Laparoscopic Major Hepatectomy-Technique and Outcomes

Implementation of robotic and laparoscopic hepatopancreatobiliary surgery in low- and middle-income settings: a systematic review and meta-analysis

BACKGROUND

Despite numerous barriers, the application of minimally invasive surgery (MIS) for hepatopancreatobiliary (HPB) conditions has been increasing globally. This study aims to review the current status of HPB MIS in LMICs.

METHODS

Relevant databases were searched, identifying 3452 publications, 38 of which met the inclusion criteria. Meta-analysis of outcomes was carried out using "R" statistical software.

RESULTS

This study reviewed reports of application of MIS for HPB conditions in LMICs, analyzing a total of 3272 procedures. India (66.87 %) and Egypt (20.11 %) contributed majorly to the procedures reviewed. Others were from Indonesia (8.68 %), Colombia (3.06 %), Pakistan (0.67 %), Sri Lanka (0.34 %), Trinidad and Tobago (0.18 %), and Nigeria (0.09 %). India was the only LMIC with robotic HPB MIS. The majority of the procedures were biliary (74.88 %). Basic procedures accounted for 55.63 %, while 44.37 % were advanced. The overall conversion rate and prevalence of morbidity were 8 % [95 % CI: 5; 13], and 15 % [95 % CI: 9; 22], respectively. Robotics was associated with higher conversion (14 % vs 6 %, p < 0.01) but lower morbidity (10 % vs 16 %, p = 0.91), compared to laparoscopic surgery. There were 5 cases of mortality from laparoscopy.

CONCLUSION

The outcomes in this systematic review, compared to findings in other settings indicate successful implementation of HPB MIS in LMICs.

Minimally Invasive Surgery in Liver Transplantation: From Living Liver Donation to Graft Implantation

Since the end of the 20th century and the establishment of minimally invasive techniques, they have become the preferred operative method by many surgeons. These techniques were applied to liver surgery for the first time in 1991, while as far as transplantation is concerned their application was limited to the living donor procedure. We performed a review of the literature by searching in Pubmed and Scopus using the following keywords: Liver transplantation, Minimally invasive surgery(MIS) living liver donor surgery. Applications of MIS are recorded in surgeries involving the donor and the recipient. Regarding the recipient surgeries, the reports are limited to 25 patients, including combinations of laparoscopic, robotic and open techniques, while in the living donor surgery, the reports are much more numerous and with larger series of patients. Shorter hospitalization times and less blood loss are recorded, especially in centers with experience in a large number of cases. Regarding the living donor surgery, MIS follows the same principles as a conventional hepatectomy and is already the method of choice in many specialized centers. Regarding the recipient surgery, significant questions arise mainly concerning the safe handling of the liver graft.

The difficulty grade of laparoscopic hepatectomy for hepatocellular carcinoma correlates with long-term outcomes

The tremendous development of laparoscopic hepatectomy helps to relieve the difficulties encountered during open hepatectomy. Therefore, a difficulty scoring system was produced to assess the difficulty grade of laparoscopic hepatectomy. The aim of this study was to explore whether the IWATE-DSS is comparable to the long-term outcomes of LH for hepatocellular carcinoma. Clinical data from all consecutive patients who underwent laparoscopic hepatectomy for hepatocellular carcinoma at the Sir Run Run Shaw Hospital, Hangzhou, were prospectively collected and reviewed. The difficulty level of the operations was graded using the IWATE-DSS. The perioperative and postoperative outcomes of laparoscopic hepatectomy were compared at each difficulty level. A total of 300 patients underwent laparoscopic hepatectomy for HCC during the study period. The perioperative and postoperative outcomes were significantly different between the groups according to the IWATE-DSS. There were significant differences in both the intraoperative (bleeding control p = 0.000; surgical time p = 0.000; estimated blood loss p = 0.033) and postoperative variables (postoperative hospital stay p = 0.005) among these four groups. The 5-year disease-free survival decreased significantly along with the LH difficulty score (p = 0.000). The 5-year overall survival also decreased significantly along with the LH difficulty score (p = 0.000). IWATE-DSS was significantly correlated with short- and long-term outcomes in patients who underwent laparoscopic hepatectomy for HCC.

