Laparoscopic liver resection for lesions adjacent to major vasculature: feasibility, safety and oncological efficiency

Current Status of Laparoscopic Liver Resection

The evolution of laparoscopic liver surgery, originating in the 1990s, has been marked by significant advancements and milestones, overcoming initial technical hurdles and gaining widespread acceptance within the surgical community as a precise and safe alternative to open procedures. Along this journey, numerous challenges emerged, leading to the accumulation of evidence and the development of guidelines aimed at assisting surgeons in determining the safety, suitability, and complexity of laparoscopic liver resection. This chapter provides a thorough examination of key aspects of laparoscopic liver resection, including difficulty scoring systems, criteria for patient selection, technical considerations, outcomes across different types of liver lesions, and the innovative solutions developed to address challenges, thus offering a comprehensive overview of laparoscopic liver resection, and highlighting its evolving significance in modern hepatobiliary surgery.

Safety and Feasibility of Laparoscopic Parenchymal-Sparing Hepatectomy for Lesions with Proximity to Major Vessels in Posterosuperior Liver Segments 7 and 8

Laparoscopic parenchymal-sparing hepatectomy (PSH) for lesions with proximity to major vessels (PMV) in posterosuperior segments (PSS) has not yet been sufficiently examined. The aim of this study is to examine the safety and feasibility of laparoscopic PSH for lesions with PMV in PSS 7 and 8. We retrospectively reviewed the outcomes of laparoscopic liver resection (LLR) and open liver resection (OLR) for PSS lesions and focused on patients who underwent laparoscopic PSH for lesions with PMV in PSS. Blood loss was lower in the LLR group (n = 110) than the OLR group (n = 16) (p = 0.009), and no other short-term outcomes were significantly different. Compared to the pure LLR group (n = 93), there were no positive surgical margins or complications in hand-assisted laparoscopic surgery (HALS) (n = 17), despite more tumors with PMV (p = 0.009). Regarding pure LLR for one tumor lesion, any short-term outcomes in addition to the operative time were not significantly different between the PMV (n = 23) and no-PMV (n = 48) groups. The present findings indicate that laparoscopic PSH for lesions with PMV in PSS is safe and feasible in a matured team, and the HALS technique still plays an important role.

Four-year experience with more than 1000 cases of total laparoscopic liver resection in a single center

BACKGROUND

Laparoscopic liver resection (LLR) has become a safe surgical procedure that needs additional summarization.

AIM

To review 4 years of total LLR surgeries, exceeding 1000 cases, which were performed at a single center.

METHODS

Patients who underwent LLR at West China Hospital of Sichuan University between January 2015 and December 2018 were identified. Surgical details, including the interventional year, category of liver disease, and malignant liver tumors prognosis, were evaluated. The learning curve for LLR was evaluated using the cumulative sum method. The Kaplan-Meier method was used to perform survival analysis.

RESULTS

Ultimately, 1098 patients were identified. Hepatocellular carcinoma (HCC) was the most common disease that led to the need for LLR at the center (n = 462, 42.08%). The average operation time was 216.94 ± 98.51 min. The conversion rate was 1.82% (20/1098). The complication rate was 9.20% (from grade II to V). The 1-year and 3-year overall survival rates of HCC patients were 89.7% and 81.9%, respectively. The learning curve was grouped into two phases for local resection (cases 1-106 and 107-373), three phases for anatomical segmentectomy (cases 1-44, 45-74 and 75-120), and three phases for hemihepatectomy (cases 1-17, 18-48 and 49-88).

CONCLUSION

LLR may be considered a first-line surgical intervention for liver resection that can be performed safely for a variety of primary, secondary, and recurrent liver tumors and for benign diseases once technical competence is proficiently attained.

An international multicenter propensity-score matched and coarsened-exact matched analysis comparing between robotic versus laparoscopic partial liver resections of the anterolateral segments

BACKGROUND

Robotic liver resections RLR may have the ability to address some of the drawbacks of laparoscopic(L)LR but few studies have done a head-to-head comparison of the outcomes after anterolateral segment resections by the two techniques.

METHODS

A retrospective study was conducted of 3202 patients who underwent minimally-invasive LR of the anterolateral liver segments at 26 international centres from 2005 to 2020. 2606 cases met study criteria of which there were 358 RLR and 1868 LLR. Peri-operative outcomes were compared between the two groups using a 1:3 Propensity Score Matched(PSM) and 1:1 Coarsened Exact Matched(CEM) analysis.

