Laparoscopic hepatectomy is theoretically better than open hepatectomy: preparing for the 2nd International Consensus Conference on Laparoscopic Liver Resection

Preoperative and intraoperative laparoscopic liver surface registration using deep graph matching of representative overlapping points

PURPOSE

In laparoscopic liver surgery, registering preoperative CT-extracted 3D models with intraoperative laparoscopic video reconstructions of the liver surface can help surgeons predict critical liver anatomy. However, the registration process is challenged by non-rigid deformation of the organ due to intraoperative pneumoperitoneum pressure, partial visibility of the liver surface, and surface reconstruction noise.

METHODS

First, we learn point-by-point descriptors and encode location information to alleviate the limitations of descriptors in location perception. In addition, we introduce a GeoTransformer to enhance the geometry perception to cope with the problem of inconspicuous liver surface features. Finally, we construct a deep graph matching module to optimize the descriptors and learn overlap masks to robustly estimate the transformation parameters based on representative overlap points.

RESULTS

Evaluation of our method with comparative methods on both simulated and real datasets shows that our method achieves state-of-the-art results, realizing the lowest surface registration error(SRE) 4.12 mm with the highest inlier ratios (IR) 53.31% and match scores (MS) 28.17%.

CONCLUSION

Highly accurate and robust initialized registration obtained from partial information can be achieved while meeting the speed requirement. Non-rigid registration can further enhance the accuracy of the registration process on this basis.

Laparoscopic liver resection utilizing the ventral avascular area of the inferior vena cava: A retrospective cohort study

BACKGROUND

Laparoscopic liver resection (LLR) can be challenging due to the difficulty of establishing a retrohepatic tunnel under laparoscopy. Dissecting the third hepatic hilum before parenchymal transection often leads to significant liver mobilization, tumor compression, and bleeding from the short hepatic veins (SHVs). This study introduces a novel technique utilizing the ventral avascular area of the inferior vena cava (IVC), allowing SHVs to be addressed after parenchymal transection, thereby reducing surgical complexity and improving outcomes in in situ LLR.

AIM

To introduce and evaluate a novel LLR technique using the ventral avascular area of the IVC and compare its short-term outcomes with conventional methods.

METHODS

The clinical cohort data of patients with pathologically confirmed hepatocellular carcinoma or intrahepatic cholangiocarcinoma who underwent conventional LLR and novel LLR between July 2021 and July 2023 at the First Affiliated Hospital of Chongqing Medical University were retrospectively analyzed. In novel LLR, we initially separated the caudate lobe from the IVC using dissecting forceps along the ventral avascular area of the IVC. Then, we transected the parenchyma of the left and right caudate lobes from the caudal side to the cephalic side using the avascular area as a marker. Subsequently, we addressed the SHVs and finally dissected the root of the right hepatic vein or left hepatic vein. The short-term postoperative outcomes and oncological results of the two approaches were evaluated and compared.

RESULTS

A total of 256 patients were included, with 150 (58.59%) undergoing conventional LLR and 106 (41.41%) undergoing novel LLR. The novel technique resulted in significantly larger tumor resections (6.47 ± 2.96 cm vs 4.01 ± 2.33 cm, P < 0.001), shorter operative times (199.57 ± 60.37 minutes vs 262.33 ± 83.90 minutes, P < 0.001), less intraoperative blood loss (206.92 ± 37.09 mL vs 363.34 ± 131.27 mL, P < 0.001), and greater resection volume (345.11 ± 31.40 mL vs 264.38 ± 31.98 mL, P < 0.001) compared to conventional LLR.

CONCLUSION

This novel technique enhances liver resection outcomes by reducing intraoperative complications such as bleeding and tumor compression. It facilitates a safer, in situ removal of complex liver tumors, even in challenging anatomical locations. Compared to conventional methods, this technique offers significant advantages, including reduced operative time, blood loss, and improved overall surgical efficiency.

Impact of thoracic shape on the surgical outcomes of laparoscopic-assisted living donor hepatectomy

Background

Although laparoscopic-assisted donor hepatectomy (LADH) has become the definitive procedure for harvesting living donor livers, its surgical outcomes in association with donor body shape have not been elucidated.

Methods

The impact of donor factors, including thoracic shape, on LADH outcomes was retrospectively investigated. Thoracic anthropometric data were examined in all LADHs with a left/right graft between 2013 and 2022.

Results

The study included 210 LADHs, consisting of 106 left- and 104 right-lobe donors with similar blood loss and similar operation time. Males have greater thoracic depth and greater thoracic width compared with females, respectively. Thoracic depth was associated with graft weight (p < 0.001), blood loss (p < 0.001), and operation time (p < 0.001). On multivariate analyses, blood loss >500 mL and operation time >8 h were associated with graft weight in the left-lobe donors, and blood loss >500 mL was associated with thoracic depth in the right-lobe donors.

Conclusion

The greater thoracic depth is associated with massive blood loss in right-lobe donors. Anthropometric parameters might be helpful for estimating LADH outcomes.

The value of total caudate lobe resection for hilar cholangiocarcinoma: a systematic review

Hilar cholangiocarcinoma (HCCA) is widely considered to have a poor prognosis. In particular, combined caudate lobe resection (CLR) as a strategy for radical resection in HCCA is important for improving the R0 resection rate. However, the criteria for R0 resection, necessity of CLR, optimal extent of hepatic resection, and surgical approach are still controversial. This review aimed to summarize the findings and discuss the controversies surrounding CLR. Numerous clinical studies have shown that combined CLR treatment for HCCA improves the R0 resection rate and postoperative survival time. Whether surgery for Bismuth type I or II is combined with CLR depends on the pathological type. Considering the anatomical factors, total rather than partial CLR is recommended to achieve a higher R0 resection rate. In the resection of HCCA, a proximal ductal margin greater than or equal to 10 mm should be achieved to obtain a survival benefit. Although there is no obvious boundary between the right side (especially the paracaval portion) and the right posterior lobe of the liver, Peng's resection line can serve as a reference marker for right-sided resection. Laparoscopic resection of the caudate lobe may be safer, more convenient, accurate, and minimally invasive than open surgery, but it needs to be completed by experienced laparoscopic doctors.

Latest Findings on Minimally Invasive Anatomical Liver Resection

Minimally invasive liver resection (MILR) is being widely utilized owing to recent advancements in laparoscopic and robot-assisted surgery. There are two main types of liver resection: anatomical (minimally invasive anatomical liver resection (MIALR)) and nonanatomical. MIALR is defined as a minimally invasive liver resection along the respective portal territory. Optimization of the safety and precision of MIALR is the next challenge for hepatobiliary surgeons, and intraoperative indocyanine green (ICG) staining is considered to be of considerable importance in this field. In this article, we present the latest findings on MIALR and laparoscopic anatomical liver resection using ICG at our hospital.

Impact of obstructive ventilatory impairment on intraoperative bleeding during laparoscopic hepatectomy

PURPOSE

An animal model of laparoscopic hepatectomy showed that bleeding from the hepatic vein is influenced by airway pressure. However, there are little research reports on how airway pressure leads to risks in clinical practice. The main objective of this study was to investigate the impact of preoperative forced expiratory volume % in 1 s (FEV1.0%) on intraoperative blood loss in laparoscopic hepatectomy.

METHODS

All patients who underwent pure laparoscopic or open hepatectomy from April 2011 to July 2020 were classified into two groups by preoperative spirometry: those with obstructive ventilatory impairment (obstructive group; FEV1.0% < 70%) and those with normal respiratory function (ormal group; FEV1.0% ≥ 70%). Massive blood loss was defined as 400 mL for laparoscopic hepatectomy.