Robotic versus laparoscopic major hepatectomy for hepatocellular carcinoma: short-term outcomes from a single institution

BACKGROUND

Currently, an increasing number of robotic major hepatectomies for hepatocellular carcinoma (HCC) are being performed. Despite the advantages of robotic surgery over laparoscopic procedures, studies comparing robotic with laparoscopic major hepatectomy in terms of short-term results remain scarce. This study was performed to compare robotic major hepatectomy and laparoscopic major hepatectomy in terms of their intraoperative and postoperative results.

METHODS

Data regarding demographics and intraoperative and postoperative results of 131 patients undergoing robotic or laparoscopic major hepatectomy between January 2017 and March 2022 were retrieved from their medical records and compared between the two types of surgery.

RESULTS

Between January 2017 and March 2022, 44 robotic major hepatectomies and 87 laparoscopic major hepatectomies were performed at the Department of Hepatobiliary and Pancreatic Surgery, Shenzhen People's Hospital. Patients undergoing robotic major hepatectomy were not significantly different from those undergoing laparoscopic major hepatectomy in terms of age (P = 0.397), sex (P = 0.624), body mass index (BMI) (P = 0.118), alpha-fetoprotein (AFP) (P = 0.09), tumor size (P = 0.176), cirrhosis (P = 0.384), fatty liver (P = 0.162), preoperative antiviral treatment (P = 0.934), hepatitis B virus (HBV) DNA (P = 0.646) and operation type (P = 0.054). Robotic major hepatectomy was associated with a longer operation time (median: 255.5 versus 206.8 min; P < 0.001) and less estimated blood loss (median: 118.9 versus 197.0 ml; P = 0.002) than laparoscopic major hepatectomy. However, robotic major hepatectomy was not significantly different from laparoscopic major hepatectomy regarding length of postoperative hospital stay (P = 0.849), open conversion (P = 0.077), ICU stay (P = 0.866), postoperative massive abdominal bleeding (P = 1.00), portal vein thrombosis (P = 1.00), abdominal infection (P = 1.00), pulmonary infection (P = 1.00), pulmonary embolism (P = 1.00), cardiac complications (P = 1.00), liver failure (P = 1.00), kidney failure (P = 1.00), biliary leak (P = 1.00), positive resection margin (P = 1.00), 30-day mortality (P = 1.00) and 90-day mortality (P = 1.00).

CONCLUSIONS

Robotic major hepatectomy was as effective as laparoscopic surgery in terms of intraoperative and postoperative results but took longer and could more efficiently control intraoperative blood loss.

Assessing the Educational Value of YouTube Videos on Major Laparoscopic Liver Resection: A Cross-sectional Study of the Top 20 Most Viewed Laparoscopic Right and Left Hepatectomy Videos

BACKGROUND

Surgical videos uploaded on social media platforms like YouTube augment the learning experience of advanced procedures like major laparoscopic liver resection (LLR). However, because of the heterogeneous quality, the educational value of such videos is unproven. This study assesses the educational value of YouTube's top 20 most viewed major LLR videos.

MATERIALS AND METHODS

The search terms "laparoscopic hemihepatectomy," "laparoscopic right hepatectomy," and "laparoscopic left hepatectomy" were searched on YouTube on October 7, 2020. Exclusion criteria were minor hepatectomy, open hepatectomy, live donor right and left hepatectomy, robotic hepatectomy videos, and nonstandard laparoscopic technique. Videos were graded based on adherence to key steps in LLR and compliance to the modified LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS); 29 of the original 37 consensus statements were used in our study.

