Laparoscopic hepatectomy: indications and outcomes

Laparoscopic liver resection in Caroli disease: A single-centre case series

Background:

Liver resection is the treatment of choice for patients with localised Caroli disease. While liver resection was traditionally performed as open procedure, this case series aims to evaluate the safety and efficacy of minimally invasive, laparoscopic liver surgery in these patients.

Methods:

A systematic review of electronic case files of patients seen between April 2015 and December 2017 at the Department of Surgery, Charité University Hospital Berlin, was conducted. Patients with Caroli disease in whom laparoscopic liver resection had been performed were identified and analysed in this single-centre case series.

Results:

Seven patients who underwent laparoscopic liver surgery for Caroli syndrome were identified and presented with a median age of 49 (range = 44–66) years, of which four (57%) were female. Preoperatively, six patients were classified as the American Society of Anaesthesiologists (ASA) 2 and one patient as ASA 3. Two operations were performed as single-incision laparoscopic surgery, whereas the others were done as multi-incision laparoscopic surgery. One patient required a conversion to an open procedure. The length of operation varied between patients, ranging from 128 to 758 min (median = 355). The length of stay in the intensive care unit ranged from 0 to 2 days. Two patients presented with post-operative complications (Clavien–Dindo Grade ≥3a), whereas no patient died. In histopathological analysis, all patients demonstrated characteristic findings of Caroli disease and no cholangiocarcinoma was found.

Conclusion:

These results indicate that minimally invasive, laparoscopic liver surgery is a safe and efficacious treatment option for patients with Caroli disease who require liver resection.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evolution and revolution of laparoscopic liver resection in Japan

Due to important technological developments and improved endoscopic techniques, laparoscopic liver resection (LLR) is now considered the approach of choice and is increasingly performed worldwide. Recent systematic reviews and meta‐analyses of observational data reported that LLR was associated with less bleeding, fewer complications, and no oncological disadvantage; however, no prospective randomized trials have been conducted. LLR will continue to evolve as a surgical approach that improves patient's quality of life. LLR will not totally supplant open liver surgery, and major LLR remains to be technically challenging procedure. The success of LLR depends on individual learning curves and adherence to surgical indications. A recent study proposed a scoring system for stepwise application of LLR, which was based on experience at high‐volume Japanese centers. A cluster of deaths after major LLR was sensationally reported by the Japanese media in 2014. In response, the Japanese Society of Hepato‐Biliary‐Pancreatic Surgery conducted emergency data collection on operative mortality. The results demonstrated that mortality was not higher than that for open procedures except for hemi‐hepatectomy with biliary reconstruction. An online prospective registry system for LLR was established in 2015 to be transparent for patients who might potentially undergo treatment with this newly developed, technically demanding surgical procedure.

Secure, low-cost technique for laparoscopic hepatic resection using the crush-clamp method with a bipolar sealer

INTRODUCTION

Laparoscopic hepatectomy is difficult because surgeons must perform the transection using many (four and more) energy devices and without direct manual maneuvers. Here we introduce hepatic transection by the classical method with a few (two or three) energy devices.

MATERIALS AND SURGICAL TECHNIQUE

We performed laparoscopic hepatectomy for 40 patients with hepatic tumor and liver dysfunction. For parenchymal transection, we used bipolar radiofrequency coagulation forceps connected to a voltage-controlled electrosurgical generator and ultrasonic dissector. The demarcation of the liver surface was made by an ultrasonic dissector. Along the demarcation line, the blades of a BiClamp were opened slightly and inserted into the hepatic parenchyma. We clamped slowly, softly, and gradually, and a small amount of hepatic parenchyma was consequently coagulated and fractured. After the crush, the small vessels and intrahepatic bile duct that were sealed were left as atrophic strings, and the strings were divided by an ultrasonic dissector. Large vessels and Glisson's sheaths were left because of the small clamp. Large Glisson's sheaths and hepatic veins were ligated with a titanium clip or autosutures, and cut without bile leakage or bleeding. The mean operation time of the procedure was 196.9 min, mean blood loss was 69.9 mL, and mean postoperative hospitalization was 9.5 days. No blood transfusions were needed. Two cases had perioperative complications-one involving right shoulder pain and the other involving ascites due to liver dysfunction-but there were no serious postoperative complications.

DISCUSSION

The present results appear to demonstrate that this simple and safe method helps decrease intraoperative bleeding and shorten hospital stay.

Short-term and middle-term evaluation of laparoscopic hepatectomies compared with open hepatectomies: A propensity score matching analysis

AIM

To compare short-term results between laparoscopic hepatectomy and open hepatectomy using a propensity score matching.

METHODS

A patient in the laparoscopic liver resection (LLR) group was randomly matched with another patient in the open liver resection (OLR) group using a 1:1 allocated ratio with the nearest estimated propensity score. Patients of the LLR group without matches were excluded. Matching criteria included age, gender, body mass index, American Society of Anesthesiologists score, potential co-morbidities, hepatopathies, size and number of nodules, preoperative chemotherapy, minor or major liver resections. Intraoperative and postoperative data were compared in both groups.

RESULTS

From January 2012 to January 2015, a total of 241 hepatectomies were consecutively performed, of which 169 in the OLR group (70.1%) and 72 in the LLR group (29.9%). The conversion rate was 9.7% (n = 7). The mortality rate was 4.2% in the OLR group and 0% in the LLR group. Prior to and after propensity score matching, there was a statistically significant difference favorable to the LLR group regarding shorter operative times (185 min vs 247.5 min; P = 0.002), less blood loss (100 mL vs 300 mL; P = 0.002), a shorter hospital stay (7 d vs 9 d; P = 0.004), and a significantly lower rate of medical complications (4.3% vs 26.4%; P < 0.001).

CONCLUSION

Laparoscopic liver resections seem to yield better short-term and mid-term results as compared to open hepatectomies and could well be considered a privileged approach and become the gold standard in carefully selected patients.

Learning curve in laparoscopic liver surgery: a fellow's perspective

The learning curve for laparoscopic liver surgery is infrequently addressed in current literature. In this paper, we explored the challenges faced in embarking on laparoscopic liver surgery in a unit that did predominantly open liver surgery. In setting up our laparoscopic liver surgery program, we adopted skills and practices learnt during fellowships at various high volume centers in North America and Australia, with modifications to suit our local patients' disease patterns. We started with simple minor resections in anterolateral segments to build confidence, which allowed us to train the surgical and nursing team before progressing to more difficult resections. Inter institutional collaboration and exchange of skills also enabled the synergistic development of techniques for safe progression to more complex surgeries. Multimedia resources and international guidelines for laparoscopic liver surgery are increasingly accessible, which further guide the practice of this emerging field, as evidence continues to validate the laparoscopic approach in well selected cases.

Clinical comparison of laparoscopic and open liver resection after propensity matching selection

BACKGROUND

This study aimed to compare the radicality for and clinical advantages of laparoscopic liver resection, which is increasingly used, and the corresponding open procedure by propensity score matching analysis.

