR).

METHODS

We analyzed the first 150 LLRs performed by a surgeon with expertise in hepatobiliary/laparoscopic surgery but with no previous LLR experience. We divided the procedures performed in 5 consecutive groups of 30 procedures, then compared groups in terms of complications, operative time, length of stay, and estimated blood loss.

RESULTS

We observed an increase in operative complexity (3.3% major operations in Group 1 vs. 23.3% in Group 5, p = 0.05). Complications decreased from Group 1 to Group 2 (20%-3%), but increased again as more complex procedures were performed (3% in Group 2-13% in Group 5). Similar improvement/regression patterns were observed for operative time and EBL.

DISCUSSION

The "true" learning curve for LLR is more appropriately described as alternating periods of improvement and regression until mastery is achieved. Surgeons should understand the true learning curves of procedures they perform, recognizing and mitigating the increased risk they assume by taking on more complex procedures.

Simultaneous Minimally Invasive Treatment of Colorectal Neoplasm with Synchronous Liver Metastasis

Purpose. To analyse perioperative and oncological outcomes of minimally invasive simultaneous resection of primary colorectal neoplasm with synchronous liver metastases. Methods. A Medline revision of the current published literature on laparoscopic and robotic-assisted combined colectomy with hepatectomy for synchronous liver metastatic colorectal neoplasm was performed until February 2015. The specific search terms were "liver metastases", "hepatic metastases", "colorectal", "colon", "rectal", "minimally invasive", "laparoscopy", "robotic-assisted", "robotic colorectal and liver resection", "synchronous", and "simultaneous". Results. 20 clinical reports including 150 patients who underwent minimally invasive one-stage procedure were retrospectively analysed. No randomized trials were found. The approach was laparoscopic in 139 patients (92.7%) and robotic in 11 cases (7.3%). The rectum was the most resected site of primary neoplasm (52.7%) and combined liver procedure was in 89% of cases a minor liver resection. One patient (0.7%) required conversion to open surgery. The overall morbidity and mortality rate were 18% and 1.3%, respectively. The most common complication was colorectal anastomotic leakage. Data concerning oncologic outcomes were too heterogeneous in order to gather definitive results. Conclusion. Although no prospective randomized trials are available, one-stage minimally invasive approach seems to show advantages over conventional surgery in terms of postoperative short-term course. On the contrary, more studies are required to define the oncologic values of the minimally invasive combined treatment.

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.

Assessing the learning curve for totally laparoscopic major-complex liver resections: a single hepatobiliary surgeon experience

BACKGROUND

Encouraging results have been reported in terms of feasibility, safety, and oncologic, outcomes even for major (≥ 3 segments) or complex for location-specific (right posterior segments) laparoscopic liver resections. Despite this, technically challenging issues and advanced laparoscopic skills required to perform it have limited its use in few highly specialized centers. The aim of this study was to assess the learning curve for major-complex totally laparoscopic liver resections (TLLR) performed by a single HPB surgeon.

MATERIALS AND METHODS

From October 2008 to February 2012, a total of 70 TLLR were performed; 24 (33.3%) were major-complex resections. This series was divided in 2 groups according to time of operation: group A (12 cases early series) and group B (12 cases late series); perioperative outcomes were retrospectively analyzed and compared.

RESULTS

Comparing the 2 groups, a statistically significant improvement was found in terms of operative time (P=0.017), blood loss (P=0.004), number of cases requiring a Pringle maneuver (P=0.006), and blood transfusion (P=0.001) from case number ten onward.

CONCLUSIONS

This study shows that a minimum of 10 cases are required to obtain a significant improvement in perioperative outcome for surgeons with specific training on hepatobiliary surgery and advanced laparoscopic surgical procedures. More studies are required to clarify the minimum standard of training to perform safely this kind of advanced laparoscopic liver surgery on a large scale.

Robot-assisted versus open liver resection in the right posterior section

BACKGROUND

Open liver resection is the current standard of care for lesions in the right posterior liver section. The objective of this study was to determine the safety of robot-assisted liver resection for lesions located in segments 6 and 7 in comparison with open surgery.

METHODS

Demographics, comorbidities, clinicopathologic characteristics, surgical treatments, and outcomes from patients who underwent open and robot-assisted liver resection at 2 centers for lesions in the right posterior section between January 2007 and June 2012 were reviewed. A 1:3 matched analysis was performed by individually matching patients in the robotic cohort to patients in the open cohort on the basis of demographics, comorbidities, performance status, tumor stage, and location.

RESULTS

Matched patients undergoing robotic and open liver resections displayed no significant differences in postoperative outcomes as measured by blood loss, transfusion rate, hospital stay, overall complication rate (15.8% vs 13%), R0 negative margin rate, and mortality. Patients undergoing robotic liver surgery had significantly longer operative time (mean, 303 vs 233 minutes) and inflow occlusion time (mean, 75 vs 29 minutes) compared with their open counterparts.

