Clinical impact of laparoscopic hepatectomy: technical and oncological viewpoints

Perioperative and short-term outcomes of laparoscopic liver resection for recurrent hepatocellular carcinoma: A retrospective study comparing open hepatectomy

Background

To compare the perioperative and short-term outcomes of laparoscopic liver resection (LLR) and open liver resection (OLR) in recurrent hepatocellular carcinoma (rHCC) based on propensity score matching (PSM) to investigate therapeutic safety, efficacy, and value for clinical application.

Methods

Forty-nine patients with rHCC who underwent surgery at Wenzhou People’s Hospital between January 2017 and March 2022 were retrospectively analyzed and classified into LLR (n=30) and OLR (n=22) cases based on the surgical method. Thirty-eight patients were screened using PSM for data analysis to compare basic clinical characteristics, perioperative outcomes, and postoperative recurrence in both groups.

Results

Before PSM, the tumour diameter was larger, tumor staging (BCLC staging system), intraoperative blood loss, units of blood transfused, constituent ratio of liver cirrhosis, incidence of MVI and intravascular tumour thrombus and postoperative complication were higher, and duration of hospital stay was significantly longer in the OLR group compared to those in the LLR group (p < 0.05). After PSM, there were no significant differences regarding tumour diameter, MVI incidence, blood transfusion amount or postoperative complication rate in the LLR and OLR groups. The tumor staging, incidence of vascular cancer thrombus, intraoperative blood loss and postoperative duration of hospitalisation were significantly higher in the OLR group than in the LLR group (p<0.05). The difference in recurrence-free survival (RFS) between the two groups was not statistically significant (p = 0.383).

Conclusion

LLR for recurrent hepatocellular carcinoma can reduce intraoperative blood loss and postoperative complication rate, shorten the duration of hospitalisation, and is superior to OLR regarding perioperative and short-term efficacy, demonstrating good safety and feasibility.

Robotic Versus Open Liver Resection in Hepatocarcinoma: Surgical and Oncological Outcomes

BACKGROUND

Minimally invasive approaches are spreading in every field of surgery, including liver surgery. However, studies comparing robotic hepatectomy with the conventional open approach regarding oncologic outcomes for hepatocellular carcinoma are limited.

MATERIALS AND METHODS

We retrospectively reviewed demographics characteristics, pathologic features, surgical, and oncological outcomes of patients who underwent robotic and conventional open liver resection for hepatocellular carcinoma.

RESULTS

No significant differences in demographics features, tumor size, tumor location, and type of liver resection were found. The morbidity rate was similar, 23% for the open group versus 17% of the robotic group (P=0.605). Perioperative data analysis showed a greater estimated blood loss in patients who underwent open resection, if compared with robotic group (P=0.003). R0 resection and disease-free resection margins showed no statistically significant differences. The 3-year disease-free survival of the robotic group was comparable with that of the open group (54% vs. 37%; P=0.592), as was the 3-year overall survival (87% vs. 78%; P=0.203).

CONCLUSIONS

The surgical and the oncological outcomes seem to be comparable between minimally invasive and open hepatectomy. Robotic liver resections are effective, and do not compromise the oncological outcome, representing a reasonable alternative to the open approach.

Laparoscopic Liver Resection: A 7-Year Experience of 123 Resections in a Single Institution

There has been a significant increase in the use of laparoscopic liver resection (LLR) over the past 2 decades. This study aimed to analyze the outcomes associated with LLR at a single tertiary care hospital. Patients with benign or malignant tumors who underwent LLR by a single surgeon from January 2012 to November 2019 were identified. There were 123 patients who underwent LLR in the study period; 52% were men, and the median age was 61 (24-90) years. Five patients (4.1%) had unplanned conversion to open resection. Ninety-five patients (77.2%) had a wedge resection or single segmentectomy, and 28 (22.8%) underwent resection of 2+ liver segments. Seventy-one cases (57.7%) were for hepatocellular carcinoma (HCC), 24 (19.5%) for colorectal metastasis, and 28 (22.8%) were for other benign and malignant tumors. Median operative time was 239 (range 89-526) minutes. Mean estimated blood loss was 192 (range 0-1800) mL. The median length of stay (LOS) overall was 2 (range 0-9) days. From 2017 to 2019, the mean LOS was 1.2 days, compared to a mean LOS of 3.3 days from 2012 to 2016. More cases were performed as same-day surgery from 2017 onward; 19 patients (33.9%) had same-day surgery from 2017 to 2019, in comparison to only 1 patient (1.5%) in the period of 2012-2016 (P < .0001). Overall, 28 patients (22.8%) experienced postoperative morbidity; major postoperative morbidity occurred in 4 patients (3.3%). The 90-day mortality was .8%, and the 30-day readmission rate was 5.7%. In conclusion, LLR can be performed safely to treat liver tumors, and LOS decreased over time. Although overall morbidity is moderate, serious morbidity is low, as was the readmission rate. Laparoscopic wedge resection may be a feasible option as an outpatient procedure in select patients.