METHODS

We analyzed 260 hepatocellular carcinoma patients who underwent initial liver resection at our department between January 2003 and June 2011, including 60 laparoscopic (the Lap group) and 200 open cases (the Open group). Propensity scores were calculated for each patient via the use of various clinicopathologic features as covariates, and patients' survival was compared.

RESULTS

The Lap group had more women and patients of advanced age (n = 60) than the Open group (n = 200). Tumor size (2.3 cm vs 3.5 cm median), multiple tumors (18.3% vs 41.0%), vascular invasion (15.0% vs 36.5%), poor differentiation status (11.2% vs 24.5%), intraoperative bleeding (110 mL vs 420 mL; median), and operative time (277 minutes vs 312 minutes; median) were significantly more favorable in the Lap group than in the Open group because of a selection bias of the patients (Lap vs Open). The postoperative recurrence-free and overall survival rates were greater in the Lap group than in the Open group; however, when 35 patients from each group were analyzed after propensity score matching of clinicopathologic characteristics of the patients, intraoperative bleeding was lesser in the Lap group. The recurrence-free survival rates at 1, 3, and 5 years were 75.0%, 43.8%, and 43.8%, respectively, in the Lap group and 73.6%, 49.3%, and 37.2%, respectively, in the Open group, which indicated no significant differences (P = .954). Similarly, the overall survival rates at 1, 3, and 5 years were 93.9%, 82.1%, and 82.1%, respectively, in the Lap group and 94.3%, 85.2%, and 61.8%, respectively, in the Open group, indicating no significant differences between the 2 groups (P = .672).

CONCLUSION

Our results indicate that laparoscopic liver resection is comparable with the corresponding open procedure in clinical safety and prognostic efficacy.

Totally laparoscopic caudate lobe resection: technical aspects and literature review

The particular anatomic location of the hepatic caudate lobe between the hilar plate and inferior vena cava means that it is still considered unsuitable for laparoscopic measures and a difficult site even for conventional surgery. Here we describe the first case to be reported in the literature of caudate lobe resection for a single metastasis from breast adenocarcinoma that was completed using an exclusively laparoscopic procedure and a simplified scheme involving the placement of 4 trocars, without any need for conversion or the Pringle maneuver. The patient was 31 years old with a history of radical right mastectomy and chemotherapy. The patient's postoperative course was uneventful and she was discharged 4 days after the surgery. Twelve months on, she is currently alive and disease free.

Modified hepatic vascular occlusion facilitates hepatectomy for malignant hepatic tumor in laparoscopy

PURPOSE

The parenchymal transection and bleeding are important problems in laparoscopic hepatectomy (LH). The study aimed to evaluate the feasibility and safety of LH for a malignant hepatic tumor (MHT) with hepatic vascular occlusion (HVO) only using a monopolar electrocautery.

METHODS

A total of 31 patients' profiles, operative data, clinical outcomes, pathologic findings, and follow-up information were collected who underwent LH with HVO.

RESULTS

The median operative time was 176 minutes and the median postoperative hospital stay was 9 days. The median estimated blood loss was 310 mL. The median tumor size was 4.6 cm and the median surgical margin was 12 mm.The ischemia injury to the liver in patients subjected to selective HVO was less than that in patients subjected to the Pringle maneuver.

CONCLUSIONS

HVO facilitates LH in transecting liver parenchyma and reduces bleeding, making LH safe and feasible only using monopolar electrocautery in selected patients with malignancies. Moreover, the selective HVO have more advantages over the Pringle maneuver in decreasing ischemic injury.

An update on laparoscopic liver resection: The French Hepato-Bilio-Pancreatic Surgery Association statement

Laparoscopic liver resection has been recognized as a safe and efficient approach since the Louisville Conference in 2008, but its use still remains confined to experienced teams in specialized centers, and may lack some standardization. The 2013 Session of French Association for Hepatobiliary and Pancreatic Surgery (ACHBT) specifically focused on laparoscopic liver surgery and the particular aspects and issues arising since the 2008 conference. Our objective is to provide an update and summarize the current French position on laparoscopic liver surgery. An overview of the current practice of laparoscopic liver resections in France since 2008 is presented. The issues surrounding standardization for left lateral sectionectomy and right hepatectomy, hybrid and hand-assisted techniques are raised and discussed. Finally, future technologies and technical perspectives are outlined.

Accessory liver lobes: anatomical description and clinical implications

Accessory liver lobes are a rare condition and appear to be due to excessive development of the liver. The presence of an accessory hepatic lobe is often diagnosed incidentally and sometimes revealed if it develops torsion, especially in pedunculated forms. In most cases, the accessory lobe is located below the liver, i.e., infrahepatic. Riedel's lobe is the best-known example of an accessory lobe, corresponding to hypertrophy of segments V and VI. While accessories lobes can simulate tumors, there have also been reports of hepatocellular tumor(s) that developed in these accessory lobes. Based on a review of the literature, this update focuses on accessory hepatic lobes.

Laparoscopic liver resection for malignancy: A review of the literature

AIM: To review the published literature about laparoscopic liver resection for malignancy.

METHODS: A PubMed search was performed for original published studies until June 2013 and original series containing at least 30 patients were reviewed.

RESULTS: All forms of hepatic resections have been described ranging from simple wedge resections to extended right or left hepatectomies. The usual approach is pure laparoscopic, but hand-assisted, as well as robotic approaches have been described. Most studies showed comparable results to open resection in terms of operative blood loss, postoperative morbidity and mortality. Many of them showed decreased postoperative pain, shorter hospital stays, and even lower costs. Oncological results including resection margin status and long-term survival were not inferior to open resection.

CONCLUSION: In the hands of experienced surgeons, laparoscopic liver resection for malignant lesions is safe and offers some short-term advantages over open resection. Oncologically, similar survival rates have been observed in patients treated with the laparoscopic approach when compared to their open resection counterparts.

Laparoscopic liver resections in normal and cirrhotic livers: a retrospective analysis in a tertiary hepato-biliary unit

BACKGROUND

Liver surgery in patients with underlying liver disease results in higher mortality and morbidity rates compared to patients without underlying liver disease. Laparoscopy seems to have good results in patients with normal liver in terms of postoperative outcomes, but is more challenging in cirrhotic patients. Aim of this study was to evaluate the feasibility of laparoscopic liver resection both in normal and cirrhotic livers, and secondary endpoint was to compare the surgical results.

METHODS

We retrospectively evaluated 105 patients who underwent laparoscopic liver resection between November 2001 and January 2012. Candidates for laparoscopic liver resection were divided into two groups according to the presence or absence of an underlying liver disease.

RESULTS

105 patients (52.4% males, median age 56.1 years) were enrolled, and 37.1% had liver cirrhosis. Hepatocellular carcinoma in hepatitis C virus-related cirrhosis (89.7%) and liver metastases (57.6%) were the main indications for surgery in patients with cirrhosis and non-cirrhotic livers, respectively. None of the patients died post-operatively. Cirrhotic patients had greater blood loss (100 vs 50 ml; p<0.012) and longer hospital stays (6 vs 4 days; p<0.031) compared to non-cirrhotics.