CONCLUSIONS

Robotic and open liver resections in the right posterior section display similar safety and feasibility.

Laparoscopic hepatectomy in cirrhotics: safe if you adjust technique

BACKGROUND

Minimally invasive liver surgery is a growing field, and a small number of recent reports have suggested that laparoscopic liver resection (LLR) is feasible even in patients with cirrhosis. However, parenchymal transection of the cirrhotic liver is challenging due to fibrosis and portal hypertension. There is a paucity of data regarding the technical modifications necessary to safely transect the diseased parenchyma.

METHODS

Patients undergoing LLR by a single surgeon between 2008 and 2015 were reviewed. Patients with cirrhosis were compared to those without cirrhosis to examine differences in surgical technique, intraoperative characteristics, and outcomes (including liver-related morbidity and general postoperative complication rates).

RESULTS

A total of 167 patients underwent LLR during the study period. Forty-eight (29 %) had cirrhosis, of which 43 (90 %) had hepatitis C. Most had Child-Pugh class A disease (85 %). Compared to noncirrhotics, patients with cirrhosis were older, had more comorbidities, and were more likely to have hepatocellular carcinoma. Precoagulation before parenchymal transection was used more frequently in cirrhotics (65 vs. 15 %, P < 0.001), and mean portal triad clamping time was longer (32 vs. 22 min, P = 0.002). There were few conversions to open surgery, though hand-assisted laparoscopy was used as an alternative to converting to open in three patients with cirrhosis. Blood loss was relatively low for both groups. Although there were more postoperative complications among cirrhotics (38 vs. 13 %, P = 0.001), this was almost entirely due to a higher rate of minor (Clavien-Dindo I or II) complications. Liver-related morbidity, major complications, and mortality rates were similar.

CONCLUSIONS

LLR is safe for selected patients with cirrhosis. The added complexity associated with the division of diseased liver parenchyma may be overcome with some form of technique modification, including more liberal use of precoagulation, portal triad clamping, or a hand-assist port.

Long-term survival in laparoscopic vs open resection for colorectal liver metastases: inverse probability of treatment weighting using propensity scores

BACKGROUND

This study compares long-term outcomes between intention-to-treat laparoscopic and open approaches to colorectal liver metastases (CLM), using inverse probability of treatment weighting (IPTW) based on propensity scores to control for selection bias.

METHOD

Patients undergoing liver resection for CLM by 5 surgeons at 3 institutions from 2000 to early 2014 were analysed. IPTW based on propensity scores were generated and used to assess the marginal treatment effect of the laparoscopic approach via a weighted Cox proportional hazards model.

RESULTS

A total of 298 operations were performed in 256 patients. 7 patients with planned two-stage resections were excluded leaving 284 operations in 249 patients for analysis. After IPTW, the population was well balanced. With a median follow up of 36 months, 5-year overall survival (OS) and recurrence-free survival (RFS) for the cohort were 59% and 38%. 146 laparoscopic procedures were performed in 140 patients, with weighted 5-year OS and RFS of 54% and 36% respectively. In the open group, 138 procedures were performed in 122 patients, with a weighted 5-year OS and RFS of 63% and 38% respectively. There was no significant difference between the two groups in terms of OS or RFS.

CONCLUSION

In the Brisbane experience, after accounting for bias in treatment assignment, long term survival after LLR for CLM is equivalent to outcomes in open surgery.

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.

Tissue management with tri-staple technology in major and minor laparoscopic liver resections

One of the most relevant technologic advancements in laparoscopic liver resection (LLR) is owing to the improved ability to safely secure and divide vascular and biliary structures and the liver parenchyma by the use of endostaplers. We compared, retrospectively, 35 LLRs with the Tri-Staple technology versus 57 LLRs without, during a 14-month period. Colorectal liver metastases were overall the main indication for LLR. Neither major hepatectomy nor left lateral sectionectomy was done in the nonstapled group. Mean surgical time and blood loss were similar, whereas the tumor number and size were significantly larger in the stapled group (P ≤ 0.01). The conversion rate was 0% and 3.5% (n = 2); and the morbidity rate was 9% (n = 3) and 12% (n = 7), respectively, in the stapled and nonstapled group (P = 0.8). No overall 3-month mortality was recorded. Endo GIA Reloads with Tri-Staple technology allow a proper division of the intrahepatic vessels and biliary structure. These devices in LLRs are safe and feasible, allowing major hepatectomy and complex cases as 2-staged procedures and laparoscopic living donor liver resections.

