Laparoscopic Hepatic Lobectomy: Advantages of a Minimally Invasive Approach

Advantages and Prospective Implications of Smart Materials in Tissue Engineering: Piezoelectric, Shape Memory, and Hydrogels

Conventional biomaterial is frequently used in the biomedical sector for various therapies, imaging, treatment, and theranostic functions. However, their properties are fixed to meet certain applications. Smart materials respond in a controllable and reversible way, modifying some of their properties because of external stimuli. However, protein-based smart materials allow modular protein domains with different functionalities and responsive behaviours to be easily combined. Wherein, these "smart" behaviours can be tuned by amino acid identity and sequence. This review aims to give an insight into the design of smart materials, mainly protein-based piezoelectric materials, shape-memory materials, and hydrogels, as well as highlight the current progress and challenges of protein-based smart materials in tissue engineering. These materials have demonstrated outstanding regeneration of neural, skin, cartilage, bone, and cardiac tissues with great stimuli-responsive properties, biocompatibility, biodegradability, and biofunctionality.

Impact of body mass index in elderly patients treated with laparoscopic liver resection for hepatocellular carcinoma

BACKGROUND

The impact of obesity on surgical outcomes in elderly patients candidate for liver surgery is still debated.

AIM

To evaluate the impact of high body mass index (BMI) on perioperative and oncological outcome in elderly patients (> 70 years old) treated with laparoscopic liver resection for hepatocellular carcinoma (HCC).

METHODS

Retrospective multicenter study including 224 elderly patients (> 70 years old) operated by laparoscopy for HCC (196 with a BMI < 30 and 28 with BMI ≥ 30), observed from January 2009 to January 2019.

RESULTS

After propensity score matching, patients in two groups presented comparable results, in terms of operative time (median range: 200 min vs 205 min, P = 0.7 respectively in non-obese and obese patients), complications rate (22% vs 26%, P = 1.0), length of hospital stay (median range: 4.5 d vs 6.0 d, P = 0.1). There are no significant differences in terms of short- and long-term postoperative results.

CONCLUSION

The present study showed that BMI did not impact perioperative and oncologic outcomes in elderly patients treated by laparoscopic resection for HCC.

Short-term outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma in older patients: a propensity score matching analysis

Background

The incidence of hepatocellular carcinoma (HCC) requiring surgical treatment in older patients has been continuously increasing. This study aimed to examine the safety and feasibility of performing laparoscopic liver resection (LLR) versus open liver resection (OLR) for HCC in older patients at a Japanese institution.

Methods

Between January 2010 and June 2021, 133 and 145 older patients (aged ≥ 70 years) who were diagnosed with HCC underwent LLR and OLR, respectively. Propensity score matching (PSM) analysis with covariates of baseline characteristics was performed. The intraoperative and postoperative data were evaluated in both groups.

Results

After PSM, 75 patients each for LLR and OLR were selected and the data compared. No significant differences in demographic characteristics, clinical data, and operative times were observed between the groups, although less than 10% of cases in each group underwent a major resection. Blood loss (OLR: 370 mL, LLR: 50 mL; P < 0.001) was lower, and the length of postoperative hospital stay (OLR: 12 days, LLR: 7 days; P < 0.001) and time to start of oral intake (OLR: 2 days, LLR: 1 day; P < 0.001) were shorter in the LLR group than in the OLR group. The incidence of complications ≥ Clavien–Dindo class IIIa was similar between the two groups.

Conclusions

LLR, especially minor resections, is safely performed and feasible for selected older patients with HCC.

A comparative study of postoperative outcomes between minimally invasive living donor hepatectomy and open living donor hepatectomy: The Korean organ transplantation registry

BACKGROUND

This study evaluated the safety and effectiveness of minimally invasive living donor hepatectomy in comparison with the open procedure, using Korean Organ Transplantation Registry data.

METHODS

We reviewed the prospectively collected data of all 1,694 living liver donors (1,071 men, 623 women) who underwent donor hepatectomy between April 2014 and December 2017. The donors were grouped on the basis of procedure type to the minimally invasive procedure group (n = 304) or to the open procedure group (n = 1,390) and analyzed the relationships between clinical data and complications.

RESULTS

No donors died after the procedure. The overall complication rates after operation in the minimally invasive procedure group and the open procedure group were 6.2% and 3.5%, respectively. Biliary complications were the most frequent events in both groups (minimally invasive procedure group, 2.4%; open procedure group, 1.6%). The majority of complications occurred within 7 days after surgery in both groups. The duration of hospitalization was shorter in the minimally invasive procedure group than in the open procedure group (9.04 ± 3.78 days versus 10.29 ± 4.01 days; P < .05).

CONCLUSION

Based on its similar outcomes in our study, minimally invasive donor hepatectomy cannot be an alternative option compared with the open procedure method. To overcome this, we need to ensure better surgical safety, such as lower complication rate and shorter duration of hospitalization.

Laparoscopic versus open major liver resection for hepatocellular carcinoma: A case-matched analysis of short- and long-term outcomes

Background

The feasibility and safety of laparoscopic major hepatectomy (LMH) are still uncertain. The purpose of the present study is to compare the short- and long-term outcomes of LMH with those of open major hepatectomy (OMH) for hepatocellular carcinoma (HCC).

Method

Between January 2012 and December 2018, a total of 26 patients received laparoscopic major hepatectomy in our center. To minimize any confounding factors, a 1:3 case-matched analysis was conducted based on the demographics and extent of liver resection. Data of demographics, perioperative outcomes, and long-term oncologic outcomes were reviewed.

Results

Intraoperative blood loss (P = 0.007) was significantly lower in the LMH group. In addition, the LMH group exhibited a lower overall complication rate (P = 0.039) and shorter postoperative hospital stay (P = 0.024). However, no statistically significant difference was found between LMH and OMH regarding operation time (P = 0.215) and operative cost (P = 0.860). Two laparoscopic cases were converted to open liver resection. In regard to long-term outcomes, there was no significant difference between LMH and OMH regarding disease-free survival (DFS) (P = 0.079) and overall survival (OS) (P = 0.172).

Conclusion

LMH can be an effective and safe alternative to OMH for selected patients with liver cancer in short- and long-term outcomes.

Comparison of clinical and economic outcomes between minimally invasive liver resection and open liver resection: a propensity-score matched analysis

BACKGROUND

Minimally invasive liver resection (MILR) has gained momentum in recent years. This study of contemporary data compares economic and clinical outcomes between MILR and open liver resection (OLR).

METHODS

We extracted data for patients undergoing liver resection between October 2015-September 2018 from the Premier Healthcare Database. We conducted a propensity score matched analysis to compare complications, in-hospital mortality, inpatient readmissions, discharge to institutional post-acute care, operating room time (ORT), length of stay (LOS), and total hospital cost between MILR and OLR patients.

RESULTS

From the eligible OLR (n = 3349) and MILR (n = 1367) patients, we propensity score matched 1261 from each cohort at a 1:1 ratio. After matching, MILR was associated with lower rates of complications (bleeding: 8.2% vs. 17.4%; respiratory failure: 5.5% vs. 10.9%; intestinal obstruction: 3.6% vs. 6.0%, and pleural effusion: 1.9% vs. 4.9%), in-hospital mortality (0.5% vs. 3.0%), 90-day inpatient readmissions (10.4% vs. 14.3%), discharge to institutional post-acute care (6.9% vs. 12.3%), shorter ORT (257 vs. 308 min) and LOS (4.3 vs. 7.2 days), and lower hospital costs ($19463 vs. $29119) (all P < 0.001).

CONCLUSION

MILR was associated with lower risk of complications and reduced hospital resource utilizations as compared with OLR.