RESULTS

Patients matched after 1:3 PSM(261 RLR vs. 783 LLR) and 1:1 CEM(296 RLR vs. 296 LLR) revealed no significant differences in length of stay, readmission rates, morbidity, mortality and involvement of or close oncological margins. RLR surgeries were associated with significantly less blood loss(50ml vs. 100ml, p<0.001) and lower rates of open conversion on both PSM(1.5% vs. 6.8%, p=0.003) and CEM(1.4% vs. 6.4%, p=0.004) compared to LLR. Though PSM analysis showed RLR to have a longer operating time than LLR(170 min vs. 160 min, p=0.036), this difference proved to be insignificant on CEM(167 min vs. 163 min. p=0.575).

CONCLUSION

This multicentre international combined PSM and CEM study showed that both RLR and LLR have equivalent perioperative outcomes when performed in selected patients at high volume centres. The robotic approach was associated with significantly lower blood loss and allowed more surgeries to be completed in a minimally-invasive fashion.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Evidence of minimally invasive oncological surgery of the liver]

BACKGROUND

The evidence for minimally invasive surgery (MIS) of the liver has significantly increased with the increasing number of publications on this topic in recent years; however, this technique has not yet gained broad acceptance among surgeons.

OBJECTIVE

Analysis and presentation of the current literature on MIS of the liver.

MATERIAL UND METHODS

Structured PubMed literature search and analysis.

RESULTS

According to the literature, MIS and open liver surgery are equivalent regarding the oncological quality. In addition to parenchyma-preserving resections, major hepatectomies (e.g. hemihepatectomy and sectorectomy), two-stage concepts and re-resections have increasingly been reported. The MIS of the liver is associated with less blood loss and other immunological advantages in addition to a shorter hospital stay. The highest level of evidence has been achieved for colorectal liver metastases for which a systematic review even revealed a survival benefit for patients undergoing MIS surgery. From an oncological perspective, laparoscopic and robotic liver surgery are considered to be equivalent.

CONCLUSION

According to the current literature MIS of the liver is recommended for the resection of colorectal liver metastases and hepatocellular carcinoma.

Middle and left hepatic vein trunk control during laparoscopic liver resection (with video)

BACKGROUND

While inflow control can be easily applied by Pringle maneuver, outflow control of the left liver has not been formally described. We report here a safe and reproductible technique of middle and left hepatic veinous trunk control (MLHVC) before parenchymal transection during laparoscopic left hepatectomy.

METHODS

A retrospective review of laparoscopic liver resection was conducted from January 2013 to March 2018 from our prospective database. All cases of laparoscopic left hepatectomy (LLH) were included, and intra- and postoperative outcomes data collected. We collected cases where the middle and left hepatic vein trunk control has been attempted and clamping used, and we analyzed outcomes associated with this maneuver.

RESULTS

MLHVC was attempted in 28 cases (77.8) of the 36 LLH identify in a monocentric study. It was technically not feasible only in 3 cases (8.3%) and clamping applied in 15 cases (41.7%). No significant intraoperative unexpected event occurred.

CONCLUSION

We present here a technique for left liver outflow control that can be safely added to the armamentarium of laparoscopic liver surgery.

Retroperitoneal laparoscopic hepatectomy of recurrent hepatocellular carcinoma: case report and literature review

BACKGROUND

Almost all liver tumours can be removed laparoscopically, but some difficult tumour locations complicate laparoscopic surgery. Recurrent liver tumours often pose great difficulties to laparoscopic surgery due to adhesions caused by previous operations. Referring to laparoscopic adrenalectomy, a retroperitoneal approach is proposed to remove liver tumours near the adrenal gland, which will provide a new method for liver surgery.

CASE PRESENTATION

Our case involves a patient with recurrent hepatocellular carcinoma (HCC) whose last operation was laparoscopic hepatectomy in our department, with a recurrence of HCC 2 years after the first surgery. In this case, based on preoperative CT and MRI, through a retroperitoneal approach, combined with intraoperative ultrasound (IOUS) localization and indocyanine green (ICG) fluorescence navigation, laparoscopic hepatectomy was successfully performed to precisely resect recurrent hepatocellular carcinoma in segment VII. The patient was discharged on the third day after the operation. The AFP decreased to normal levels on the 28th postoperative day.