Elderly Hepatocellular Carcinoma Patients: Open or Laparoscopic Approach?

It remains unclear whether the short-term benefits and long-term outcomes of laparoscopic liver resection (LLR) accrue to elderly patients with medical comorbidities. The aim of the present study was to compare the outcomes between LLR and open liver resection (OLR) in elderly patients (≥65 years) with solitary, treatment-naïve solitary hepatocellular carcinoma (HCC). From January 2013 to August 2017, 256 elderly patients with solitary treatment-naive HCC underwent liver resection. All patients were Child–Pugh class A and older than 65 years. The OLR and LLR groups contained 160 and 96 patients, respectively. The median tumor size in the OLR group was significantly larger than that in the LLR group (3.9 vs. 2.6 cm), but the tumor size did not differ between the two groups after matching. The median operation time, blood loss, transfusion rate, and postoperative complications in the OLR group did not differ from those in the LLR group, but the operation time in the LLR group was longer than that in the OLR group after matching. The median hospitalization in the LLR group was significantly shorter than that in the OLR group. Disease-free survival (DFS) in the LLR group was better than that in the OLR group before and after matching, but the difference was not significant. Patient survival (PS) in the LLR group was similar to that in the OLR group. LLR is feasible and safe for elderly patients with solitary, treatment-naïve HCC. The short- and long-term benefits of LLR are evident in geriatric oncological liver surgery patients.

Surgical Glove Technique for Laparoscopic Liver Resection

BACKGROUND

Liver tumors located in segments 7 and 8 pose a technical challenge to standard laparoscopic liver resection. Intraoperative placement of a surgical glove behind the right liver after the right triangular ligament and coronary ligament are divided facilitates liver exposure during parenchymal transection and control of the bleeding at the deeper part of the parenchymal plane. The aim of this study was to describe our standardized technique in detail and to assess the feasibility of this technique in patients with different clinical backgrounds and clarify the limits of this technique.

METHODS

Medical records of 20 consecutive patients considered for laparoscopic liver resection using the surgical glove technique were reviewed.

RESULTS

All patients had malignant disease and the vast majority of patients had colorectal metastatic tumors. Overall, 65% of patients had tumors located in segment 8. Placing the surgical water glove could be achieved without complication in all 20 patients. One surgical glove was used in this series (usually size 6.5 to 7.5 is an adequate size). Time for preparing the surgical green water glove was estimated to be less than 1 min. The mean duration of operation ranged from 136 to 332 min (median, 240 min). Intermittent Pringle's maneuver was applied in all patients with a median time of 33 min. No additional intercostal trocars were required. There was no intraoperative blood transfusion or conversion to open surgery. The median maximum size of the tumor was 23 mm. There was no operative mortality. Overall morbidity was 30%. Surgical margins were negative in 80% of patients.

CONCLUSIONS

The surgical glove technique is easy, reproducible, effective, and safe and can be applied to both laparoscopic and robotic liver resection.

Surgical and oncological outcomes after laparoscopic vs. open major hepatectomy for hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

The short- and long-term prognoses are unclear following laparoscopic major hepatectomy (LMH) for hepatocellular carcinoma (HCC). We performed a meta-analysis to compare the surgical and oncological outcomes of LMH vs. open major hepatectomy (OMH) in patients with HCC.

METHODS

All studies comparing LMH with OMH for HCC published until April 2019 were identified independently by searching PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials. We analyzed data for surgical and oncological outcomes, namely, operative time, intraoperative blood loss, blood transfusion rate, postoperative morbidity, major complications, mortality, hospital stay, margin distance, negative margin rate, long-term overall survival, and corresponding disease-free survival (DFS).