RESULTS

The videos have a median of 7647 views (range: 2675 to 67,449), a median of 34 likes (range: 3 to 67), and a median of 1 dislike (range: 0 to 22). The median duration of major LLR videos was 11.0 minutes (range: 6.38 to 223 min). Majority of the videos had duration of <30 minutes (n=18/20, 90%). There were 14 videos (70%) demonstrating all defined surgical steps. The liver mobilization was shown in 17 videos (75%). Vascular inflow control of hepatic artery and portal vein and vascular outflow control were demonstrated in 18 videos (90%). Parenchymal transection and hemostasis were shown in all videos. The median LAP-VEGaS score across all 20 videos is 6 (range: 1 to 11) out of 29, translating to a median score of 20.6% (range: 3.4% to 37.9%). Thirteen out of 29 of the LAP-VEGaS criteria graded (44.8%) were not met by any of the 20 videos.

CONCLUSIONS

The top 20 most viewed surgical videos on laparoscopic right and left hepatectomy may not be the ideal material for the educational value of surgical trainees. The LAP-VEGaS guidelines are too exhaustive for relevance to social media platforms as an educational tool.

Limited upper midline incision for major hepatectomy in adults: safety and feasibility

Objective: Optimal incision for major hepatectomy remains controversial. In this study, we described our experience with a limited upper midline incision (UMI) for major hepatectomy. The objective was to analyze the feasibility and safety of UMI in major hepatectomy.

Material and Methods: Fifty-seven consecutive patients who underwent major hepatectomies performed via an UMI were compared to a control group of 36 patients who underwent major hepatectomies with a conventional incision (CI).

Results: In 85% of the patients, the indication was malignancy, with a median tumor size of 6 cm. Fifty-three percent of the patients had underlying chronic liver disease, and liver fibrosis was found in 61% of the patients. Ninteen percent of the patients had previous upper abdominal surgery. Twenty- six patients underwent left hepatectomy, 20 patients had right hepatectomy and 11 patients trisegmentectomy. Additional combined surgical proce- dures were performed in 42% of the patients. Median operative time was 323 minutes, estimated blood loss was 500 ml, and median post-operative hospital stay was seven days. Surgical complications occurred in 22 patients (39%). 5-year overall survival was 67%. When compared with the control group with CI, patients with UMI had no statistical difference on operative time, estimated blood loss, length of hospital stay, complication rate, and overall survival.

Conclusion: Major hepatectomies can be safely performed through UMI. This approach should be considered as a reasonable option in addition to conventional and laparoscopic approaches for major hepatectomies.

Short-term Outcomes of "Difficult" Laparoscopic Liver Resection at Specialized Centers: Report From INSTALL (International Survey on Technical Aspects of Laparoscopic Liver Resection)-2 on 4478 Patients

OBJECTIVE

To define the current status of "difficult" LLR, a global database was created and investigated.

BACKGROUND

In the Second International Consensus Conference in 2014, minor LLR was considered as a standard practice and major LLR remained an innovative procedure. Since then, no updates on worldwide trends have been available.

METHODS

A questionnaire on all consecutive patients who underwent difficult LLR (major hepatectomy, posterosuperior segmentectomy, sectionectomy, living donor hepatectomy, tumor size ≥10 cm, Child-Pugh grade ≥B, combined with biliary reconstruction, and Iwate criteria difficulty score ≥7) in 2014-2018 was distributed via email to 65 high-volume LLR centers worldwide. Individual data on patient and tumor demographics, surgical information, and short-term outcomes were obtained to create a large-scale international registry for analyses.

RESULTS

Overall, 58 centers in 19 countries performed 4478 difficult LLR (median, 58.5; range, 5-418) during the study period. Hepatocellular carcinoma accounted for ≥40% of all indications. Half of the patients underwent major hepatectomy, followed by sectionectomy, posterosuperior segmentectomy, and living donor hepatectomy. In the vast majority of procedures, Clavien-Dindo grade ≥IIIa complication rates of ≈10% and 90-day mortality rates of ≈1% were achieved. Left or right trisectionectomy had the worst Clavien-Dindo grade ≥IIIa complication rate of ≥10% and 90-day mortality rate of 5%-10%. No significant correlation was observed between center volume and short-term outcomes.