Minimally Invasive Resection of Colorectal Cancer Liver Metastases Leads to an Earlier Initiation of Chemotherapy Compared to Open Surgery

INTRODUCTION

Previous studies have shown benefit not only from postoperative chemotherapy but also from a short interval to initiation of treatment after resection of primary colorectal cancer. The aim of this study was to determine difference in timing to postoperative chemotherapy for minimally invasive resection (MIR) vs. open resection (OR) of colorectal cancer liver metastases (CRCLM).

METHODS

This is a retrospective review of 1:1 matched patients undergoing MIR (n = 66) and OR (n = 66) for CRCLM at a single institution.

RESULTS

Patients undergoing MIR of CRCLM had significantly shorter length of hospital stay, fewer major complications, and shorter interval to postoperative chemotherapy (median 42 vs. 63 days, p < 0.001). Univariable analysis showed that surgical approach, postoperative complications, blood loss, number of lesions, and length of stay were associated with timing to chemotherapy. On multivariable analysis, surgical approach was still associated with timing to chemotherapy, and postoperative complications resulted in a delay of chemotherapy among patients who underwent OR but not among those who underwent MIR. In addition, worse disease-free survival was seen among patients who received postoperative chemotherapy more than 60 days after surgery.

CONCLUSION

By modifying the deleterious effects of postoperative complications on timing of postoperative chemotherapy, patients undergoing MIR for CRCLM are treated with chemotherapy sooner after surgery compared to those undergoing OR.

Laparoscopic first step approach in the two stage hepatectomy

Resection is the gold standard therapeutic option for patients with colorectal liver metastases. However, only 20-30% of patients are resectable. In patients with a concomitant future liver remnant (FLR) less than 25-30%, a single stage resection is not feasible. The aim of this study is to evaluate the feasibility and the rates of morbidity and mortality of the laparoscopic approach in the first-step of two stage hepatectomy. From 2004 to March 2014, 73 patients underwent a two stage hepatectomy: of these, four underwent a totally laparoscopic first step [wedge left liver resection and right portal vein ligation (PVL)]. All the patients were male. Median age was 55 years. One patient underwent an atypical wedge resection of segment II-III and a laparoscopic PVL (LPVL), one patient had a first wedge resection of segment II and LPVL, and two patients underwent a wedge resection of segment III and LPVL. First step surgical mean time was 189 (range, 160-244) min, mean blood loss was 22 (range, 0-50) cc. No transfusion was required in this series. The results of our study demonstrate that the first step of hepatic resection and PVL is feasible with a laparoscopic approach in patients with bilobar liver metastases.

Short-term outcomes of simultaneous laparoscopic colectomy and hepatectomy for primary colorectal cancer with synchronous liver metastases

Although simultaneous resection of primary colorectal cancer and synchronous liver metastases is reported to be safe and effective, the feasibility of a laparoscopic approach remains controversial. This study evaluated the safety, feasibility, and short-term outcomes of simultaneous laparoscopic surgery for primary colorectal cancer with synchronous liver metastases. From September 2008 to December 2013, 10 patients underwent simultaneous laparoscopic resection of primary colorectal cancer and synchronous liver metastases with curative intent at our institute. The median operative time was 452 minutes, and the median estimated blood loss was 245 mL. Median times to discharge from the hospital and adjuvant chemotherapy were 13.5 and 44 postoperative days, respectively. Negative resection margins were achieved in all cases, with no postoperative mortality or major morbidity. Simultaneous laparoscopic colectomy and hepatectomy for primary colorectal cancer with synchronous liver metastases appears feasible with low morbidity and favorable outcomes.

Long-term and perioperative outcomes of laparoscopic versus open liver resection for colorectal liver metastases with propensity score matching: a multi-institutional Japanese study

BACKGROUND

The aim of the present study was to clarify the surgical outcome and long-term prognosis of laparoscopic liver resection (LLR) compared with conventional open liver resection (OLR) in patients with colorectal liver metastases (CRLM).

METHODS

A one-to-two propensity score matching (PSM) analysis was applied. Covariates (P < 0.2) used for PSM estimation included preoperative levels of CEA and CA19-9; primary tumor differentiation; primary pathological lymph node metastasis; number, size, location, and distribution of CRLM; existence of extrahepatic metastasis; extent of hepatic resection; total bilirubin and prothrombin activity levels; and preoperative chemotherapy. Perioperative data and long-term survival were compared.

RESULTS

From 2005 to 2010, 1,331 patients with hepatic resection for CRLM were enrolled. By PSM, 171 LLR and 342 OLR patients showed similar preoperative clinical characteristics. Median estimated blood loss (163 g vs 415 g, P < 0.001) and median postoperative hospital stay (12 days vs 14 days; P < 0.001) were significantly reduced in the LLR group. Morbidity and mortality were similar. Five-year rates of recurrence-free, overall, and disease-specific survival did not differ significantly. The R0 resection rate was similar.

CONCLUSIONS

In selected CRLM patients, LLR is strongly associated with lower blood loss and shorter hospital stay and has equivalent long-term survival comparable with OLR.