RESULTS

In total, 247 and 445 patients underwent pure laparoscopic and open hepatectomy, respectively. Regarding laparoscopic hepatectomy group, blood loss was significantly greater in the obstructive group (122 vs. 100 mL, P = 0.042). Multivariate analysis revealed that high IWATE criteria which classify the surgical difficulty of laparoscopic hepatectomy (≥ 7, odds ratio (OR): 4.50, P = 0.004) and low preoperative FEV1.0% (< 70%, OR: 2.28, P = 0.043) were independent risk factors for blood loss during laparoscopic hepatectomy. In contrast, FEV1.0% did not affect the blood loss (522 vs. 605 mL, P = 0.113) during open hepatectomy.

CONCLUSION

Obstructive ventilatory impairment (low FEV1.0%) may affect the amount of bleeding during laparoscopic hepatectomy.

Cerebral infarction by paradoxical gas embolism detected after laparoscopic partial hepatectomy with an insufflation management system: a case report

BACKGROUND

Laparoscopic surgery has reduced surgical morbidity and postoperative duration of hospital stay. Gas embolism is commonly known as a risk factor for all laparoscopic procedures. We report a case of severe cerebral infarction presumably caused by paradoxical CO₂ embolism in laparoscopic partial hepatectomy with an insufflation management system.

CASE PRESENTATION

A male in his 60 s was diagnosed with recurrence of liver metastasis in the right hepatic lobe after laparoscopic lower anterior resection for rectal cancer. We performed laparoscopic partial hepatectomy with an AirSeal® under 10 mmHg of intra-abdominal pressure. During the surgery, the patient's end-tidal CO₂ and percutaneous oxygen saturation dropped from approximately 40-20 mmHg and 100-90%, respectively, while the heart rate increased from 60 to 120 beats/min; his blood pressure remained stable. Postoperatively, the patient developed right hemiplegia and aphasia. Brain magnetic resonance imaging showed cerebral infarction in the broad area of the left cerebral cortex. Thereafter, transesophageal echocardiography revealed a patent foramen ovale, suggesting cerebral infarction due to paradoxical gas embolism.

CONCLUSIONS

A patent foramen ovale is found in approximately 15-20% of healthy individuals. While gas embolism is a rare complication of laparoscopic surgery, cerebral infarction must be considered a possible complication even if the intra-abdominal pressure is constant under 10 mmHg with an insufflation management system.

Intraoperative laparoscopic liver surface registration with preoperative CT using mixing features and overlapping region masks

PURPOSE

Laparoscopic liver resection is a minimal invasive surgery. Augmented reality can map preoperative anatomy information extracted from computed tomography to the intraoperative liver surface reconstructed from stereo 3D laparoscopy. However, liver surface registration is particularly challenging as the intraoperative surface is only partially visible and suffers from large liver deformations due to pneumoperitoneum. This study proposes a deep learning-based robust point cloud registration network.

METHODS

This study proposed a low overlap liver surface registration algorithm combining local mixed features and global features of point clouds. A learned overlap mask is used to filter the non-overlapping region of the point cloud, and a network is used to predict the overlapping region threshold to regulate the training process.

RESULTS

We validated the algorithm on the DePoLL (the Deformable Porcine Laparoscopic Liver) dataset. Compared with the baseline method and other state-of-the-art registration methods, our method achieves minimum target registration error (TRE) of 19.9 ± 2.7 mm.

CONCLUSION

The proposed point cloud registration method uses the learned overlapping mask to filter the non-overlapping areas in the point cloud, then the extracted overlapping area point cloud is registered according to the mixed features and global features, and this method is robust and efficient in low-overlap liver surface registration.

Editorial: Surgical Advances in Pancreaticobiliary Diseases

Pancreaticobiliary diseases include malignant tumors arising in organs with a complex anatomy, such as the pancreas and bile ducts, often presenting as locally advanced or metastatic lesions, and they frequently have a poor prognosis [...].

Positioning of Minimally Invasive Liver Surgery for Hepatocellular Carcinoma: From Laparoscopic to Robot-Assisted Liver Resection

Laparoscopic liver resection (LLR) is widely accepted in the surgical treatment of hepatocellular carcinoma (HCC) through international consensus conferences and the development of difficulty classifications. LLR has been reported to result in earlier postoperative recovery and fewer postoperative complications than open liver resection (OLR) for HCC. However, the prevalence of liver cirrhosis, obesity, the elderly, HCC recurrence (repeat liver resection), and major resection must be considered for LLR for HCC. Some systematic reviews, meta-analysis studies, and large cohort studies indicated that LLR is technically feasible for selected patients with HCC with these factors that led to less intraoperative blood loss, fewer transfusions and postoperative complication incidences, and shorter hospital stays than OLR. Furthermore, some reported LLR prevents postoperative loss of independence. No difference was reported in long-term outcomes among patients with HCC who underwent LLR and OLR; however, some recent reports indicated better long-term outcomes with LLR. In recent years, robot-assisted liver resection (RALR) has gradually become popular, and its short- and long-term results for HCC are not different from those of LLR. Additionally, RALR is expected to become the mainstay of minimally invasive surgery in the future.

The role of laparoscopic surgery in the surgical management of recurrent liver malignancies: A systematic review and meta-analysis

Objective

To evaluate the efficiency of laparoscopic surgery in treating recurrent liver tumors vs. conventional open surgery.

Methods

Database searching was conducted in PubMed, the Cochrane Library and EMBASE. Rev Man 5.3 software and Stata 13.0 software were applied in statistical analyses.

Results

A total of fourteen studies were finally included with 1,284 patients receiving LRH and 2,254 with ORH. LRH was associated with less intraoperative hemorrhage, a higher R0 resection rate, a lower incidence of Pringle Maneuver, a lower incidence of postoperative morbidities, a better overall survival and an enhanced postoperative recovery vs. ORH. Patients receiving LRH shared similar operative time, tumor number and disease-free survival as those with ORH. However, tumor size was relatively larger in patients receiving ORH and major hepatectomy, anatomic hepatectomy were rarely performed in patients with LRH. Additional analyses between LRH and laparoscopic primary hepatectomy revealed less intraoperative blood loss in patients with LRH.

Conclusion

LRH is safe and feasible with more favorable peri-operative outcomes and faster postoperative recovery. However, it is only applicable for some highly-selected cases not requiring complex surgical procedures. Future larger well-designed studies are expected for further validation.

Current status of minimally invasive liver surgery for cancers

Hepatocellular carcinoma (HCC) patients have chronic liver disease with functional deterioration and multicentric oncogenicity. Liver surgeries for the patients should be planned on both oncological effects and sparing liver function. In colorectal patients with post-chemotherapy liver injury and multiple bilateral tumors, handling multiple tumors in a fragile/easy-to-bleed liver is an important issue. Liver surgery for biliary tract cancers is often performed as a resection of large-volume functioning liver with extensive lymphadenectomy and bile duct resection/reconstruction. Minimally invasive liver surgery (MILS) for HCC is applied with the advantages of laparoscopic for cases of cirrhosis or repeat resections. Small anatomical resections using the Glissonian, indocyanine green-guided, and hepatic vein-guided approaches are under discussion. In many cases of colorectal liver metastases, MILS is applied combined with chemotherapy owing to its advantage of better hemostasis. Two-stage hepatectomy and indocyanine green-guided tumor identification for multiple bilateral tumors are under discussion. In the case of biliary tract cancers, MILS with extensive lymphadenectomy and bile duct resection/reconstruction are developing. A robot-assisted procedure for dissection of major vessels and handling fragile livers may have advantages, and well-simulated robot-assisted procedure may decrease the difficulty for biliary tract cancers.