CONCLUSIONS

Total 4478 patients underwent difficult LLR worldwide in 2014-2018. Most procedures are safe and feasible when conducted in specialized centers.

Correlation Between Type of Retrieval Incision and Postoperative Outcomes in Laparoscopic Liver Surgery: A Critical Assessment

Background: At the end of a laparoscopic major hepatectomy, an incision wide enough for specimen retrieval is required. Classically, Pfannenstiel (PF) incision is the type of access favored as service incision in laparoscopy. However, in specific settings the use of a midline (ML) incision can be favorable, with doubtful impaction on the outcomes of a purely laparoscopic operation. The aim of this study was to investigate on clinical outcomes after laparoscopic hemihepatectomies using PF/ML incisions in comparison with open. Methods: The institutional clinical database of the Hepatobiliary Division at San Raffaele Hospital (Milan, Italy) was retrospectively reviewed identifying cases of laparoscopic and open hemihepatectomies. Three analyses were performed: whole laparoscopic versus open; ML versus open; PF versus ML. Clinical outcomes such as intraoperative blood loss, operative time, postoperative morbidity, motility resumption, perceived pain, and length of stay (LOS) were used for comparisons. Results: Laparoscopy was confirmed to be superior to open approach also in the present series in terms of lower blood loss (300 versus 400 mL, P = .041), fewer complications (14.2% versus 25.9%, P = .024), shorter hospitalization (5 versus 7 days, P = .033), and enhanced recovery in terms of better pain control (P = .035) and mobility resumption (P = .047). Similar outcomes were observed comparing ML alone with open (estimated blood loss 300 mL versus 400 mL, P = .039; complications 13.1% versus 25.9%, P = .037; LOS 5 days versus 7 days, P = .04; lower pain perception, P = .048 and faster mobility resumption, P = .046). No significant differences were observed in postoperative outcomes of PF versus ML. Conclusions: Suprapubic and ML incisions at the end of a pure laparoscopic case lead to comparable outcomes between each other. The adoption of ML incision for specimen retrieval does not affect outcomes of minimal invasiveness.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Propensity Score-Matched Analysis of Pure Laparoscopic Versus Hand-Assisted/Hybrid Major Hepatectomy at Two Western Centers

BACKGROUND

Laparoscopic major hepatectomy is expanding, but little data exist comparing surgical approaches. The aim of this study was to test the hypothesis that pure laparoscopic liver resection (PLAP) has advantages over hand-assisted (HALS) or hybrid (HYB) resection for major hemi-hepatectomy at two western centers.

METHODS

Using propensity score matching, 65 cases of HALS + HYB (18 hand-assisted and 47 hybrid) were matched to 65 cases of PLAP. Baseline characteristics were well matched for gender, age, ASA score, Childs A cirrhosis, right/left hepatectomy, malignancy, tumor size, and type between the groups.

RESULTS

The HALS + HYB group had 27 right and 38 left major hepatectomies (n = 65) versus 29 right and 36 left (n = 65) in the PLAP group (p = NS). The median number of lesions resected was 1 in each group, with median size 5.6 cm (HALS + HYB) versus 6.0 cm (PLAP), (p = NS). The HALS + HYB group had shorter OR time (240 versus 330 min, p < 0.01), and less blood loss (EBL 150 ml vs. 300 ml, p < 0.01) versus the PLAP group, respectively. Median length of stay (LOS) was 4 days with HALS + HYB versus 5 days in the PLAP group (p = 0.02). There were no significant differences in use of the Pringle maneuver, transfusion rate, ICU stay, post-op morbidity, liver-specific complications, or R0 resection. Pain regimen/usage in each group is provided. There were no 30/90-day deaths in either group.

CONCLUSION

This is the first reported series of propensity score matching of HALS + HYB versus PLAP for major hepatectomy. The HALS + HYB group had non-inferior OR time, blood loss, and LOS versus the PLAP group, while the other perioperative parameters were comparable. We conclude that minimally invasive liver resection with either PLAP or HALS + HYB technique yields excellent results.

