Laparoscopic vs open right hepatectomy: a value-based analysis

Comparative analysis of the safety and feasibility of laparoscopic and open approaches for right anterior sectionectomy

Laparoscopic hepatectomy has minimally invasive advantages, but reports on laparoscopic right anterior sectionectomy (LRAS) are rare. Herein, we try to explore the benefits and drawbacks of LRAS by comparing it with open right anterior sectionectomy (ORAS). Between January 2015 and September 2023, 39 patients who underwent LRAS (n = 18) or ORAS (n = 21) were enrolled in the study. The patients' characteristics, intraoperative details, and postoperative outcomes were compared between the two groups. No significant differences in the preoperative data were observed between the two groups. The LRAS group had significantly lesser blood loss (P = 0.019), a shorter hospital stay (P = 0.045), and a higher rate of bile leak (P = 0.039) than the ORAS group. There was no significant difference in the operative time (P = 0.156), transfusion rate (P = 0.385), hospital expenses (P = 0.511), rate of other complications, postoperative white blood cell count, and alanine aminotransferase and aspartate aminotransferase levels between the two groups (P > 0.05). Beside, there was no significant difference in disease-free survival (P = 0.351) or overall survival (P = 0.613) in patients with hepatocellular carcinoma between the two groups. LRAS is a safe and feasible surgical procedure. It may be preferred for lesions in the right anterior lobe of the liver.

A Comprehensive Review on Comparative Analysis of Operative Efficiency and Postoperative Recovery in Robotic Versus Laparoscopic Hepatectomy

Minimally invasive liver surgery, particularly hepatectomy, has evolved significantly with the advent of laparoscopic and robotic techniques. These approaches offer potential benefits over traditional open surgery, including reduced postoperative pain, shorter hospital stays, faster recovery, and improved cosmetic outcomes. This comprehensive review aims to compare the operative efficiency and postoperative recovery outcomes of robotic and laparoscopic hepatectomy. It seeks to provide an in-depth analysis of the advantages and limitations of each technique, assess their cost-effectiveness, and explore emerging trends and future directions in minimally invasive liver surgery. A comprehensive literature search was conducted to identify studies comparing robotic and laparoscopic hepatectomy. The review includes an analysis of operative time, intraoperative blood loss, conversion rates, postoperative pain, length of hospital stay, complication rates, oncological outcomes, and overall cost. Additionally, advancements in technology and future research directions were explored to provide a comprehensive overview of the current landscape and future potential of these surgical techniques. Both robotic and laparoscopic hepatectomy have demonstrated comparable outcomes in terms of oncological safety and effectiveness. However, robotic hepatectomy offers advantages in terms of precision and dexterity, particularly in complex cases, due to its advanced visualization and instrumentation. Laparoscopic hepatectomy, while associated with shorter operative times and lower costs, is limited by technical challenges, especially in major liver resections. The review also highlights the increasing adoption of robotic systems, despite their higher costs and the need for specialized training. Robotic and laparoscopic hepatectomy are both viable options for minimally invasive liver surgery, each with distinct advantages and limitations. The choice between the two should be based on patient-specific factors, the complexity of the procedure, and the surgeon's expertise. Ongoing advancements in technology, including the integration of artificial intelligence and augmented reality, are expected to further refine these techniques, enhancing their efficacy and accessibility. Future research should focus on large-scale, multicenter trials to provide more definitive comparisons and guide clinical decision-making.

Short-term outcomes of laparoscopic extended hepatectomy versus major hepatectomy: a single-center experience

INTRODUCTION

Laparoscopic major hepatectomy (LMH) remains restricted to a few specialized centers and poses a challenge to surgeons performing laparoscopic resections. Laparoscopic extended resections are even more complex and rarely conducted.

METHODS

From a single-institution database, we compared the short-term outcomes of patients who underwent major and extended laparoscopic resections, stratifying the entire retrospective cohort into four groups: right hepatectomy, left hepatectomy, right extended hepatectomy, and left extended hepatectomy. Patient demographics, tumor characteristics, operative variables, and especially postoperative outcomes were evaluated.

RESULTS

250 patients underwent major and extended laparoscopic liver resections, including 160 right, 31 right extended, 36 left, and 23 left extended laparoscopic hepatectomies. The most common indication for resection was colorectal liver metastases (64%). Laparoscopic extended hepatectomy (LEH) showed significantly longer operative time, more blood loss, need for Pringle maneuver, conversion to open surgery, higher rates of liver failure, postoperative ascites, and intra-abdominal hemorrhage, R1 margins and length of stay when compared with the LMH group. Mortality rates were similar between groups. Multivariate analysis revealed intraoperative blood transfusion (OR = 5.1[CI-95%: 1.15-6.79]; p = 0.02) as an independent predictor for major complications.

CONCLUSIONS

LEH showed to be feasible, however with higher blood loss and significantly associated to major complications.