Laparoscopic central hepatectomy using a parenchymal-first approach: how we do it

BACKGROUND

Laparoscopic central hepatectomy (LCH) is a difficult and challenging procedure. This study aimed to describe our experience with LCH using a parenchymal-first approach.

METHODS

Between July 2017 and June 2021, 19 consecutive patients underwent LCH using a parenchymal-first approach at our institution. Herein, the details of this procedural strategy are described, and the demographic and clinical data of the included patients were retrospectively analyzed.

RESULTS

There were 1 female and 18 male patients, all with hepatocellular carcinoma without major vascular invasion. The mean age was 57 ± 10 years. No patients underwent conversion to open surgery, and no blood transfusions were needed intraoperatively. The average operative duration and the average Pringle maneuver duration were 223 ± 65 min and 58 ± 11 min. respectively. The median blood loss was 200 ml (range: 100-800 ml). Postoperative morbidities occurred in 3 patients (15.8%), including 2 cases of bile leakage and 1 case of acquired pulmonary infection; there were no postoperative complications happened such as bleeding, hepatic failure, or mortality. The average postoperative hospital stay was 10 ± 3 days.

CONCLUSION

The optimized procedure of LCH using a parenchymal-first approach is not only feasible but also expected to provide an advantage in laparoscopic anatomical hepatectomy.

Trocar layouts in laparoscopic liver surgery

BACKGROUND

Since the first laparoscopic wedge resection reported by Reich, laparoscopic liver resection (LLR) has been progressively developed, acquiring safety and feasibility. The time has witnessed a milestone leap for laparoscopic hepatectomy from pure laparoscopic partial hepatectomy to anatomical hepatectomy and from minor liver resection to major liver resection. The numerous previous studies have paid more attention to the short-time and long-time surgical outcomes caused by surgical techniques corresponding to various segments and approaches. However, focus on trocar layouts remains poorly described, but it plays an indispensable role in surgical process.

METHODS

We have searched PubMed for English language articles with the key words "trocar," "laparoscopic liver resection," and "liver resection approaches."

RESULTS

This review highlighted each type of trocar layouts corresponding to specific circumstances, including targeted resection segments with various approaches. Notably, surgeon preferences and patients body habitus affect the trocar layouts to some extent as well.

CONCLUSIONS

Although there were fewer researches focus on trocar layouts, they determine the operation field and manipulation space and be likely to have an impact on outcomes of surgery. Therefore, further studies are warranted to firm the role of trocar layouts in LLR.

Caudal Approach to Laparoscopic Liver Resection-Conceptual Benefits for Repeated Multimodal Treatment for Hepatocellular Carcinoma and Extended Right Posterior Sectionectomy in the Left Lateral Position

We had reported the novel concept of "caudal approach in laparoscopic liver resection" in 2013. In the first report, the caudal approach of laparoscopic transection-first posterior sectionectomy without prior mobilization of the liver in the left lateral position was described. Thereafter, 10 complex laparoscopic extended posterior sectionectomies with combined resection of the right hepatic vein or diaphragm were performed using the same approach. In the present study, the short-term outcomes of these cases and 42 cases of laparoscopic sectionectomies or hemi-hepatectomies (excluding left lateral sectionectomy) were compared. There was no statistically significant difference between the groups in terms of patients' backgrounds, diseases for resection, preoperative liver function, tumor number and size, as well as outcomes, operation time, intraoperative blood loss, morbidity, conversion to laparotomy, and post-operative hospital stay. Even complex laparoscopic extended posterior sectionectomy was safely performed using this procedure. This approach has the technical benefits of acquiring a well-opened transection plane between the resected liver fixed to the retroperitoneum and the residual liver sinking to the left with the force of gravity during parenchymal transection, and less bleeding from the right hepatic vein due to its higher position than the inferior vena cava. Furthermore, it has an oncological benefit similar to that of the anterior approach in open liver resection, even in posterior sectionectomy. The detailed procedure and general conceptual benefits of the caudal approach to laparoscopic liver resection for repeated multimodal treatment for hepatocellular carcinoma are described.

Laparoscopic and Robot-Assisted Hepatic Surgery: An Historical Review

Hepatic surgery is a rapidly expanding component of abdominal surgery and is performed for a wide range of indications. The introduction of laparoscopic cholecystectomy in 1987 was a major change in abdominal surgery. Laparoscopic surgery was widely and rapidly adopted throughout the world for cholecystectomy initially and then applied to a variety of other procedures. Laparoscopic surgery became regularly applied to hepatic surgery, including segmental and major resections as well as organ donation. Many operations progressed from open surgery to laparoscopy to robot-assisted surgery, including colon resection, pancreatectomy, splenectomy thyroidectomy, adrenalectomy, prostatectomy, gastrectomy, and others. It is difficult to prove a data-based benefit using robot-assisted surgery, although laparoscopic and robot-assisted surgery of the liver are not inferior regarding major outcomes. When laparoscopic surgery initially became popular, many had concerns about its use to treat malignancies. Robot-assisted surgery is being used to treat a variety of benign and malignant conditions, and studies have shown no deterioration in outcomes. Robot-assisted surgery for the treatment of malignancies has become accepted and is now being used at more centers. The outcomes after robot-assisted surgery depend on its use at specialized centers, the surgeon's personal experience backed up by extensive training and maintenance of international registries. Robot-assisted hepatic surgery has been shown to be associated with slightly less intraoperative blood loss and shorter hospital lengths of stay compared to open surgery. Oncologic outcomes have been maintained, and some studies show higher rates of R0 resections. Patients who need surgery for liver lesions should identify a surgeon they trust and should not be concerned with the specific operative approach used. The growth of robot-assisted surgery of the liver has occurred in a stepwise approach which is very different from the frenzy that was seen with the introduction of laparoscopic cholecystectomy. This approach allowed the identification of areas for improvement, many of which are at the nexus of engineering and medicine. Further improvements in robot-assisted surgery depend on the combined efforts of engineers and surgeons.

An International Retrospective Observational Study of Liver Functional Deterioration after Repeat Liver Resection for Patients with Hepatocellular Carcinoma

Whether albumin and bilirubin levels, platelet counts, ALBI, and ALPlat scores could be useful for the assessment of permanent liver functional deterioration after repeat liver resection was examined, and the deterioration after laparoscopic procedure was evaluated. For 657 patients with liver resection of segment or less in whom results of plasma albumin and bilirubin levels and platelet counts before and 3 months after surgery could be retrieved, liver functional indicators were compared before and after surgery. There were 268 patients who underwent open repeat after previous open liver resection, and 224 patients who underwent laparoscopic repeat after laparoscopic liver resection. The background factors, liver functional indicators before and after surgery and their changes were compared between both groups. Plasma levels of albumin (p = 0.006) and total bilirubin (p = 0.01) were decreased, and ALBI score (p = 0.001) indicated worse liver function after surgery. Laparoscopic group had poorer preoperative performance status and liver function. Changes of liver functional values before and after surgery and overall survivals were similar between laparoscopic and open groups. Plasma levels of albumin and bilirubin and ALBI score could be the indicators for permanent liver functional deterioration after liver resection. Laparoscopic group with poorer conditions showed the similar deterioration of liver function and overall survivals to open group.

The cost-effectiveness analysis of laparoscopic hepatectomy compared with open liver resection in the early stage of hepatocellular carcinoma: a decision-analysis model in Thailand

BACKGROUND

Laparoscopic liver resection is increasing operate. In the early stage of hepatocellular carcinoma (HCC), many studies supported that laparoscopic liver resection was a safe procedure and showed some clinical benefits. However, the full economic evaluation has not been fully investigated.