Laparoscopic hepatectomy is superior to open procedures for hepatic hemangioma

BACKGROUND

Laparoscopic hepatectomy (LH) has become increasingly popular for liver neoplasms, but its safety and effectiveness remain controversial. Hepatic hemangiomas are the most common benign liver neoplasm; the main approaches to hepatic hemangiomas include open hepatectomy (OH) and LH. In this study, we compared early outcomes between patients undergoing OH and those with LH.

METHODS

Patients underwent OH or LH in our hospital for hepatic hemangiomas between December 2013 and December 2017 were enrolled. All patients underwent comprehensive preoperative evaluations. The clinicopathological index and risk factors of hemangioma resection were assessed.

RESULTS

In total, 41 patients underwent OH while 53 underwent LH. There was no significant difference in any preoperative clinical variables, including liver function, prothrombin time, or platelet count. Hepatic portal occlusion time and operative time were 39.74 vs. 38.35 minutes (P = 0.717) and 197.20 vs. 203.68 minutes (P = 0.652) in the OH and LH groups, respectively. No mortality nor significant perioperative complications were observed between the two groups. In LH group, two cases were converted to OH, one for an oversized tumor and the other for hemorrhage. Compared with OH patients, those with LH had less blood loss (361.69 vs. 437.81 mL, P = 0.024), shorter postoperative hospital stay (7.98 vs. 11.07 days, P = 0.001), and lower postoperative C-reactive protein (43.63 vs. 58.21 mg/L, P = 0.026).

CONCLUSIONS

LH is superior to OH in terms of postoperative recovery and blood loss for selected patients with hepatic hemangioma.

Body mass index and surgical outcomes in laparoscopic liver resections: a systematic review

BACKGROUND

Laparoscopic liver resection is gaining momentum; however, there is limited evidence on its efficacy and safety in obese patients. The aim of this study was to examine the relationship between BMI and outcomes after laparoscopic liver resection (LLR) using a systematic review of the existing literature.

METHODS

A systematic search of Medline (Ovid 1946-present), PubMed (NCBI), Embase (Ovid 1966-present) and Cochrane Library was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for parameters of LLR and BMI. Operative, post-operative and oncological outcomes were recorded.

RESULTS

Of 1460 abstracts, seven retrospective studies were analysed, published between 2015 and 2017 (study periods 1998-2017). Total patient cohort were classified as 481 obese and 1180 non-obese with a median age range of 42.5-69.4 years. Variations existed in definitions of obesity (Asia BMI >25 kg/m² , Western BMI >30 kg/m² ). Rates of conversion were examined in four studies (0-31%) with one reporting BMI >28 kg/m² as an independent risk factor. Estimated blood loss and transfusion rates were similar. Operative time was increased in obese patients in one study (P = 0.02). Mortality rates ranged from 0% to 4.3% with no difference between BMI classes. No difference in major morbidity was demonstrated. Bile leak rates were increased in obese groups in one study (0-3.44%, P < 0.05). Wound infections were reported in five studies, with higher rates in obese patients (0-5.8% versus 0-1.9%). Tumour size was comparable in both groups. Completeness of resection was analysed in four studies with one study reporting increased R0 rates in obese patients (P = 0.012).

CONCLUSION

This systematic review highlights that current evidence shows LLR in obese patients is safe, however, further studies are required.

Laparoscopic hepatectomy reduces postoperative complications and hospital stay in overweight and obese patients

BACKGROUND

Laparoscopic liver surgery is currently considered the standard of care for various liver malignancies. However, studies focusing on perioperative outcome after laparoscopic hepatectomy (LH) in overweight patients are still sparse and its benefit compared to open hepatectomy (OH) is a matter of debate.

AIM

To analyze postoperative outcomes in overweight [body mass index (BMI) over 25 kg/m²] and obese (BMI over 30 kg/m²) patients undergoing LH and compare postoperative outcome with patients undergoing OH.

METHODS

Perioperative data of 68 overweight (BMI over 25 kg/m²) including a subcohort of obese (BMI over 30 kg/m²) patients (n = 27) who underwent LH at our institution between 2015 and 2019 were retrospectively analyzed regarding surgical outcome and compared to an equal number of patients undergoing OH.

RESULTS

The mean BMI was 29.8 ± 4.9 kg/m² in the LH group and 29.7 ± 3.6 kg/m² in the OH group with major resections performed in 20.6% (LH) and 26.5% (OH) of cases, respectively. Operative time (194 ± 88 min vs 275 ± 131 min; P < 0.001) as well as intensive care (0.8 ± 0.7 d vs 1.1 ± 0.8 d; P = 0.031) and hospital stay (7.3 ± 3.6 d vs 15.7 ± 13.5 d; P < 0.001) were significant shorter in the LH group. Also, overall complications (20.6% vs 45.6%; P = 0.005) and major complications (1.5% vs 14.7%, P = 0.002) were observed less frequently after LH. An additional investigation analyzing the subgroup of obese patients who underwent LH (n = 27) and OH (n = 29) showed a shorter operative time (194 ± 81 min vs 260 ± 137 min; P = 0.009) and a reduced length of hospitalization (7.7 ± 4.3 d vs 17.2 ± 17 d; P < 0.001) but no difference in postoperative complications or overall cost.

CONCLUSION

LH is safe and cost-effective in overweight and obese patients. Furthermore, LH is significantly associated with fewer postoperative complications and reduced hospital stay compared to OH in these patients.

Comparison of liver regeneration in laparoscopic versus open right hemihepatectomy for adult living donor liver transplantation

Backgrounds/Aims

This study aims to compare differences between laparoscopic donor right hemihepatectomy (LDRH) and open donor right hemihepatectomy (ODRH) in the quality of the operation, postoperative complications, and liver regeneration measured via volumetry.

Methods

This study included 119 patients who underwent living donor right hemihepatectomy at Samsung Medical Center from January 2016 to December 2017. We compared several aspects of LDRH and ODRH and analyzed the results using the independent t-test, chi-square test and Fisher's exact test.

Results

Among 119 enrolled patients, 66 patients (55.5%) underwent open surgery, and 53 patients (44.5%) underwent laparoscopic surgery. The mean operation time was significantly shorter for ODRH (290.57±54.04 minutes) than LDRH (312.28±53.5 minutes) (p=0.031). Estimated blood loss was significantly less in LDRH (258.49±119.99 ml) than ODRH (326.52±157.68 ml) (p=0.011). The remnant liver recovered to 83.35±10.71% of the preoperative estimate whole liver volume (pre-EWLV) in the ODRH group and 84.04±8.98% of the pre-EWLV in the LDRH group (p=0.707). The percentage of increased estimated liver volume to postoperative estimate remnant liver volume (post-ERLV) was 137.62±40.34% in the ODRH group and 130.56±36.78% in the LDRH group, and there was no statistically significant difference between the two groups (p=0.326). An analysis of postoperative complications showed no significant differences.

Conclusions

LDRH is safe, and there is no significant difference in hepatic regeneration compared with ODRH. Therefore, LDRH can be applied for living donation of liver.

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.

Evaluation and Management of Cirrhotic Patients Undergoing Elective Surgery

PURPOSE OF REVIEW

Cirrhotic patients have an increased risk of surgical complications and higher perioperative morbidity and mortality based on the severity of their liver disease. Liver disease predisposes patients to perioperative coagulopathies, volume overload, and encephalopathy. The goal of this paper is to discuss the surgical risk of cirrhotic patients undergoing elective surgeries and to discuss perioperative optimization strategies.

RECENT FINDINGS

Literature thus far varies by surgery type and the magnitude of surgical risk. CTP and MELD classification scores allow for the assessment of surgical risk in cirrhotic patients. Once the decision has been made to undergo elective surgery, cirrhotic patients can be optimized pre-procedure with the help of a checklist and by the involvement of a multidisciplinary team. Elective surgeries should be performed at hospital centers staffed by healthcare providers experienced in caring for cirrhotic patients. Further research is needed to develop ways to prepare this complicated patient population before elective surgery.