CT-guided high-dose-rate brachytherapy in the interdisciplinary treatment of patients with liver metastases of pancreatic cancer

BACKGROUND

CT-guided high-dose-rate brachytherapy (CT-HDRBT) is an interventional radiologic technique for local ablation of primary and secondary malignomas applying a radiation source through a brachycatheter percutaneously into the targeted lesion. The aim of this study was to assess local tumor control, safety and efficacy of CT-HDRBT in the treatment of liver metastases of pancreatic cancer.

METHODS

Twenty consecutive patients with 49 unresectable liver metastases of pancreatic cancer were included in this retrospective trial and treated with CT-HDRBT, applied as a single fraction high-dose irradiation (15-20 Gy) using a 192Ir-source. Primary endpoint was local tumor control and secondary endpoints were complications, progression-free survival and overall survival.

RESULTS

The mean tumor diameter was 29 mm (range 10-73). The mean irradiation time was 20 minutes (range 7-42). The mean coverage of the clinical target volume was 98% (range 88%-100%). The mean D100 was 18.1 Gy and the median D100 was 19.78 Gy. Three major complications occurred with post-interventional abscesses, three of which were seen in 15 patients with biliodigestive anastomosis (20%) and overall 15%. The mean follow-up time was 13.7 months (range 1.4-55.0). The median progression-free survival was 4.9 months (range 1.4-42.9, mean 9.4). Local recurrence occurred in 5 (10%) of 49 metastases treated. The median overall survival after CT-HDRBT was 8.6 months (range 1.5-55.3). Eleven patients received chemotherapy after ablation with a median progression-free survival of 4.9 months (mean 12.9). Nine patients did not receive chemotherapy after intervention with a median progression-free survival of 3.2 months (mean 5.0). The rate of local tumor control was 91% in both groups after 12 months.

CONCLUSION

CT-HDRBT was safe and effective for the treatment of liver metastases of pancreatic cancer.

Laparoscopic versus open liver resection for metastatic colorectal cancer

BACKGROUND

Application of minimally invasive surgery for oncologic liver resection is still limited to expert centers. We describe our experience in laparoscopic liver resection (LLR) for colorectal liver metastases (CLM).

PATIENTS AND METHODS

Between February 2010 and February 2015, 174 patients underwent resection of CLM. LLR was chosen according to surgeon's preferences. Data was retrieved from the institutes' electronic charts and retrospectively analyzed.

RESULTS

LLR was performed in 42 patients (24.5%) and OLR in 132. Increased number of metastases were found in OLR (2.82 ± 2.81 versus 1.78 ± 1.16, P = 0.02), with no difference in maximal lesion size (33.1 ± 22 versus 34.9 ± 27.5 cm, P = 0.7). Altogether 55 patients underwent major hepatectomy, and 50 of the OLR group (37.8%, 37 right hepatectomy and 7 left hepatectomy) (P = 0.02). In 5 patients (11.6%) a conversion to open surgery was indicated. Operative time was longer in LLR. Estimated blood loss was decreased in laparoscopic minor resections. One OLR patient died during the postoperative period (0.7%). Eight patients in the OLR group had major complications, versus 1 in the LLR group (P = 0.0016). Reoperation within 30 days was performed in 4 OLR patients and none in the LLR group. Patients in the LLR group had shorter length of stay (LOS) (6.78 ± 2.75 versus 8.39 ± 5.64 days, P = 0.038). R0 resection was 88% in both groups.

CONCLUSIONS

In selected patients with CLM, LLR is feasible, safe and may achieve shorter LOS without inferior oncologic outcome.

Laparoscopic anterior approach of major hepatectomy combined with colorectal resection for synchronous colorectal liver metastases

PURPOSE

The aim of the study was to evaluate the feasibility and operative outcomes of the anterior approach technique for a simultaneous colorectal and liver laparoscopic procedure given its demonstrated benefits and discuss the advantages of this strategy.

PATIENT AND METHODS

In the presented case, a total laparoscopic anterior approach was used for a left hemihepatectomy in combination with laparoscopic colorectal resections for synchronous liver metastases, which emphasizes the technical aspects of this procedure. The duration of surgery, blood loss, and postoperative outcomes were evaluated.

RESULTS

The laparoscopic anterior approach for a left hepatectomy with simultaneous colon resection for liver metastases was feasible and safe without postoperative complications. The duration of surgery was 190 minutes with an estimated blood loss of 200 mL. The postoperative course was uneventful.

CONCLUSIONS

The laparoscopic anterior approach for a major hepatectomy for unilobular synchronous metastases can be safely performed simultaneously with colorectal surgery in select patients.

Segmentectomy: is minimally invasive surgery going to change a liver dogma?