CONCLUSIONS

Laparoscopic liver resections are safe and feasible procedures in both patients with cirrhotic and non-cirrhotic livers.

Benefits of simultaneous laparoscopic resection of primary colorectal cancer and liver metastases

INTRODUCTION

Recently, consensus on the optimal strategy for resectable synchronous colorectal liver metastases (LM) seems to have shifted toward simultaneous resection. However, there are still relatively few reports about simultaneous laparoscopic resection. The aim of this study is to evaluate the outcomes of patients who underwent simultaneous laparoscopic resection.

METHODS

We evaluated 14 patients who underwent simultaneous resection of primary colorectal cancer and LM in our hospital from 2004 to 2012. Patients were selected by matched pair analysis based on the number of LM (≤4) and tumor size (≤5 cm). We divided them into two groups: the simultaneous laparoscopic resection of primary colorectal cancer and LM (Lap-S) group (n = 7) and the simultaneous open resection of primary colorectal cancer and LM (Open-S) group (n = 7). Clinical and oncologic outcomes were compared between the groups.

RESULTS

The Lap-S patients were significantly older than the Open-S patients. The mean operative times of Lap-S and Open-S were 472 min and 466 min, respectively. The mean blood loss was significantly smaller in the Lap-S group (153 mL) than in the Open-S group (496 mL). There was no surgical mortality in either group. The incidence of postoperative complications in the Lap-S and Open-S groups was 12.3% and 33.0%, respectively. The mean postoperative hospital stay was significantly shorter in the Lap-S group (16 days) than in the Open-S group (36 days). There was no significant difference in long-term survival between the two groups.

CONCLUSION

Lap-S patients had equivalent long-term outcomes to Open-S patients. Therefore, given its technical feasibility and safety, Lap-S may be one of the most promising options in selected patients.

Long-term outcome of laparoscopic versus open liver resection for hepatocellular carcinoma: a case-controlled study with propensity score matching

BACKGROUND

Laparoscopic liver resection (LR) for hepatocellular carcinoma (HCC) is usually applied to superficial and left-side small lesions. Therefore, well designed comparative studies about the results of LR versus open liver resection (OR) for HCC are difficult and still uncommon. The aim of this study was to compare the perioperative and long-term oncologic outcomes of LR versus OR for HCC between well-matched patient groups.

METHODS

Between January 2000 and March 2012, 205 patients (43 with intent-to-treat with LR, 162 OR) underwent primary liver resection of less than three segments for HCC in our center. To select a comparison group, propensity score matching (PSM) was used at 1:1 ratio with covariates of baseline characteristics, including tumor characteristics. Outcomes were compared between the matched groups.

RESULTS

The two groups were well balanced by PSM and 29 patients were matched respectively. In LR, there was more non-anatomical resection (65.5 vs. 34.5 %; p = 0.012), less postoperative ascites (0.0 vs. 17.2 %; p = 0.025), and shorter hospital stay (7.69 ± 2.94 vs. 13.38 ± 7.37 days; p < 0.001). With the exception of these, there were no significant differences in perioperative and long-term outcomes. The 1-, 3- and 5-year survivals were 100, 100 and 92.2 % in LR, and 96.5, 92.2 and 87.7 % in OR (p = 0.267), respectively. The 1-, 3- and 5-year disease-free survivals were 81.7, 61.7 and 54.0 % in LR, and 78.6, 60.9 and 40.1 % in OR, respectively (p = 0.929).

CONCLUSIONS

The outcome of LR for HCC was technically feasible and safe in selected patients, and LR showed similar perioperative and long-term oncologic outcomes when compared with OR matched with PSM.

Laparoscopic liver resection for hepatocellular carcinoma: korean experiences

The development of laparoscopic liver resection (LLR) has been slow due to technical difficulties. Therefore, LLR has been limited to easily accessible lesions. Recently, this procedure has been well applied to hepatocellular carcinoma. However, until now, the indications for LLR have been tumors in the peripheral portion of the anterolateral segments of the liver (segments II, III, V and VI and the inferior part of IV according to the classification of Couinaud). Due to the growing interest in LLR, there have been many attempts to apply this technique in difficult locations. The lesions in the posterior or superior part of the liver (segments I, VII, VIII and the superior part of IV), which are considered to be poor indications for LLR, have been reported to be successfully operated on by laparoscopic surgery. Accordingly, this laparoscopic approach has become similar to open surgery in many ways. One of the major advancements of LLR is anatomic liver resection including major and minor resection. Laparoscopic mono- and bisegmentectomies have also become possible with growing experience. There are a variety of monosegmentectomies and bisegmentectomies. The common representatives of bisegmentectomies are left lateral sectionectomy, right anterior sectionectomy and right posterior sectionectomy. The common operative types of monosegmentectomies are S4, S5, and S6 monosegmentectomies, etc. Central bi-sectionectomy will also be discussed. The Glissonian approach has been useful for these types of anatomic liver resection. The difficulty of controlling hemorrhage has been overcome by performing meticulous surgical techniques with newly developed instruments, and intraoperative sonography has been used to locate the lesions and guide the resection plane even for deep-seated or invisible lesions. Further accumulation of experience and technical refinements will make theses challenging procedures more reproducible and safer.

Laparoscopic resection of hepatocellular carcinoma

The current treatment of HCC is truly multidisciplinary. Notwithstanding, surgical management remains the gold standard which other therapies are compared to. Operative management is divided into transplantation and resection; the latter is further subdivided among open and laparoscopic approaches. Resection has become safer, remains superior to locoregional treatments, and can be a life-prolonging bridge to transplantation. The decision to pursue laparoscopic resection for HCC is driven by safety and a view toward the long-term management of both the malignancy and the underlying liver disease. For patients with a solitary HCC <5 cm in segments 2, 3, 4b, 5, and 6, no evidence of extrahepatic tumor burden, compensated liver disease, and the absence of significant portal hypertension, laparoscopy has an important role. Under these circumstances, resection can be performed with reduced mortality and morbidity and equivalent oncologic outcomes, disease-free survival, and overall survival when compared with similarly selected cirrhotic patients undergoing open resection. Blood loss and transfusion requirements are low, and laparoscopy itself does not expose the patient to complications and does not increase the risk of cancer recurrence or dissemination. Finally, because HCC recurrence remains high in the cirrhotic liver, treatment following surgical resection mandates routine surveillance and treatment by locoregional therapy, reresection, or transplantation as required-the latter two of which are facilitated by an initial laparoscopic resection.

Meta-analysis of laparoscopic vs open liver resection for hepatocellular carcinoma

AIM: To conduct a meta-analysis to determine the safety and efficacy of laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC).