Laparoscopic combined resection of liver metastases and colorectal cancer: a multicenter, case-matched study using propensity scores

Background

Combined laparoscopic resection of liver metastases and colorectal cancer (LLCR) may hold benefits for selected patients but could increase complication rates. Previous studies have compared LLCR with liver resection alone. Propensity score-matched studies comparing LLCR with laparoscopic colorectal cancer resection (LCR) alone have not been performed.

Methods

A multicenter, case-matched study was performed comparing LLCR (2009–2016, 4 centers) with LCR alone (2009–2016, 2 centers). Patients were matched based on propensity scores in a 1:1 ratio. Propensity scores were calculated with the following preoperative variables: age, sex, ASA grade, neoadjuvant radiotherapy, type of colorectal resection and T and N stage of the primary tumor. Outcomes were compared using paired tests.

Results

Out of 1020 LCR and 64 LLCR procedures, 122 (2 × 61) patients could be matched. All 61 laparoscopic liver resections were minor hepatectomies, mostly because of a solitary liver metastasis (n = 44, 69%) of small size (≤ 3 cm) (n = 50, 78%). LLCR was associated with a modest increase in operative time [206 (166–308) vs. 197 (148–231) min, p = 0.057] and blood loss [200 (100–700) vs. 75 (5–200) ml, p = 0.011]. The rate of Clavien–Dindo grade 3 or higher complications [9 (15%) vs. 13 (21%), p = 0.418], anastomotic leakage [5 (8%) vs. 4 (7%), p = 1.0], conversion rate [3 (5%) vs. 5 (8%), p = 0.687] and 30-day mortality [0 vs. 1 (2%), p = 1.0] did not differ between LLCR and LCR.

Conclusion

In selected patients requiring minor hepatectomy, LLCR can be safely performed without increasing the risk of postoperative morbidity compared to LCR alone.

Performing laparoscopic surgery - Perspectives of young Chinese hepatobiliary surgeons

Laparoscopic liver resection (LLR) has garnered attention as a new form of liver surgery. In China, many hepatobiliary surgeons are now encouraging the examination and assessment of LLC in order to improve its outcomes, and several young hepatobiliary surgeons recently shared their clinical experiences and the results of their research in presentations at the Akamon Forum as part of the 118th Annual Congress of the Japan Surgical Society, which was held April 5-7, 2018 in Tokyo, Japan. In China, LLR has gradually improved over the past 20 years, including both expanded indications and improved surgical approaches. However, China is a vast country, and the level of medical care varies nationwide. Medical facilities that can perform advanced laparoscopic techniques are currently limited to those in large cities. Moreover, additional clinical studies of the long-term oncological outcomes of LLR need to be performed in the future.

Laparoscopic versus open major hepatectomy: a systematic review and meta-analysis of individual patient data

BACKGROUND

The role of laparoscopy for major hepatectomies remains a matter of development to be further assessed. The purpose of this study is to compare the short- and long-term outcomes between laparoscopic and open major hepatectomies meta-analyzing individual patient data from published comparative studies.

METHODS

All retrospective studies comparing between laparoscopic and open major hepatectomies published until March 2017 were identified independently by 2 reviewers by searching in PubMed and Cochrane Central Register of Controlled Trials. Individual patient data were sought from all selected studies. Postoperative outcomes, including intraoperative blood loss, operative time, hospital stay, postoperative complications, mortality rates, and long-term survival were analyzed.

RESULTS

A total of 917 patients were divided into the laparoscopic (427) and open (490) groups from 8 selected studies. The hospital stay was significantly shorter, and the total morbidity was lower in the laparoscopic group. When classified by severity, the incidence of postoperative minor complications was lower; however, that of major complications was not significantly different. The operative time was longer in the laparoscopic group; however, intraoperative blood loss, perioperative mortality, and blood transfusions were comparable between the 2 groups. The overall survival in the patients with colorectal liver metastases and hepatocellular carcinoma was not significantly different between the 2 groups.

CONCLUSION

Laparoscopic major hepatectomies offer some perioperative advantages, including fewer complications and shorter hospital stay, without increasing the blood loss volume and mortality. Whether these results can anticipate the outcomes in future randomized controlled trials has not been determined.

Stepwise introduction of laparoscopic liver surgery: validation of guideline recommendations

BACKGROUND

Uncontrolled introduction of laparoscopic liver surgery (LLS) could compromise postoperative outcomes. A stepwise introduction of LLS combined with structured training is advised. This study aimed to evaluate the impact of such a stepwise introduction.

METHODS

A retrospective, single-center case series assessing short term outcomes of all consecutive LLS in the period November 2006-January 2017. The technique was implemented in a stepwise fashion. To evaluate the impact of this stepwise approach combined with structured training, outcomes of LLS before and after a laparoscopic HPB fellowship were compared.

RESULTS

A total of 135 laparoscopic resections were performed. Overall conversion rate was 4% (n = 5), clinically relevant complication rate 13% (n = 18) and mortality 0.7% (n = 1). A significant increase in patients with major LLS, multiple liver resections, previous abdominal surgery, malignancies and lesions located in posterior segments was observed after the fellowship as well as a decrease in the use of hand-assistance. Increasing complexity in the post fellowship period was reflected by an increase in operating times, but without comprising other surgical outcomes.

CONCLUSION

A stepwise introduction of LLS combined with structured training reduced the clinical impact of the learning curve, thereby confirming guideline recommendations.

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.

Laparoscopic Versus Open Liver Resection for Colorectal Liver Metastases: A Comprehensive Systematic Review and Meta-analysis

The effects of laparoscopic liver resection (LLR) and open liver resection (OLR) on oncological outcomes for colorectal cancer liver metastases (CCLM) remain inconclusive. Major databases were searched from January 1992 to October 2016. Effects of LLR vs OLR were determined. The primary endpoints were oncological outcomes. In total, 32 eligible non-randomized studies with 4697 patients (LLR: 1809, OLR: 2888) were analyzed. There were higher rates of clear surgical margins (OR: 1.64, 95%CI: 1.32 to 2.05, p < 0.00001) in the LLR group, without significant differences in disease recurrence, 3- or 5-year overall survival(OS) and disease free survival(DFS) between the two approaches. LLR was associated with less intraoperative blood loss (WMD: −147.46 [−195.78 to −99.15] mL, P < 0.00001) and fewer blood transfusions (OR: 0.41 [0.30–0.58], P < 0.00001), but with longer operation time (WMD:14.44 [1.01 to 27.88] min, P < 0.00001) compared to OLR. Less overall morbidity (OR: 0.64 [0.55 to 0.75], p < 0.00001) and shorter postoperative hospital stay (WMD: −2.36 [−3.06 to −1.66] d, p < 0.00001) were observed for patients undergoing LLR, while there was no statistical difference in mortality. LLR appears to be a safe and feasible alternative to OLR in the treatment of CCLM in selected patients.

Laparoscopic living donor right hemihepatectomy with venous outflow reconstruction using cadaveric common iliac artery allograft: Case report and literature review

RATIONALE

With the development of laparoscopic technique, the total laparoscopic living donor right hemihepatectomy (LLDRH) procurement surgery has been successfully performed in many liver transplant centers all over the world, and the number of cases is continuing to increase. We report our case of laparoscopic right graft resection with venous outflow reconstruction using cadaveric common iliac artery allograft in our center and review literatures about total LLDRH surgery.

PATIENT CONCERNS AND DIAGNOSES

A 40-year-old male living donor for right hepatectomy was selected after pretransplant evaluation including laboratory tests, liver volume, anatomy of hepatic vein, artery, portal vein, and bile duct. Living donor liver transplantation surgery was approved by Sichuan Provincial Health Department and the ethics committee of the West China Hospital, Sichuan University.

