The Extrahepatic Glissonian Versus Hilar Dissection Approach for Laparoscopic Formal Right and Left Hepatectomies in Patients with Hepatocellular Carcinoma

Laparoscopic liver resection or enucleation for giant hepatic hemangioma: how to choose?

BACKGROUND

Laparoscopic treatment has been increasingly adopted for giant hepatic hemangioma (HH), but the role of liver resection or enucleation remains uncertain. The aim of this study is to compare the laparoscopic resection (LR) with laparoscopic enucleation (LE) for HH, and to provide evidence on how to choose the most suitable approach for HH.

METHODS

A retrospective analysis of HH patients underwent laparoscopic treatment between March 2015 and August 2022 was performed. Perioperative outcomes were compared based on the surgical approaches, and risk factors for increased blood loss was calculated by logistic regression analysis.

RESULTS

A total of 127 patients in LR group and 287 patients in LE group were enrolled in this study. The median blood loss (300 vs. 200 mL, P < 0.001) was higher in LE group than that in LR group. Independent risk factors for blood loss higher than 400 mL were tumor size ≥ 10 cm, tumor adjacent to major vessels, tumor occupying right liver or caudate lobe, and the portal phase enhancement ratio (PER) ≥ 38.9%, respectively. Subgroup analysis showed that LR was associated with less blood loss (155 vs. 400 mL, P < 0.001) than LE procedure in patients with high PER value. Both LR and LE approaches exhibited similar perioperative outcomes in patients with low PER value.

CONCLUSIONS

Laparoscopic treatment for HH could be feasibly and safely performed by both LE and LR. For patients with PER higher than 38.9%, the LR approach is recommended.

Intrahepatic Glisson Intrathecal Dissection via a Hepatic Parenchymal Transection-First Approach for Laparoscopic Anatomical Hemihepatectomy in Patients with Left/Right Glisson Pedicle Involvement

Background: Because of lack of an appropriate surgical approach, laparoscopic surgery in patients with left/right Glisson pedicle involvement is still rarely conducted. This study aimed to discusses the methods of intrahepatic Glisson intrathecal dissection via a hepatic parenchymal transection-first approach for laparoscopic hemihepatectomy in patients with left/right Glisson pedicle involvement. Materials and Methods: We retrospectively analyzed the clinical data of 21 patients who underwent laparoscopic hepatectomy in the Second Affiliated Hospital, Third Military Medical University (Army Medical University) from March 2021 to May 2022. Results: The mean age of the patients was 53.1 ± 11.6 years; mean operation time, 191.9 ± 22.3 minutes; median intraoperative blood loss, 205 mL (160-300 mL); and median length of hospital stay, 8 days (7-9 days). None of the patients underwent conversion to open procedure. Thirteen patients had pathologically confirmed hepatocellular carcinoma (HCC) with portal tumor thrombi (PVTT), and 8 was confirmed hepatolithiasis. Intraoperative frozen pathology and final pathology showed tumor free surgical margins in HCC with PVTT patients. After conservative treatment, all the complications such as postoperative liver section effusion, pleural effusion, pneumonia, intra-abdomen bleeding, and bile leak were cured. During outpatient follow-up examination, no other abnormality was detected. All HCC with PVTT patients were treated with a tyrosine kinase inhibitor after the operation and survived tumor-free. Conclusions: Proposed here is a more safe and feasible method of laparoscopic hemihepatectomy in patients with left/right Glisson pedicle involvement, but many problems still needs further exploration.

A novel Laennec's capsule tunnel approach for pure laparoscopic left hemihepatectomy: a propensity score matching study

Background

With the development of laparoscopic hepatectomy, there are different surgical approaches and pedicle anatomical methods for laparoscopic left hepatectomy. Combined with our practical experience, we proposed a method of transhepatic Laennec membrane tunnel for laparoscopic left hemihepatectomy (LT-LLH) and investigated the feasibility by comparison with the extrahepatic Glissonian approach for laparoscopic left hemihepatectomy (GA-LLH).

Patients and methods

The data of patients who underwent laparoscopic left hepatectomy in the Department of Hepatobiliary Pancreatic surgery of Fujian Provincial Hospital from December 2019 to March 2022 were analyzed retrospectively. Among them, 45 cases underwent laparoscopic left hemihepatectomy with an extrahepatic Glissonian approach, and 38 cases underwent laparoscopic left hemihepatectomy via transhepatic Laennec membrane tunnel approach. A 1:1 propensity score matching (PSM) method was performed to compare the perioperative indexes and long-term tumor prognosis between the two groups.

Results

After 1:1 PSM, 33 patients in each group were selected for further analysis. Compared with the GA-LLH group, the operation time of the LT-LLH group was shorter. There was no significant difference in the incidence of total complications between the two groups. Moreover, no statistical differences were found in disease-free survival and overall survival between the two groups.