Study: International Multicentric Minimally Invasive Liver Resection for Colorectal Liver Metastases (SIMMILR-CRLM)

(1) Background: Here we report on a retrospective study of an international multicentric cohort after minimally invasive liver resection (SIMMILR) of colorectal liver metastases (CRLM) from six centers. (2) Methods: Resections were divided by the approach used: open liver resection (OLR), laparoscopic liver resection (LLR) and robotic liver resection (RLR). Patients with macrovascular invasion, more than three metastases measuring more than 3 cm or a solitary metastasis more than 5 cm were excluded, and any remaining heterogeneity found was further analyzed after propensity score matching (PSM) to decrease any potential bias. (3) Results: Prior to matching, 566 patients underwent OLR, 462 LLR and 36 RLR for CRLM. After PSM, 142 patients were in each group of the OLR vs. LLR group and 22 in the OLR vs. RLR and 21 in the LLR vs. RLR groups. Blood loss, hospital stay, and morbidity rates were all highly statistically significantly increased in the OLR compared to the LLR group, 636 mL vs. 353 mL, 9 vs. 5 days and 25% vs. 6%, respectively (p < 0.001). Only blood loss was significantly decreased when RLR was compared to OLR and LLR, 250 mL vs. 597 mL, and 224 mL vs. 778 mL, p < 0.008 and p < 0.04, respectively. (4) Conclusions: SIMMILR indicates that minimally invasive approaches for CRLM that follow the Milan criteria may have short term advantages. Notably, larger studies with long-term follow-up comparing robotic resections to both OLR and LLR are still needed.

First 100 minimally invasive liver resections in a new tertiary referral centre for liver surgery

BACKGROUND

In the last decades, there has been an exponential diffusion of minimally invasive liver surgery (MILS) worldwide. The aim of this study was to evaluate our initial experience of 100 patients undergoing MILS resection comparing their outcomes with the standard open procedures.

MATERIALS AND METHODS

One hundred consecutive MILS from 2016 to 2019 were included. Clinicopathological data were reviewed to evaluate outcomes. Standard open resections were used as the control group and compared exploiting propensity score matching.

RESULTS

In total, 290 patients were included. The rate of MILS has been constantly increasing throughout years, representing the 48% in 2019. Of 100 (34.5%) MILS patients, 85 could be matched. After matching, the MILS conversion rate was 5.8% (n = 5). The post-operative complication rates were higher in the open group (45.9% vs. 31.8%, P = 0.004). Post-operative blood transfusions were less common in the MILS group (4.7% vs. 16.5%, P = 0.021). Biliary leak occurred in 2 (2.4) MILS versus 13 (15.3) open. The median comprehensive complication index was higher in the open group (8.7 [0-28.6] vs. 0 [0-10.4], P = 0.0009). The post-operative length of hospital stay was shorter after MILS (median 6 [5-8] vs 8 [7-13] days, P < 0.0001).

CONCLUSIONS

The rate of MILS has been significantly increasing throughout the years. The benefits of MILS over the traditional open approach were confirmed. The main advantages include lower rates of post-operative complications, blood transfusions, bile leaks and a significantly decreased hospital stay.

The initiation, standardization and proficiency (ISP) phases of the learning curve for minimally invasive liver resection: comparison of a fellowship-trained surgeon with the pioneers and early adopters

BACKGROUND

Using the Ideal Development Exploration Assessment and Long-term study (IDEAL) paradigm, Halls et al. created risk-adjusted cumulative sum (RA-CUSUM) curves concluding that Pioneers (P) and Early Adopters (EA) of minimally invasive (MI) liver resection obtained similar results after fewer cases. In this study, we applied this framework to a MI Hepatic-Pancreatic and Biliary fellowship-trained surgeon (FT) in order to assess where along the curves this generation fell.

METHODS

The term FT was used to designate surgeons without previous independent operative experience who went from surgical residency directly into fellowship. Three phases of the learning curve were defined using published data on EAs and Ps of MI Hepatectomy, including phase 1 (initiation) (i.e., the first 17 or 50), phase 2 (standardization) (i.e., cases 18-46 or 1-50) and phase 3 (proficiency) (i.e., cases after 46, 50 or 135). Data analysis was performed using the Social Science Statistics software ( www.socscistatistics.com ). Statistical significance was defined as p < .05.

RESULTS

From November 2007 until April 2018, 95 MI hepatectomies were performed by a FT. During phase 1, the FT approached larger tumors than the EA group (p = 0.002), that were more often malignant (94.1%) when compared to the P group (52.5%) (p < 0.001). During phase 2, the FT operated on larger tumors and more malignancies (93.1%) when compared to the Ps (p = 0.004 and p = 0.017, respectively). However, there was no difference when compared to the EA. In the phase 3, the EAs tended to perform more major hepatectomies (58.7) when compared to either the FT (30.6%) (p = 0.002) or the P's cases 51-135 and after 135 (35.3% and 44.3%, respectively) (both p values < 0.001). When compared to the Ps cases from 51-135, the FT operated on more malignancies (p = 0.012), but this was no longer the case after 135 cases by the Ps (p = 0.164). There were no statistically significant differences when conversions; major complications or 30- and 90-day mortality were compared among these 3 groups.

DISCUSSION

Using the IDEAL framework and RA-CUSUM curves, a FT surgeon was found to have curves similar to EAs despite having no previous independent experience operating on the liver. As in our study, FTs may tend to approach larger and more malignant tumors and do more concomitant procedures in patients with higher ASA classifications than either of their predecessors, without statistically significant increases in major morbidity or mortality.

CONCLUSION

It is possible that the ISP (i.e., initiation, standardization, proficiency) model could apply to other innovative surgical procedures, creating different learning curves depending on where along the IDEAL paradigm surgeons fall.

Economic analysis of open versus laparoscopic versus robotic hepatectomy: a systematic review and meta-analysis

BACKGROUND

Following the publication of reports from landmark international consensuses (Louisville 2008 and Morioka 2014), minimally invasive hepatectomy became widely accepted as a legitimate alternative to open surgery. We aimed to compare the operative, hospitalization, and total economic costs of open (OLR) vs. laparoscopic (LLR) vs. robotic liver resection (RLR).