METHODS

A hybrid model of decision tree and Markov state transition model was constructed. Health outcomes were life-year gained (LYs), and quality-adjusted life years (QALYs). A deterministic sensitivity analysis was performed and a probabilistic sensitivity analysis was conducted by 1,000 micro-simulation. The incremental cost-effectiveness ratio (ICER) was reported and the willingness to pay (WTP) was defined at 160,000 THB per QALY gained.

RESULTS

Laparoscopic liver resection in the early stage of HCC was not cost-effective. In the base-case analysis, the total lifetime cost of laparoscopic approach was an average of 413,377 THB (US$13,214) higher than open approach by 55,474 THB (US$1,773) with a small QALY gained. The resulting ICER was 1,356,521 THB (US$43,362) per QALY gained.

CONCLUSION

Laparoscopic liver resection is not considered as a cost-effective alternative to open liver surgery in the early stage of HCC. In the Thai healthcare perspective, the results from this study may inform policymakers for the future policy implementation and healthcare resource allocation.

The Tokyo 2020 terminology of liver anatomy and resections: Updates of the Brisbane 2000 system

BACKGROUND

The Brisbane 2000 Terminology for Liver Anatomy and Resections, based on Couinaud's segments, did not address how to identify segmental borders and anatomic territories of less than one segment. Smaller anatomic resections including segmentectomies and subsegmentectomies, have not been well defined. The advent of minimally invasive liver resection has enhanced the possibilities of more precise resection due to a magnified view and reduced bleeding, and minimally invasive anatomic liver resection (MIALR) is becoming popular gradually. Therefore, there is a need for updating the Brisbane 2000 system, including anatomic segmentectomy or less. An online "Expert Consensus Meeting: Precision Anatomy for Minimally Invasive HBP Surgery (PAM-HBP Surgery Consensus)" was hosted on February 23, 2021.

METHODS

The Steering Committee invited 34 international experts from around the world. The Expert Committee (EC) selected 12 questions and two future research topics in the terminology session. The EC created seven tentative definitions and five recommendations based on the experts' opinions and the literature review performed by the Research Committee. Two Delphi Rounds finalized those definitions and recommendations.

RESULTS

This paper presents seven definitions and five recommendations regarding anatomic segmentectomy or less. In addition, two future research topics are discussed.

CONCLUSIONS

The PAM-HBP Surgery Consensus has presented the Tokyo 2020 Terminology for Liver Anatomy and Resections. The terminology has added definitions of liver anatomy and resections that were not defined in the Brisbane 2000 system.

Anterior approach in situ resection for total laparoscopic pancreaticoduodenectomy

Background

Laparoscopic pancreaticoduodenectomy (LPD) is gaining popularity in last decade. However, it is still technical challenging to perform LPD for patients with large periampullary tumors.

Methods

From January 2019 to January 2020, 13 cases of LPD were performed via anterior approach. Data were collected prospectively in terms of demographic characteristics (age, gender, body mass index, pathological diagnosis and tumor size), intra-operative variables (operative time, estimated blood loss, transfusion), and post-operative variables (time for oral intake, post-operative hospital stay, and complications).

Results

There were five male patients and eight female patients included in this study. The median age of these patients was 52.7 ± 14.5 years. The median size of tumors was 7.2 ± 2.9 cm. One patient converted to open surgery because of uncontrollable hemorrhage. The median operative time was 356 ± 47 min. The median estimated blood loss was 325 ± 216 ml. The mean post-operative hospital stay was 12.4 ± 1.9 days. One patient suffered from grade B pancreatic fistula. One patient suffered from delayed gastric emptying which was cured by conservative therapy. 90-day mortality was zero.

Conclusions

Laparoscopic pancreaticoduodenectomy via anterior approach is safe and feasible for patients with large periampullary tumors. Its oncological benefit requires further investigation.

Laparoscopic versus open hepatectomy for malignant liver tumours in the elderly: systematic review and meta-analysis

To evaluate comparative outcomes of laparoscopic versus open hepatectomy for malignant liver tumours in elderly patients. A systematic online search was conducted using the following databases: PubMed, Scopus, Cochrane database, The Virtual Health Library, Clinical trials.gov, and Science Direct. Comparative studies comparing laparoscopic (LH) versus open hepatectomy (OH) for both primary and metastatic malignant liver tumours in the elderly were included. Total operative time (minutes), need to perform Pringle's manoeuvre, blood loss (ml), the requirement for blood transfusion intra-operatively/post-operatively, post-operative complications, r0 resection rate, specimen resection margin (mm), re-operation rate, length of hospital stay (LOS), and 90-day mortality were the evaluated outcome parameters. Twelve studies reporting a total number of 1762 patients who underwent laparoscopic (n = 831) or open (n = 931) hepatectomy were included. OH group was associated with a significantly higher overall number of post-operative complications compared to LH (P = 0.00001). Complications such as post-operative liver failure (P = 0.02), ascites formation (P = 0.002), surgical site infection (P = 0.02), blood loss (P = 0.03), blood transfusion rate (P = 0.05), and LOS (P = 0.00001) were significantly higher in the OH group when compared to LH. There was no significant difference between the two groups in terms of total operative time (P = 0.53), bile leak (P = 0.12), r0 resection rate (P = 0.36), re-operation (P = 0.70), and 90-day mortality (P = 0.11). Laparoscopic liver resections are safe with at least equal or superior peri-operative outcomes in the elderly population, although available data regards mainly the results of minor resections. Laparoscopic major resections in the elderly population should be carefully evaluated and preferably performed in expert centres.

Laparoscopic vs. Open Repeat Hepatectomy for Recurrent Liver Tumors: A Propensity Score-Matched Study and Meta-Analysis

Background: It remains unclear whether the short-term benefits of laparoscopic repeat hepatectomy (LRH) accrue to patients with recurrent liver tumors. The present study aimed to report our own center's experience and perform a meta-analysis to evaluate the safety and feasibility of LRH in comparison with open repeat hepatectomy (ORH) for treating recurrent liver tumors.

Patients and Methods: A propensity score–matched study was performed including 426 patients receiving LRH or ORH for recurrent hepatocellular carcinoma between January 2017 and December 2018. Surgical outcomes and perioperative inflammation-based markers, including monocyte-to-lymphocyte ratio, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and systemic immune–inflammation index were collected from medical records and analyzed. Additionally, a systematic literature review was performed to identify relevant studies in PubMed, EMBASE, Web of Science, and Cochrane library databases up to October 1, 2020. Information including patient demographics, pathologic characteristics, and short-term outcomes was extracted and analyzed using random- or fixed-effects models.

Results: Of 68 LRHs, 57 were matched with an ORH finally. Our study demonstrated that LRH was significantly associated with less intraoperative blood loss (50 vs. 100 mL; P < 0.001), lower rate of hepatic inflow occlusion (10.52 vs. 33.3%; P = 0.003), and shorter postoperative hospital stay (5 vs. 6 days; P = 0.001) after 1:1 propensity score matching. The operation time, rate of blood transfusion, and postoperative complications were similar between the two groups. Moreover, all four inflammation-based markers were significantly lower in LRH group on postoperative day 1. In the meta-analysis, a total of 12 studies comprising 1,315 patients receiving repeat hepatectomy met the selection criteria. Similar to our own study, the meta-analysis showed shorter hospital stay [standard mean difference (SMD) = −0.51, 95% confidence interval (CI) = −0.79 to −0.22, P < 0.001], less intraoperative blood loss (SMD = −0.79, 95% CI = −1.11 to −0.47, P < 0.001), and lower rate of major postoperative complications [odds ratio (OR) = 0.35, 95% CI = 0.19–0.66, P = 0.001] in the LRH group. There was no difference in the field of overall postoperative complication and operation time between LRH and ORH groups.