Outcomes following laparoscopic versus open major hepatectomy: a meta-analysis

OBJECTIVE

The role of laparoscopic major hepatectomy (LMH) remains uncertain in current liver surgery. This meta-analysis aimed to compare surgical and oncological outcomes of LMH versus open major hepatectomy (OMH).

METHODS

A systematic search was conducted in PubMed, Embase, and the Cochrane Library database to identify all relevant publications. The statistical analysis was performed using Review Manager version 5.3. Continuous variables were calculated by standardized mean differences (SMD) with 95% confidence interval (CI), whereas dichotomous variables were calculated by odds ratio (OR) with 95%CI.

RESULTS

A total of 10 eligible studies with 1130 patients were identified, of which 455 (40.3%) patients in the LMH group and 675 (59.7%) patients in the OMH group. LMH was associated with less blood loss (SMD = -0.30, 95%CI: -0.43 to -0.18, p < .00001), less transfusion requirement (OR = 0.49, 95%CI: 0.29-0.82, p = .007), decreased postoperative morbidity (OR = 0.56, 95%CI: 0.42-0.76, p = .0001), and shorter hospital stay (SMD = -0.46, 95%CI: -0.69 to -0.24, p < .0001) when compared with the OMH group. But the operative time was significantly longer in LMH group (SMD = 0.61, 95%CI: 0.79-1.86, p = .01). Both the two groups achieved similar surgical margin and R0 resection rate for malignant lesions.

CONCLUSIONS

This meta-analysis demonstrated that LMH appeared to be feasible and safe in current liver surgery. LMH is associated with less blood loss, decreased postoperative morbidity, shorter hospital stay, and comparable oncological outcomes compared with OMH.

Comparative Effectiveness of Minimally Invasive Surgery and Conventional Approaches for Major or Challenging Hepatectomy

BACKGROUND

The benefits of minimally invasive surgery (MIS) for low-risk or minor liver resection are well established. There is growing interest in MIS for major hepatectomy (MH) and other challenging resections, but there remain unanswered questions of safety that prevent broad adoption of this technique.

STUDY DESIGN

We conducted a retrospective cohort study of patients undergoing hepatectomy at 65 hospitals participating in the NSQIP Hepatopancreatobiliary Collaborative in 2014. We assessed serious morbidity or mortality (SMM; including organ/space infection and organ failure). Secondary outcomes included transfusion, bile leak, liver failure, reoperation or intervention, and 30-day readmission. We also measured factors considered to make resection more challenging (ie large tumors, cirrhosis, ≥3 concurrent resections, previous neoadjuvant chemotherapy, and morbid obesity).

RESULTS

There were 2,819 patients who underwent hepatectomy (aged 58 ± 14 years; 53% female; 25% had MIS). After adjusting for clinical and operative factors, the odds of SMM (odds ratio [OR] = 0.57; 95% CI 0.34 to 0.96; p = 0.03) and reoperation or intervention (OR = 0.52; 95% CI 0.29 to 0.93; p = 0.03) were significantly lower for patients undergoing MIS compared with open. In the MH group (n = 1,015 [13% MIS]), there was no difference in the odds of SMM after MIS (OR = 0.37; 95% CI 0.13 to 1.11; p = 0.08); however, minimally invasive MH met criteria for noninferiority. There were no differences in liver-specific complications or readmission between the groups. Odds of SMM were significantly lower after MIS among patients who had received neoadjuvant chemotherapy (OR = 0.33; 95% CI 0.15 to 0.70; p = 0.004).

CONCLUSIONS

In this large study of minimally invasive MH, we found safety outcomes that are equivalent or superior to conventional open surgery. Although the decision to offer MIS might be influenced by factors not included in this evaluation (eg surgeon experience and other patient factors), these findings support its current use in MH.

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.

Infrahepatic inferior vena cava clamping with Pringle maneuvers for laparoscopic extracapsular enucleation of giant liver hemangiomas

Background

This study aimed to determine the feasibility of the extracapsular enucleation method for giant liver hemangiomas by infrahepatic inferior vena cava (IVC) clamping and the Pringle maneuver to control intraoperative bleeding under laparoscopic hepatectomy.