METHODS

We performed a systematic literature review (end-of-search date: July 3, 2020) according to the PRISMA statement. Random-effects meta-analyses were conducted. Quality assessment was performed with the Cochrane Risk of Bias tool for randomized controlled trials, and the Newcastle-Ottawa Scale for non-randomized studies.

RESULTS

Thirty-eight studies reporting on 3847 patients (1783 OLR; 1674 LLR; 390 RLR) were included. The operative costs of LLR were significantly higher than those of OLR, while subgroup analysis also showed higher operative costs in the LLR group for major hepatectomy, but no statistically significant difference for minor hepatectomy. Hospitalization costs were significantly lower in the LLR group, with subgroup analyses indicating lower costs for LLR in both major and minor hepatectomy series. No statistically significant difference was observed regarding total costs between LLR and OLR both overall and on subgroup analyses in either major or minor hepatectomy series. Meta-analyses showed higher operative, hospitalization, and total costs for RLR vs. LLR, but no statistically significant difference regarding total costs for RLR vs. OLR.

CONCLUSION

LLR's higher operative costs are offset by lower hospitalization costs compared to OLR leading to no statistically significant difference in total costs, while RLR appears to be a more expensive alternative approach.

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.

Safety and feasibility for laparoscopic versus open caudate lobe resection: a meta-analysis

BACKGROUND

Laparoscopic hepatectomy has been used widely due to its advantages as a minimally invasive surgery. However, multicenter, large-scale, population-based laparoscopic caudate lobe resection (LCLR) versus open caudate lobe resection (OCLR) has rarely been reported. We assessed the feasibility and safety of LCLR compared with OCLR using meta-analysis.

METHODS

Relevant literature was retrieved using PubMed, Embase, Cochrane, Ovid Medline, Web of Science, CNKI, and WanFang Med databases up to July 30th, 2020. Multiple parameters of feasibility and safety were compared between the treatment groups. Quality of studies was assessed with the Newcastle-Ottawa Scale (NOS). The data were analyzed by Review Manager 5.3. Results are expressed as odds ratio (OD) or mean difference (MD) with 95% confidence interval (95% CI) for fixed- and random-effects models.

RESULTS

Seven studies with 237 patients were included in this meta-analysis. Compared with OCLR, the LCLR group had a lower intraoperative blood loss (MD - 180.84; 95% CI - 225.61 to - 136.07; P < 0.0001), shorter postoperative hospital stays (MD - 4.38; 95% CI - 7.07 to - 1.7; P = 0.001), shorter operative time (MD - 50.24; 95% CI - 78.57 to - 21.92; P = 0.0005), and lower rates in intraoperative blood transfusion (OR 0.12; P = 0.01). However, there were no statistically significant differences between LCLR and OCLR regarding hospital expenses (MD 0.92; P = 0.12), pedicle clamping (OR 1.57; P = 0.32), postoperative complications (OR 0.58; P = 0.15), bile leak (P = 0.88), ascites (P = 0.34), and incisional infection (P = 0.36).

CONCLUSIONS

LCLR has multiple advantages over OCLR, especially intraoperative blood loss and hospital stays. LCLR is a very useful technology and feasible choice in patients with caudate lobe lesions.

Contemporary Management of Hepatic Cyst Disease: Techniques and Outcomes at a Tertiary Hepatobiliary Center

BACKGROUND

Hepatic cyst disease is often asymptomatic, but treatment is warranted if patients experience symptoms. We describe our management approach to these patients and review the technical nuances of the laparoscopic approach.

METHODS

Medical records were reviewed for operative management of hepatic cysts from 2012 to 2019 at a single, tertiary academic medical center.

RESULTS

Fifty-three patients (39 female) met the inclusion criteria with median age at presentation of 65 years. Fifty cases (94.3%) were performed laparoscopically. Fourteen patients carried diagnosis of polycystic liver disease. Dominant cyst diameter was median 129 mm and located within the right lobe (30), left lobe (17), caudate (2), or was bilobar (4). Pre-operative concern for biliary cystadenoma/cystadenocarcinoma existed for 7 patients. Operative techniques included fenestration (40), fenestration with decapitation (7), decapitation alone (3), and excision (2). Partial hepatectomy was performed in conjunction with fenestration/decapitation for 15 cases: right sided (7), left sided (7), and central (1). One formal left hepatectomy was performed in a polycystic liver disease patient. Final pathology yielded simple cyst (52) and one biliary cystadenoma. Post-operative complications included bile leak (2), perihepatic fluid collection (1), pleural effusion (1), and ascites (1). At median 7.1-month follow-up, complete resolution of symptoms occurred for 34/49 patients (69.4%) who had symptoms preoperatively. Reintervention for cyst recurrence occurred for 5 cases (9.4%).

CONCLUSIONS

Outcomes for hepatic cyst disease are described with predominantly laparoscopic approach, approach with minimal morbidity, and excellent clinical results.

