Routes for virtually guided endoscopic liver resection of subdiaphragmatic liver tumors

Left-lateral decubitus jackknife position for laparoscopic resection of right posterior liver tumors: A safe and effective approach

PURPOSE

To compare outcomes of LLR in VI/VII of the liver in Left-lateral Decubitus Jackknife Position (LDJP) and traditional Supine Position (SP). We used propensity score matching (PSM) to analyze clinical outcomes.

PATIENTS & METHODS

This study retrospectively analyzed patients undergoing LLR for liver tumors in segments VI and/or VII at Shandong Provincial Hospital from 2018 to 2023. A total of 218 cases were included (LDJP, n = 94; SP, n = 124). Matched 1:1 PSM groups were created and clinical indicators compared between groups.

RESULTS

218 LLR patients, 94 LDJP and 124 supine. After 1:1 PSM, each group had 62 patients. No significant differences in clinical or laboratory parameters. All surgeries were successful, 1 LDJP conversion to open resection and 4 SP conversions (P = 0.375). LDJP average surgery duration: 220.6 ± 29.9 min, supine position: 262.6 ± 35.6 min (P < 0.001). LDJP perioperative blood loss: 169.0 ± 74.4 mL, supine position: 231.6 ± 84.6 mL (P < 0.001). Four LDJP patients required intraoperative blood transfusion compared to 16 supine position patients (P = 0.012). All cases had negative margins postoperatively. No significant differences in postoperative complications (8 LDJP vs 9 supine, P = 0.675) or length of hospital stay (25 LDJP vs 26 supine, ≥ 7 days) (P = 1.000).

CONCLUSION

Laparoscopic partial hepatectomy in LDJP for hepatic VI/VII tumor safe and feasible. Reduces operative time, blood loss, transfusion requirement, improving outcomes.

Laparoscopic Liver Surgery Guided by Virtual Real-time CT-Guided Volume Navigation

BACKGROUND

Recently, virtual navigation system has been applied to hepatic surgery, enabling better visualization of intrahepatic vascular branches and location of tumor. Intraoperative ultrasonography (IOUS) is the most common form of image guidance during liver surgery. However, during laparoscopic hepatectomies (LH), IOUS has several limitations and its reliability has been poorly evaluated. The objective of this work is to evaluate VRCT (virtual real-time CT-guided volume navigation) during LH. This system aims to provide accurate anatomical orientation for surgeons enhancing the safety of LH.

METHODS

Twenty-seven hepatic neoplasms were resected laparoscopically at our institution under reference guidance of VRCT. During operation, electromagnetic tracking of the surgical instrument was used for navigating the direction of accurate liver transection.

RESULTS

Twenty-six (96.3%) of the 27 lesions (mean diameter 11 mm) were successfully performed under VRCT guidance. Average registration time was < 2 min. Average setup time was approximately 7 min per procedure. VRCT allows the surgeon to navigate liver transection with acceptable accuracy. The mean error was 12 mm. All surgical margins were negative and the mean histologic resection margin was 9 mm.

CONCLUSIONS

VRCT-guided LH is feasible and provides valuable real-time anatomical feedback during hepatic resections. Advancement of such systems to improve accuracy might greatly compensate for the limitation of laparoscopic IOUS.

Virtual reality with three-dimensional image guidance of individual patients' vessel anatomy in laparoscopic distal pancreatectomy

PURPOSE

Three-dimensional virtual endoscopy (3DVE) has the potential advantage of enhanced anatomic delineation and spatial orientation during laparoscopic procedures. In the present study, we aimed to evaluate the impact of 3DVE guidance in laparoscopic distal pancreatectomy (LDP).

METHODS

Thirty-eight patients presenting to our hospital with a variety of pancreatic tumors underwent preoperative computed tomography scanning to clearly define the major peripancreatic vasculature and correlate it with a 3DVE system (SYNAPSE VINCENT: Fujifilm Medical, Tokyo, Japan). This map served as the guide during preoperative planning, surgical education, and simulation and as intraoperative navigation reference for LDP. Operative records and pathological findings were analyzed for each procedure. Operative parameters were compared between the 38 patients in this study and 8 patients performed without 3DVE guidance at our institution.

RESULTS

The 3DVE navigation system successfully created a preoperative resection map in all patients. Relevant peripancreatic vasculature displayed on the system was identified and compared during the intervention. The mean blood loss in LDP performed under 3DVE guidance versus LDP without 3DVE was 168.5 +/- 347.6 g versus 330.0 +/- 211.4 g, p = 0.008 while and the operative time was 171.9 +/- 51.7 min versus 240.6 +/- 24.8 min, p = 0.001.

CONCLUSIONS

3DVE in conjunction with a "laparoscopic eye" creates a preoperative and intraoperative three-dimensional data platform that potentially enhances the accuracy and safety of LDP.

3D simulation assisted resection of giant hepatic mesenchymal hamartoma in children

OBJECTIVE

To evaluate the usefulness of Hisense Computer Assisted Surgery System (Hisense CAS) in pre-operative surgical planning and intra-operative navigation for resection of pediatric giant hepatic mesenchymal hamartoma (HMH).

METHODS

Five children with HMH underwent hepatectomy in our hospital. Pre-operative abdominal enhanced CT was performed for diagnosis and treatment planning. Using CT DICOM files, three-dimensional reconstruction was performed in three cases for operation planning and intra-operative navigation, with SID carrying out precise liver resection during the operation with Hisense CAS.

RESULT

Two patients underwent right and left lobe hepatectomy, respectively, based only on enhanced CT. In 3 patients, by using the Hisense CAS system, three-dimensional reconstruction of the liver and tumors was successfully completed, and virtual hepatectomy performed successfully according to surgical plans. Hisense CAS could clearly and directly indicate the HMH location and shape, as well as its relationship with the intra-hepatic Glisson system, assisting safe hepatectomy. All five patients recovered well from surgery without any complications, and pathological examinations confirmed that all cases were HMH. No recurrence was observed during the follow-up period of 3 months to 5 years.

CONCLUSION

Hisense CAS system is useful for preoperative planning and intra-operative navigation, assisting safer hepatectomy.

Systematic review of the feasibility and future of laparoscopic liver resection for difficult lesions

Laparoscopic liver resection (LLR) is now performed widely, but is difficult to accomplish in some anatomical locations, such as the posterosuperior segments (S7 and S8) and caudate lobe (S1). An international survey revealed that lesions in these locations are less frequently indicated for LLR than those in other segments. Recent reports from experienced centers document several case series and present technical tips for treating such lesions. The lateral approach using intercostal (transdiaphragmatic) trocars was reported to be useful for lesions in the posterosuperior segments with a semi- to full-decubitus position. The thoracoscopic approach was also reported to be useful for lesions just under the diaphragm dome, but the tumor location and patient selection should be considered carefully because pneumoperitoneum pressure and Pringle's maneuver cannot be applied. Several case series have described the feasibility of LLR for caudate lobe lesions, with similar operative outcomes to lesions in the posterosuperior segments, but this demands technical expertise. The caudal view of laparoscopy is advantageous for approaching the caudate lobe. We conducted a systematic review to clarify the feasibility of LLR for difficult lesions and discuss its current and future status.