METHODS: PubMed (Medline), EMBASE and Science Citation Index Expanded and Cochrane Central Register of Controlled Trials in the Cochrane Library were searched systematically to identify relevant comparative studies reporting outcomes for both LLR and OLR for HCC between January 1992 and February 2012. Two authors independently assessed the trials for inclusion and extracted the data. Meta-analysis was performed using Review Manager Version 5.0 software (The Cochrane Collaboration, Oxford, United Kingdom). Pooled odds ratios (OR) or weighted mean differences (WMD) with 95%CI were calculated using either fixed effects (Mantel-Haenszel method) or random effects models (DerSimonian and Laird method). Evaluated endpoints were operative outcomes (operation time, intraoperative blood loss, blood transfusion requirement), postoperative outcomes (liver failure, cirrhotic decompensation/ascites, bile leakage, postoperative bleeding, pulmonary complications, intraabdominal abscess, mortality, hospital stay and oncologic outcomes (positive resection margins and tumor recurrence).

RESULTS: Fifteen eligible non-randomized studies were identified, out of which, 9 high-quality studies involving 550 patients were included, with 234 patients in the LLR group and 316 patients in the OLR group. LLR was associated with significantly lower intraoperative blood loss, based on six studies with 333 patients [WMD: -129.48 mL; 95%CI: -224.76-(-34.21) mL; P = 0.008]. Seven studies involving 416 patients were included to assess blood transfusion requirement between the two groups. The LLR group had lower blood transfusion requirement (OR: 0.49; 95%CI: 0.26-0.91; P = 0.02). While analyzing hospital stay, six studies with 333 patients were included. Patients in the LLR group were found to have shorter hospital stay [WMD: -3.19 d; 95%CI: -4.09-(-2.28) d; P < 0.00001] than their OLR counterpart. Seven studies including 416 patients were pooled together to estimate the odds of developing postoperative ascites in the patient groups. The LLR group appeared to have a lower incidence of postoperative ascites (OR: 0.32; 95%CI: 0.16-0.61; P = 0.0006) as compared with OLR patients. Similarly, fewer patients had liver failure in the LLR group than in the OLR group (OR: 0.15; 95%CI: 0.02-0.95; P = 0.04). However, no significant differences were found between the two approaches with regards to operation time [WMD: 4.69 min; 95%CI: -22.62-32 min; P = 0.74], bile leakage (OR: 0.55; 95%CI: 0.10-3.12; P = 0.50), postoperative bleeding (OR: 0.54; 95%CI: 0.20-1.45; P = 0.22), pulmonary complications (OR: 0.43; 95%CI: 0.18-1.04; P = 0.06), intra-abdominal abscesses (OR: 0.21; 95%CI: 0.01-4.53; P = 0.32), mortality (OR: 0.46; 95%CI: 0.14-1.51; P = 0.20), presence of positive resection margins (OR: 0.59; 95%CI: 0.21-1.62; P = 0.31) and tumor recurrence (OR: 0.95; 95%CI: 0.62-1.46; P = 0.81).

CONCLUSION: LLR appears to be a safe and feasible option for resection of HCC in selected patients based on current evidence. However, further appropriately designed randomized controlled trials should be undertaken to ascertain these findings.

Novel strategy for the control of postoperative pain: long-lasting effect of an implanted analgesic hydrogel in a rat model of postoperative pain

BACKGROUND

The administration of nonsteroidal anti-inflammatory drugs (NSAIDs) is the most common nonopioid analgesic currently used for postoperative pain management. We tested the sustained analgesic effect of ketoprofen emanating from a biodegradable gelatin hydrogel in a rat model of postoperative pain.

METHODS

A sheet of analgesic-infiltrated hydrogel was inserted below the plantaris muscle at the end of surgery. Mechanical thresholds were measured by use of von Frey filaments before and 2 weeks after the operation. The effect of ketoprofen on the postoperative pain was also assessed immunohistochemically by assessing microglial activation in the spinal cord with anti-OX-42 and phosphorylated p38 mitogen-activated protein kinase antibodies.

RESULTS

Implantation of ketoprofen-infiltrated gelatin hydrogel exerted a sustained analgesic effect for 1 week after the operation. Preemptive analgesia with zaltoprofen, another NSAID, produced an additive analgesic effect in conjunction with the ketoprofen-infiltrated hydrogel. Microglial activation was attenuated by the treatment with ketoprofen-infiltrated hydrogel on day 3 after the incision.

CONCLUSIONS

These results demonstrate that ketoprofen was effective in reducing mechanical hypersensitivity for 1 week in a rat model of postoperative pain and that the implantation of NSAID-infiltrated gelatin hydrogel may serve as a useful analgesic method for the long-term relief of patients after surgery.

Single center experience of laparoscopic hepatectomy: the comparison of perioperative outcomes between early and late period

BACKGROUNDS/AIMS

The aim of this study is to clarify the safety and feasibility of laparoscopic hepatectomy, through comparing the early and late periods of perioperative outcomes.

METHODS

We retrospectively analyzed 138 patients who underwent laparoscopic hepatectomy from January 2003 to June 2011, at Yeungnam University Hospital. We divided the total patients to early period (from January 2003 to February 2007, n=49) and late period (from March 2007 to June 2011, n=89) groups and compared the perioperative outcomes including the mean operation time, intra-operative blood loss, postoperative hospital stay, intensive care unit (ICU) stay, and duration of liver function test (LFT) normalization.

RESULTS

The mean operation time was 308 minutes (range: 140-510) in the early group and 193 minutes (range: 40-350) in the late period group (p<0.001). The mean intraoperative blood loss was 171 ml (range: 50-1,200) in the early and 44 ml (range: 0-400) in the late group (p=0.005). The postoperative hospital stay was 9.7 days (range: 4-31) in the early and 6.8 days (range: 2-9) in the late period (p<0.001). The ICU stay hour was 21.6 hours (range: 0-120) in the early and 2.8 hour (range: 0-24) in the late period (p<0.001). The duration of LFT normalization was 5.7 days (range: 0-39) in the early and 2.1 days (range: 0-20) in the late period (p=0.003). The perioperative outcomes in the late period were better than the early period, which showed a statistically significant difference.

CONCLUSIONS

Laparoscopic hepatectomy is feasible and can be safely performed in selected patients but requires a long experience in open liver resection and mastery of laparoscopic surgical skills.

Multimedia manuscript: laparoscopic resection of hepatocellular carcinoma at segment 7: the posterior approach to anatomic resection

BACKGROUND

Open anatomical liver resections remain one of the most effective treatments of hepatocellular carcinoma (HCC) and results in better recurrence-free and overall survival compared to nonanatomical resections [1]. On the other hand, laparoscopic hepatectomies for HCC have recently emerged with the benefits of reduced blood loss, shorter hospital stay, and less severe wound pain [2, 3]. Classically, liver lesions considered suitable for laparoscopic resection were those small tumors (<4 cm) located over the anterior and left lateral segments [3]. However, we would like to expand the current indications and here we present our techniques of laparoscopic anatomical resection for a HCC that was located at right posteriosuperior segment 7.

METHODS

Our patient was a 60-year-old gentleman who had Child's A hepatitis B cirrhosis and was on entecavir. During a follow-up CT scan, a 2.6-cm segment 7 lesion with early arterial enhancement and contrast washout was noted and was subsequently confirmed with arteriogram. α-Fetoprotein was 3 ng/ml (normal < 20 ng/ml). The video demonstrates a posterior approach to laparoscopic resection of segment 7.