Laparoscopic versus open hemihepatectomy: comprehensive comparison of complications and costs at 90 days using a propensity method

Laparoscopic hemihepatectomy (LHH) may offer advantages over open hemihepatectomy (OHH) in blood loss, recovery, and hospital stay. The aim of this study is to evaluate our recent experience performing hemihepatectomy and compare complications and costs up to 90 days following laparoscopic versus open procedures. Retrospective evaluation of patients undergoing hemihepatectomy at our center 01/2010-12/2018 was performed. Patient, tumor, and surgical characteristics; 90-day complications; and costs were analyzed. Inverse probability of treatment weighting (IPTW) was used to balance covariates. A total of 141 hemihepatectomies were included: 96 OHH and 45 LHH. While operative times were longer for LHH, blood loss and transfusions were less. At 90 days, there were similar rates of liver-specific and surgical complications but fewer medical complications following LHH. Medical complications that arose with greater frequency following OHH were primarily pulmonary complications and urinary and central venous catheter infections. Complications at 90 days were lower following LHH (Clavien-Dindo grade ≥ III OHH 23%, LHH 11%, p = 0.130; Comprehensive Complication Index OHH 20.0 ± 16.1, LHH 10.9 ± 14.2, p = 0.001). While operating costs were higher, costs for hospital stay and readmissions were lower with LHH. Patients undergoing LHH experience a significant reduction in postoperative medical complications and costs, resulting in 90-day cost equity compared with OHH.

Intention to Treat Laparoscopic Versus Open Hemi-Hepatectomy: A Paired Case-Matched Comparison Study

BACKGROUND

The benefits of laparoscopic hemi-hepatectomy compared to open hemi-hepatectomy are not clear.

OBJECTIVE

This study aims to share our experience with the laparoscopic hemi-hepatectomy compared to an open approach.

METHODS

A total of 40 consecutive laparoscopically started hemi-hepatectomy (intention-to-treat analysis) cases between August 2012 and October 2015 were matched against open cases using the following criteria: laterality of surgery and pathology (essential criteria); American Society of Anesthesiologists score, body mass index, pre-operative bilirubin, neo-adjuvant chemotherapy, additional procedures, portal vein embolization, and presence of cirrhosis/fibrosis on histology (secondary criteria); age and gender (tertiary criteria). Hand-assisted and extended hemi-hepatectomy cases were excluded from the study. The two groups were compared for blood loss, operative time, hospital stay, morbidity, mortality, and oncological outcomes. All complications were quantified using the Clavien-Dindo classification.

RESULTS

Two groups were well matched (p = 1.00). In the two groups, 10 patients had left and 30 had right hemi-hepatectomy. Overall conversion rate was 15%. Median length of hospital and high dependency unit stay was less in the intention to treat laparoscopic hemi-hepatectomy group: 6 versus 8 days, p = 0.025 and 1 versus 2 days, p = 0.07. Median operative time was longer in the intention to treat laparoscopic hemi-hepatectomy group: 420 min (range: 389.5-480) versus 305 min (range: 238.8-348.8; p = 0.001). Intra-operative blood loss was equivalent, but the overall blood transfusions were higher in the intention to treat laparoscopic hemi-hepatectomy (50 vs 29 units, p = 0.36). The overall morbidity (18 vs 20 patients, p = 0.65), mortality (2.5%), and the positive resection margin status were similar (18% vs 21%, p = 0.76). The 1- (87.5% vs 92.5%, p = 0.71) and 3-year survival (70% vs 72.5%, p = 1.00) was also similar.

CONCLUSIONS

We observed lower hospital and high dependency unit stay in the laparoscopic group. However, the laparoscopic approach was associated with longer operating time and a non-significant increase in blood transfusion requirements. There was no difference in morbidity, mortality, re-admission rate, and oncological outcomes.

Laparoscopic major liver resections: Current standards

Laparoscopic liver resection was slow to be adopted in the surgical arena at the beginning as there were major barriers including the fear of gas embolism, risk of excessive blood loss from the inability to control bleeding vessels effectively, suboptimal surgical instruments to perform major liver resection and the concerns about oncological safety of the procedure. However, it has come a long way since the early 1990s when the first successful laparoscopic liver resection was performed, spurring liver surgeons worldwide to start exploring the roles of laparoscopy in major liver resections. Till date, more than 9000 cases have been reported in the literature and the numbers continue to soar as the hepatobiliary surgical communities quickly learn and apply this technique in performing major liver resection. Large bodies of evidence are available in the literature showing that laparoscopic major liver resection can confer improved short-term outcomes in terms of lesser operative morbidities, lesser operative blood loss, lesser post-operative pain and faster recovery with shorter length of hospitalization. On the other hand, there is no compromise in the long-term and oncological outcomes in terms of comparable R₀ resection rate and survival rates of this approach. Many innovations in laparoscopic major hepatectomies for complex operations have also been reported. In this article, we highlight the journey of laparoscopic major hepatectomies, summarize the technical advancement and lessons learnt as well as review the current standards of outcomes for this procedure.

A comparison between robotic, laparoscopic and open hepatectomy: A systematic review and network meta-analysis

BACKGROUND

The evidence of pairwise meta-analysis of Robotic Hepatectomy (RH) vs Laparoscopic Hepatectomy (LH) and RH vs Open Hepatectomy (OH) is inconclusive. Therefore, the aim of this study, was to compare the outcomes of RH, LH and OH by performing a network meta-analysis.

METHODS

A systematic literature search was performed in the following databases: Pubmed, Google scholar, EMBASE and Cochrane library. Cost-effectiveness and survival benefits were selected as primary outcomes.

