Anterior approach for pure laparoscopic donor right hepatectomy

Laparoscopic Donor Left Lateral Sectionectomy Using the Glissonean Pedicle Approach: Technical Details With Video

INTRODUCTION

Pure laparoscopy for living donor hepatectomy is gaining popularity due to its advantages. However, despite the long-standing application of laparoscopic donor left lateral sectionectomy, the dissection of the Glisson branch, portal vein, and biliary ducts, particularly those of the caudate lobe, remains insufficiently described. Although the Glissonean approach offers easy standardization for hilar dissection, clear landmarks for parenchymal transection, and reduces postoperative bile leakage, it has not been widely adopted in laparoscopic donor hepatectomy. Here, we introduce a modified Glissonean pedicle approach to address the movement restrictions in laparoscopic surgery.

SURGICAL TECHNIQUE

After liver mobilization, the Glisson of Spiegel lobe (G1L) was divided, followed by encircling the left Glissonean pedicle. A tape for the liver hanging maneuver was placed from the right edge of the left Glissonean pedicle, along the Arantius plate, to the left edge of the left hepatic vein. When the parenchymal transection was completed, the left hepatic vein was automatically taped. The left hepatic artery and left portal vein were exposed, and some branches of P1 were divided to lengthen for anastomosis. The left hepatic duct was taped by removing the left hepatic artery and left hepatic vein from the left Glissonean pedicle. The left hepatic duct was divided under intraoperative cholangiography. Next, the left hepatic artery, left portal vein, and left hepatic vein were sequentially divided, and the graft liver was retrieved.

DISCUSSION

Our Glissonean approach can help standardize donor left lateral sectionectomy, minimize the exposure of the left hepatic duct, and clarify B1 branch dissection.

Risk-Adjusted Assessment of the Learning Curve for Pure Laparoscopic Donor Hepatectomy for Adult Recipients

BACKGROUND

Studies on pure laparoscopic donor hepatectomy (PLDH) have been reported. However, only few studies have reported on the learning curve of PLDH. In this report, we aimed to determine the learning curve of PLDH in adult patients using cumulative sum (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) analyses.

METHODS

The data of donors who underwent PLDH at a single center between December 2012 and May 2022 were retrospectively reviewed. The learning curve was evaluated using the CUSUM and RA-CUSUM methods based on surgery duration.

RESULTS

Forty-eight patients were finally included in the present study. The mean operation time was 393.6 ± 80.3 min. PLDH was converted to laparotomy in three cases (6.3%). According to the Clavien-Dindo classification, nine cases (18.8%) had higher-than-grade III postoperative complications and the most frequent complications were biliary complications. The CUSUM graph shows two peaks, at the 13th and 27th case. The multivariate analysis revealed that a body mass index ≥ 23 kg/m2 and intraoperative cholangiography were the only factors that were independently associated with longer operation time. Based on these results, an RA-CUSUM analysis was performed to assess the learning curve, which showed a decrease in the learning curve after 33 to 34 PLDH procedures.

CONCLUSIONS

A learning curve effect was demonstrated in this study after 33 to 34 PLDH procedures. There are relatively many biliary complications, and it is necessary to further examine the method of bile duct transection.

Efficacy of Standardized Process Management of Early Postoperative Enteral Nutrition After Laparoscopic Hepatectomy: A Randomized Controlled Trial

BACKGROUND

We sought to investigate the efficacy of standardized process management of early postoperative enteral nutrition in patients undergoing laparoscopic hepatectomy.

METHODS

From January 2022 to January 2023, a total of 98 patients undergoing laparoscopic hepatectomy in our hospital were enrolled in this prospective study. The participants were allocated into the study group (49 cases, given standardized process management of early postoperative enteral nutrition) and the control group (49 cases, given conventional early postoperative enteral nutrition) based on a random number table. Observation indicators included postoperative recovery, nutritional status, quality of life, and complications.

RESULTS

The time of first anal exhaust, eating, off-bed, first defecation, and postoperative hospital stay in the 2 groups was significantly shorter than those in the control group ( P <0.05). After the intervention, the levels of transferrin, prealbumin, and albumin in the study group were evidently higher than those in the control group ( P <0.05). The scores of overall health, body pain, body function, physiological function, vitality, social function, emotional function, and mental health in the study group were significantly higher than those in the control group after intervention ( P <0.05).

CONCLUSIONS

The standardized process management of early postoperative enteral nutrition showed promising results in effectively improving the nutritional status, rehabilitation, and quality of life, as well as reducing the incidence of related complications among patients undergoing laparoscopic hepatectomy, which supports a wide application in clinical practice.

Long-term outcomes of laparoscopic liver resection versus open liver resection for hepatocellular carcinoma: A single-center 10-year experience

Background

Laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) has increased. However, the long-term outcomes of LLR for HCCs should be validated further. Besides, the validity of laparoscopic minor liver resection in difficult segments (1, 4a, 7, 8) (LMLR-DS) and laparoscopic major hepatectomy (LMH) for HCCs need to be studied.

Methods

A total of 1773 HCC patients were collected: 683 received LLR and 1090 received OLR. Propensity score matching (PSM) with 1:1 ratio was used to eliminate the selection bias. Short-term and long-term outcomes were compared. In subgroup analyses, the validity of LMLR-DS or LMH for HCCs was studied.