Conclusion: Compared with ORH, LRH results in relatively better surgical outcomes and faster postoperative recovery. It could be considered a feasible and effective option for the treatment of recurrent liver tumors.

Laparoscopic hepatectomy versus open hepatectomy for tumors located in right posterior segment: A single institution study

OBJECT

With the gradual advancement of laparoscopic technology, surgeries can be successfully performed with the help of laparoscopy increasingly. This study initially explored the difference between laparoscopic right posterior sectionectomy (LRPS) and open right posterior sectionectomy (ORPS)of liver in our center, discussed the effectiveness, benefits and safety of LRPS and introduce some surgical techniques in our center.

MATERIALS AND METHODS

We retrospectively analyze 96 cases of liver tumor located in the right posterior lobe of liver in our institution from January 2015 to January 2018. There were 46 cases performed the LRPS surgery and 50 cases performed the ORPS surgery. Through analysis of the perioperative outcomes of these two groups by a case control study, we compare the differences between these two groups.

RESULTS

There was no significant difference between the LRPS and ORPS group in demographic and baseline characteristics before surgery. Patients in the LRPS group were significantly superior to ORPS in terms of postoperative liver function recovery, postoperative inflammatory factor level, pain sensation (3.03 ± 0.79 vs 4.58 ± 1.25), abdominal incision length (6.25 ± 2.34 vs 32.15 ± 3.21), carrying abdominal drainage tube time (3.26 ± 0.77 vs 4.83 ± 0.76), recovery of bowel function time (1.6 ± 0.61 VS 3.05 ± 0.85)and postoperative hospital stay (5.73 ± 0.99 vs 7.16 ± 0.95) (P < 0.05).

CONCLUSION

Compared with the traditional ORPS, LRPS has the advantages of minor injury, faster recovery and mild inflammatory reaction. The LRPS is safe and feasible, and it should be gradually promoted in clinical practice.

Pure Laparoscopic Hepatectomy for Tumors Close to the Major Hepatic Veins: Intraparenchymal Identification of the Major Hepatic Veins using the Ventral Approach

BACKGROUND

Laparoscopic hepatectomy for tumors close to the major hepatic veins (HVs) is a technically demanding procedure that is relatively contraindicated. We investigated this surgical technique and the outcomes of intraparenchymal identification of the major HVs using the ventral approach in pure laparoscopic hepatectomy for tumors close to the major HVs.

METHODS

In the present study, tumors < 10 mm from the major HVs were defined as lesions in proximity to the major HVs. The cranio-ventral part of the liver parenchyma along the targeted major hepatic veins was opened to facilitate an open cutting plane. After a wide exposure of the surgical plane, the targeted major HVs were identified.

RESULTS

Thirteen patients with tumors close to the major HVs underwent laparoscopic hepatectomy. The median operative time was 260 min (range, 160-410 min), while the intraoperative blood loss was 100 mL (range, 30-310 mL). The median Pringle maneuver time was 45 min (range, 40-75 min). The median tumor size was 50 mm (range, 17-140 mm), and the median tumor margin was 4 mm (range, 0-10 mm). Three patients (23.1%) experienced minor postoperative complications. The median postoperative hospital stay was 7 days (range, 4-25 days).

CONCLUSIONS

Pure laparoscopic hepatectomy for tumors close to the major HVs is technically feasible in selected patients. Intraparenchymal identification of the major HVs using the ventral approach achieves transection plane accuracy and avoids inadvertent injury to the major HVs.

A new strategy of laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein combined with transhepatic duct lithotomy for complex hemihepatolithiasis: A propensity score matching study

BACKGROUND

There have been no studies on laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein combined with transhepatic duct lithotripsy for the treatment of complex hemihepatolithiasis. This study aimed to investigate the safety and efficacy of laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein combined with transhepatic duct lithotomy to treat complex hemihepatolithiasis.

METHODS

The clinical data for patients who underwent laparoscopic anatomical hemihepatectomy for complex intrahepatic bile duct stones with or without common bile duct stones from January 2016 to June 2020 were prospectively collected. Patients were divided into 2 groups according to surgical approach: laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein (middle hepatic vein group) or laparoscopic anatomical hemihepatectomy not guided by the middle hepatic vein (nonmiddle hepatic vein group). The safety and short-term and long-term efficacy outcomes of the 2 groups were compared with 1:1 propensity score matching.

RESULTS

With only a slightly longer operative time (P = .006), the initial and final stone residual rates in the middle hepatic vein group (n = 70) were significantly lower than those in the nonmiddle hepatic vein group (n = 70) (P = .002, P = .009). The bile leakage rate and stone recurrence rate were also significantly lower (P = .001, P = .001).

CONCLUSION

Laparoscopic anatomical hemihepatectomy guided by the middle hepatic vein is safe and effective for treating intrahepatic bile duct stones and can decrease the stone residual rate, reduce the bile leakage rate and stone recurrence rate, and accelerate early recovery. However, owing to the complicated technical requirements for surgeons and anesthesiologists, use of the procedure is limited to large and experienced medical centers.

Improved Outcomes of Laparoscopic Liver Resection for Hepatocellular Carcinoma Located in Posterosuperior Segments of the Liver

BACKGROUND

LLR is widely adapted for HCC, while LLR in PS segments is still challenging. With recent improvement of techniques and accumulation of experiences, LLR in PS segments is feasible, but studies investigating the result after the modifications are lacking.

METHODS

In this single-center, retrospective study, 149 patients who underwent LLR for HCC located in PS segments from September 2003 to December 2016 were analyzed. The patients were divided into Group 1 (n=43) and Group 2 (n=106) who underwent LLR before and after 2012, respectively, when advanced techniques including use of intercostal trocars, Pringle maneuver, and semi-lateral position of patient were introduced. Also, these patients were compared with those who underwent open liver resection (OLR; n=124) for HCC in PS segments during the same period.

RESULTS

Mean operative time (394.7 minutes vs 331.2 minutes; P=0.013), intraoperative blood loss (1545.8 ml vs 1208.2 ml; P=0.020), and hospital stay (11.6 days vs 9.2, P<0.001) were significantly less in Group 2. Postoperative complication rate (18.6% vs 18.9%; P=0.970), open conversion rate (23% vs 17%; P=0.374), 5-year overall (79% vs 89%; P=0.607) and 5-year disease-free (52% vs 53%; P=0.657) survival rates were not significantly different between the groups. Compared to the OLR group, complication rate (40.3% vs 18.8%; P< 0.001) and hospital stay (17.6 days vs 9.7 days; P< 0.001) were significantly lower in the LLR group.

CONCLUSION

The complexity of LLR for HCC in PS segments is being gradually overcome by the introduction of advanced techniques.

Laparoscopic resection reduces superficial surgical site infection in liver surgery

BACKGROUND

Laparoscopic liver resection is beneficial compared to open liver resection. This study aimed to evaluate whether laparoscopic liver resection could reduce postoperative infections.

METHODS

This study included 125 and 115 patients with liver tumors who underwent open and pure laparoscopic partial resections or left lateral sectionectomies, respectively. Propensity score matching and stabilized inverse probability of treatment weighting were carried out to compare the postoperative infectious complication rates between the two groups.

RESULTS

Patients with tumors located in Couinaud segment 1, 7, or 8; with tumors adjacent to major vessels; or who underwent repeated resections were more likely to receive open resection. After propensity score matching, the superficial incisional surgical site infection rate tended to be lower in the laparoscopic liver resection group than in the open liver resection group. Moreover, overall infectious complication rate and superficial incisional surgical site infection rate were lower in the laparoscopic group (the cohort formed by the stabilized inverse probability of treatment weighting).