Conclusion

It is safe, faster, and convenient for selective appropriate cases to carry out laparoscopic left hemihepatectomy through the hepatic Laennec membrane tunnel, which is suitable for clinical promotion.

Intrathecal hydromorphone for analgesia after partial hepatectomy: a randomized controlled trial

INTRODUCTION

There is substantial interest in adding intrathecal opioids, such as hydromorphone to the multimodal pain management strategies. We conducted a randomized controlled trial to examine whether adding intrathecal hydromorphone to a multimodal strategy could safely improve analgesic efficacy for patients undergoing partial hepatectomy.

METHODS

A total of 126 adult patients undergoing partial hepatectomy under general anesthesia were randomly assigned to receive intrathecal hydromorphone (100 μg) or no block. The primary outcome was the incidence of moderate to severe pain during movement at 24 hours after surgery. Secondary outcomes included the incidence of moderate to severe pain during rest or movement at different times within 72 hours, pain scores during rest or movement within 72 hours after surgery, analgesic use, adverse events, and indicators of postoperative recovery.

RESULTS

Among the 124 patients analyzed, the intrathecal hydromorphone group showed a lower incidence of moderate to severe pain during movement at 24 hours after surgery (29.0% vs 50%; RR 0.58, 95% CI 0.37 to 0.92) than the control group. However, the absolute difference in pain scores on a numerical rating scale was less than 1 between the two groups at 24 hours after surgery. Mild pruritus within the first 24 hours after surgery was more frequent in the intrathecal hydromorphone group (19.4% vs 4.8%; p=0.01).

DISCUSSION

Intrathecal hydromorphone 100 μg reduced the incidence of moderate to severe pain and pain scores during movement within 24 hours after partial hepatectomy. However, the difference in pain scores may not be clinically significant, and intrathecal hydromorphone 100 μg did not significantly improve other analgesic or functional outcomes. Further investigation is needed to optimize the intrathecal hydromorphone dose.

TRIAL REGISTRATION NUMBER

ChiCTR2000030652.

Laparoscopic Left Hemihepatectomy Using the Hilar Plate-First Approach (with Video)

BACKGROUND

Effective inflow and outflow control of the liver is essential for a safe hepatectomy. Detachment of the hilar plate is a fundamental technique in the Glissonean approach. The hilar plate is situated near the middle hepatic vein, which runs in the midplane of the liver, and serves as a landmark during hemihepatectomy. In this study, we describe the technical details and surgical outcomes of laparoscopic left hemihepatectomy using the hilar plate-first approach.

METHODS

The key procedures of the hilar plate-first approach included the following: (1) detachment of the hilar plate for the left Glissonean approach, (2) the middle hepatic vein approach from the hilar plate, (3) parenchymal transection along the ischemic line and middle hepatic vein, and (4) transection of the left Glissonean pedicle at the ventral aspect of the Arantius ligament.

RESULTS

Between September 2020 and September 2021, 12 patients underwent laparoscopic left hemihepatectomy using the hilar plate-first approach. The median operation time was 227 min (range 140-350 min), and the median estimated blood loss was 82.5 ml (range 50-150 ml). The median length of postoperative hospital stay was 7 days (range 5-10 days). No major complications, including biliary complications, were observed.

CONCLUSION

The hilar plate-first approach contributes to the standardization of surgical techniques for laparoscopic left hemihepatectomy. This technique is a safe and effective approach for the inflow and outflow systems of the left hemiliver.

Is the anterior approach suitable for laparoscopic right hemihepatectomy in patients with large HCC (5-10 cm)? A propensity score analysis

BACKGROUND

Right hemihepatectomy via the anterior approach was initially employed to improve the survival of patients with large hepatocellular carcinoma (HCC). To date, the safety and feasibility of laparoscopic right hemihepatectomy via the anterior approach (ALRH) for patients with large HCC remains unclear; thus, we compared short-term and long-term outcomes between ALRH and open right hemihepatectomy via the anterior approach (AORH).

METHODS

161 patients with HCC who met the inclusion and exclusion criteria in our department were enrolled in this study between January 2015 and August 2018. Perioperative and oncological outcomes were compared using propensity score matching analysis (PSM).

RESULTS

There were 45 patients in the ALRH group and 116 patients in the AORH group. After 1:3 PSM, 40 ALRH patients and 95 AORH patients were well matched. The intraoperative time was longer in the ALRH group than in the AORH group after PSM (median, 297.5 vs. 205 min, P < 0.001). However, ALRH led to less intraoperative blood loss than AORH after PSM (median, 265 vs. 350 ml, P = 0.049). The rates of overall complications (12.5% vs. 30.5%, P = 0.028) in the ALRH group were significantly lower than those in the AORH group after PSM. Moreover, the survival outcomes were equivalent between the two groups with regard to 1-, 3-, and 5-year overall survival rates (P = 0.698) and disease-free survival rates (P = 0.510).