Methods

From January 2012 to January 2016, 36 patients underwent laparoscopic extracapsular enucleation of giant liver hemangiomas. Patients were divided into two groups: infrahepatic IVC clamping + Pringle maneuvers group (IVCP group, n = 15) and the Pringle maneuvers group (Pringle group, n = 21). Operative parameters, postoperative laboratory tests, and morbidity and mortality were analyzed.

Results

The mean size of liver hemangiomas was 13.3 cm (range 10–25 cm). Infrahepatic IVC clamping + the Pringle maneuvers with laparoscopic extracapsular enucleation significantly reduced intraoperative blood loss (586.7 vs 315.3 mL, p < 0.001) and transfusion rates (23.8 vs 6.7%, p = 0.001), compared with the Pringle maneuver alone. The gallbladder was retained in both groups. The mean arterial pressure (MAP) in Pringle group remained virtually stable before and after clamping of hepatic portal, while it was significantly decreased after IVC clamping in IVCP group than that pre-clamping (p < 0.001). The heart rate of all patients was significantly increased after clamping when compared to pre-clamping heart rates (p < 0.001). Once vascular occlusion was released, MAP returned to normal levels within a few minutes. There were no significant differences in postoperative complications between two groups. The vascular occlusion techniques in both groups had no serious effect on postoperative of hepatic and renal function.

Conclusions

Extracapsular enucleation with infrahepatic IVC clamping + the Pringle maneuver is a safe and effective surgical treatment to control bleeding for giant liver hemangiomas in laparoscopic hepatectomy.

Laparoscopic Right Hepatectomy: Toward Protocolization and Simplification

BACKGROUND

Major hurdles for laparoscopic right hepatectomy (LapRH) include difficulties in (1) mobilization and (2) applying hanging maneuver and (3) lack of experienced assistants. We discuss the protocolization of lapRH, introducing our simplified technique.

METHODS

The procedure was disassembled into six steps: (1) curtailed mobilization of the right liver so as to align the resection plane with the laparoscopic camera view, (2) inflow vascular control, (3) setting up the parenchymal resection applying the rubber band retraction method, (4) parenchymal resection approaching the caudate lobe, (5) a lifting-up maneuver using a laparoscopic grasper or retractor instead of the hanging maneuver, and (6) completion of resection dividing the caudate lobe, right hepatic vein, and remaining ligament.

RESULTS

Between March 2014 and August 2015, 13 LapRH surgeries were attempted. The patients consisted of eight males and five females with a mean age of 58.5 ± 11.6 years. Final pathological diagnoses were hepatocellular carcinoma in seven patients, intrahepatic duct stone in 4, and colorectal liver metastasis in 2. The mean total operative time was 381 ± 66 minutes, and the mean intraoperative estimated blood loss was 633 ± 619 ml. One patient was converted to open surgery. There was no clinically significant complication, and the mean length of stay after surgery was 9.1 ± 2.3 days.

CONCLUSIONS

Protocolization and simplification of the procedure may allow professionals to better understand the respective process and determine appropriate port placements, resulting in safe and successful minimally invasive hepatectomy procedures.

Evidence supporting laparoscopic major hepatectomy

Laparoscopic liver resection (LLR) has been increasing in frequency with over 9,000 cases done worldwide. Benefits of laparoscopic resection include less blood loss, smaller incisions, decreased postoperative morbidity, and shorter length of stay compared to open liver resection. With increased experience, several centers have reported series of laparoscopic major hepatectomy, although this represents only about 25% of total LLR performed. Evidence is accumulating to support laparoscopic major hepatectomy with the understanding that there is a steep learning curve, and surgeons should begin with minor LLR before moving on to laparoscopic major hepatectomy. Controversy still remains concerning indications, techniques, learning curve, risks, and long-term cancer outcomes with laparoscopic major hepatectomy.