INTERVENTIONS

Hepatic parenchyma transection was performed by ultrasonic scalpel and Cavitron Ultrasonic Surgical Aspirator (CUSA). Right branch of portal vein, right hepatic artery, right hepatic duct, and right hepatic vein were meticulously dissected. The right hepatic duct was ligated and transected 2 mm far from the bifurcation of common hepatic duct, right hepatic artery, and portal vein were also ligated and transected, the right hepatic vein was transected by laparoscopic linear cutting stapler. The gap between short hepatic veins and right hepatic vein was bridged and reconstructed by cadaveric common iliac artery allograft.

OUTCOMES

The operation time was 480 minutes and warm ischemia time was 4 minutes. Blood loss was 300 mL without blood transfusion. The donor was discharged on postoperative day 7 uneventfully without complications. Literatures about laparoscopic living donor right hemihepatectomy are compared and summarized in table.

LESSONS

The total laparoscopic living donor right hemihepatectomy is technically feasible and safe in some transplant centers which should have rich open living donor liver transplantation experience and skilled laparoscopic techniques. Venous outflow tract reconstruction is necessary if orifice diameter of short hepatic vein is greater than 0.5 cm on the graft cutting surface.

Laparoscopic left lateral sectionectomy: a population-based study

BACKGROUND

Laparoscopic left lateral sectionectomy (LLS) has now become standard practice. However, published series are small and retrospective. The aim was to compare at a national level the use and short-term outcome of laparoscopic and open LLS.

METHODS

National hospital discharge databases were screened to identify all adult patients who had undergone elective LLS in France between 2007 and 2012. Outcome measurements included blood transfusion, severe morbidity, mortality and length of hospital stay. The independent influence of the laparoscopic approach on these outcomes was tested overall and after stratifying for the indication (benign condition, primary malignancy, liver metastasis).

RESULTS

Over the 6-year study period, 2198 patients underwent LLS, accounting for 6.9% of all elective liver resections. Some 28.5% of LLS procedures were performed laparoscopically. Among hospitals in which LLS was carried out, 33.2% of procedures were done laparoscopically (median 2 laparoscopic LLS resections per year). The laparoscopic approach was independently associated with a shorter length of hospital stay irrespective of the indication, and a lower transfusion rate in patients with benign condition or primary malignancy.

CONCLUSION

LLS is seldom performed and the laparoscopic approach has not been adopted widely. The potential benefit of laparoscopic LLS varies according to the indication.

Laparoscopic hepatectomy significantly shortens the time to postoperative chemotherapy in patients undergoing major hepatectomies

BACKGROUND

The benefit of adjuvant chemotherapy occurs with early initiation, but is commonly delayed due to postoperative complications. Minimally invasive surgery is proven to significantly reduce complications and hospital length of stay. This study compares open versus laparoscopic liver resection in patients requiring adjuvant chemotherapy.

METHODS

120 consecutive patients with metastatic colorectal liver cancer who underwent liver resection between 2007 through 2012 were reviewed from an IRB prospective database.

RESULTS

44 laparoscopic cases were compared to 76 open cases having equivalent resections. Laparoscopic liver resection patients had lower blood loss (276 ml) than patients with open resection (614 ml). Patients with laparoscopy had shorter length of hospital stay (5 days) than patients with open resection (9 days). Patients with laparoscopic resection had a shorter time of chemotherapy initiation postoperatively (24 days v 39 days). Overall complication rates were higher, but statistically insignificant in patients with open resection.

CONCLUSIONS

Our data showed that the shorter LOS with laparoscopic major hepatectomies allows earlier initiation of chemotherapy compared to the open group, without jeopardizing surgical margins or extent of resection.

SUMMARY

Over the past decade multiple authors have established that, despite occasional longer operating times, laparoscopic liver surgery is associated with reduced blood loss, reduced postoperative morbidity and shorter hospital stay. The purpose of this analysis was to determine if the advantages of a minimally invasive approach correspond to shorter initiation of adjuvant chemotherapy versus an open approach.

Pure Laparoscopic Liver Resection for Malignant Liver Tumor: Anatomic Resection Versus Nonanatomic Resection

Background:

Laparoscopic liver resection (LLR) has been considered to be safe and feasible. However, few studies focused on the comparison between the anatomic and nonanatomic LLR. Therefore, the purpose of this study was to compare the perioperative factors and outcomes of the anatomic and nonanatomic LLR, especially the area of liver parenchymal transection and blood loss per unit area.

Methods:

In this study, surgical and oncological data of patients underwent pure LLR procedures for malignant liver tumor were prospectively collected. Blood loss per unit area of liver parenchymal transection was measured and considered as an important parameter. All procedures were conducted by a single surgeon.

Results:

During nearly 5 years, 84 patients with malignant liver tumor received a pure LLR procedure were included. Among them, 34 patients received anatomic LLR and 50 received nonanatomic LLR, respectively. Patients of the two groups were similar in terms of demographic features and tumor characteristics, despite the tumor size was significantly larger in the anatomic LLR group than that in the nonanatomic LLR group (4.77 ± 2.57 vs. 2.87 ± 2.10 cm, P = 0.001). Patients who underwent anatomic resection had longer operation time (364.09 ± 131.22 vs. 252.00 ± 135.21 min, P < 0.001) but less blood loss per unit area (7.85 ± 7.17 vs. 14.17 ± 10.43 ml/cm², P = 0.018). Nonanatomic LLR was associated with more blood loss when the area of parenchymal transection was equal to the anatomic LLR. No mortality occurred during the hospital stay and 30 days after the operation. Moreover, there was no difference in the incidence of postoperative complications. The disease-free and overall survival rates showed no significant differences between the anatomic LLR and nonanatomic LLR groups.

Conclusions:

Both anatomic and nonanatomic pure LLR are safe and feasible. Measuring the area of parenchymal transection is a simple and effective method to estimate the outcomes of the liver resection surgery. Blood loss per unit area is an important parameter which is comparable between the anatomic LLR and nonanatomic LLR groups.

A systematic examination of preoperative surgery warm-up routines

BACKGROUND

Recent evidence indicates that a preoperative warm-up is a potentially useful tool in facilitating performance. But what factors drive such improvements and how should a warm-up be implemented?

METHODS

In order to address these issues, we adopted a two-pronged approach: (1) we conducted a systematic review of the literature to identify existing studies utilising preoperative simulation techniques; (2) we performed task analysis to identify the constituent parts of effective warm-ups. We identified five randomised control trials, four randomised cross-over trials and four case series. The majority of these studies reviewed surgical performance following preoperative simulation relative to performance without simulation.

RESULTS

Four studies reported outcome measures in real patients and the remainder reported simulated outcome measures. All but one of the studies found that preoperative simulation improves operative outcomes-but this improvement was not found across all measured parameters. While the reviewed studies had a number of methodological issues, the global data indicate that preoperative simulation has substantial potential to improve surgical performance. Analysis of the task characteristics of successful interventions indicated that the majority of these studies employed warm-ups that focused on the visual motor elements of surgery. However, there was no theoretical or empirical basis to inform the design of the intervention in any of these studies.

CONCLUSIONS

There is an urgent need for a more rigorous approach to the development of "warm-up" routines if the potential value of preoperative simulation is to be understood and realised. We propose that such interventions need to be grounded in theory and empirical evidence on human motor performance.

Short and long-term outcomes of laparoscopic compared to open liver resection for colorectal liver metastases

BACKGROUND

Minimally invasive surgery (MIS) is now established as standard of care for a variety of gastrointestinal procedures for benign and malignant indications. However, due to concerns regarding superiority to open liver resection (OLR), the uptake of laparoscopic liver resection (LLR) has been slow. Data on long-term outcomes of LLR for colorectal liver metastases (CRLM) remain limited. We conducted a systematic review and meta-analysis of short and long-term outcomes of LLR compared to OLR for CRLM.

METHODS

Five electronic databases were systematically searched for studies comparing LLR and OLR for CRLM and reporting on survival outcomes. Two reviewers independently selected studies and extracted data. Primary outcomes were overall survival (OS) and recurrence free survival (RFS). Secondary outcomes were operative time, estimated blood loss, post-operative major morbidity, mortality, length of stay (LOS), and resection margins.