CONCLUSIONS

Retroperitoneal hepatectomy has the advantages of less trauma, shorter operation times, fewer complications and faster recovery for hepatic tumours near the adrenal gland. Accurate localization of tumours is needed to ensure accurate resection; therefore, IOUS and ICG fluorescence are very important. Liver parenchyma was severed strictly according to fluorescent labelling during hepatectomy, which prevented the deviation of liver parenchyma from the plane and ensured that the margin of hepatectomy was tumour-free. In order to ensure a radical resection of the tumour, it may be necessary to enter the abdominal cavity.

Expanding indications for laparoscopic parenchyma-sparing resection of posterosuperior liver segments in patients with colorectal metastases: comparison with open hepatectomy for immediate and long-term outcomes

BACKGROUND

Laparoscopic liver resection (LLR) of posterosuperior segments (PSS) is still technically demanding procedure for highly selective patients. There is no long-term survival comparative estimation after LLR and open liver resection (OLR) for colorectal liver metastases (CRLM) located in PSS. We aimed to compare long-term overall (OS) and disease-free survival (DFS) after parenchyma-sparing LLR with expanding indications and open liver resection (OLR) of liver PSS in patients with CRLM.

METHODS

Two Russian centers took part in the study. Patients with missing data, hemihepatectomy and extrahepatic tumors were excluded. One of contraindications for LLR was suspicion for tumor invasion in large hepatic vessels. Logistic regression was used for 1:1 propensity score matching (PSM).

RESULTS

PSS were resected in 77 patients, which accounted for 42% of the total number of liver resections for CRLM. LLR were performed in 51 (66%) patients. Before and after matching, no differences were found between groups in the following factors: median size of the largest metastatic tumor; proximity to the large liver vessels; the rate of anatomical parenchyma sparing resection of PSS; a positive response to chemotherapy before and after surgery. Regardless of matching, the size of the largest metastases was above 50 mm in more than one-third of patients who received LLR. Before matching, intraoperative blood loss, ICU stay and hospital stay were significantly greater in the group of OLR. No 90-day mortality was observed within both groups. There were no differences in long-term oncological outcomes: 5-year OS after PSM was 78% and 63% after LLR and OLR, respectively; 4-year DFS after PSM was 27% in both groups.

CONCLUSION

Laparoscopic parenchyma-sparing resection of PSS for CRLM are justified in majority of patients who have an indication for OLR if performed in high volume specialized centers expertized in laparoscopic liver surgery.

Laparoscopic liver resection for liver tumours in proximity to major vasculature: A single-center comparative study

BACKGROUND

With growing popularity and experience in laparoscopic liver surgery, the options for more difficult procedures increase. Only small case series have been published regarding laparoscopic liver resection (LLR) for tumours in proximity to major vessels (MVs). The aim was to compare outcomes of LLR for tumours located less or more than 15 mm from MVs.

METHODS

This was a retrospective analysis of a prospectively collected database of consecutive LLR (October 2011-August 2017). Proximity to MVs (PMV) was defined as lesions located within 15 mm to the caval vein, hepatic veins and portal vein (main trunk and first branches). The control group were all lesions located more than 15 mm from MVs.

RESULTS

Some 60/235 LLR were performed for lesions in proximity to major vasculature (24%). In the PMV group, median IWATE Difficulty Score was higher (8.5 (IQR: 6.0-9.0) VS 5.0 (IQR: 3.0-6.0), p < 0.001) as was the use of CUSA® (45.0% VS 8.6%, p < 0.001) and Pringle manoeuvre (8.3% VS 1.7%; p = 0.028). Operative time was longer (180min (IQR: 140-210) VS 120min (IQR: 75-150), p < 0.001) and blood loss was higher (190 ml (IQR: 100-325) VS 75 ml (IQR: 50-220), p < 0.001) in the PMV group. There was no difference in perioperative blood transfusion (3.3% VS 1.7%, p = 0.60) or postoperative morbidity (15.0% VS 14.3%, p = 0.89). There was no mortality in both groups. On mean follow-up of 21 months, no significant differences could be found in disease free (p = 0.77) and overall survival (p = 0.12).

CONCLUSION

In experienced hands, LLR of lesions in proximity to MVs is safe and feasible with acceptable short and long-term results.

The clinical and biological impacts of the implementation of fast-track perioperative programs in complex liver resections: A propensity score-based analysis between the open and laparoscopic approaches

BACKGROUND

The aim of this study was to evaluate the impact of the fast-track approach in patients undergoing complex liver procedures and to analyse factors that influence morbidity and functional recovery.