RESULTS

We included 13 studies involving 1,225 patients with HCC (LMH: 534 patients; OMH: 691 patients) in the meta-analysis. Regarding short-term outcomes, the pooled data showed that LMH was associated with longer operative time [weighted mean difference (WMD): 72.14 min; 95% confidence interval (CI): 43.07-101.21; P<0.00001], less blood loss (WMD: -102.32 mL; 95% CI: -150.99 to -53.64; P<0.0001), shorter hospital stay (WMD: -3.77 d; 95% CI: -4.95 to -2.60; P<0.00001), lower morbidity [risk difference (RD): -0.01; 95% CI: -0.16 to -0.06; P<0.00001], and lower major complication rates (RD: -0.08; 95% CI: -0.11 to -0.05; P<0.00001). However, the need for blood transfusion (RD: -0.01; 95% CI: -0.06 to 0.05; P=0.78), mortality (RD: -0.01; 95% CI: -0.02 to 0.01; P=0.57), margin distance (WMD: 0.05 mm; 95% CI: -0.1 to 0.19; P=0.52), and negative margin rate (RD: 0.01; 95% CI: -0.03 to 0.05; P=0.65) were significantly comparable between the two groups. Regarding long-term outcomes, there was no difference in 3-year DFS [hazard ratio (HR): 0.99; 95% CI: 0.72-1.37; P=0.95], 3-year overall survival (HR: 1.25; 95% CI: 0.70-2.21; P=0.45), 5-year DFS (HR: 0.94; 95% CI: 0.64-1.38; P=0.76), and 5-year overall survival (HR: 0.94; 95% CI: 0.45-1.99; P=0.88).

CONCLUSIONS

LMH can be performed as safely as OMH in select patients and provides improved short-term surgical outcomes without affecting long-term survival. However, confirming our results requires more evidence from high-quality and prospective randomized controlled trials.

Surgical and oncological outcomes after ultrasound-guided robotic liver resections for malignant tumor. Analysis of a prospective database

AIM

Robotic surgery is thought to have a role in widening the application of minimally invasive liver surgery. Nonetheless, data concerning surgical results for liver malignancies are presently still lacking. We aimed to evaluate the surgical and oncological outcomes of ultrasound guided robotic liver resections for hepatic malignancies.

METHODS

All consecutive patients who received robotic resection of primary and secondary liver malignancies from September 2008 to January 2017 were analyzed. The same surgical team performed all procedures following the principle of parenchymal-sparing surgery.

RESULTS

From a total of 51 patients, 13 patients (25%) underwent major and 38 (75%) minor hepatectomy. No mortality occurred. Two procedures were converted to open surgery. Five patients experienced major complications, with a reintervention rate of 6%. Median hospital stay was 5 days.

CONCLUSIONS

Robotic surgery is a safe and feasible procedure for liver resection even when dealing with malignancies. Our data show that robotic surgery can be considered a valid option to treat patients with liver malignancies in a minimally invasive manner, without compromise the oncological results.

Is the treatment outcome of hepatocellular carcinoma inferior in elderly patients?

In view of the increasing life expectancy in different parts of the world, a larger proportion of elderly patients with hepatocellular carcinoma (HCC) requiring oncological treatment is expected. The clinicopathological characteristics of HCC in elderly patients and in younger patients are different. Elderly patients, in general, also have more comorbidities. Evaluation of the efficacy of different HCC treatment options in elderly patients is necessary to optimize treatment outcomes for them. Treatment modalities for HCC include hepatectomy, liver transplantation, radiofrequency ablation, transarterial chemoembolization, and molecular-targeted therapy with sorafenib. In this review, current evidence on the risks and outcomes of the different HCC treatments for elderly patients are discussed. According to data in the literature, elderly patients and younger patients benefited similarly from HCC treatments. More clinical data are needed for the determination of selecting criteria on elderly HCC patients to maximize their chance of getting the most appropriate and effective treatments. As such, further studies evaluating the outcomes of different HCC treatment modalities in elderly patients are warranted.

Long-term perioperative outcomes of pure laparoscopic liver resection versus open liver resection for hepatocellular carcinoma: a retrospective study

BACKGROUND

Laparoscopic treatment for hepatocellular carcinoma (HCC) has increased. We retrospectively compared the perioperative and long-term oncological outcomes of laparoscopic liver resection (LLR) with those of open liver resection (OLR) for hepatocellular carcinoma (HCC) in well-matched patient groups using propensity score matching (PSM).

METHODS

We reviewed medical records of patients with HCC who underwent liver resection between July 2007 and April 2016 at our center. In total, 2335 patients were included in this study and divided into LLR (n = 264) and OLR (n = 2071) groups. For group comparisons, 1:2 PSM was used with covariates of baseline characteristics, including tumor characteristics and surgical liver resection procedures.