RESULTS

The cost was less in OH compared to both minimally invasive procedures, LH demonstrated lower cost compared to RH, but the differences were not statistically significant. Both the RH and LH cohorts demonstrated significantly lower estimated blood loss, reduced major morbidity rate and shorter length of stay compared to OH cohort. The LH and OH cohorts demonstrated significantly shorter operative time and duration of clamping compared to the RH cohort. The LH cohort included significantly smaller tumours compared to the OH cohort.

CONCLUSION

The present network meta-analysis, demonstrated that both RH and LH in malignant and benign conditions were associated with lower morbidity rates, shorter hospital stay and the procedure related costs were statistically nonsignificant between RH, LH and OH.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A propensity-matched study of full laparoscopic versus hand-assisted minimal-invasive liver surgery

BACKGROUND AND AIM

The implications of multi-incision (MILS) and hand-assisted (HALS) laparoscopic techniques for minimally invasive liver surgery with regard to perioperative outcomes are not well defined. The purpose of this study was to compare MILS and HALS using propensity score matching.

METHODS

309 patients underwent laparoscopic liver resections (LLR) between January 2013 and June 2018. Perioperative outcomes were analyzed after a 1:1 propensity score match. Subgroup analyses of matched groups, i.e., radical lymphadenectomy (LAD) as well as resections of posterosuperior segments (VII and/or VIII), were performed.

RESULTS

MILS was used in 187 (65.2%) and HALS in 100 (34.8%) cases, with a significant decrease of HALS resections over time (p = 0.001). There were no significant differences with regard to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) Score, previous abdominal surgery and cirrhosis between both groups. Patients scheduled for HALS were characterized by a significantly higher rate of malignant tumors (p < 0.001) and major resections (p < 0.001). After propensity score matching (PMS), 70 cases remained in each group and all preoperative variables as well as resection extend were well balanced. A significantly higher rate of radical LAD (p = 0.039) and posterosuperior resections was found in the HALS group (p = 0.021). No significant differences between the matched groups were observed regarding operation time, conversion rate, frequency of major complications, length of intensive care unit (ICU) stay, overall hospital stay and R1 rate.

CONCLUSION

Our analysis suggests MILS and HALS to be equivalent regarding postoperative outcomes. HALS might be particularly helpful to accomplish complex surgical procedures during earlier stages of the learning curve.

Surgical technique and clinical results of one- or two-stage laparoscopic right hemihepatectomy after portal vein embolization in patients with initially unresectable colorectal liver metastases: A case series

BACKGROUND

The use of the laparoscopic approach in one-stage or second-step of two-stage right hemihepatectomy (RHH) after portal vein embolization (PVE) in patients with initially unresectable colorectal liver metastases (CRLMs) is technically demanding. Currently, there is limited published data regarding the technique and results required to better understand its safety and feasibility. This paper reports our experience, results, techniques and variety of tips and tricks (highlighted in the attached video), to facilitate this resection.

METHODS

A prospectively maintained database of laparoscopic liver surgery within our unit at a tertiary referral centre between August 2003 and March 2019 was reviewed. Patients with initially unresectable CRLMs who underwent laparoscopic RHH or extended RHH after PVE in the context of a one or two-stage procedure were included.

RESULTS

Between August 2003 and March 2019, 19 patients with initially unresectable CRLMs underwent laparoscopic RHH after PVE. Twelve patients (63.2%) had RHH in the context of a two-stage hepatectomy and 7 as a one-stage procedure. Median time interval between PVE and surgery was 42.5 days (IQR, 34.5-60.0 days). Mean operating time was 351.8 ± 80.5 minutes. Median blood loss was 850 mL (IQR, 475-1350 mL). Conversion to open surgery occurred in 2 of 19 cases (10.5%). Severe postoperative morbidity occurred in 2 patients. The mortality rate was 5.3%. Median postoperative hospital stay was 5 days (IQR, 4-7 days). Radical resection was obtained in eighteen patients (94.7%).

CONCLUSION

Laparoscopic RHH after PVE in the context of a one- or two-stage resection in patients with initially unresectable CRLMs is a safe and feasible procedure with favourable oncological outcomes.

Pure laparoscopic versus open hemihepatectomy: a critical assessment and realistic expectations - a propensity score-based analysis of right and left hemihepatectomies from nine European tertiary referral centers

INTRODUCTION

A stronger evidence level is needed to confirm the benefits and limits of laparoscopic hemihepatectomies.

METHODS

Laparoscopic and open hemihepatectomies from nine European referral centers were compared after propensity score matching (right and left hemihepatectomies separately, and benign and malignant diseases sub-analyses).

RESULTS

Five hundred and forty-five laparoscopic hemihepatectomies were compared with 545 open. Laparoscopy was associated with reduced blood loss (P < 0.001), postoperative stay (P < 0.001) and minor morbidity (P = 0.002), supported by a lower Comprehensive Complication Index (CCI) (P = 0.035). Laparoscopic right hemihepatectomies were associated with lower ascites (P = 0.016), bile leak (P = 0.001) and wound infections (P = 0.009). Laparoscopic left hemihepatectomies exhibited a lower incidence of bile leak and cardiovascular complications (P = 0.024; P = 0.041), lower minor and major morbidity (P = 0.003; P = 0.044) and reduced CCI (P = 0.002). Laparoscopic major hepatectomies (LMH) for benign disease were associated with lower blood loss (P = 0.001) and bile leaks (P = 0.037) and shorter total stay (P < 0.001). LMH for malignancy were associated with lower blood loss (P < 0.001) and minor morbidity (P = 0.027) supported by a lower CCI (P = 0.021) and shorter stay (P < 0.001).