RESULTS

Eight non-randomized studies (NRS) were included (n=2,017 total patients). Six were matched cohort studies. LLR reduced estimated blood loss [mean difference: -108.9; 95% confidence interval (CI), -214.0 to -3.7) and major morbidity [relative risk (RR): 0.68; 95% CI, 0.56-0.83], but not mortality. No difference was observed in operative time, LOS, resection margins, R0 resections, and recurrence. Survival data could not be pooled. No studies reported inferior survival with LLR. OS varied from 36% to 60% for LLR and 37% to 65% for OLR. RFS ranged from 14% to 30% for LLR and 22% to 38% for OLR. According to the grade classification, the strength of evidence was low to very low for all outcomes. The use of parenchymal sparing resections with LLR and OLR could not be assessed.

CONCLUSIONS

Based on limited retrospective evidence, LLR offers reduced morbidity and blood loss compared to OLR for CRLM. Comparable oncologic outcomes can be achieved. Although LLR cannot be considered as standard of care for CRLM, it is beneficial for well-selected patients and lesions. Therefore, LLR should be part of the liver surgeon's armamentarium.

Pure Laparoscopic Versus Open Liver Resection in Treatment of Hepatolithiasis Within the Left Lobes: A Randomized Trial Study

OBJECTIVE

The application of laparoscopic technology to liver surgery has been developing rapidly, yet very few studies have been conducted to compare the outcomes between open and laparoscopic liver resections. So little is known about their advantages and disadvantages. The aim of this prospective randomized study was to compare the outcomes between laparoscopic and open liver resection in treatment of hepatolithiasis within the left lateral lobes.

PATIENTS AND METHODS

Between January 2010 and May 2013, 98 patients with hepatolithiasis within the left lateral lobes diagnosed by preoperative computed tomography and magnetic resonance cholangiopancreatography were randomized into open group and laparoscopic group. Each group had 49 patients. We compared the operation time, the amount of bleeding, the length of their stay in hospital, and complications.

RESULTS

Of the laparoscopic group, 2 patients were converted to open surgery. No fatal complication occurred in either the open group or the laparoscopic group. There was no statistically significant difference in the complications between the 2 groups (4.08% vs. 6.12%, P=0.64), but the operating time, the amount of bleeding, and the length of stay in hospital were significantly shorter in the laparoscopic group than in the open group (P<0.05).

CONCLUSIONS

Laparoscopic liver resection displays similar safety and feasibility for hepatolithiasis within the left lateral lobes, and they were also similar with respect to the overall complications, but the laparoscopic group has an advantage in the operating time, the amount of bleeding, and the length of their staying in hospital. It is, however, agreed between the authors of this paper that further studies with larger number of patients and longer follow-up observations are necessary to make a definitive conclusion.

Perioperative and oncologic outcomes of minimally invasive liver resection for colorectal metastases: A case-control study of 130 patients

BACKGROUND

Our aim was to compare the perioperative and oncologic outcomes of open liver resection and minimally invasive liver resection in the management of colorectal liver metastases.

METHODS

Patients who underwent minimally invasive liver resection for colorectal liver metastases between January 2006 and June 2015 at a single center were identified and matched by extent of resection to consecutive open liver resection patients from the same period. Clinicopathologic characteristics, perioperative data, recurrence, and survival outcomes were collected and analyzed based on intention-to-treat.

RESULTS

Sixty-five patients underwent minimally invasive liver resection during this period and were matched to 65 consecutive open liver resection patients, with similar baseline demographic, tumor, and chemotherapy parameters. Conversion to open occurred in 5 (7.7%) minimally invasive liver resection patients. R0 resection rates and operative times were comparable, but the estimated blood loss was less in the minimally invasive liver resection group (median 200 mL vs 400 mL, P < .001), as were perioperative transfusion rates (4.6% vs 15.4%, P = .04). The duration of stay was shorter after minimally invasive liver resection (median 4 days vs 6 days, P < .001), while major and minor complication rates were similar and no perioperative mortality was recorded. At a median follow-up of 28 months, there was no difference regarding disease-free (P = .90) or overall survival (P = .37).

CONCLUSION

In selected patients with colorectal liver metastases, minimally invasive liver resection resulted in similar oncologic outcomes, with decreased blood loss and shorter duration of stay compared to patients who underwent open liver resection.

Comparative Short-term Benefits of Laparoscopic Liver Resection: 9000 Cases and Climbing

OBJECTIVE

To perform a systematic review of worldwide literature on laparoscopic liver resections (LLR) and compare short-term outcomes against open liver resections (OLR) by meta-analyses.

SUMMARY BACKGROUND DATA

There are no updated pooled data since 2009 about the current status and short-term outcomes of LLR worldwide.

PATIENTS AND METHODS

All English language publications on LLR were screened. Descriptive worldwide data and short-term outcomes were obtained. Separate analyses were performed for minor-only and major-only resection series, and series in which minor/major resections were not differentiated. Apparent case duplications were excluded.

RESULTS

A set of 463 published manuscripts were reviewed. One hundred seventy-nine single-center series were identified that accounted for 9527 LLR cases worldwide. Minor-only, major-only, and combined major-minor series were 61, 18, and 100, respectively, including 32, 8, and 43 comparative series, respectively. Of the total 9527 LLR cases reported, 6190 (65%) were for malignancy and 3337 (35%) were for benign indications. There were 37 deaths reported (mortality rate = 0.4%). From the meta-analysis comparing case-matched LLR to OLR (N = 2900 cases), there was no increased mortality and significantly less complications, transfusions, blood loss, and hospital stay observed in LLR vs OLR.

CONCLUSIONS

This is the largest review of LLR available to date with over 9000 cases published. It confirms growing safety when performed in selected patients and by trained surgeons, and suggests that LLR may offer improved patient short-term outcomes compared with OLR. Improved levels of evidence, standardized reporting of outcomes, and assuring proper training are the next challenges of laparoscopic liver surgery.

Clinical Utility of the Difficulty Scoring System for Predicting Surgical Time of Laparoscopic Liver Resection

INTRODUCTION

Laparoscopic liver resection (LLR) has several problems, such as technical complexity and patient and tumor factors. A difficulty scoring system to preoperatively evaluate the difficulty of LLR was established at the second International Consensus Conference on Laparoscopic Liver Resection. The aim of this study was to explore the clinical usefulness of the difficulty scoring system for LLR.

PATIENTS AND METHODS

From January 2010 to June 2015, the records of 78 patients who had undergone LLR were retrospectively reviewed. The patients' data were used to assign a difficulty score, and the correlations between scores and surgical outcomes were investigated.

RESULTS

The mean surgical time was 256 minutes, and the mean blood loss was 168 mL. The difficulty score significantly correlated with surgical time and blood loss, but not with morbidity and postoperative hospital stay. Multivariate analysis showed that the difficulty score was an independent predictor of prolonged surgical time.

CONCLUSIONS

The difficulty score was found to be an effective predictor of surgical time for LLR.

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.

Minimally Invasive Hepatic Surgery

This review provides an overview of the background and progress that has been made in minimally invasive liver surgery. The essential steps of minimally invasive right and left lobectomy as well as left lateral sectionectomy are reviewed. In addition, existing data regarding the feasibility and oncologic outcomes of minimally invasive hepatic resection for malignancy are discussed.

Minimally Invasive Surgery of the Liver

Operations on the liver have been undertaken for centuries for numerous indications including trauma, infections, and even for malignancy, but it was not until the past few decades that rates dramatically increased. This expanse in liver operations is due to a multitude of factors, including broader indications as well as improved safety. Our understanding of metastatic disease to the liver, especially colorectal cancer metastases, has vastly amplified the number of patients who would be candidates for hepatic resections and liver-directed therapies. We will focus our discussion here on planned minimally invasive operations for benign and malignant tumors as the majority of the literature relates to this setting.