RESULTS

After PSM, there were 217 and 434 patients in the LLR and OLR groups, respectively. The LLR group had shorter hospital stays (8.9 vs. 14.8 days; P < 0.001) and lower postoperative morbidity (6.5% vs. 12.0%; P = 0.022). The 1-, 3-, and 5-year overall survival rates were 98.1%, 87.0%, and 78.6%, respectively, for the LLR group, and 98.3%, 90.8%, and 84.3%, respectively, for the OLR group (P = 0.570). The 1-, 3-, and 5-year disease-free survival rates were 81.0%, 62.0%, and 49.1%, respectively, for the LLR group, and 85.3%, 64.7%, and 56.2%, respectively, for the OLR group (P = 0.563).

CONCLUSIONS

Long-term oncological outcomes were comparable between LLR and OLR for selected patients. LLR was associated with multiple benefits, even for selected patients with cirrhosis who underwent major hepatectomy. LLR for HCC performed by an experienced surgeon could be considered a safe and feasible alternative to OLR for selected patients.

Outcomes of robotic liver resections for colorectal liver metastases. A multi-institutional analysis of minimally invasive ultrasound-guided robotic surgery

BACKGROUND

Current evidence supporting robotics to perform minimally invasive liver resection is based on single center case series reporting surgical outcomes in heterogeneous groups of patients. On the contrary, relatively scarce data specifically focusing on secondary hepatic malignancies is available. The objective of this study is to assess short- and long-term outcomes following liver resection for colorectal liver metastasis on a multi-institutional series of patients.

METHODS

All consecutive patients undergoing robotic surgery for colorectal liver metastasis at three different tertiary hospitals over a 10-year time frame were included in this analysis. All patients received ultrasound-guided liver resection according to tumor location following the principle of parenchymal sparing surgery. Perioperative, clinicopathologic and oncological outcomes were assessed.

RESULTS

A total of 59 patients underwent liver resection. There were 7 cases of conversion to open surgery. The postoperative complication rate was 27%, 5% being the rate of major morbidity. Overall, the mean postoperative hospital stay was 6 days and no mortality occurred. R0 resection was achieved for 92% of lesions. At a mean follow-up of 19 months, the 1-year and 3-year DFS was 83.5% and 41.9%, while the 1-year and 3-year OS was 90.4% and 66.1%, respectively.

CONCLUSIONS

Robotic liver surgery does not impair surgical outcome and oncological results in patients with liver metastases from colorectal cancer.

Real-Time Navigation Guidance Using Fusion Indocyanine Green Fluorescence Imaging in Laparoscopic Non-Anatomical Hepatectomy of Hepatocellular Carcinomas at Segments 6, 7, or 8 (with Videos)

Background

The right area and posterior area of the liver are considered relatively unfavorable portions for laparoscopic hepatectomy (LH) due to the limited gross inspection and poor tactile feedback. Fusion indocyanine green fluorescence fusion imaging (ICGFI) may be a reliable real-time navigation tool for LH. The aim of the present study was to evaluate the usefulness of ICGFI for laparoscopic non-anatomical hepatectomy in patients with hepatocellular carcinoma at the right area and posterior area.

Material/Methods

We conducted a retrospective comparison of surgical and perioperative outcomes for 21 hepatocellular carcinoma patients who had undergone LH with fusion ICGFI guidance and 21 matched patients who underwent the procedure without the guidance of ICGFI between November 2017 to August 2018.

Results

Preoperative characteristics were comparable between the groups. Tumor fluorescence images were clearly displayed in all 21 ICGFI patients, providing precise information about tumor location. Laparoscopic parenchymal transection could be performed safely and quickly through tracing the fusion ICGFI on the cutting surface. Operation time was significantly reduced in the ICGFI group. Postoperative complications were comparable between the groups. There was no positive margin in either group.

Conclusions

These preliminary data suggest that fusion ICGFI may be a useful tool that provides real-time navigation for non-anatomical LH. It may assist in the safe and accurate completion of LH for tumors located at the right posterior areas. Further studies are needed to fully clarify the advantages and disadvantages of ICGFI in LH, including short-term perioperative outcomes and long-term prognosis.

Minimally invasive management of the entire treatment sequence in patients with stage IV colorectal cancer: a propensity-score weighting analysis

BACKGROUND

In patients with stage IV colorectal cancer (CRC), minimally invasive surgery (MIS) may offer optimal oncologic outcome with low morbidity. However, the relative benefit of MIS compared to open surgery in patients requiring multistage resections has not been evaluated.

METHODS

Patients who underwent totally minimally invasive (TMI) or totally open (TO) resections of CRC primary and liver metastases (CLM) in 2009-2016 were analyzed. Inverse probability of weighted adjustment by propensity score was performed before analyzing risk factors for complications and survival.