CONCLUSION

This multicenter study confirms some associated advantages of laparoscopic left and right hemihepatectomies in malignant and benign conditions highlighting the need for realistic expectations of the minimally invasive approach based on the resected hemiliver and the patients treated.

Clinical outcomes of laparoscopic versus open right hepatectomy for liver tumors: A meta-analysis

BACKGROUND

Laparoscopic right hepatectomy (LRH) is one of the most challenging procedures. Right liver resections have been always performed in open procedure and open right hepatectomy (ORH) was initially considered as routine way. Moreover, it is unclear how beneficial the minimally invasive technique is to patients; thus, we conducted a meta-analysis to acquire a more reliable conclusion about the feasibility and safety of LRH compared with ORH.

METHODS

We comprehensively searched the electronic databases of PubMed, Embase, and the Cochrane Library using the key words. Meta-analysis was performed using the Review Manager, with results expressed as odds ratio and weighted mean difference with 95% confidence intervals. The fixed-effect model was selected initially if high heterogeneity was not present between the studies; otherwise, the randomized-effect model was used. Subgroup analysis was performed based on different surgical methods of pure laparoscopic operation or hand-assisted operation.

RESULTS

Seven studies with 467 patients were included. In the overall analysis, less intraoperative blood loss (MD = -155.17; 95% CI, -238.89, -71.45; P = .0003) and a shorter length of stay (MD = -4.45; 95% CI, -5.84, -3.07; P < .00001) were observed in the LRH group compared to the ORH group. There were fewer overall complications (OR = 0.30; 95% CI, 0.10, 0.90; P = 0.03) and severe complications (OR = 0.24; 95% CI, 0.10, 0.58; P = .002;) in the LRH group than in the ORH group. The disadvantage of LRH was the longer operative time (MD = 49.39; 95% CI, 5.33, 93.45; P = .03). No significant difference was observed between the 2 groups in portal occlusion, rate of R0 resection, transfusion rate, mild complications, and postoperative mortality. In the subgroup analysis, intraoperative blood loss was significantly lower in the pure LRH group and hand-assist LRH group compared with ORH group. Length of stay was shorter by use of pure LRH and hand-assisted LRH manners than ORH. The incidence rate of complications was lower in the pure LRH group than in the ORH group. In contrast, there was no significant difference between hand-assisted LRH group and ORH group.

CONCLUSION

Compared to ORH, LRH has short-term surgical advantages and leads to a shorter recovery time in selected patients. We speculate that the operative time of LRH is closer with ORH. Overall, LRH can be considered a feasible choice in routine clinical practice with experienced surgeons, although more evidence is needed to make a definitive conclusion.

Safety and feasibility of laparoscopy technology in right hemihepatectomy

Laparoscopic hepatectomy (LH) has been accepted widely owing to its advantages as a minimally invasive surgery; however, laparoscopic right hemihepatectomy (LRH) has rarely been reported. We aimed to compare the benefits and drawbacks of LRH and open approaches. Between January 2014 and October 2017, 85 patients with tumor and hepatolithiasis who underwent LRH (n = 30) and open right hemihepatectomy (ORH) (n = 55) were enrolled in this study. For tumors, LRH showed significantly better results with respect to blood loss (P = 0.024) and duration of hospital stay (P = 0.008) than ORH, while hospital expenses (P = 0.031) and bile leakage rate (P = 0.012) were higher with LRH. However, the operative time and rate of other complications were not significantly different between the two groups. However, for hepatolithiasis, there was less blood loss (P = 0.015) and longer operative time (P = 0.036) with LRH than with ORH. There were no significant difference between LRH and ORH in terms of hospital stay, hospital expenses, and complication rate (P > 0.05). Moreover, the postoperative white blood cell count, alanine aminotransferase level, aspartate aminotransferase level, and total bilirubin were not significantly different in both types of patients (P > 0.05). Our results suggest the safety and feasibility of laparoscopy technology for right hemihepatectomy in both tumor and hepatolithiasis patients.

A novel exposure maneuver in laparoscopic right hepatectomy

BACKGROUND AND OBJECTIVES

Laparoscopic access to the posterosuperior and lateral parts of the right liver is difficult for blocked and deep surgical situations. We invented a novel water bag device (WBD) to improve the exposure of the right liver.

METHODS

Eighteen consecutive patients with lesions isolated to the posterosuperior or lateral right liver were included in our research. They underwent laparoscopic right hepatectomy with the help of the device and were compared with previous similar laparoscopic cases of our operating surgeon.

RESULTS

The device was successfully employed without related complications and provided enhanced and stable surgical exposure. All patients were operated on without the need for blood transfusions or laparotomy conversion. The median operation time and estimated blood loss were 227 minutes (range, 114-568) and 88 mL (range, 25-250), respectively. In all cases, tumor-free surgical margins were confirmed and no major complications were observed. The results were better than those in previous similar laparoscopic cases.

CONCLUSIONS

The WBD is safe and effective for laparoscopic exposure when lesions are located in the posterosuperior and lateral parts of the right liver. With the help of the device, laparoscopic right liver resection is easier to perform instead of undergoing open hepatectomy.

Laparoscopic Versus Open Major Hepatectomy: Analysis of Clinical Outcomes and Cost Effectiveness in a High-Volume Center

BACKGROUND

Considering the increasing evidence on the feasibility of laparoscopic major hepatectomies (LMH), their clinical outcomes and associated costs were herein evaluated compared to open (OMH).