Laparoscopic versus open hepatic resection for hepatocellular carcinoma: improvement in outcomes and similar cost

OBJECTIVE

To compare outcomes of laparoscopic versus open hepatic resection (OHR) exclusively for hepatocellular carcinoma in terms of morbidity and cost.

BACKGROUND

Laparoscopic hepatic resection (LHR) has become more prevalent with recent improvements in instrumentation and surgeon experience.

METHODS

A review of multicenter, prospectively collected hepatobiliary databases from three institutions was performed from 12/1990 to 12/2009. Prospective evaluation of all patients undergoing hepatectomy for hepatocellular cancer was performed.

RESULTS

A total of 354 patients who had resections for Hepatocellular carcinoma (HCC) were analyzed, 100 were performed laparoscopically. The two groups were similar in terms of demographics and comorbidities. Evaluation of outcomes showed significantly higher intraoperative estimated blood loss although postoperative transfusion rates were similar. The incidence of any complication (44 vs 44%, p = 0.23) and 90-day mortality (6 vs 6%, p = 0.8) were similar between the two groups, with a similar reoperation rate (4.0 vs. 2.4%; p = 0.9). Using Cox regression analysis, the laparoscopic approach had no effect on disease-free interval (OR 1.4, CI 0.31-6.3, p = 0.66) or overall survival (HR 1.2, CI 0.59-2.5 p = 0.6). Length of stay was significantly shorter in the laparoscopic group 6.2 vs. 9.3 days (p = 0.001). Adjusted operative charges ($41 vs. $39 k, p = 0.601) and adjusted total hospital charges ($71 vs. $82 k, p = 0.368) were similar in LHR versus OHR.

CONCLUSION

Our study confirms previous literature showing comparable perioperative outcomes and recurrence. We further show comparable cost with laparoscopic versus open liver resection for HCC.

Laparoscopic living donor hepatectomy: a review of current status

Over the last two decades, laparoscopic surgery has been adopted in various surgical fields. Its advantages of reduced blood loss, reduced postoperative morbidity, shorter hospital stay, and excellent cosmetic outcome compared with conventional open surgery are well validated. In comparison with other abdominal organs, laparoscopic hepatectomy has developed relatively slowly due to the potential for massive bleeding, technical difficulties and a protracted learning curve. Furthermore, applications to liver graft procurement in living donor liver transplantation (LDLT) have been delayed significantly due to concerns about donor safety, graft outcome and the need for expertise in both laparoscopic liver surgery and LDLT. Now, laparoscopic left lateral sectionectomy in adult-to-pediatric LDLT is considered the standard of care in some experienced centers. Currently, the shift in application has been towards left lobe and right lobe graft procurement in adult LDLT from left lateral section in pediatric LDLT. However, the number of cases is too small to validate the safety and reproducibility. The most important concern in LDLT is donor safety. Even though a few studies reported the technical feasibility and comparable outcomes to conventional open surgery, careful validating through larger sample sized studies is needed to achieve standardization and wide application.

Influence of body mass index on postoperative outcomes after laparoscopic liver resection

BACKGROUND

Despite the increasing prevalence of obesity, the impact of body weight on postoperative outcomes of laparoscopic liver resection (LLR) still remains poorly evaluated. The present study aimed to explore the impact of body mass index (BMI) on perioperative outcomes in patients undergoing LLR.

STUDY DESIGN

All patients undergoing LLR from January 2008 to December 2013 were retrospectively reviewed. BMI was subdivided into normal weight (<24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)), and obese (≥30.0 kg/m(2)). These three groups were compared in terms of demographic data, intraoperative factors, and postoperative outcomes. Logistic regression was used to determine odds ratios with 95% confidence intervals and evaluate BMI as an independent risk factor for morbidity.

RESULTS

Among 228 selected patients, 83 (36.4%) patients were overweight and 32 (14.0%) were obese. Despite higher rates of diabetes mellitus, hypertension, and ischemic heart disease with an increase in BMI, no significant difference in operative time, blood loss, and conversion rate was observed in the three groups. There were no significant differences in postoperative mortality rate between the groups (0.9 vs. 1.2 vs. 0%). The rate of overall complications (31.0 vs. 31.3 vs. 40.6%) and major complications (14.2 vs. 9.6 vs. 18.8%) did not differ in the three groups. Major hepatectomy (HR 6.810, CI 1.437-32.267, p = 0.016) and operative time >180 min (HR 2.639, CI 1.179-5.908, p = 0.018) were independently associated with postoperative complications.

CONCLUSIONS

The present study demonstrated that BMI does not negatively affect the postoperative short-term outcomes. Therefore, obesity and overweight should not be a contraindication for LLR.

Surgical management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the second most common cause of death from cancer worldwide. Standard potentially curative treatments are either resection or transplantation. The aim of this paper is to provide an overview of the surgical management of HCC, as well as highlight current issues in hepatic resection and transplantation. In summary, due to the relationship between HCC and chronic liver disease, the management of HCC depends both on tumour-related and hepatic function-related considerations. As such, HCC is currently managed largely through non-surgical means as the criteria, in relation to the above considerations, for surgical management is still largely restrictive. For early stage tumours, both resection and transplantation offer fairly good survival outcomes (5 years overall survival of around 50%). Selection therefore would depend on the level of hepatic function derangement, organ availability and local expertise. Patients with intermediate stage cancers have limited options, with resection being the only potential for cure. Otherwise, locoregional therapy with transarterial chemoembolization or radiofrequency ablation are viable options. Current issues in resection and transplantation are also briefly discussed such as laparoscopic resection, ablation vs resection, anatomical vs non-anatomical resection, transplantation vs resection, living donor liver transplantation and salvage liver transplantation.

Systematic review of the use of pre-operative simulation and navigation for hepatectomy: current status and future perspectives

Pre-operative simulation using three-dimensional (3D) reconstructions have been suggested to enhance surgical planning of hepatectomy. Evidence on its benefits for hepatectomy patients remains limited. This systematic review examined the use and impact of pre-operative simulation and intraoperative navigation on hepatectomy outcomes. A systematical searched electronic databases for studies reporting on the use and results of simulation and navigation for hepatectomy was performed. The primary outcome was change in operative plan based on simulation. Secondary outcomes included operating time (min), estimated blood loss, surgical margins, 30-day postoperative morbidity and mortality, and study-specific outcomes. From 222 citations, we included 11 studies including 497 patients. All were observational cohort studies. No study compared hepatectomy with and without simulation. All studies performed 3D reconstruction and segmentation, most commonly with volumetrics measurements. In six studies reporting intraoperative navigation, five relied on ultrasound, and one on a resection map. Of two studies reporting on it, the resection line was changed intraoperatively in one third of patients, based on simulation. Virtually predicted liver volumes (Pearson correlation r = 0.917 to 0.995) and surgical margins (r = 0.84 to 0.967) correlated highly with actual ones in eight studies. Heterogeneity of the included studies precluded meta-analysis. Pre-operative simulation seems accurate in measuring volumetrics and surgical margins. Current studies lack intraoperative transposition of simulation for direct navigation. Simulation appears useful planning of hepatectomies, but further work is warranted focusing on the development of improved tools and appraisal of their clinical impact compared to traditional resection.

Laparoscopic liver resection for living donation: Where do we stand?