RESULTS

The study included 43 TMI and 121 TO patients. Before and after adjustment, TMI patients had significantly less cumulated postoperative complications (41% vs. 59%, p = 0.001), blood loss (median 100 vs. 200 ml, p = 0.001) and shorter length of hospital stay (median 4.5 vs. 6.0 days, p < 0.001). Multivariate analysis identified TO approach vs. MIS (OR = 2.4, p < 0.001), major liver resection (OR = 4.4, p < 0.001), and multiple CLM (OR = 2.3, p = 0.001) as independent risk factors for complications. 5-year overall survival was comparable (81% vs 68%, p = 0.59).

CONCLUSION

In patients with CRC undergoing multistage surgical treatment, MIS resection contributes to optimal perioperative outcomes without compromise in oncologic outcomes.

Which approach is preferred in left hepatocellular carcinoma? Laparoscopic versus open hepatectomy using propensity score matching

Background

Laparoscopic liver resection has been reported as a safe and effective approach for the management of hepatocellular carcinoma (HCC). However, its perioperative and oncological outcomes have not been evaluated in left hepatectomy patients. The aim of the present study is to compare the outcomes of left hepatectomy through laparoscopic and open approaches in left HCC.

Methods

From December 2012 to October 2016, laparoscopic left hepatectomy (LLH) was performed in 40 patients and open left hepatectomy (OLH) was performed in 80 patients. All clinical data were analyzed retrospectively. Propensity score matching of patients in a 1:1 ratio was conducted based on tumor size and presence of microvascular invasion.

Results

Tumor size and presence of microvascular invasion were higher in the OLH group than the LLH group (P < 0.05). However, the operative time was longer in the LLH group than in the OLH group (266 min vs. 239 min; P = 0.005). The median postoperative hospital stay was significantly shorter in the LLH group than in the OLH group before and after matching (9 days vs. 13 days; P < 0.001). The incidence of complications in the LLH and OLH groups was 10.0 and 7.5%, respectively. The disease-free survival (DFS) and overall survival (OS) in the LLH group were not different from those in the OLH group after propensity score matching.

Conclusions

A laparoscopic approach is feasible and safe for left HCC. The oncologic outcome of LLH is comparable to that of OLH.

The Asia Pacific Consensus Statement on Laparoscopic Liver Resection for Hepatocellular Carcinoma: A Report from the 7th Asia-Pacific Primary Liver Cancer Expert Meeting Held in Hong Kong

BACKGROUND

Laparoscopic liver resection has been gaining momentum, and it has become an accepted practice after the two international consensus conferences where experts worked up guidelines to standardize this approach and improve its safety. However, most laparoscopic hepatectomies were performed in patients with liver metastases. The concurrent presence of liver cirrhosis with hepatocellular carcinoma (HCC) poses a great challenge to clinicians trying to establish a routine use of laparoscopic liver resection for HCC.

SUMMARY

The first Asia Pacific consensus meeting on laparoscopic liver resection for HCC was held in July 2016 in Hong Kong. A group of expert liver surgeons with experience in both open and laparoscopic hepatectomy for HCC convened to formulate recommendations on the role and perspective of laparoscopic liver resection for primary liver cancer. The recommendations consolidate the most recent evidence pertaining to laparoscopic hepatectomy together with the latest thinking of practicing clinicians involved in laparoscopic hepatectomy, and give detailed guidance on how to deploy the treatment effectively for patients in need.

KEY MESSAGE

The panel of experts gathered evidence and produced recommendations providing guidance on the safe practice of laparoscopic hepatectomy for patients with HCC and cirrhosis. The inherent advantage of the laparoscopic approach may result in less blood loss if the procedure is performed in experienced centers. The laparoscopic approach to minor hepatectomy, particularly left lateral sectionectomy, is a preferred practice for HCC at experienced centers. Laparoscopic major liver resection for HCC remains a technically challenging operation, and it should be carried out in centers of excellence. There is emerging evidence that laparoscopic liver resection produces a better oncological outcome for HCC when compared with radiofrequency ablation, particularly when the lesions are peripherally located. Augmented features in laparoscopic liver resection, including indocyanine green fluorescence, 3D laparoscopy, and robot, will become important tools of surgical treatment in the near future. A combination of all of these features will enhance the experience of the surgeons, which may translate into better surgical outcomes. This is the first consensus workforce on laparoscopic liver resection for HCC, which is a unique condition that occurs in the Asia Pacific region.

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

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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