CONCLUSIONS

Using the laparoscopic approach for partial resections and left lateral sectionectomies for liver tumors, the superficial incisional surgical site infection rate could be reduced.

RESSECÇÃO LAPAROSCÓPICA DE TUMORES BENIGNOS DO FÍGADO: POSIÇÃO ATUAL

The main indications of the use of laparoscopic liver surgery (LLS), in the early days, were benign liver lesions. As LLS became more popular, indications for malignant diseases outnumbered those for benign ones. This study aims to rule out the indications and results of LLS for the treatment of benign liver tumors.

Robotic isolated partial and complete hepatic caudate lobectomy: A single institution experience

BACKGROUND

Current reports on robotic hepatic caudate lobectomy are limited to Spiegel lobectomy. This study aimed to compare the safety and feasibility of robotic isolated partial and complete hepatic caudate lobectomy.

METHODS

Clinical data of 32 patients who underwent robotic resection of the hepatic caudate lobe in our department from May 2016 to January 2020 were retrospectively analyzed. The patients were divided into three groups according to the lobectomy location: left dorsal segment lobectomy (Spiegel lobectomy), right dorsal segment lobectomy (caudate process or paracaval portion lobectomy), and complete caudate lobectomy. General information and perioperative results of the three groups were compared and analyzed.

RESULTS

Among the 32 patients, none had conversion to laparotomy, three received intraoperative blood transfusion (9.38%), and none had complications of Clavien-Dindo grade III or higher or died in the perioperative period. Among them, 17 patients (53.13%) underwent Spiegel lobectomy, 7 (21.88%) underwent caudate process or paracaval portion lobectomy, and 8 (25.00%) underwent complete caudate lobectomy. The operative time and blood loss in the left dorsal segment lobectomy group were significantly better than those in the right dorsal segment lobectomy and complete caudate lobectomy groups (operative time: P = 0.010 and P = 0.005; blood loss: P = 0.005 and P = 0.017, respectively). The postoperative hospital stay in the left dorsal segment lobectomy group was significantly shorter than that in the complete caudate lobectomy group (P = 0.003); however, there was no difference in the postoperative hospital stay between the left dorsal segment lobectomy group and right dorsal segment lobectomy group (P = 0.240).

CONCLUSIONS

Robotic isolated partial and complete caudate lobectomy is safe and feasible. Spiegel lobectomy is relatively straightforward and suitable for beginners.

Benefits of simultaneous laparoscopic colorectal surgery and liver resection for colorectal cancer with synchronous liver metastases: Retrospective case-matched study

Introduction

Laparoscopic surgery for colorectal cancer and liver tumors are accepted as alternative procedure to open surgery. However, few studies reported outcomes of simultaneous laparoscopic surgery of these two procedures. The aim of this study was to compare short-term outcomes between laparoscopic and open approach.

Materials and methods

Between June 2010 to December 2019, simultaneous laparoscopic cases were retrospectively matched (1:2) to open cases. Peri-operative and short-term outcomes were compared between both groups.

Results

Twelve patients in laparoscopic group were matched to 24 patients in open group according to age, gender, body mass index, american society of anesthesiologists physical status, preoperative laboratory data, number and size of liver metastases and extent of colorectal and liver resection, Most patients in each group had left-sided colon or rectal cancer and underwent wedge liver resection. The mean number of liver metastases was 1.3 vs 1.5 and size of liver metastases was 2.2 ± 1.4 vs 2.7 ± 1.1 cm in laparoscopic compared to open group. Estimated blood loss and length of hospital stay were significantly lower in laparoscopic group. However, operative time was significantly longer in laparoscopic group. Peri-operative complication was not significant difference between both groups and there was no mortality.

Conclusion

Simultaneous laparoscopic colorectal surgery and minor liver resection is feasible and safe. Laparoscopic approach has better peri-operative outcome in term of shorter length of hospital stay compared to open approach.

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Outcome of simultaneous laparoscopic surgery for colorectal cancer with synchronous liver metastases remains controversy.

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This study showed comparable peri-operative outcomes of simultaneous laparoscopic compared to open surgery.

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Simultaneous laparoscopic surgery had shorter length of hospital stay and less operative blood loss.

Laparoscopic repeat liver resection

Recurrence of liver cancers inside the liver are often treated with liver resection (LR). However, increased risks of complications and conversion during operation were reported in laparoscopic repeat LR (LRLR). The indication is still controversial. One multi-institutional propensity score matching analysis of LRLR vs open repeat LR for hepatocellular carcinoma, two propensity score matching analyses for colorectal metastases, and two meta-analyses including hepatocellular carcinoma, intrahepatic cholangiocarcinoma, metastases, and other tumors have been reported to date. LRLR was reported with better to comparable short-term and similar long-term outcomes. Furthermore, the shorter operation time and the smaller amount of intraoperative bleeding for LRLR was reported for the patients who had undergone laparoscopic rather than open LR as an earlier procedure. The speculations are presented, that complete dissection of adhesion can be dodged and laparoscopic minor repeated LR can minimize the liver functional deterioration in cirrhotic patients. LRLR, as a powerful local therapy, could contribute to the long-term outcomes of those with deteriorated liver function. However, the procedure is now in its developing stage worldwide and further accumulation of experiences and evaluation are needed.

Is minimally invasive surgery of lesions in the right superior segments of the liver justified? A multi-institutional study of 245 patients

BACKGROUND

Controversy exists regarding the safety and feasibility of minimally invasive resection for lesions in segments 7 or 8. We compare outcomes of minimally invasive surgery (MIS) and Open parenchymal sparing liver resections at two high-volume centers.

METHODS

From 2003 to 2016 we identified patients who underwent MIS or Open resections for lesions in segments 7 or 8 at two institutions (MSKCC and SGH). Outcomes were compared using univariate and multivariate analyses.

RESULTS

Two-hundred and forty-five patients underwent resection of lesions in segments 7 or 8 (MIS 30% and Open 70%). Compared to the Open group, the MIS group had longer operative time (223 ± 88 vs 188 ± 72 minutes, P = .003), lower blood loss (297 ± 287 vs 448 ± 670 mL, P = .03), and shorter mean length of stay (5.2 ± 7.4 vs 8.3 ± 11.7 days, P < .001), which remained significant on multivariate analysis. No differences in Pringle time, rate of postoperative complications, or R0 resections were detected.

CONCLUSIONS

With appropriately selected patients treated by experienced MIS hepatopancreatobiliary surgeons, MIS resection of segments 7 or 8 is safe with similar rates of complications and R0 resections, with significantly less blood loss and shorter length of stay.

Laparoscopic-specific procedure using dorsal approach to the middle hepatic vein in laparoscopic left hemihepatectomy

BACKGROUND

Exposing the middle hepatic vein (MHV) is required in left hemihepatectomy [1]. Laparoscopy enables us to perform unique approach in performing hepatectomy [2,3]. Herein we show a video of dorsal approach in left hemihepatectomy and measure anatomical parameters useful for approaching to the MHV.

PATIENT

A 79-year-old man with colorectal liver metastasis underwent laparoscopic left hemihepatectomy.

TECHNIQUE

After mobilizing left lateral section and encircling left Glissonian trunk, we firstly flipped up left lateral section inside and began parenchymal transection from dorsal surface around the root of left hepatic vein (LHV). Immediately we touched the MHV and, by cutting the left Glissonian trunk, could extend complete MHV exposure in central-to-peripheral direction without split injuries of MHV branches [2]. Next, we flipped down the left lateral section and divided ventral remaining parenchyma in caudal-to-cranial direction without risk of MHV injury. As this is not one-way procedure [4], as if open a book, we adjusted the ventral cutting plane to match with the dorsal one. Finally, by cutting the LHV, we completed left hemihepatectomy.