RESULTS

Operative time was 510 min. Blood loss was 800 ml and no perioperative transfusion was required. Postoperative recovery was uneventful and only simple oral analgesics were required for pain control. He was discharged on postoperative day 6. Histology showed a moderately differentiated hepatocellular carcinoma and all resection margins were clear. Subsequent follow-up CT scan 6 months after the operation showed no evidence of recurrence and α-fetoprotein level was normal.

CONCLUSIONS

Laparoscopic hepatectomy for HCC over the right posterior segment of the liver is feasible in selected patients with favorable results in terms of wound size, postoperative recovery, and hospital stay. Maximal liver conservation was achieved in performing oncologic anatomical resection of segment 7 instead of a posterior sectionectomy. On the other hand, a posterior approach was recommended because it allowed early intrahepatic control of pedicles and identification of the right hepatic vein to guide parenchymal transection along the intersegmental plane.

Simultaneous laparoscopic resection of colorectal cancer and synchronous metastatic liver tumor

Laparoscopic colorectal resection has been applied to advanced colorectal cancer. Synchronous liver metastasis of colorectal cancer would be treated safely and effectively by simultaneous laparoscopic colorectal and hepatic resection. Seven patients with colorectal cancer and synchronous liver metastasis treated by simultaneous laparoscopic resection were analyzed retrospectively. Three patients received a hybrid operation using a small skin incision, 2 patients underwent hand-assisted laparoscopic surgery using a small incision produced for colonic anastomosis, and 2 patients were treated with pure laparoscopic resection. The mean total operation duration was 407 minutes, and mean blood loss was 207 mL. Negative surgical margins were achieved in all cases. Mean postoperative hospital stay was 16.4 days. No recurrence at the surgical margin was observed in the liver. For selected patients with synchronous liver metastasis of colorectal cancer, simultaneous laparoscopic resection is useful for minimizing operative invasiveness while maintaining safety and curability, with satisfying short- and long-term results.

Auxiliary partial orthotopic liver transplantation for adult onset type II citrullinemia

Adult-onset type II citrullinemia (CTLN2) is a disorder caused by an inborn error of metabolism affecting the liver. CTLN2 is an autosomal recessive disorder characterized by recurrent encephalopathy with hyperammonemia due to highly elevated plasma levels of citrulline and ammonia, caused by a deficiency of argininosuccinate synthetase in the liver. A small number of patients have undergone liver transplantation with favorable results. In Korea, the limitations of the deceased donor pool have made living donor liver transplantation a common alternative treatment option. We report the case of a patient with type II citrullinemia who was treated successfully with auxiliary partial orthotopic liver transplantation (APOLT) from a living donor. This is the first description of an APOLT for a patient with adult onset type II citrullinemia in Korea.

Robotic-assisted laparoscopic anatomic hepatectomy in China: initial experience

OBJECTIVE

To assess the feasibility and safety of robotic-assisted laparoscopic anatomic hepatectomy.

BACKGROUND

The development of minimally invasive surgery has led to an increase in the use of laparoscopic hepatectomy. However, laparoscopic hepatectomy remains technically challenging and is not widely developed. Robotic surgery represents a recent evolution in minimally invasive surgery that is being used increasingly for complex minimally invasive surgical procedures. Herein, we report our initial experience with robotic-assisted laparoscopic anatomic hepatectomy in 13 consecutive patients.

PATIENTS AND METHODS

Between April and July 2009, 13 consecutive patients underwent robotic-assisted laparoscopic anatomic hepatectomies for benign and malignant hepatic diseases. Major hepatectomies were performed in 9 patients, left lateral sectionectomies in 4 patients. Eight major hepatectomies were for malignant diseases and 5 hepatectomies (1 left hepatectomy and 4 left lateral sectionectomies) were for benign diseases. All the robotic-assisted hepatectomy procedures were performed anatomically with hilum dissection. Prior to starting the parenchymal transaction, vascular control of the portal vessels was carried out whenever possible. These robotic-assisted laparoscopic anatomic hepatectomies were compared with 20 traditional laparoscopic hepatectomies and 32 open resections that were contemporaneous and cohort-matched.

RESULTS

All 13 robotic-assisted laparoscopic anatomic hepatectomies were performed successfully in the manner of pure laparoscopic resection. No conversion to laparotomy or hand-assisted laparoscopic resection occurred. Despite its longer operative time (338 minutes) and higher hospital cost ($12,046), robotic liver surgery compared favorably with traditional laparoscopic hepatectomy and open resection in blood loss (280 vs. 350, 470 mL), transfusion requirement (0 vs. 3 of 20, 4 of 32), use of the Pringle maneuver (0 vs. 3 of 20, 6 of 32) and overall operative complications (7.8% vs. 10%,12.5%). Neither ascites nor transient hepatic decompensation occurred in the robotic group. The surgical margins in all 8 patients with malignant lesions were negative and as yet, no intrahepatic recurrences or metastases have been observed in the robotic group. The mean postoperative stay was shorter with the traditional laparoscopic procedure (5.2 days) than with robotic (6.7 days)or open surgery (9.6 days). Conversions from traditional laparoscopic to open and hand-assisted laparoscopic resection occurred in 2 patients (10.0%) who underwent right hemihepatectomy and left hepatectomy, respectively.

CONCLUSIONS

These preliminary results show that robotic-assisted laparoscopic anatomic hepatectomy is safe and feasible with a much lower complication and conversion rate than traditional laparoscopic hepatectomy or open resection. The robotic surgical system may broaden the indications for laparoscopic hepatactomy, and it enabled the surgeon to perform precise laparoscopic liver resection which required hylum dissection, hepatocaval dissection, endoscopic suturing, and microanastamosis. However, more long-term, evidence-based outcomes will be necessary to prove its efficacy, and further research on its cost-effectiveness is still required.

Prognosis of patients with hepatocellular carcinoma after hepatic resection: are elderly patients suitable for surgery?

AIM

The indication for hepatectomy is still controversial in elderly patients with hepatocellular carcinoma (HCC). We examined the clinicopathological features and survival of 188 HCC patients who underwent hepatectomy.

PATIENTS/METHODS

Patients were divided into four age groups: Age(<50) group (young patients <50 years of age, n = 9), Age(50-69) group (between 50-69 years, n = 110), Age(70-79) group (70-79 years, n = 57), and Age(≥80) group (≥80 years, n = 12). Physiologic ability and surgical stress (E-PASS) score, including preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS) were assessed.

RESULTS

Proportion of patients of Age(70-79) and Age(≥80) groups increased significantly in the last 5 years (P < 0.01). Co-morbidity, performance status, and American Society of Anesthesiologists score significantly increased with age (P < 0.05). Proportions of patients with irregular findings and necro-inflammatory activity were significantly lower in Age(70-79) and Age(≥80) groups than in other groups (P < 0.05). Systemic postoperative complications were high in Age(70-79) and Age(≥80) groups. PRS increased significantly with age (P < 0.05). Multivariate analysis identified PRS ≥0.32 and age ≥70 years as significant determinants of systemic complications (P < 0.05). There were no significant differences in postoperative survivals among the groups.