Nowadays, the respective approach to hepatic resections (for malignant or benign liver lesions) is oriented toward minimal parenchymal resection. This surgical behavior is sustained by several observations that surgical margin width is not correlated with recurrence of malignancies. Parenchymal-sparing resection reduces morbidity without changing long-term results and allows the possibility of re-do liver resection in case of recurrence. Minimally invasive liver surgery (MILS) is performed worldwide and is considered a standard of care for many surgical procedures. MILS is associated with less blood loss, less analgesic requirements, and shorter length of hospital with a better quality of life. One of the more frequent criticisms to MILS is that it represents a more challenging approach for anatomical segmentectomies and that in most cases a non-anatomical resection could be performed with thinner resection margins compared with open surgery. But even in the presence of reduced surgical margins, oncological results in the short- and long-term follow-up seem to be the same such as open surgery. The purpose of this review is to try to understand whether chasing at any cost laparoscopic anatomical segmentectomies is still necessary whereas non-anatomical resections, with a parenchymal-sparing behavior, are feasible and overall recommended also in a laparoscopic approach. The message coming from this review is that MILS is opening more and more new frontiers that are still need to be supported by further experience.

Outcomes of robotic vs laparoscopic hepatectomy: A systematic review and meta-analysis

AIM

To perform a systematic review and meta-analysis on robotic-assisted vs laparoscopic liver resections.

METHODS

A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central. Participants of any age and sex, who underwent robotic or laparoscopic liver resection were considered following these criteria: (1) studies comparing robotic and laparoscopic liver resection; (2) studies reporting at least one perioperative outcome; and (3) if more than one study was reported by the same institute, only the most recent was included. The primary outcome measures were set for estimated blood loss, operative time, conversion rate, R1 resection rate, morbidity and mortality rates, hospital stay and major hepatectomy rates.

RESULTS

A total of 7 articles, published between 2010 and 2014, fulfilled the selection criteria. The laparoscopic approach was associated with a significant reduction in blood loss and lower operative time (MD = 83.96, 95%CI: 10.51-157.41, P = 0.03; MD = 68.43, 95%CI: 39.22-97.65, P < 0.00001, respectively). No differences were found with respect to conversion rate, R1 resection rate, morbidity and hospital stay.

CONCLUSION

Laparoscopic liver resection resulted in reduced blood loss and shorter surgical times compared to robotic liver resections. There was no difference in conversion rate, R1 resection rate, morbidity and length of postoperative stay.

Italian experience in minimally invasive liver surgery: a national survey

This survey provides an overview about current spread of Minimally Invasive Liver Resection (MILR) in Italy. Primary endpoint was to assess evolution of MILR in recent years and its degree of application among centres with different experience in laparoscopic and hepatic surgery. A questionnaire with items describing activity MILR was sent to Italian surgical centers. Diagnosis, technical approaches, resection extent, devices and vascular control, reasons for conversion, morbidity and mortality were recorded. Level of expertise per centre was analysed in terms of learning curve acquisition and relationship with hepatobiliary background. 1497 MILRs from 39 centers (median 27 patients/center, range 1-145, period 1995-2012) were collected. Conversion rate was 10.7% (180 patients out of 1677, excluded from subsequent analysis), with bleeding representing most frequent cause of conversion (34.4%). Eleven centers completed learning curve, performing >60 MILR. Benign lesions were 27.5% and malignant 72.5%, with hepatocellular carcinoma being the most frequent indication. 92.6% of cases were performed with a totally laparoscopic technique (1.3% were hand-assisted, 1.9% single-port and 4.2% robotic). Minor resections accounted for 92.9% (left lateral sectionectomy resulted the most frequent procedure; 23.8%), while major resections represented 7.1%. Overall mortality was 0.2% (3 of 1497 patients) and morbidity 22.8%. Mean length of stay was 5 days. Correlation between MILR activity and a hepatobiliary background was not clear comparing MILR cases and liver resection volumes per center. MILR has been significantly widespread in Italy in recent years, with several centers having definitely completed the learning curve as attested by clinical results consistent with major series from the Western and Eastern countries. MILR programs in Italy seem to arise from both centers with specific hepatobiliary expertise and centers performing advanced general laparoscopic surgery.