In Western countries, living donor liver transplantation (LDLT) may represent a valuable alternative to deceased donor liver transplantation. Yet, after an initial peak of enthusiasm, reports of high rates of complications and of fatalities have led to a certain degree of reluctance towards this procedure especially in Western countries. As for living donor kidney transplantation, the laparoscopic approach could improve patient’s tolerance in order to rehabilitate this strategy and reverse the current trend. In this setting however, initial concerns regarding patient’s safety and graft integrity, need for acquiring surgical expertise in both laparoscopic liver surgery and living donor transplantation and lack of evidence supporting the benefits of laparoscopy have delayed the development of this approach. Similarly to what is performed in classical resectional liver surgery, initial experiences of laparoscopy have therefore begun with left lateral sectionectomy, which is performed for adult to child living donation. In this setting, the laparoscopic technique is now well standardized, is associated with decreased donor blood loss and hospital stays and provides graft of similar quality compared to the open approach. On the other hand laparoscopic major right or left hepatectomies for adult-adult LDLT currently lack standardization and various techniques such as the full laparoscopic approach, the hand assisted approach and the hybrid approach have been reported. Hence, even-though several reports highlight the feasibility of these procedures, the true benefits of laparoscopy over laparotomy remain to be fully assessed. This could be achieved through standardization of the procedures and creation of international registries especially in Eastern countries where LDLT keeps on flourishing.

Laparoscopic liver resection: Wedge resections to living donor hepatectomy, are we heading in the right direction?

Despite inception over 15 years ago and over 3000 completed procedures, laparoscopic liver resection has remained mainly in the domain of selected centers and enthusiasts. Requirement of extensive open liver resection (OLR) experience, in-depth understanding of anatomy and considerable laparoscopic technical expertise may have delayed wide application. However healthy scepticism of its actual benefits and presence of a potential publication bias; concern about its safety and technical learning curve, are probably equally responsible. Given that a large proportion of our work, at least in transplantation is still OLR, we have attempted to provide an entirely unbiased, mature opinion of its pros and cons in the current invited review. We have divided this review into two sections as we believe they merit separate attention on technical and ethical grounds. The first part deals with laparoscopic liver resection (LLR) in patients who present with benign or malignant liver pathology, wherein we have discussed its overall outcomes; its feasibility based on type of pathology and type of resection and included a small section on application of LLR in special scenarios like cirrhosis. The second part deals with the laparoscopic living donor hepatectomy (LDH) experience to date, including its potential impact on transplantation in general. Donor safety, graft outcomes after LDH and criterion to select ideal donors for LLR are discussed. Within each section we have provided practical points to improve safety in LLR and attempted to reach reasonable recommendations on the utilization of LLR for units that wish to develop such a service.

Restrictive blood transfusion protocol in liver resection patients reduces blood transfusions with no increase in patient morbidity

BACKGROUND

Management of anemia in surgical oncology patients remains one of the key quality components in overall care and cost. Continued reports demonstrate the effects of hospital transfusion, which has been demonstrated to lead to a longer length of stay, more complications, and possibly worse overall oncologic outcomes. The hypothesis for this study was that a dedicated restrictive transfusion protocol in patients undergoing hepatectomy would lead to less overall blood transfusion with no increase in overall morbidity.

METHODS

A cohort study was performed using our prospective database from January 2000 to June 2013. September 2011 served as the separation point for the date of operation criteria because this marked the implementation of more restrictive blood transfusion guidelines.

RESULTS

A total of 186 patients undergoing liver resection were reviewed. The restrictive blood transfusion guidelines reduced the percentage of patients that received blood from 31.0% before January 9, 2011 to 23.3% after this date (P = .03). The liver procedure that was most consistently associated with higher levels of transfusion was a right lobectomy (16%). Prior surgery and endoscopic stent were the 2 preoperative interventions associated with receiving blood. Patients who received blood before and after the restrictive period had similar predictive factors: major hepatectomies, higher intraoperative blood loss, lower preoperative hemoglobin level, older age, prior systemic chemotherapy, and lower preoperative nutritional parameters (all P < .05). Patients who received blood did not have worse overall progression-free survival or overall survival.

CONCLUSIONS

A restrictive blood transfusion protocol reduces the incidence of blood transfusions and the number of packed red blood cells transfused. Patients who require blood have similar preoperative and intraoperative factors that cannot be mitigated in oncology patients. Restrictive use of blood transfusions can reduce cost and does adversely affect patients undergoing liver resection.

Laparoscopic liver resection using a rubber band retraction technique: usefulness and perioperative outcome in 100 consecutive cases

BACKGROUND

Although laparoscopic liver resection is increasingly performed worldwide, surgeons still face technical challenges because of the variety of procedures used according to tumor location. In the current study, we introduce a unique retraction method using an elastic rubber band and present its learning curve in addition to the perioperative outcomes of 100 consecutive patients.

METHODS

A series of 100 consecutive patients who underwent laparoscopic liver resection using a rubber band technique between August 2008 and June 2013 were analyzed retrospectively. All the study patients underwent the rubber band technique as a method to expose the parenchymal resection plane.

RESULTS

The study subjects consisted of 56 males and 44 females with a mean age of 56.7 ± 9.6 years. There were a total of four open conversions. There was no postoperative mortality. Eighty-five patients underwent minor resection, and 15 patients underwent major resection. Among the 85 patients who underwent a minor resection, 65 patients who had favorably located tumors were compared with the 20 patients who had unfavorably located tumors. A comparison of perioperative outcomes revealed a significant difference in operative time (197.3 ± 81.9 vs. 245.9 ± 116.8 min, P = 0.040) but no differences in any other parameters. There were three (4.6 %) and one (5 %) open conversions in the favorable and unfavorable tumor location group, respectively (P = 0.954). The postoperative complication rates were not statistically different between the two groups [4 (6.2 %) vs. 1 (5 %), P = 0.848]. In the learning curve analysis, operative time and blood loss for left lateral sectionectomy (n = 14) and left hepatectomy (n = 12) and minor limited resections for posterosuperior lesions (n = 20) reached a plateau after approximately ten cases.

CONCLUSION

The retraction technique describes here using an elastic rubber band is a useful approach that results in a safe laparoscopic liver resection. Moreover, this can be applied proficiently after a reasonable learning curve.

Evaluation of a laparoscopic liver resection in the setting of cirrhosis

INTRODUCTION

Patients presenting with cirrhosis and hepatic tumours represent a fragile group that have typically been avoided in early series of laparoscopic liver resection. This study was undertaken to evaluate the results of a laparoscopic hepatectomy in the setting of cirrhosis.

METHODS

Subgroup analysis of patients with cirrhosis within a series of 327 patients undergoing a laparoscopic resection was performed. Comparisons were made with patients without cirrhosis where appropriate to highlight differences in patient selection and outcomes. Specific variables assessed included operative details and short-term outcomes including length of stay (LOS), morbidity and mortality. Outcomes specific to hepatocellular carcinoma (HCC) were also assessed.

RESULTS

There were 52 patients with cirrhosis undergoing a laparoscopic hepatic resection. Ninety per cent of patients were Childs class A, with a median model for end-stage liver disease (MELD) score of 8. Hepatitis C was the most common cause of cirrhosis (88.5%), whereas the most common indication for an operation was HCC (71.2%). Resections were generally limited, with the median number of segments resected being 2 (range: 1-4). Complications occurred in 13 (25%) patients, with a 90-day mortality of 5.8%. The median LOS was 3 days.

CONCLUSIONS

A laparoscopic hepatectomy is safe in the setting of cirrhosis, provided the application of appropriate selection criteria and sufficient experience with the procedure.

Stroke volume variation in hepatic resection: a replacement for standard central venous pressure monitoring

BACKGROUND

Central venous pressure (CVP) is the standard method of volume status evaluation during hepatic resection. CVP monitoring requires preoperative placement of a central venous catheter (CVC), which can be associated with increased time, cost, and adverse events. Stroke volume variation (SVV) is a preload index that can be used to predict an individual's fluid responsiveness through an existing arterial line. The purpose of this study was to determine if SVV is as safe and effective as CVP in measuring volume status during hepatic resection.