METHODS

Major contributors of perioperative expenses were considered. With respect to the occurrence of conversion, a primary intention-to-treat analysis including conversions in the LMH group (ITT-A) was performed. An additional per-protocol analysis excluding conversions (PP-A) was undertaken, with calculation of additional costs of conversion analysis.

RESULTS

One hundred forty-five LMH and 61 OMH were included (14.5% conversion rate). At the ITT-A, LMH showed lower blood loss (p < 0.001) and morbidity (global p 0.037, moderate p 0.037), shorter hospital stay (p 0.035), and a lower need for intra- and postoperative red blood cells transfusions (p < 0.001), investigations (p 0.004), and antibiotics (p 0.002). The higher intraoperative expenses (+ 32.1%, p < 0.001) were offset by postoperative savings (- 27.2%, p 0.030), resulting in a global cost-neutrality of LMH (- 7.2%, p 0.807). At the PP-A, completed LMH showed also lower severe complications (p 0.042), interventional procedures (p 0.027), and readmission rates (p 0.031), and postoperative savings increased to - 71.3% (p 0.003) resulting in a 29.9% cost advantage of completed LMH (p 0.020). However, the mean additional cost of conversion was significant.

CONCLUSIONS

Completed LMH exhibit a high potential treatment effect compared to OMH and are associated to significant cost savings. Despite some of these benefits may be jeopardized by conversion, a program of LMH can still provide considerable clinical benefits without cost disadvantage and appears worth to be implemented in high-volume centers.

Global hospital and operative costs associated with various ventral cavity procedures: a comprehensive literature review and analysis across regions

Objectives: The aim of this literature review was to provide a comprehensive report on hospital costs, and cost components, for a range of ventral cavity surgical procedures across three regions of focus: (1) Americas, (2) Europe, Middle East and Africa (EMEA), and (3) Asia-Pacific. Methods: A structured search was performed and utilized a combination of controlled vocabulary (e.g., "Hepatectomy", "Colectomy", "Costs and Cost Analysis") and keywords (e.g. "liver resection", "bowel removal", "economics"). Studies were considered eligible for inclusion if they reported hospital-related costs associated with the procedures of interest. Cost outcomes included operating room (OR) time costs, total OR costs, ward stay costs, total admission costs, OR cost per minute and ward cost per day. All costs were converted to 2018 USD. Results: Total admission costs were observed to be highest in the Americas, with an average cost of $15,791. The average OR time cost per minute was found to vary by region: $24.83 (Americas), $14.29 (Asia-Pacific), and $13.90 (EMEA). A cost-breakdown demonstrated that OR costs typically comprised close to 50%, or more, of hospital admission costs. This review also demonstrates that decreasing OR time by 30 min provides cost savings approximately equivalent to a 1-day reduction in ward time. Conclusion: This literature review provided a comprehensive assessment of hospital costs across various surgical procedures, approaches, and geographical regions. Our findings indicate that novel processes and healthcare technologies that aim to reduce resources such as operating time and hospital stay, can potentially provide resource savings for hospital payers.

The hidden costs of open hepatectomy: A 10-year, single institution series of right-sided hepatectomies

BACKGROUND

Incisional ventral hernias(IVH) are a common complication following open abdominal surgery. The aim of this study was to uncover the hidden costs of IVH following right-sided hepatectomy.

METHODS

Outcomes and hospital billing data for patients undergoing open(ORH) and laparoscopic right-sided hepatectomies(LRH) were reviewed from 2008 to 2018.

RESULTS

Of 327 patients undergoing right-sided hepatectomies, 231 patients were included into two groups: ORH(n = 118) and LRH(n = 113). Median follow-up-times and time-to-hernia were 24.9-months(0.3-128.4 months) and 40.5-months(0.4-81.4 months), respectively. The incidence of hernias at 1, 3, 5, and 10 years was 6/231(2.6%), 13/231(5.6%), 15(6.5%), and 17/231(7.4%); ORH = 14, LRH = 3, p = 0.003), respectively. In terms of IVH repair(IVHR), total operative costs ($10,719.27vs.$4,441.30,p < 0.001) and overall care costs ($20,541.09vs.$7,149.21,p = 0.044) were significantly greater for patients undergoing ORH. Patients whom underwent ORHs had longer hospital stays and more complications following IVHR. Risk analysis identified ORH(RR-10.860), male gender(RR-3.558), BMI ≥30 kg/m²(RR-5.157), and previous abdominal surgery(RR-6.870) as predictors for hernia development (p < 0.030).

CONCLUSION

Evaluation of pre-operative hernia risk factors and utilization of a laparoscopic approach to right-sided hepatectomy reduces incisional ventral hernia incidence and cost when repair is needed.

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.

Advantages of laparoscopic left hemihepatectomy: A meta-analysis

BACKGROUND

Laparoscopic left hemihepatectomy (LLH) has been widely accepted as a minimally invasive alternative to open liver surgery. We assessed the benefits and drawbacks of LLH compared with open left hemihepatectomy (OLH) using meta-analysis.

METHODS

Relevant literature was retrieved using PubMed, Embase, Cochrane, and Ovid Medline databases. Multiple parameters of efficacy and safety were compared between the treatment groups. Results are expressed as odds ratio (OD) or mean difference (MD) with 95% confidence interval (95% CI) for fixed- and random-effects models.