CONCLUSIONS

Careful follow-up and proper decision on hepatectomy upon assessment of PRS are important in elderly HCC patients.

Laparoscopic repeat resection of recurrent hepatocellular carcinoma

BACKGROUND

The present study was designed to explore the safety and feasibility of laparoscopic re-resection of recurrent liver tumors.

METHODS

Among 120 hepatocellular carcinoma patients who received laparoscopic hepatectomy, six were carefully selected to receive laparoscopic re-resection. Surgical indications were evaluated by specific selection criteria for tumor location, size, metastases, vessel invasion, and liver function. Four patients received laparoscopic partial hepatectomy, and two received laparoscopic anatomical left lateral lobe resection. Results were analyzed retrospectively.

RESULTS

The six surgeries (four laparoscopic partial hepatectomies, two laparoscopic anatomical left lateral lobe resections) were successfully performed with no intraoperative complications. Mean operative time was 140.83 ± 35.69 min, mean blood loss was 283.33 ± 256.25 ml, and mean hospital stay was 5.67 ± 1.63 days.

CONCLUSIONS

Our experience with carefully selected cases meeting specific criteria suggests that laparoscopic hepatic re-resection is a safe, feasible procedure that may offer multiple benefits for treating recurrent hepatocellular carcinoma.

Laparoscopic liver resection for benign and malignant liver tumors

BACKGROUND

Laparoscopic liver resection is one of the most complex procedures in hepatobiliary surgery. In the last two decades, laparoscopic liver surgery has emerged as an option at major academic institutions. The purpose of this study is to describe the initial experience of minimally invasive liver resections at a non-academic institution.

METHODS

We retrospectively reviewed medical records of patients undergoing laparoscopic liver resections between June 2006 and December 2009 at our center. Indications, technical aspects, and outcomes of these patients are described.

RESULTS

Laparoscopic liver resection was attempted in 28 patients. Of these, 27 patients underwent laparoscopic liver resection (22 total laparoscopic and 5 hand assisted) and one needed conversion to open surgery. Twenty patients had a benign lesion and 8 had malignant lesions. Three patients had multiple lesions in different segments requiring separate resections. The lesions were located in segments II-III (n=18), IV (n=3), V-VI (n=9), and VII (n=1). Tumor size ranged from 1.5 cm to 8.5 cm. The surgical procedures included left lateral sectionectomy (n=17), left hepatectomy (n=2), sectionectomy (n=8), and local resections (n=4). Median operative time was 110 minutes (range 55-210 minutes), and the median length of hospital stay was 2.5 days (range 1-7 days). There was no perioperative mortality. One patient developed hernia at the site of tumor extraction requiring repair at 3 months.

CONCLUSIONS

Laparoscopic liver resections can be safely performed in selected patients with benign and malignant liver tumors. With increasing experience, laparoscopic liver resections are likely to become a favorable alternative to open resection.

A comparative study of the long-term outcomes after laparoscopy-assisted and open left lateral hepatectomy for hepatocellular carcinoma

BACKGROUND

Laparoscopic hepatectomy was initially reported in 1992. However, the reported experiences are scarce, and this operation has not been a standard procedure until now. The aims of this study were to assess our results of laparoscopy-assisted left lateral hepatectomy for hepatocellular carcinoma (HCC) and to compare them with those of open conventional procedures.

METHODS

From 1984 to 2002, left lateral hepatectomy for HCC less than 5 cm in diameter was carried out in 21 patients. Ten patients received a laparoscopy-assisted procedure, and remaining 11 patients received an open procedure.

RESULTS

There were no significant differences in the operation time, blood loss, resected liver weight, and resection margin between the 2 groups. The total time that analgesics were given, body temperature on postoperative day 1, weight loss on postoperative day 7, and postoperative hospital stay in the laparoscopic group were significantly better than in the conventional group. With regard to the long-term prognosis, there were no differences in patient survival or disease-free survival rates between the 2 groups.

CONCLUSIONS

Laparoscopy-assisted left lateral hepatectomy for HCC is superior to the conventional open surgery in terms of its short-term results and does not cause the long-term survival to deteriorate. Therefore, laparoscopic hepatectomy may be an alternative choice for treatment of HCC.

Laparoscopic resection for liver tumors: initial experience in a single center

BACKGROUND

Laparoscopic liver resections are 1 of the most complex procedures in hepatobiliary surgery. During the last 20 years, laparoscopic liver surgery has had an important development in specialized centers.

OBJECTIVE

To describe the initial experience in laparoscopic liver resection for benign and malignant tumors, to assess its indications and outcomes, and to describe technical aspects of these resections.

METHODS

Review of the records of 28 patients who underwent laparoscopic liver resection between November 2000 and November 2007. Analysis of the data regarding preoperative management and postoperative outcomes.

RESULTS

Twenty-six liver resections were performed laparoscopically (20 purely laparoscopic, 3 hand assisted, and 3 hybrid technique) and 2 were converted to open surgery. The laparoscopic approach was attempted in 6% (28 out of 459) of the liver resections carried out in the analyzed period. Indications for resection were: benign tumors in 22 patients (78%) and malignant tumors in 6 patients (22%). Resections were minor in 27 patients (96%) and major in 1 patient (4%). Pringle maneuver was performed in 14 patients (50%). Margins were negative in all the cases. Mean operative time was 170 minutes (range 70 to 350), and the mean length of stay was 3 days (range 1 to 6). Mortality rate was 0%. Only 2 patients (7%) had postoperative minor complications (self-limited bile leaks).

CONCLUSIONS

In selected patients with benign and malignant liver tumors, laparoscopic liver resections can be safely performed. This procedure must be carried out by the surgeons trained in both the hepatobiliary and laparoscopic surgery.

A single-incision laparoscopic hepatectomy for hepatocellular carcinoma: initial experience in a Japanese patient

Minimally invasive approaches for small liver tumors are desirable. We describe a single-incision laparoscopic hepatectomy (SILH) using total laparoscopic surgery (TLS) technique. SILH was performed to remove a solitary 2-cm hepatocellular carcinoma located at segment 3. The technique included a one-inch skin incision with three ports (one 12 mm and two of 5 mm each). The liver was sealed and dissected by three different devices: Harmonic scalpel, TissueLink sealing dissector, and Endoclip. Operation time was 70 minutes and blood loss was trivial. The patient required no analgesia postoperatively and walked unaided the next day. Various aspects of the procedure were not different from TLS. SILH is a safe procedure with several advantages. The procedure is promising as minimally invasive liver surgery.

World review of laparoscopic liver resection-2,804 patients

OBJECTIVE

To provide a review of the world literature on laparoscopic liver resection.

SUMMARY BACKGROUND DATA

Initially described for peripheral, benign tumors resected by nonanatomic wedge resections, minimally invasive liver resections are now being performed more frequently, even for larger, malignant tumors located in challenging locations. Although a few small review articles have been reported, a comprehensive review on laparoscopic liver resection has not been published.