METHODS

Hepatic resections (2014-2016) were stratified according to difficulty score, obtaining a group of 215 complex resections (102 laparoscopic, 163 open). The laparoscopic group was matched by propensity score with open patients to obtain the minimally invasive liver surgery group (n = 102) and the open group (n = 102).

RESULTS

Groups were similar in terms of patient and disease characteristics. The postoperative morbidity was 31.4% in the minimally invasive liver surgery and 38.2% in the open group (P = .05), and functional recovery was shorter in the minimally invasive liver surgery (respectively 4 versus 6 days, P = .041). The adherence to fast-track was high in both groups, with several items with higher penetrance in the minimally invasive liver surgery group. Among factors associated with morbidity and functional recovery, a laparoscopic approach and strict adherence to a fast-track protocol resulted in protective factors.

CONCLUSION

The combination of minimally invasive approaches and fast-track protocols allows a reduced rate of postoperative morbidity and satisfactory functional recovery even in the setting of complex liver resections. When the laparoscopic approach is not feasible, strict adherence to a fast-track program is associated with the achievement of adequate results and should be implemented.

Comparative analysis of learning curve in complex robot-assisted and laparoscopic liver resection

BACKGROUND

There is no comparative analysis of the learning curves for robot-assisted and laparoscopic liver resection. We aimed to compare learning curves in complex robotic and conventional laparoscopic liver resections with regards to estimation of the difficulty index score.

METHODS

The results of 131 consecutive liver resections were analyzed retrospectively (40 robot-assisted and 91 laparoscopic). The learning curve evaluation was based on calculation of procedures number before significant change of the difficulty index for minimally invasive liver resection or the rate of posterosuperior segments resection. Groups of early and late experience were compared in every type of approach (robot-assisted and laparoscopic).

RESULTS

Significant increase of difficulty index (from 5.0 [3.0-7.7] to 7.3 [4.3-10.2]) of robotic procedures required 16 procedures. It was necessary to perform 29 laparoscopic resections in order to significantly increase the rate of laparoscopic posterosuperior segments resection but without significant increase of difficulty index. The implementation of minimally invasive liver resection started with the robotic approach.

CONCLUSION

The learning curve for robot-assisted liver resections is shorter in comparison with laparoscopic resections. The inclusion of robot-assisted resections in a minimally invasive liver surgery program may be useful to rapidly increase the complexity of laparoscopic liver resections.

Diffusion, outcomes and implementation of minimally invasive liver surgery: a snapshot from the I Go MILS (Italian Group of Minimally Invasive Liver Surgery) Registry

The Italian Group of MILS (I Go MILS) prospective registry was established in 2014 with the goals to create a hub for data and projects on a national basis and to promote the diffusion and implementation of MILS programs on a national scale. The primary endpoint of the present study is to give a snapshot of the real diffusion and outcomes of MILS in Italy, while analyzing the role of the registry in the implementation of MILS programs nationwide. The I Go MILS Registry is a prospective and intention-to-treat registry opened to any Italian center performing MILS, without restriction criteria based on number of procedures. The Registry is developed through the eClinical, an electronic platform for the management of clinical trials and is based on 34 clinical variables, regarding indication, intra- and postoperative course. Clinical outcomes and data regarding implementation of MILS activity have been analyzed for the aim of the study. Between November 2014 and June 2017, data from 1678 MILS performed in 48 centers have been collected (mean number of procedures per center 35, range 1-302). 22% of procedures were performed for benign and 78% for malignant disease (HCC constituted the 49.1% and CRLM the 31.2% of malignant tumors). Major liver resections (>3 liver segments), including right and left hepatectomies, trisectionectomies and ALPPS procedures were 10% of the series. Mean blood loss was 200 ± 230 mL Morbidity rate was 20.5% and mortality was 0.3%. 10.4% of cases were converted to open approach. Median length of stay was 5 days. MILS/total resections ratio in 13 experienced centers increased from 14 to 30% after Registry establishment. MILS programs are well established in Italy, with progressive increase both in the number of cases and in the numerosity of centers. The I Go MILS Registry is playing a crucial role in monitoring the development of MILS in the real world on a national basis while giving a significant contribution to the implementation of MILS programs.