Oncological outcomes of laparoscopic surgery of liver metastases: a single-centre experience

In the era of multimodal management of liver metastases, surgical resection remains the only curative option, with open approach still being referred to as the standard of care. Currently, the feasibility and benefits of the laparoscopic approach for liver resection have been largely demonstrated. However, its oncologic adequacy remains to be confirmed. The aim of this study is to report the oncological results of laparoscopic liver resection for metastatic disease in a single-centre experience. A single-centre database of 413 laparoscopic liver resections was reviewed and procedures for liver metastases were selected. The assessment of oncologic outcomes included analysis of minimal tumour-free margin, R1 resection rate and 3-year survival. The feasibility and safety of the procedures were also evaluated through analysis of perioperative outcomes. The study comprised 209 patients (294 procedures). Colorectal liver metastases were the commonest indication (67.9%). Fourteen patients had conversion (6.7%) and oncological concern was the commonest reason for conversion (42.8%). Median tumour-free margin was 10 mm and complete radical resections were achieved in 211 of 218 curative-intent procedures (96.7%). For patients affected by colorectal liver metastases, 1- and 3-year OS resulted 85.9 and 66.7%. For patients affected by neuroendocrine liver metastases, 1- and 3-year OS resulted 93 and 77.8%. Among the patients with metastases from other primaries, 1- and 3-year OS were 83.3 and 70.5%. The laparoscopic approach is a safe and valid option in the treatment of patients with metastatic liver disease undergoing curative resection. It does offer significant perioperative benefits without compromise of oncologic outcomes.

Total abdominal approach for postero-superior segments (7, 8) in laparoscopic liver surgery: a multicentric experience

Laparoscopic liver resections are frequently performed for peripheral lesions located in the antero-inferior segments. Resection of postero-superior segments is more demanding and dangerous than other segmentectomies, resulting in a longer operation time and increased blood loss. To reduce technical challenges, some authors advocated a modified surgical approach for these segments with the patient placed in the left lateral decubitus with the right arm suspended and suggested technical variations like the use of an additional intercostal trocar, the placement of one or two additional trans-thoracic trocars, a hand-assisted approach or a hybrid method with a median laparotomy. In the present series of 88 patients from four hepatobiliary centers with high volume of activity in Italy, a standard lithotomic position has been routinely used without the need for left lateral decubitus or semi-prone position and through abdominal wall without use of trans-thoracic trocars. This approach allows a more comfortable use of the Pringle maneuver that we used routinely in hepatic resection for PS segments; and, a very short time is needed for conversion, whenever it is required. In our series, laparoscopic resection of liver tumors located in the postero-superior segments of the liver with a total abdominal approach is technically feasible and safe with short-term results similar to other laparoscopic liver resections.

Indications for liver surgery: laparoscopic or robotic approach

Laparoscopic liver resections have been demonstrated to be safe and effective with the advantages of a shorter hospital stay, less blood loss, less adhesions and better postoperative recovery compared to open surgery. However, indications are usually confined to peripheral, small lesions, due to issues intrinsic to the approach. In the effort to overcome some of these technical limitations, robotic technology has been developed, with encouraging findings. We performed a review of the literature to assess the current indications for laparoscopic hepatic resections and to investigate the role of robotics in broadening the application of minimally invasive liver surgery. Although a paucity of data exists, especially regarding long-term oncological outcomes and specific comparisons with laparoscopy, robotics has been proved to facilitate several complex liver procedures, including parenchyma-saving resections. Thus, the number of patients who can benefit from less invasive, conservative approach is potentially increased.

Salvage liver transplantation after laparoscopic resection for hepatocellular carcinoma: a multicenter experience

Liver transplantation is the ideal treatment for patients affected by early stage hepatocellular carcinoma and chronic liver disease. Considering organs shortage, alternative treatments have to be adopted to minimize the waitlist drop-out, and in case of recurrence within the accepted criteria, salvage transplantation can be considered. Surgical resection is one of the most effective treatments, with the possibility of oncological radicality and pathological analysis of the specimen. Although these theoretical advantages, surgical strategy cannot be applied to all patients because of the impaired liver function as well as the amount of parenchyma to be resected does not allow a sufficient future liver remnant. Furthermore, resection by laparotomy may lead to strong intra-abdominal adhesions in a contest of portal hypertension and, as potential consequence, increase transplantation difficulty raising morbidity. Laparoscopic liver resection is now performed as a routine procedure in tertiary referral centers, with increasing evidence of long-term results comparable to traditional surgery together with the advantages of a minimally invasive approach. In addition, with a salvage transplantation strategy that has been shown to be comparable to primary transplantation, the patient can live with his native liver avoiding an invasive procedure and long-term immunosuppression, allowing the use of liver grafts for the community. We present the results of an Italian multicenter experience of salvage liver transplantation following the recurrence of HCC initially treated by laparoscopic resection in 31 patients, performed by four referral centers. Mean operative transplantation time was 450 min, morbidity was 41.9%, 90-days mortality was 3.2%, and median post-operative length of stay was 17.9 days. Salvage liver transplantation after laparoscopic liver resection for HCC is comparable to open surgery in terms of operative time, oncologic radicality, morbidity and mortality, with the advantages of laparoscopic surgery.

A cost effective analysis of a laparoscopic versus an open left lateral sectionectomy in a liver transplant unit

INTRODUCTION

This study aimed to assess the cost effectiveness of a laparoscopic left lateral sectionectomy (LLLS) compared with an open (OLLS) procedure and its role as a training operation as well as the learning curve associated with a laparoscopic approach.