METHODS

We conducted a literature search using Pubmed, screening all English publications on laparoscopic liver resections. All data were analyzed and apparent case duplications in updated series were excluded from the total number of patients. Tumor type, operative characteristics, perioperative morbidity, and oncologic outcomes were tabulated.

RESULTS

A total of 127 published articles of original series on laparoscopic liver resection were identified, and accounted for 2,804 reported minimally invasive liver resections. Fifty percent were for malignant tumors, 45% were for benign lesions, 1.7% were for live donor hepatectomies, and the rest were indeterminate. Of the resections, 75% were performed totally laparoscopically, 17% were hand-assisted, and 2% were laparoscopic-assisted open hepatic resection (hybrid) technique, with the remainder being other techniques or conversions to open hepatectomies. The most common laparoscopic liver resection was a wedge resection or segmentectomy (45%) followed by anatomic left lateral sectionectomy (20%), right hepatectomy (9%), and left hepatectomy (7%). Conversion from laparoscopy to open laparotomy and from laparoscopy to hand-assisted approach occurred in 4.1% and 0.7% of reported cases, respectively. Overall mortality was 9 of 2,804 patients (0.3%), and morbidity was 10.5%, with no intraoperative deaths reported. The most common cause of postoperative death was liver failure. Postoperative bile leak was observed in 1.5% of cases. For cancer resections, negative surgical margins were achieved in 82% to 100% of reported series. The 5-year overall and disease-free survival rates after laparoscopic liver resection for hepatocellular carcinoma were 50% to 75% and 31% to 38.2%, respectively. The 3-year overall and disease-free survival rates after laparoscopic liver resection for colorectal metastasis to the liver were 80% to 87% and 51%, respectively.

CONCLUSION

In experienced hands, laparoscopic liver resections are safe with acceptable morbidity and mortality for both minor and major hepatic resections. Oncologically, 3- and 5-year survival rates reported for hepatocellular carcinoma and colorectal cancer metastases are comparable to open hepatic resection, albeit in a selected group of patients.

The learning curve in laparoscopic liver resection: improved feasibility and reproducibility

OBJECTIVE

To evaluate the "learning curve" effect on feasibility and reproducibility of laparoscopic liver resection (LLR).

SUMMARY BACKGROUND DATA

LLR is currently limited to few centers and to few procedures. Its reproducibility is still debated.

METHODS

: Patients undergoing LLR between 1996 and 2008 were included. Indications and type of hepatectomies were compared with those of open resections performed in the same period, considering 3 periods (1996-1999, 2000-2003, and 2004-2008). LLRs were divided into 3 equal groups of 58 cases and technical data and outcomes were compared. Risk-adjusted Cumulative Sum model was used for determining the learning curve based on the need for conversion.

RESULTS

Of 782, 174 (22.3%) patients underwent LLR. Proportion of LLR progressively increased (17.5%, 22.4%, and 24.2%), such as hepatocellular carcinoma (17.6%, 25.6%, and 39.4%, P < 0.05), colorectal metastases (0%, 6.5%, and 13.1%, P < 0.05), major hepatectomies (1.1%, 9.1%, 8.5%, P < 0.05), and right hepatectomies (0%, 13.2%, and 13.1%, P < 0.05). Comparing groups, results of LLR significantly improved in terms of conversion rate (15.5%, 10.3%, and 3.4%, P < 0.05), operative time (210, 180, and 150 minutes, P < 0.05), blood loss (300, 200, and 200 mL, P < 0.05), and morbidity (17.2%, 22.4%, and 3.4%, P < 0.05). Pedicle clamping was less used over time (77.6%, 62.1%, and 17.2%, P < 0.05) and for shorter durations (45, 30, and 20 minutes, P < 0.05). Having adjusted for case-mix, the Cumulative Sum analysis demonstrated a learning curve for laparoscopic hepatectomies of 60 cases.

CONCLUSION

A slow but constant evolution of LLR occurred: indications and magnitude of procedures increased and technical outcomes improved. The learning curve demonstrated in this study suggests that LLR is reproducible in liver units but specific training to advanced laparoscopy is required.

The international position on laparoscopic liver surgery: The Louisville Statement, 2008

OBJECTIVE

To summarize the current world position on laparoscopic liver surgery.

SUMMARY BACKGROUND DATA

Multiple series have reported on the safety and efficacy of laparoscopic liver surgery. Small and medium sized procedures have become commonplace in many centers, while major laparoscopic liver resections have been performed with efficacy and safety equaling open surgery in highly specialized centers. Although the field has begun to expand rapidly, no consensus meeting has been convened to discuss the evolving field of laparoscopic liver surgery.

METHODS

On November 7 to 8, 2008, 45 experts in hepatobiliary surgery were invited to participate in a consensus conference convened in Louisville, KY, US. In addition, over 300 attendees were present from 5 continents. The conference was divided into sessions, with 2 moderators assigned to each, so as to stimulate discussion and highlight controversies. The format of the meeting varied from formal presentation of experiential data to expert opinion debates. Written and video records of the presentations were produced. Specific areas of discussion included indications for surgery, patient selection, surgical techniques, complications, patient safety, and surgeon training.

RESULTS

The consensus conference used the terms pure laparoscopy, hand-assisted laparoscopy, and the hybrid technique to define laparoscopic liver procedures. Currently acceptable indications for laparoscopic liver resection are patients with solitary lesions, 5 cm or less, located in liver segments 2 to 6. The laparoscopic approach to left lateral sectionectomy should be considered standard practice. Although all types of liver resection can be performed laparoscopically, major liver resections (eg, right or left hepatectomies) should be reserved for experienced surgeons facile with more advanced laparoscopic hepatic resections. Conversion should be performed for difficult resections requiring extended operating times, and for patient safety, and should be considered prudent surgical practice rather than failure. In emergent situations, efforts should be made to control bleeding before converting to a formal open approach. Utilization of a hand assist or hybrid technique may be faster, safer, and more efficacious. Indications for surgery for benign hepatic lesions should not be widened simply because the surgery can be done laparoscopically. Although data presented on colorectal metastases did not reveal an adverse effect of the laparoscopic approach on oncological outcomes in terms of margins or survival, adequacy of margins and ability to detect occult lesions are concerns. The pure laparoscopic technique of left lateral sectionectomy was used for adult to child donation while the hybrid approach has been the only one reported to date in the case of adult to adult right lobe donation. Laparoscopic liver surgery has not been tested by controlled trials for efficacy or safety. A prospective randomized trial appears to be logistically prohibitive; however, an international registry should be initiated to document the role and safety of laparoscopic liver resection.

CONCLUSIONS

Laparoscopic liver surgery is a safe and effective approach to the management of surgical liver disease in the hands of trained surgeons with experience in hepatobiliary and laparoscopic surgery. National and international societies, as well as governing boards, should become involved in the goal of establishing training standards and credentialing, to ensure consistent standards and clinical outcomes.

Laparoscopic liver resection-understanding its role in current practice: the Henri Mondor Hospital experience

OBJECTIVE

To report our complete experience with laparoscopic liver resection (LLR) to understand what role it may play in the broader context of liver surgery.