Laparoscopic Versus Open Liver Resection for Lesions Adjacent to Major Vessels: A Propensity Score Matched Analysis

BACKGROUND

Laparoscopic liver resection (LLR) for lesions adjacent to major vessels was still associated with difficulty and challenge. This study aimed to compare outcomes after LLR and open liver resection (OLR) of lesions adjacent to major vessels.

MATERIALS AND METHODS

A retrospective analysis of patients with hepatic tumors close to main or second branches of Glisson's tree, to the major hepatic vein, or to the inferior vena cava within 1 cm between January 2015 and January 2017 was performed based on the propensity score matching (PSM) method. Perioperative and oncological outcomes were then evaluated.

RESULTS

A total of 64 patients underwent LLR and 86 patients had OLR. After 1:1 PSM, well-matched 40 patients in each group were obtained. The operative time (240 versus 210 minutes, P = .012) in the LLR group was significantly longer than that in the OLR group, whereas blood loss (200 versus 400 mL, P = .003) was less in the laparoscopic group. The median hospital stay for LLR (6 versus 8 days, P = .032) was shorter than for the open procedure. No statistical differences was noted according to overall postoperative complications, but the OLR group tended to be vulnerable to more severe complications. For patients with hepatocellular carcinoma, the comparable oncological results in terms of 2-year overall survival (P = .898) and disease-free survival (P = .992) were observed.

CONCLUSIONS

LLR for tumors adjacent to major vessels appears to be feasible and safe in selected patients. LLR is associated with less blood loss, shorter hospital stay, and similar oncological outcomes compared with OLR.

Are Hybrid Liver Resections Truly Minimally Invasive? A Propensity Score Matching Analysis

BACKGROUND

Hybrid liver resection is considered a modality of minimally invasive surgery; however, there are doubts regarding loss of benefits of laparoscopy due to the use of an auxiliary incision. We compared perioperative results of patients undergoing hybrid × open and hybrid × pure laparoscopic resections.

METHODS

Consecutive patients undergoing liver resection between June 2008 and January 2016 were studied. Study groups were compared after propensity score matching (PSM).

RESULTS

Six hundred forty-four resections were included in the comparative analysis: 470 open, 120 pure laparoscopic, and 54 hybrids. After PSM, 54 patients were included in each group. Hybrid × open: hybrid technique had shorter operative time (319.5 ± 108.6 × 376.2 ± 155.8 minutes, P = .033), shorter hospital stay (6.0 ± 2.7 × 8.1 ± 5.6 days, P = .001), and lower morbidity (18.5% × 40.7%, P = .003). Hybrid × pure laparoscopic: hybrid group had lower conversion rate (0% × 13%, P = .013). There was no difference regarding estimated blood loss, transfusion rate, hospital stay, complications, or mortality.

CONCLUSIONS

Hybrid resection has better perioperative results than the open approach and is similar to pure laparoscopy. The hybrid technique should be considered a minimally invasive approach.

Recurrence of Hepatocellular Carcinoma After Laparoscopic Hepatectomy: Risk Factors and Treatment Strategies

PURPOSE

To investigate the risk factors for recurrence and treatment strategies after patients with hepatocellular carcinoma (HCC) undergo total laparoscopic hepatectomy (LH).

METHODS

The study included 109 patients who underwent LH (laparoscopy resection [LR] group, n = 50) or open hepatectomy [OH] (open resection [OR] group, n = 59) for HCC in our hospital between March 2011 and June 2016. Perioperative outcomes, disease recurrence, survival, and risk factors for recurrence were analyzed.

RESULTS

Patient characteristics did not significantly differ between groups. The 1- and 3-year survival rates were 90.7% and 78.1%, respectively, for the LR group and 83.1% and 74.4%, respectively, for the OR group (P = .71). The 1- and 3-year disease-free survival rates were 89.6% and 51.4%, respectively, for the LR group and 84.7% and 59.6%, respectively, for the OR group (P = .935). Tumor size, differentiation, vascular invasion, surgical bleeding, and surgical resection margin were risk factors for tumor recurrence after LH.

CONCLUSION

LH for HCC did not increase the risk of recurrence compared with OH. Tumor size, differentiation, vascular invasion, surgical bleeding, and surgical resection margin were risk factors for tumor recurrence. Reducing bleeding during surgery and ensuring sufficient surgical margins were the most important measures to reduce postoperative recurrence of HCC.