METHOD

Between 2004 and 2013, a prospectively maintained database was reviewed. LLLS were compared with age- and sex-matched OLLS. In addition, the outcomes of LLLS with a consultant as the primary surgeon were compared with those performed by trainees.

RESULTS

Forty-three LLLS were performed during the study period. LLLS was a significantly cheaper operation compared with OLLS (P = 0.001, £3594.14 versus £5593.41). The median hospital stay was shorter in the laparoscopic group (P = 0.002, 3 versus 7 days). No difference was found in outcomes between a LLLS performed by a trainee or consultant (operating time, morbidity or R1 resection rate). The procedure length was significantly shorter during the later half of the study period [120 versus 129 min (P = 0.045)].

CONCLUSION

LLLS is a significantly cost effective operation compared with an open approach with a reduction in hospital stay. In addition, it is suitable to use as a training operation.

Pure laparoscopic liver resection for large malignant tumors: does size matter?

BACKGROUND

Laparoscopic liver resection (LLR) for large malignant tumors can be technically challenging. Data on this topic are scarce, and many question its feasibility, safety, and oncologic efficiency. This study aimed to assess outcomes of LLR for large (≥ 5 cm) and giant (≥ 10 cm) malignant liver tumors.

METHODS

A prospectively collected database of 422 LLRs was reviewed from August 2003 to August 2013. The data for 52 patients undergoing LLR for large malignant tumors were analyzed. A subgroup analysis of giant tumors also is reported.

RESULTS

During the period studied, 52 LLRs were performed (males, 53.8 %; mean age, 64.6 years) for large malignant tumors. Colorectal liver metastasis was the most common indication (42.3 %). The 52 LLRs included 32 major (61.5 %) and 20 minor (38.5 %) LLRs for tumors with a mean diameter of 83 mm. The median operative time was 240 min [interquartile range (IQR), 150-330 min], and the blood loss was 500 ml (IQR, 200-1,373 ml). Eight conversions (15.4 %) were performed. Six patients experienced complications (11.5 %). Among the 44 patients with successful LLRs, two patients (4.5 %) had an R1 resection. The median hospital stay was 5 days (range, 1-21 days), and no mortality occurred during a 90-day period. A subgroup analysis of patients with giant tumors showed greater blood loss (p = 0.002) and a longer operative time (p = 0.052) but no difference in terms of conversions (p = 0.64) or complications (p = 0.32).

CONCLUSION

The findings showed that LLR is feasible and safe for large malignant tumors and can be performed with acceptable morbidity and oncologic efficiency. When used for giant malignant tumors, LLR is associated with greater blood loss and a longer operative time but no increase in complications.

How surgical technology translates into practice: the model of laparoscopic liver resections performed in France

OBJECTIVES

Analyze, at a national level, the adoption and practice of laparoscopic liver resections (LAP), compared to open resections (OPEN).

BACKGROUND

LAP initiated 20 years ago, has been described for all hepatectomies, and is considered as the reference technique for some resections. There are, however, no data on its adoption outside selected specialty centers.

METHODS

French Healthcare databases were screened to identify all patients who underwent an elective LAP or OPEN between 2007 and 2012. Patients' demographics, associated conditions, indication for surgery, hepatectomy performed, and hospital type and hepatectomy caseload were retrieved. Patients who had possible overcoding of biopsies as wedge resections were identified to select REAL resections. Time trend analyses were performed using a piecewise linear regression and the average annual percent change (AAPC) calculated.

RESULTS

There were 7881 (17.8%) LAP and 36,359 (82.2%) OPEN performed in an average of 483 hospitals. Of these, biopsies accounted for 29.9% of the LAP (7.3% of the OPEN, P<0.0001) and the incidence of LAP biopsies increased after 2009. The AAPC of the incidence of real LAP increased more than that of real OPEN (7.0% vs 1.3%) but most were minor resections (61.1% vs 28.9% for OPEN, P<0.0001), only 15% of patients were operated by LAP and intermediate (or major) resections were performed in 19.5% (or 4.8%) of hospitals performing liver resections. The proportion of resections performed by LAP was inversely related to annual caseload. The overall incidence of resections performed for benign conditions did not increase.

CONCLUSIONS

LAP is not developing, has not been adopted for intermediate/major resections, does not result in overuse for benign indications and some of the 2009 -consensus statements are not applied.

The impact of laparoscopic versus open colorectal cancer surgery on subsequent laparoscopic resection of liver metastases: A multicenter study

BACKGROUND

Laparoscopic liver surgery is expanding. Most laparoscopic liver resections for colorectal carcinoma metastases are performed subsequent to the resection of the colorectal primary, raising concerns about the feasibility and safety of advanced laparoscopic liver surgery in the context of an abdomen with possible postoperative adhesions. The aim was to compare the outcome of laparoscopic hepatectomy for colorectal metastases after open versus laparoscopic colorectal surgery.