MEASURING ANATOMICAL PARAMETERS

We divided a sectional image into four zones (cranio-dorsal, caudal-dorsal, caudal-ventral, and cranio-ventral zones) and measured each anatomical parameter to expose the MHV. The area of cranio-dorsal zone was smallest to expose the MHV (3.5cm²). The distance from the Arantius' ligament to the MHV was also shortest (1.1cm).

CONCLUSIONS

Dorsal approach might be the nearest and safe road way to the MHV. This approach might make it easy to complete laparoscopic left hemihepatectomy.

The "Tenting Sign of the Hepatic Vein" Is Important for Laparoscopic Anatomical Hepatectomy Along the Major Hepatic Vein

BACKGROUND

Laparoscopic hepatectomy has rapidly evolved and has become a viable alternative to open hepatectomy. However, the dissection of liver parenchyma via the laparoscopic caudal approach (parenchymal transection from the caudal to cranial direction under a laparoscopic caudal view) has several limitations. To avoid these limitations in anatomical hepatectomy along the hepatic vein with the caudal approach, it is important to recognize the "tenting sign of the hepatic vein," which helps to identify the running of the main trunk of the hepatic vein.

TECHNICAL PRESENTATION

In the bifurcation of the hepatic vein, there is a possibility of splitting of the hepatic vein branch or disorientation between the main trunk and branch. Therefore, it is vital that when the branch is pulled, the main trunk of the hepatic vein appears to be toward the direction of the branch. As a result, the main trunk appears in the direction from the original route to the pseudo route. In the caudal approach, this phenomenon is called "tenting sign of the hepatic vein." Therefore, liver dissection should be performed in the contralateral and cranial sides of the main trunk, with the "tenting sign of the hepatic vein" in mind. This report describes specific cases of the "tenting sign of the hepatic vein."

CONCLUSION

The "tenting sign of the hepatic vein" from the caudal approach is essential knowledge for safe and reliable anatomical laparoscopic hepatectomy and can lead to expansion of indications in the future.

Laparoscopic versus open liver resection for intrahepatic cholangiocarcinoma: the first meta-analysis

BACKGROUND

Laparoscopic liver resection (LLR) has gained increasing acceptance for surgical treatment of malignant and benign liver tumors. LLR for intrahepatic cholangiocarcinoma (ICC) is not commonly performed because of the concern for the frequent need for major hepatectomy, vascular-biliary reconstructions, and lymph node dissection (LND). The aim of this present meta-analysis is to compare surgical and oncological outcomes of laparoscopic (LLR) versus open liver resection (OLR) for ICC.

MATERIALS AND METHODS

A systematic review was conducted using the PubMed, MEDLINE, and Cochrane library database of published studies comparing LLR and OLR up to October 2019. Two reviewers independently assessed the eligibility and quality of the studies. Dichotomous data were calculated by odds ratio (OR), and continuous data were calculated by mean difference (MD) with 95% confidence intervals (95% CI).

RESULTS

Four retrospective observational studies describing 204 patients met the inclusion criteria. With respect to surgical outcomes, laparoscopic compared with open liver resection was associated with lower blood loss [MD - 173.86, (95% CI - 254.82, -92.91) p < 0.0001], less requirement of blood transfusion [OR 0.34, (95% CI 0.14, 0.82) p = 0.02], less need for Pringle maneuver [OR 0.17, (95% CI 0.07, 0.43) p = 0.0002], shorter hospital stay [MD - 3.77, (95% CI - 5.09, - 2.44; p < 0.0001], and less morbidity [OR 0.44, (95% CI 0.21, 0.94) p = 0.03]. With respect to oncological outcomes, the LLR group was prone to lower rates of lymphadenectomy [OR 0.12, (95% CI 0.06, 0.25) p < 0.0001], but surgical margins R0 and recurrence rate were not significantly different.

CONCLUSION

Laparoscopic liver resection for ICC seems to achieve better surgical outcomes, providing short-term benefits without negatively affecting oncologic adequacy in terms of R0 resections and disease recurrence. However, a higher LND rate was observed in the open group. Due to the risk of bias and the statistical heterogeneity between the studies included in this review, further RCTs are needed to reach stronger scientific conclusions.

A multicenter cohort analysis of laparoscopic hepatic caudate lobe resection

INTRODUCTION

Laparoscopic resection of the hepatic caudate lobe (LRCL) requires a high level of expertise due to its challenging anatomical area. Only case reports, case series, and single-center cohort studies have been published. The aim of this study was to assess the safety and feasibility of this laparoscopic procedure.

METHODS

A multicenter retrospective cohort study including all patients who underwent LRCL in 4 high-volume hepatobiliary units between January 2000 and May 2018 was performed. Perioperative, postoperative, and survival outcomes were assessed. Postoperative morbidity was stratified according to the Clavien-Dindo classification with severe complications defined by grade III or more. The Kaplan-Meier method was used for survival analysis.

RESULTS

A total of 32 patients were included, including 22 (68.8%) with colorectal liver metastasis (CRLM), one (3.1%) with cholangiocarcinoma, four (12.5%) with other malignancies, and five (15.6%) with symptomatic benign lesions. Simultaneous colorectal and/or additional liver resection was performed in 20 (62.5%) patients. The median (IQR) operative time was 155 (121-280) minutes, blood loss was 100 (50-275) ml, conversion rate was 9.4% (n = 3), severe complications were observed in 2 patients (6.3%), and median (range) length of hospital stay was 3 [1-39] days. No 90-day postoperative mortality was noticed. The median (IQR) follow-up for the CRLM group was 14 [10-23] months. Five-year overall survival rate was 82% in this subgroup. Small interinstitutional differences were observed without major impact on surgical outcomes.

CONCLUSION

LRCL is safe and feasible when performed in high-volume centers. Profound anatomical knowledge, advanced laparoscopic skills, and mastering intraoperative ultrasound are essential. No major interinstitutional differences were ascertained.

Laparoscopic versus open two-stage hepatectomy for bilobar colorectal liver metastases: A bi-institutional, propensity score-matched study

BACKGROUND

The safety and feasibility of laparoscopic, two-stage hepatectomy for bilobar colorectal liver metastases is poorly evaluated.

METHODS

We reviewed retrospectively 86 consecutive patients who underwent complete two-stage hepatectomy (left lobe clearance as the first stage and standard/extended right hepatectomy as the second stage) for bilobar colorectal liver metastases between 2007 and 2017 in 2 tertiary centers. Short- and long-term outcomes were compared between laparoscopic and open two-stage hepatectomy before and after propensity score matching.

RESULTS

Laparoscopic two-stage hepatectomy was performed in 38 patients and open two-stage hepatectomy in 48. After propensity score matching, 25 laparoscopic and 25 open patients showed similar preoperative characteristics. For the first stage, a laparoscopic approach was associated with lesser hospital stays (4 vs 7.5 days; P < .001). For the second stage, a laparoscopic approach was associated with less blood loss (250 vs 500 mL; P = .040), less postoperative complications (32% vs 60%; P = .047), lesser hospital stays (9 vs 16 days; P = .013), and earlier administration of chemotherapy (1.6 vs 2 months; P = .039). Overall survival, recurrence-free survival, and liver-recurrence-free survival were comparable between the groups (3-year overall survival: 80% vs 54%; P = .154; 2-year recurrence-free survival: 20% vs 18%; P = .200; 2-year liver-recurrence-free survival: 39% vs 33%; P = .269). Although both groups had comparable recurrence patterns, repeat hepatectomies for recurrence were performed more frequently in the laparoscopic two-stage hepatectomy group (56% vs 0%; P = .006).