Results

After PSM, 567 patients were in LLR or OLR group. LLR had lower intraoperative blood-loss and shorter postoperative hospital-stays than OLR. The postoperative complications were lower in LLR group (23.8% vs. 32.8%, P=0.001). The Overall survival (OS) and disease-free survival (DFS) had no significant difference between LLR and OLR groups (P=0.973, P=0.812). The cumulative 1-, 3-, and 5-year OR rates were 87.9%, 68.9%, and 57.7% for LLR group, and 85.9%, 68.8%, 58.8% for OLR group. The cumulative 1-, 3-, and 5-year DFS rates were 73.0%, 51.5%, 40.6% for LLR group, and 70.3%, 49.0%, 42.4% for OLR group. In subgroup analyses, 178 patients were in LMLR-DS or open surgery (OMLR-DS) group after PSM. LMLR-DS had lower intraoperative blood-loss and shorter postoperative hospital-stays than OMLR-DS. The postoperative complications were lower in LMLR-DS group. The OS and DFS had no difference between LMLR-DS and OMLR-DS groups. The cumulative 5-year OR and DFS rates were 61.6%, 43.9% for LMLR-DS group, and 66.5%, 47.7% for OMLR-DS group. In another subgroup analyses, 115 patients were in LMH or open major hepatectomy (OMH) group. LMH had lower blood-loss and shorter postoperative hospital-stays than OMH. The complications, OS and DFS had no significantly differences between two groups. The cumulative 5-year OR and DFS rates were 44.3%, 29.9% for LMH group, and 44.7%, 33.2% for OMH group.

Conclusions

LLR for HCCs showed better short-term outcomes and comparable long-term outcomes with OLR, even for patients who received LMLR-DS or LMH. LLR could be reliable and recommended for HCC treatment.

Is Laparoscopic Hepatectomy Safe for Giant Liver Tumors? Proposal from a Single Institution for Totally Laparoscopic Hemihepatectomy Using an Anterior Approach for Giant Liver Tumors Larger Than 10 cm in Diameter

BACKGROUND

The efficacy and safety of laparoscopic liver resections for liver tumors that are larger than 10 cm remain unclear. We developed a safe laparoscopic right hemihepatectomy for giant liver tumors using an anterior approach.

METHODS

Eighty patients who underwent laparoscopic hemihepatectomy between January 2011 and December 2021 were divided into a nongiant tumor group (n = 65) and a giant tumor group (n = 15) for comparison.

RESULTS

The median operating time, amount of blood loss, and length of postoperative hospital stay did not differ significantly between the nongiant and giant tumor groups. The sizes of the tumors and weights of the resected liver were significantly larger in the giant tumor group. A comparison between a nongiant group (n = 23) and a giant group (n = 12) treated with laparoscopic right hemihepatectomy showed similar results.

CONCLUSIONS

Laparoscopic hemihepatectomy, especially that performed on the right side, for giant tumors larger than 10 cm can be performed safely. Surgical techniques for giant liver tumors have been standardized, and their application is expected to spread widely in the future.

Pure Laparoscopic Living Donor Left Lateral Sectionectomy Using Glissonean Approach and Original Bridging Technique

BACKGROUND

Living donor liver transplantation (LDLT) is the final treatment for children with end-stage liver disease. Congenital biliary atresia (CBA) is the most common disease requiring LDLT in Japan, and a left lateral sector graft is preferably procured owing to its anatomic predictivity and identical graft volume for preschool recipients. Laparoscopic left lateral sectionectomy (L-LLS) for LDLT has been recently established; however, there is no report about the innovative technique in L-LLS. The aim of this study was to introduce our L-LLS using the Glissonean approach and bridging technique for pediatric LDLT.

MATERIALS AND METHODS

From September 2017 to September 2020, 5 cases of L-LLS for pediatric LDLT because of CBA were performed and we performed L-LLS using the original technique on their donors. In this novel procedure, the left Glissonean pedicle was encircled at the parenchymal side of the Laennec capsule after mobilization of the lateral sector and visualization of the left hepatic vein. Then, we passed 2 tapes through the encircled Glissonean pedicle at the hepatic side and the duodenal side, as the caudate lobe branch is enclosed like a bridge. By virtue of this bridging technique, we encircled the caudate lobe branch alone by switching the tape, and we clipped and divided it; this technique secured an adequately long hepatic duct on the graft side to perform a hepaticojejunostomy. The left hepatic duct was divided after indocyanine green fluorescence cholangiography, and the left hepatic artery and portal vein were divided as well. Finally, the left hepatic vein was transected and procured from an extended intraumbilical incision.

RESULTS

We achieved L-LLS by using the Glissonean approach and the bridging technique in the 5 donors. The median operating time and blood loss were 282 (268 to 332) minutes and 34 (25 to 75) mL, respectively. There was no conversion to hybrid or open LLS and no postoperative complications. Regarding recipient outcomes, hepatic artery thrombosis occurred on postoperative day 4 in a 5-year-old female. All grafts function well and all recipients are alive after discharge (range of observation period, 3 to 26 mo).

CONCLUSIONS

We herein present standardized L-LLS using the Glissonean approach and bridging technique for pediatric LDLT. Our technique can secure a longer margin of the left hepatic duct for recipients' hepaticojejunotomy. Our results have demonstrated the advantage in pediatric LDLT, especially in patients with CBA after the Kasai procedure.