Laparoscopic Liver Resection of Hepatocellular Carcinoma with a Tumor Size Larger Than 5 cm: Review of 45 Cases in a Tertiary Institution

INTRODUCTION

Although laparoscopic liver resection (LLR) has developed rapidly, its usefulness for the treatment of large tumors is less clear, due to concerns about compromising oncological principles and patient safety. The purpose of this study was to explore the feasibility and safety of LLR for the treatment of hepatocellular carcinoma (HCC) with a tumor size larger than 5 cm.

PATIENTS AND METHODS

From January 2007 to December 2014, we performed LLR in 45 patients with HCC with a tumor size ≥5 cm. Perioperative outcome, tumor recurrence, and overall patient survival were analyzed.

RESULTS

Median age was 60 years (interquartile range [IQR] 52-68) and 64.4% (29/45) were male. Seven patients (15.6%) had larger than 10 cm of HCC. No operative deaths occurred and six of the laparoscopic procedures were converted to open resection (conversion rate 13.3%). Median operation time was 365 minutes (IQR 277-443) and median estimated blood loss (EBL) was 400.0 mL (IQR 275-600). There was no R1 or R2 resection and median resection margin was 19.0 mm (IQR 8.0-33.0). Complications above Clavien-Dindo classification grade III occurred in four patients (8.9%). The median overall follow-up time was 10.7 month (range 1.1-62.1). One-year recurrence free survival (RFS) and overall survival (OS) were 86.0% and 95.5%, and 3-year RFS and OS were 70.7% and 86.0%.

CONCLUSION

LLR appears safe and feasible in patients with HCC with a tumor size larger than 5 cm. Expansion of indication for LLR in patients with HCC may be considered.

Precoagulation-assisted parenchyma-sparing laparoscopic liver surgery: rationale and surgical technique

BACKGROUND

For the treatment of both primary and metastatic liver tumors, laparoscopic parenchyma-sparing surgery is advocated to reduce postoperative liver failure and facilitate reoperation in the case of recurrence. However, atypical and wedge resections are associated with a higher amount of intraoperative bleeding than are anatomical resections, and such bleeding is known to affect short- and long-term outcomes. Beyond the established role of radiofrequency and microwave ablation in the setting of inoperable liver tumors, the application of thermoablative energy along the plane of the liver surface to be transected results in a zone of coagulative necrosis, possibly minimizing bleeding of the cut liver surface during parenchymal transection.

METHODS

From January 2013 to March 2016, a total of 20 selected patients underwent laparoscopic ultrasound-guided liver resection with thermoablative precoagulation of the transection line.

RESULTS

During a period of 38 months, 50 laparoscopic thermoablative procedures were performed. Colorectal liver metastases were the most frequent diagnosis. Seventy-two percent of the nodules were removed using parenchymal transection with radiofrequency-precoagulation, while microwave-precoagulation was performed for 20 % of the resected nodules. The remaining 8 % of the nodules were treated by thermoablation alone. The hepatic pedicle was intermittently clamped in six patients. The mean blood loss was 290 mL, and four patients required perioperative transfusions.

CONCLUSIONS

Precoagulation-assisted parenchyma-sparing laparoscopic liver surgery can get minimal blood loss during parenchymal transection and lower the need for perioperative transfusions, providing a nonquantifiable margin of oncological safety on the remaining liver. Additional results from larger series are advocated to confirm these preliminary data.

Laparoscopic liver resection: Experience based guidelines

Laparoscopic liver resection (LLR) has been progressively developed along the past two decades. Despite initial skepticism, improved operative results made laparoscopic approach incorporated to surgical practice and operations increased in frequency and complexity. Evidence supporting LLR comes from case-series, comparative studies and meta-analysis. Despite lack of level 1 evidence, the body of literature is stronger and existing data confirms the safety, feasibility and benefits of laparoscopic approach when compared to open resection. Indications for LLR do not differ from those for open surgery. They include benign and malignant (both primary and metastatic) tumors and living donor liver harvesting. Currently, resection of lesions located on anterolateral segments and left lateral sectionectomy are performed systematically by laparoscopy in hepatobiliary specialized centers. Resection of lesions located on posterosuperior segments (1, 4a, 7, 8) and major liver resections were shown to be feasible but remain technically demanding procedures, which should be reserved to experienced surgeons. Hand-assisted and laparoscopy-assisted procedures appeared to increase the indications of minimally invasive liver surgery and are useful strategies applied to difficult and major resections. LLR proved to be safe for malignant lesions and offers some short-term advantages over open resection. Oncological results including resection margin status and long-term survival were not inferior to open resection. At present, surgical community expects high quality studies to base the already perceived better outcomes achieved by laparoscopy in major centers’ practice. Continuous surgical training, as well as new technologies should augment the application of laparoscopic liver surgery. Future applicability of new technologies such as robot assistance and image-guided surgery is still under investigation.