CONCLUSION

Laparoscopic two-stage hepatectomy for bilobar colorectal liver metastases is safe and feasible with favorable surgical and oncologic outcomes compared to open two-stage hepatectomy.

Developments and perspectives of laparoscopic liver resection in the treatment of hepatocellular carcinoma

Laparoscopic liver resection (LLR) was introduced in the early 1990s, initially for partial resection of the anterolateral segments, from where it has expanded in a stepwise fashion. Movement restriction makes bleeding control demanding. Managing pneumoperitoneum pressure with inflow control can inhibit venous bleeding and create a dry surgical field for easier hemostasis. Since the lack of overview leads to disorientation, simulation and navigation with imaging studies have become important. Improved direct access to the liver inside the rib cage can be obtained in LLR, reducing destruction of the associated structures and decreasing the risk of refractory ascites and liver failure, especially in patients with a cirrhotic liver. Although LLR can be performed as bridging therapy to transplantation for severe cirrhosis, its impact on expanding the indications of liver resection (LR) and the consequent survival benefits must be evaluated. For repeat LR, LLR is advantageous by producing fewer adhesions and reducing the need for adhesiolysis. The laparoscopic approach facilitates better access in a small operative field between adhesions. Further evaluations are needed for repeat anatomical resection, since alterations of the anatomy and surrounding scars and adhesions of major vessels have a larger impact.

Highlights, limitations and future challenges of laparoscopic resection for colorectal liver metastases

The liver is the most common site for metastatic colorectal cancer (CRLM). Despite advances in oncologic treatment, resection of metastases is still the only curative option. Although laparoscopic surgery for primary colorectal cancer is well documented and widely used, laparoscopic surgery for liver metastases has developed more slowly. However, in spite of some difficulties, laparoscopic approach demonstrated strong advantages including minimal parietal damage, decreased morbidity (reduced blood loss and need for transfusion, fewer pulmonary complications), and simplification of subsequent iterative hepatectomy. Up to now, more than 9 000 laparoscopic procedures have been reported worldwide and long-term results in colorectal liver metastases seem comparable to the open approach. Only one recent randomized controlled trial has compared the laparoscopic and the open approach. The purpose of the present update was to identify the barriers limiting widespread acceptance of laparoscopic approach, the benefits and the limits of laparoscopic hepatectomies in CRLM.

Standardization of surgical procedures for laparoscopic Spiegel lobectomy: A single-institutional experience

INTRODUCTION

Surgical techniques for Spiegel lobectomy remain technically difficult because of its deep anatomical location. Laparoscopic Spiegel lobectomy has not yet been standardized or widely reported. In the current study, we introduce technical improvements, including the liver hanging maneuver, to laparoscopic Spiegel lobectomy. Additionally, we demonstrate the safety and feasibility of this procedure.

MATERIALS AND SURGICAL TECHNIQUE

We performed consecutive laparoscopic Spiegel lobectomy on six patients: five with hepatocellular carcinoma and one with colorectal liver metastasis. As preparation before liver parenchymal resection, necessary and sufficient mobilization of the Spiegel lobe was performed. A few Glissonian pedicles of the Spiegel lobe were exposed from the hilar plate and divided to reduce the inflow to the Spiegel lobe. After that, vessel tape was used in the hanging maneuver. The tape was pulled forward to give the cutting plane moderate tension during liver parenchymal resection. Lifting this tape provided better exposure for determining the correct cutting plane during liver parenchymal transection. The median operation time was 207 min (range, 147-240 min) and the median intraoperative blood loss was 35 mL (range, 15-85 mL). There were no severe postoperative complications.

DISCUSSION

We safely performed laparoscopic Spiegel lobectomy. To maintain a sufficient surgical view, especially during liver parenchymal resection, the hanging maneuver may be a useful technique. This single-center investigation into standardized laparoscopic Spiegel lobectomy featuring improvements in technique showed potential for favorable results.

Intrahepatic Glissonian Approach to the Ventral Aspect of the Arantius Ligament in Laparoscopic Left Hemihepatectomy

BACKGROUND

Laparoscopic left hemihepatectomy using the Glissonian approach is technically challenging secondary to a thick Glissonian pedicle and limited maneuverability of laparoscopic instruments. This procedure demands extreme caution owing to the high risk of bile leakage associated with left hemihepatectomy. We describe the technical details and surgical outcomes of the intrahepatic Glissonian approach to the ventral aspect of the Arantius ligament in laparoscopic left hemihepatectomy.

METHODS

After detachment of the left side of hilar plate, the meticulous dissection was performed in the liver capsule above the left Glissonian pedicle. Dissection of the ventral aspect of the Arantius ligament creates the space between the liver parenchyma and the left Glissonian pedicle. The left Glissonian pedicle was isolated and encircled using the long curved laparoscopic instrument. During the parenchymal transection, the left Glissonian pedicle was transected using lateral to the Arantius ligament.

RESULTS

Between February 2013 and July 2018, 13 consecutive patients underwent pure laparoscopic left hemihepatectomy. The median operation time was 230 min (range 180-300 min), and the median estimated blood loss was 300 mL (range 100-600 mL). Two patients (15%) required transfusion. The median tumor size was 40 mm (range 10-105 mm). All patients showed negative resection margins. The median postoperative hospital stay was 8 days (range 6-15 days). Major postoperative complications occurred in 1 patient (7.7%). No perioperative deaths occurred.

CONCLUSION

An intrahepatic Glissonian approach to the ventral aspect of the Arantius ligament is a feasible and effective technique in laparoscopic left hemihepatectomy.

Laparoscopic Versus Open Resection for Colorectal Liver Metastases: The OSLO-COMET Randomized Controlled Trial

OBJECTIVE

To perform the first randomized controlled trial to compare laparoscopic and open liver resection.

SUMMARY BACKGROUND DATA

Laparoscopic liver resection is increasingly used for the surgical treatment of liver tumors. However, high-level evidence to conclude that laparoscopic liver resection is superior to open liver resection is lacking.

METHODS

Explanatory, assessor-blinded, single center, randomized superiority trial recruiting patients from Oslo University Hospital, Oslo, Norway from February 2012 to January 2016. A total of 280 patients with resectable liver metastases from colorectal cancer were randomly assigned to undergo laparoscopic (n = 133) or open (n = 147) parenchyma-sparing liver resection. The primary outcome was postoperative complications within 30 days (Accordion grade 2 or higher). Secondary outcomes included cost-effectiveness, postoperative hospital stay, blood loss, operation time, and resection margins.

RESULTS

The postoperative complication rate was 19% in the laparoscopic-surgery group and 31% in the open-surgery group (12 percentage points difference [95% confidence interval 1.67-21.8; P = 0.021]). The postoperative hospital stay was shorter for laparoscopic surgery (53 vs 96 hours, P < 0.001), whereas there were no differences in blood loss, operation time, and resection margins. Mortality at 90 days did not differ significantly from the laparoscopic group (0 patients) to the open group (1 patient). In a 4-month perspective, the costs were equal, whereas patients in the laparoscopic-surgery group gained 0.011 quality-adjusted life years compared to patients in the open-surgery group (P = 0.001).

CONCLUSIONS

In patients undergoing parenchyma-sparing liver resection for colorectal metastases, laparoscopic surgery was associated with significantly less postoperative complications compared to open surgery. Laparoscopic resection was cost-effective compared to open resection with a 67% probability. The rate of free resection margins was the same in both groups. Our results support the continued implementation of laparoscopic liver resection.