METHODS

Two cohorts of 40 consecutive patients (80 total) were evaluated during hepatic resection between December 2010 and August 2012. The initial evaluation group of 40 patients had continuous CVP monitoring and SVV monitoring performed simultaneously to establish appropriate SVV parameters for hepatic resection. A validation group of 40 patients was then monitored with SVV alone to confirm the accuracy of the established SVV parameters. Type of hepatic resection, transection time, blood loss, complications, and additional operative and postoperative factors were collected prospectively. SVV was calculated using the Flotrac™/Vigileo™ System.

RESULTS

The evaluation group included 40 patients [median age 62 (29-82) years; median body mass index (BMI) 27.7 (16.5-40.6)] with 18 laparoscopic, 22 open, and 24 undergoing major (≥3 segments) hepatectomy. Median transection times were 43 (range 20-65) min, median blood loss 250 (range 20-950) cc, with no Pringle maneuver utilized. In this evaluation group, a CVP of -1 to 1 significantly correlated to a SVV of 18-21 (R (2) = 0.85, p < 0.001). The validation group included 40 patients [median age 61 (35-78) years; median BMI 28.1 (17-41.2)], with 24 laparoscopic, 16 open, and 33 undergoing major hepatectomy. Using a SVV goal of 18 to 21, median transection time was 55 (25-78) min, median blood loss of 255 (range 100-1,150) cc, again without the use of a Pringle maneuver.

CONCLUSIONS

SVV can be used safely as an alternative to CVP monitoring during hepatic resection with equivalent outcomes in terms of blood loss and parenchymal transection time. Using SVV as a predictor of fluid status could prove to be advantageous by avoiding the need for CVC insertion and therefor eliminating the risk of CVC related complications in patients undergoing hepatic resection.

Caudate lobe resections: a single-center experience and evaluation of factors predictive of outcomes

Background

Despite the increasing frequency of liver resection for multiple types of disease, caudate lobe resection remains a rare surgical event. The goal of this study is to review our experience and evaluate possible predictors of adverse outcomes in patients undergoing caudate lobectomy.

Methods

We reviewed a 1,900-patient prospective hepato-pancreatico-biliary database from January 2000 to December 2011, identifying 36 hepatectomy patients undergoing caudate lobe resection. Clinicopathologic characteristic and outcome data were compared using chi-square, T-test, ANOVA, Kaplan-Meier, and Cox regression analysis. Primary endpoints were the incidence and severity of complications, and secondary endpoints were blood loss, hospital stay, and transfusion requirements. Patients were also divided in two groups with group A being patients operated on before December 2007 and group B after 2007. We compared the demographics, risk factors, complication rates, and operative details between the two groups.

Results

Thirty-six patients underwent caudate lobe resection for cholangiocarcinoma (47.2%), metastatic colorectal cancer (36.1%), hepatocellular carcinoma (8.3%), or benign disease (8.3%). Nine patients (29%) had additional liver resection. Median overall survival (OS) was 21 months. Complications occurred in 52.7% (19/36) of patients with a median grade of 2. Tobacco abuse was associated with an increased risk of operative complications (73.3% vs. 38.9%, p = 0.03). Prior history of cardiac disease was associated with a higher complication rate (87% vs. 42%, p = 0.03). Neoadjuvant chemotherapy, biliary procedures, hepatitis, and prior major abdominal surgery were not predictive of complications. Major complication was also predicted by the volume of RBC transfusion (2.7 vs. 4.1 units, p = 0.003). In our subgroup analysis of the patients undergoing surgery before and after 2007, the two groups were well matched based on age, comorbidities, and risk factors. The complication rates and rates of high-grade complications were similar, but blood loss (600 ml vs. 400 ml, p = 0.03), inflow occlusion time (Pringle time 12.6 vs. 6, p = 0.00), and hospital stay (9.5 vs. 7 days, p = 0.01) were significantly lower in group B.

Conclusions

With appropriate patient selection, caudate lobe resection is an effective component of surgery for hepatic disease. Tobacco use and prior cardiac history increase the risk of complications.

Health-related quality of life changes following major and minor hepatic resection: the impact of complications and postoperative anemia

BACKGROUND

Few studies have evaluated the health-related quality-of-life (QOL) changes in patients following major liver resection for malignancy.

METHODS

QOL parameters were recorded prospectively at baseline (preoperative), and through 6 months of follow-up using various instruments.

RESULTS

Major complications occurred in 10 of 41 patients. At the initial outpatient visit, patients reported decreased global QOL with increased fatigue compared with baseline, which normalized at 6 weeks' follow-up and remained stable at 6 months. Those with major complications reported increased severity of pain over baseline at initial follow-up and at 6 months. Patients anemic at the time of discharge had worse physical QOL at 6 weeks, but levels similar to nonanemic patients at 3 months.

CONCLUSIONS

Major complications are associated with increased reporting of pain persisting at 6 months. Attention to pain control, especially among patients with major complications, may improve QOL after major hepatic resection.

Laparoscopic Hepatectomy is a Safe and Effective Approach for Resecting Large Colorectal Liver Metastases

Hepatectomy is an accepted treatment modality for large (greater than 5 cm) colorectal liver metastases (CLM). Recently, laparoscopic hepatectomy has emerged as a viable option; however, its use for patients with large CLM is undefined. A retrospective analysis of a single institution's prospective database was performed for patients with large CLM resected between 1995 and 2010. Patients were stratified by operative approach. Patient characteristics, tumor burden, operative factors, hospital course, and long-term outcomes were compared using nonparametric, Fisher's exact, and Kaplan-Meier testing. Eighty-four patients were identified. Eight patients (9.5%) underwent laparoscopic resection. Age (59.5 vs 60 years), body mass index (26.8 vs 27.5 kg/m2), size of largest tumor (6.8 vs 7.5 cm), R0 resection (100 vs 89.5%), hepatic recurrence (25 vs 43.4%), and transfusion rate (14.3 vs 30.9%) of laparoscopic compared with open resection were similar. However, complication rate (12.5 vs 60.5%; P = 0.0192), blood loss (225 vs 400 mL; P = 0.0427), and length of stay (3.5 vs 7.0 days; P = 0.0005) were significantly higher in the open resection cohort. Median disease-free survival was 14.4 and 13.2 months for laparoscopic and open patients, respectively. Laparoscopic resection appears to be a safe approach for resecting large CLM. Tumor size does not preclude laparoscopic hepatectomy.

Financial comparison of laparoscopic versus open hepatic resection using deviation-based cost modeling

BACKGROUND

There is a growing body of evidence suggesting the equivalence and in some cases superiority of laparoscopic liver resection versus open resection. Fewer data exist regarding the financial impact of laparoscopic liver resection.

METHODS

Retrospective review of 98 consecutive patients at a single institution from 2007 through 2011 undergoing first time hepatic resection was performed. Laparoscopic and open cases were compared primarily on OR and hospital charges. Deviation-based cost modeling and weighted average mean cost for the two procedures were used to determine both financial and clinical efficacy on the basis of differences in length of stay, complications, and charges.

RESULTS

There were 57 laparoscopic and 41 open cases included in the study. Right hepatectomy was the most common procedure performed in both the laparoscopic (n=23, 40.4%) and open (n=22, 53.7%) groups. Patients in the laparoscopic group were significantly more likely to have an "on course" postoperative hospitalization (73.7 vs. 26.8%; p<0.001), which translated into a WAMC of $58,401 for the laparoscopic cases and $69,728 for the open cases. In the subset of patients undergoing right hepatectomy, patients in the laparoscopic group remained more likely to have an on course hospitalization (61.2 vs. 31.8%; p=0.025). WAMC for the laparoscopic right hepatectomy group, however, was higher than the open group ($69,544 vs. $68,266).

CONCLUSIONS

The cost-effectiveness of laparoscopic hepatectomy appears to vary with the complexity of the procedure. Overall, laparoscopy offers a cost advantage; however, with more complex procedures such as right hepatectomy, higher up-front operating room charges offset the financial benefits of less complicated hospitalization.