CONCLUSION

ALRH could be safe and feasible for some patients with large HCCs (5-10 cm) when performed by experienced surgeons, and it had superior perioperative outcomes and equivalent oncological outcomes to AORH.

Expert Consensus Guidelines: How to safely perform minimally invasive anatomic liver resection

BACKGROUND

The concept of minimally invasive anatomic liver resection (MIALR) is gaining popularity. However, specific technical skills need to be acquired to safely perform MIALR. The "Expert Consensus Meeting: Precision Anatomy for Minimally Invasive HBP Surgery (PAM-HBP Surgery Consensus)" was developed as a special program during the 32nd meeting of the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS).

METHODS

Thirty-four international experts gathered online for the consensus. A Research Committee performed a comprehensive literature review, classifying studies according to the Scottish Intercollegiate Guidelines Network method. Based on the literature review and experts' opinions, tentative recommendations were drafted and circulated among experts using online Delphi Rounds. Finally, formulated recommendations were presented online in the Expert Consensus Meeting of the JSHBPS on February 23rd, 2021. The final recommendations were validated and finalized by the 2nd Delphi Round in May 2021.

RESULTS

Seven clinical questions were selected, and 22 recommendations were formulated. All recommendations reached more than 85% consensus among experts at the final Delphi Round.

CONCLUSIONS

The Expert Consensus Meeting for safely performing MIALR has presented a set of clinical guidelines based on available literature and experts' opinions. We expect these guidelines to have a favorable effect on the safe implementation and development of MIALR.

Glissonean approach for hepatic inflow control in minimally invasive anatomic liver resection: A systematic review

BACKGROUND

The Glissonean approach has been widely validated for both open and minimally invasive anatomic liver resection (MIALR). However, the possible advantages compared to the conventional hilar approach are still under debate. The aim of this systematic review was to evaluate the application of the Glissonean approach in MIALR.

METHODS

A systematic review of the literature was conducted on PubMed and Ichushi databases. Articles written in English or Japanese were included. From 2,390 English manuscripts evaluated by title and abstract, 43 were included. Additionally, 23 out of 463 Japanese manuscripts were selected. Duplicates were removed, including the most recent manuscript.

RESULTS

The Glissonean approach is reported for both major and minor MIALR. The 1st, 2nd and 3rd order divisions of both right and left portal pedicles can be reached following defined anatomical landmarks. Compared to the conventional hilar approach, the Glissonean approach is associated with shorter operative time, lower blood loss, and better peri-operative outcomes.

CONCLUSIONS

Glissonean approach is safe and feasible for MIALR with several reported advantages compared to the conventional hilar approach. Clear knowledge of Laennec's capsule anatomy is necessary and serves as a guide for the dissection. However, the best surgical approach to be performed depends on surgeon experience and patients' characteristics. Standardization of the Glissonean approach for MIALR is important.

Patterns, timing, and predictors of recurrence after laparoscopic liver resection for hepatocellular carcinoma: results from a high-volume HPB center

Background

Although long-term outcomes may be comparable between laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC), there has been little discussion regarding the patterns of recurrence after LLR.

Methods

Patients with HCC who underwent hepatectomy between April 2015 and November 2018 were included in this study. The recurrence patterns were analyzed in detail. The recurrence outcomes following laparoscopic versus OLR for HCC were compared after 1:2 propensity score matching. Potential risk factors for recurrence were also assessed with Cox proportional risk models.

Results

Among 425 patients after LLR, 144 (33.8%) experienced recurrence at the last follow-up, with a median recurrence-free survival (RFS) of 10.0 months (range 1–58 months). The most frequent recurrence site was the liver (n = 99, 68.8%), followed by the surgical margin (n = 15, 10.4%) and distant metastases (n = 12, 8.3%). Liver recurrence with distant metastasis (n = 10, 6.9%) tended to occur early (median 8.0 months), while peritoneal recurrence (n = 8, 5.6%) occurred later (median 14.0 months). A total of 120 (83.3%) patients had recurrence within 2 years after LLR. No trocar site recurrence was observed in this study. The recurrence patterns, timing, and treatment did not show significant differences between the LLR and OLR. The independent risk factors for recurrence included ALBI grade, postoperative α-fetoprotein > 8 ng/ml, tumor size > 5 cm, surgical margin ≤ 1 cm, and multiple tumors. Patients with recurrence had 1- and 5-year overall survival rates of 81.1% and 60.7%, respectively, compared with rates of 95.8% and 92.9% for patients without recurrence (P < 0.000).

Conclusion

This study suggested that intrahepatic recurrence was still the most common recurrence pattern for HCC after LLR and that LLR did not increase the risk of trocar hole recurrence or implantation. Most cases of recurrence occurred within 2 years after LLR, suggesting that surveillance should be targeted to early recurrence.

Supplementary Information

The online version of this article (10.1007/s00464-021-08390-5) contains supplementary material, which is available to authorized users.