METHODS

This observational, multicenter study reviewed 394 patients undergoing laparoscopic minor and major liver resection for colorectal carcinoma metastases. Main outcome measures were intraoperative unfavorable incidents and short-term results in patients who had previous open versus laparoscopic colorectal cancer surgery.

RESULTS

Three hundred six patients (78%) had prior open and 88 (22%) had prior laparoscopic colorectal resection. Laparoscopic major hepatectomies were undertaken in 63 (16%). Intraoperative unfavorable incidents during laparoscopic liver surgery were significantly higher among patients who had prior open colorectal surgery (26%) compared with the laparoscopic group (14%; P = .017). Positive resection margins and postoperative complications were not associated with the approach adopted for the resection of the primary cancer. On multivariate logistic regression analysis, intraoperative unfavorable incidents were associated significantly only with prior open colorectal surgery (odds ratio, 2.8; P = .006) and laparoscopic major hepatectomy (odds ratio, 2.4; P = .009).

CONCLUSION

Laparoscopic minor hepatectomy can be performed safely in patients who have undergone previous open colorectal surgery. Laparoscopic major hepatectomy after open colorectal surgery may be challenging. Careful risk assessment in the decision-making process is required not to compromise patient safety and to guarantee the expected benefits from the minimally invasive approach.

Laparoscopic right hepatectomy combined with partial diaphragmatic resection for colorectal liver metastases: Is it feasible and reasonable?

BACKGROUND

The impact of diaphragmatic invasion in patients with colorectal liver metastases (CRLMs) remains poorly evaluated. We aimed to evaluate feasibility and safety of laparoscopic right hepatectomy (LRH) with or without diaphragmatic resection for CRLM.

METHODS

From 2002 to 2012, 52 patients underwent LRH for CRLM. Of them, 7 patients had combined laparoscopic partial diaphragmatic resection ("diaphragm" group). Data were retrospectively collected and short and long-term outcomes analyzed.

RESULTS

Operative time was lower in the control group (272 vs 345 min, P = .06). Six patients required conversion to open surgery. Blood loss and transfusion rate were similar. Portal triad clamping was used more frequently in the "diaphragm" group (42.8% vs 6.6%, P = .02). Maximum tumor size was greater in the "diaphragm" group (74.5 vs 37.1 mm, P = .002). Resection margin was negative in all cases. Mortality was nil and general morbidity similar in the 2 groups. Specific liver-related complications occurred in 2 patients in the "diaphragm" group and 17 in the control group (P = .69). Mean hospital stay was similar (P = 56). Twenty-two (42.3%) patients experienced recurrence. One-, 3-, and 5-year overall survival after surgery in "diaphragm" and control groups were 69%, 34%, 34%, and 97%, 83%, 59%, respectively (P = .103). One- and 3-year disease-free survival after surgery in "diaphragm" and control groups were 57%, 47% and 75%, 54%, respectively (P = .310).

CONCLUSION

LRH with en-bloc diaphragmatic resection could be reasonably performed for selected patients in expert centers. Technical difficulties related to diaphragmatic invasion must be circumvented. Further experience must be gained to confirm our results.

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.

Robotic liver surgery: preliminary experience in a tertiary hepato-biliary unit

Minimally invasive liver surgery is performed with increasing frequency by hepatic surgeons. Laparoscopy was the first approach to be used and it is currently safely feasible in selected patients by experienced surgeons. Minor and major laparoscopic hepatectomies are now performed as a routine procedure in tertiary referral centers, with increasing evidence of long-term results comparable to traditional surgery together with the advantages of a minimally invasive approach. Robotic surgery, first developed for military purposes, showed to overcome some of the limits of laparoscopy, with an improved visual magnification, a 3-dimensional view and enhanced dexterity with better movement control. This allows an easier approach for resections in the posterior segments and for lesions close to major vessels. We present our preliminary experience of 20 consecutive robotic liver resection. Indications were colo-rectal liver metastasis (n = 7), hepatocellular carcinoma (n = 6), liver hemangioma (n = 2), biliary cystoadenoma (n = 2), breast cancer liver metastasis (n = 1), lung cancer liver metastasis (n = 1), symptomatic left liver lithiasis (n = 1). No conversion to laparotomy have been made and no hepatic pedicle clamping has been performed. The median duration of surgery was 141 min. There was no mortality, global morbidity was 10%. Median tumor size was 36 mm. Median post-operative length of stay was 5.7 days. Robotic surgery can be safely performed by experienced hepatic surgeons, resections of lesions in the posterior segments and close to the major vessels seem to be the best indication. Further studies are needed to clarify the exact role of robotics in liver surgery.