BACKGROUND

The goal of LLR is to extend the benefits of the laparoscopic approach without compromising the fundamental principles of open liver surgery. LLR, however, presents unique technical challenges and its evaluation is made difficult by the restricted indications for this approach, the few centers world-wide experienced in the technique, and the heterogeneity of procedures and pathologies involved.

METHODS

Retrospective analysis of a prospectively maintained database of liver resections from a unit with a comprehensive liver program, including resection and transplantation.

RESULTS

There were 166 laparoscopic liver resections between May 23, 1996 and December 31, 2007, including 100 (60%) for malignant pathology (64 HCC, 3 cholangiocarcinoma, 33 hepatic metastases) and 66 for benign pathology (adenoma, 23; FNH, 19; cystic, 17; other, 7). Numbers of resections for benign indications remained stable over time whereas those for malignant indications increased. There were 31 major resections, 56 left lateral sectionectomies, 28 segmentectomies, and 51 tumorectomies. There was 0% mortality and 15.1% morbidity. Median blood loss was 200 mL, 9 patients (5.4%) required transfusion, and median operating time was 180 minutes. Left lateral sectionectomies demonstrated reduced bleeding (median, 175 vs. 300 mL, P = 0.0015) and faster operating time (median, 170 vs. 180 minutes, P = 0.0265). In the second half of the experience, there was reduced bleeding (median, 200 vs. 300 mL, P = 0.0022) and a lower conversion rate (2.4% vs. 16.9%, P = 0.0015).

CONCLUSIONS

Good patient selection and refined surgical technique are the keys to successful LLR. The indications for resection of asymptomatic benign lesions should not be increased because the laparoscopic approach is available. Hepatocellular carcinomas (HCCs) are more likely to be suitable to a laparoscopic approach than colorectal liver metastases. Left lateral sectionectomy and limited resection of solitary peripheral lesions are particularly suitable while hemihepatectomies remain challenging procedures. LLR requires an ongoing robust audit to identify any emerging problems.

Laparoscopic major hepato-biliary-pancreatic surgery: formidable challenge to standardization

INTRODUCTION

Although laparoscopic colorectal or gastric surgery has become widely accepted as a superior alternative to conventional open surgery, the surgical management of hepato-biliary-pancreatic disease has traditionally involved open surgery. Recently, many reports have described laparoscopic partial liver resection, lateral segmentectomy, and distal pancreatectomy. However, laparoscopic major hepato-biliary-pancreatic surgery, such as hepatic lobectomy and pancreaticoduodenectomy, has not been widely developed because of technical difficulties.

METHODS

We describe our experience with laparoscopic major hepato-biliary-pancreatic surgery, including right hepatectomy using hilar Glissonean pedicle transaction, and pylorus-preserving pancreaticoduodenectomy.

CONCLUSION

Although our experience is limited, and randomized study is necessary to elucidate the appropriate indications for and effects of the present procedures, we believe that laparoscopic major hepato-biliary-pancreatic surgery can be feasible, safe, and effective in highly selected patients, and that it will be one of the standard therapeutic options for carefully selected patients with hepato-biliary-pancreatic disease.

Laparoscopic liver resection: a systematic review

BACKGROUND

Outcomes of laparoscopic liver resection (LLR) are not clarified. The objective of this article is to depict the state of the art of LLR by means of a systematic review of the literature.

METHODS

Studies about LLR published before September 2008 were identified and their results summarized.

RESULTS

Indications for laparoscopic hepatectomy do not differ from those for open surgery. Technical feasibility is the only limiting factor. Bleeding is the major intraoperative concern, but, if managed by an expert surgeon, do not worsen outcomes. Hand assistance can be useful in selected cases to avoid conversion. Patient selection must take both tumor location and size into consideration. Potentially good candidates are patients with peripheral lesions requiring limited hepatectomy or left lateral sectionectomy; their outcomes, including reduced blood loss, morbidity, and hospital stay, are better than those of their laparotomic counterparts. The same advantages have been observed in cirrhotics. Laparoscopic major hepatectomies and resections of postero-superior segments need further evaluation. The results of LLR in cancer patients seem to be similar to those obtained with the laparotomic approach, especially in cases of hepatocellular carcinoma, but further analysis is required.

CONCLUSIONS

Laparoscopic liver resection is safe and feasible. The laparoscopic approach can be recommended for peripheral lesions requiring limited hepatectomy or left lateral sectionectomy. Preliminary oncological results suggest non-inferiority of laparoscopic to laparotomic procedures.

Minimally invasive laparoscopic liver resection: 3D MDCT simulation for preoperative planning

BACKGROUND/PURPOSE

Laparoscopic liver resection has not gained wide acceptance compared with other laparoscopic procedures. We evaluated the impact of simulated surgery using data from multidetector CT scanning on planning for laparoscopic hepatectomy.

METHODS

The hepatectomy simulation system was programmed to perform three-dimensional reconstruction of the vasculature and to calculate the liver resection volume and surgical margin. In 35 patients undergoing laparoscopic hepatectomy or laparoscopy-assisted hepatectomy, the liver resection volume and margin were estimated by simulation preoperatively. Then, the estimated values were compared with the actual resected liver weight and margin.

RESULTS

Three-dimensional reconstruction allowed stereoscopic identification of the tumor-bearing portal vein and draining vein. The predicted liver resection volume and margin both showed a significant correlation with the actual values: the mean difference was 21 mL (P < 0.0001) and 1.3 mm (P < 0.01), respectively. Preoperative planning based on simulated resection facilitated laparoscopic mobilization of the liver and mini-laparotomy resection of a large tumor located in the upper right lobe.

CONCLUSIONS

Three-dimensional simulation of hepatectomy facilitated intraoperative identification of the vascular anatomy, and accurately predicted the resected liver volume and surgical margin. This simulation method should contribute to preoperative planning for safe and curative laparoscopic hepatectomy.

Laparoscopic hepatectomy for hepatocellular carcinoma in cirrhotic patients

INTRODUCTION

We have used laparoscopic hepatectomy as a surgical treatment for HCC in patients with cirrhosis. We describe the indications, evaluate invasiveness and analyze the outcomes of laparoscopic hepatectomy.

METHODS AND RESULTS

With respect to operative method, laparoscopic hepatectomy involving either partial hepatectomy or left lateral sectionectomy is a less invasive procedure in patients with cirrhosis than conventional hepatectomy. Among our laparoscopic hepatectomy cases, operative time was shorter and bleeding was less in recent, as compared to earlier, cases. Furthermore, laparoscopic hepatectomy was less invasive than conventional hepatectomy, as determined by the E-PASS scoring system. Patients also recovered more quickly, which resulted in shorter hospital stays even for patients with cirrhosis. Both the 5-year survival rate and the rate of survival without recurrence of HCC were nearly identical to those of open conventional hepatectomy.

CONCLUSION

These findings indicate that laparoscopic hepatectomy avoids the disadvantages of standard hepatectomy for HCC in properly selected patients with cirrhosis and that its minimal invasiveness improves patients' quality of life.