Oncological outcomes of laparoscopic surgery of liver metastases: a single-centre experience

In the era of multimodal management of liver metastases, surgical resection remains the only curative option, with open approach still being referred to as the standard of care. Currently, the feasibility and benefits of the laparoscopic approach for liver resection have been largely demonstrated. However, its oncologic adequacy remains to be confirmed. The aim of this study is to report the oncological results of laparoscopic liver resection for metastatic disease in a single-centre experience. A single-centre database of 413 laparoscopic liver resections was reviewed and procedures for liver metastases were selected. The assessment of oncologic outcomes included analysis of minimal tumour-free margin, R1 resection rate and 3-year survival. The feasibility and safety of the procedures were also evaluated through analysis of perioperative outcomes. The study comprised 209 patients (294 procedures). Colorectal liver metastases were the commonest indication (67.9%). Fourteen patients had conversion (6.7%) and oncological concern was the commonest reason for conversion (42.8%). Median tumour-free margin was 10 mm and complete radical resections were achieved in 211 of 218 curative-intent procedures (96.7%). For patients affected by colorectal liver metastases, 1- and 3-year OS resulted 85.9 and 66.7%. For patients affected by neuroendocrine liver metastases, 1- and 3-year OS resulted 93 and 77.8%. Among the patients with metastases from other primaries, 1- and 3-year OS were 83.3 and 70.5%. The laparoscopic approach is a safe and valid option in the treatment of patients with metastatic liver disease undergoing curative resection. It does offer significant perioperative benefits without compromise of oncologic outcomes.

Intermittent Pringle maneuver versus continuous hemihepatic vascular inflow occlusion using extra-glissonian approach in laparoscopic liver resection

BACKGROUND

Despite accumulated experience and advancing techniques for laparoscopic hepatectomy, bleeding remains the major concern during parenchymal transection. The vascular inflow control technique is still important to decrease intraoperative blood loss. The objective of this study was to compare intermittent Pringle with continuous hemihepatic vascular inflow occlusion using extra-glissonian approach in laparoscopic liver resection.

METHODS

Between January 2011 and January 2015, a total of 79 consecutive patients with tumors locating either in the right or in the left hemiliver were included into this retrospective study (45 in the Pringle group vs. 34 in the half-Pringle group). Preoperative clinical characteristics, intraoperative details, postoperative complications and outcomes of patients were compared.

RESULTS

The two groups were well matched according to clinical characteristics, tumor features, types of liver resection and histopathology (P > 0.05). The mean operative time (247.5 ± 61.3 vs. 221.4 ± 48.7 min, P = 0.0446), ischemic duration (62.8 ± 28.3 vs. 44.1 ± 20.5 min, P = 0.0017) and overall declamping time (21.2 ± 8.2 vs. 0.9 ± 1.9 min, P < 0.05) were significantly longer in the Pringle group than in the half-Pringle group. The mean amount of intraoperative blood loss (568.2 ± 325.1 vs. 420.7 ± 307.2 mL, P = 0.0444) and transfusion (266.1 ± 123.4 vs. 203.2 ± 144.6 mL, P = 0.0406) were significantly greater in the Pringle group. The overall operative morbidity rate was significantly higher in the Pringle group (40 vs. 17.6%, P = 0.0324). The Pringle group was associated with significantly higher alanine aminotransferase and aspartate transaminase levels on postoperative day (POD) 7 and lower albumin levels on PODs 1 and 3 (P < 0.05). The C-reactive protein levels were significantly higher in the Pringle group than in the half-Pringle group on POD 1 (37.5 ± 21.4 vs. 28.2 ± 19.0 mg/L, P = 0.0484), POD 3 (114.0 ± 53.4 vs. 90.6 ± 47.9 mg/L, P = 0.0474) and POD 7 (54.9 ± 29.8 vs. 40.1 ± 26.4 mg/L, P = 0.0245).

CONCLUSION

Continuous hemihepatic vascular inflow occlusion using extra-glissonian approach offers the advantages of less operative time and blood loss, less injury and better recovery in laparoscopic liver resection.