RESULTS

The meta-analysis included 13 trials involving 1163 patients. Compared with OLH, LLH significantly reduced intraoperative blood loss (MD, -91.01; 95% CI, -139.12 to -42.89; P = .0002), transfusion requirement (OR, 0.24; 95% CI, 0.11-0.54; P = .0004), time to oral intake (MD, -0.80; 95% CI, -1.27 to -0.33; P = .0008), and hospital stay (MD, -3.94; 95% CI, -4.85 to -3.03; P < .0001). However, operative time; complications rate; and postoperative alanine transferase, albumin, and total bilirubin levels did not differ significantly between the 2 surgical groups (P > .05). For hepatolithiasis treatment, there were no significant differences in operative time, residual stones, stone recurrence, and complications rate between the groups (P > .05), but LLH resulted in lower incisional infection rate (OR, 0.44; 95% CI, 0.22-0.89; P = .02) than OLH. The LLH group demonstrated higher bile leakage rate (OR, 1.79; 95% CI, 1.14-2.81; P = .01) and incurred greater hospital costs (MD, 618.56; 95% CI, 154.47-1082.64; P = .009).

CONCLUSIONS

LLH has multiple advantages over OLH and should thus be considered as the first choice for left hemihepatectomy.

Standardization of operative technique in minimally invasive right hepatectomy: improving cost-value relationship through value stream mapping in hepatobiliary surgery

BACKGROUND

With current emphasis on improving cost-quality relationship in medicine, it is imperative to evaluate cost-value relationships for surgical procedures. Previously the authors demonstrated comparable clinical outcomes for minimally invasive right hepatectomy (MIRH) and open right hepatectomy (ORH). MIRH had significantly higher intraoperative cost, though overall costs were similar.

METHODS

MIRH was decoded into its component critical steps using value stream mapping, analyzing each associated cost. MIRH technique was prospectively modified, targeting high cost steps and outcomes were re-examined. Records were reviewed for elective MIRH before (pre-MIRH n = 50), after (post MIRH n = 25) intervention and ORH (n = 98), between January 1, 2008 and November 30, 2016.

RESULTS

Average overall cost was significantly lower for post-standardization MIRH (post-MIRH $21 768, pre-MIRH $28 066, ORH $33 020; p < 0.001). Average intraoperative blood loss was reduced with MIRH (167, 292 and 509 mL p < 0.001). Operative times were shorter (147, 190 and 229 min p < 0.001) and LOS was reduced for MIRH (3, 4, 7 days p < 0.002).

CONCLUSIONS

Using a common quality improvement tool, the authors established a model for cost effective clinical care. These tools allow surgeons to overcome personal or traditional biases such as stapler choices, but most importantly eliminate non-value added interventions for patients.

Minimally invasive liver resection in the era of robotics: analysis of 214 cases

BACKGROUND

Minimally Invasive Liver Resection (MILR) techniques range from a hybrid-technique to full robotic approaches. When compared with open techniques, MILR has been shown to be advantageous by reducing pain, complications, length of stay and blood loss. The aim of this study was to compare clinical outcomes and hospital resource utilization between full laparoscopic, hand-assisted, and robotic liver resections among major (≥ 3 segments) and minor (≤ 2 segments) resections.

METHODS

A single-center comparative retrospective review was completed on 214 patients undergoing full laparoscopic, hand-assisted, or robotic liver resection procedures between 2005 and 2018.

RESULTS

Among minor resections: 85 full laparoscopic, 40 hand-assisted, and 35 robotic liver resection cases were analyzed; and among major resections: 13, 33, and 8 cases were analyzed, respectively. In the adjusted subgroup analysis of minor resections, OR time was significantly longer for the minor hand-assisted group ([Formula: see text] = 181 min; p < 0.05), and the average lesion size was smaller for the minor full laparoscopic group ([Formula: see text] = 4.2 cm; p < 0.05). Overall, direct hospital charges were lowest in the group of patients who underwent a minor resection using the full laparoscopic technique ([Formula: see text] = $39,054.90; p < 0.05), compared to the robotic technique. Due to the smaller sample size (n = 54) in the major resection subgroup, only two significant observations were made - the full laparoscopic group had the least amount of blood loss ([Formula: see text] = 227 cc; p < 0.05) and incurred the least amount of room and board charges compared to the other two techniques.

CONCLUSIONS

The robotic approach appears favorable for minor resections as evidenced by shorter length of stay but more costly than full laparoscopy. Clinical outcomes appear to be more dependent upon the magnitude of the resection (i.e. major vs. minor) than the MILR technique chosen. Randomized trials may be indicated to discern the best indications and advantages of each technique.

Current topics in liver surgery

Liver resection is one of the main treatment strategies for liver malignancies. Mortality and morbidity of liver surgery has improved significantly with progress in selection criteria, development of operative procedures and improvements in perioperative management. Safe liver resection has thus become more available worldwide. We have identified four current topics related to liver resection (anatomical liver resection, laparoscopic liver resection, staged liver resection and chemotherapy-induced liver injury). The balance between treatment effect and patient safety needs to be considered when planning liver resection. Progress in this area has been rapid thanks to the efforts of many surgeons, and outcomes have improved significantly as a result. These topics remain to be solved and more robust evidence is needed. Precise selection of the optimal procedure and risk evaluation should be standardized with further development of each topic. The present article reviews these four current topics with a focus on safety and efficacy in recent series.

Low conversion rate during minimally invasive major hepatectomy: Ten-year experience at a high-volume center

BACKGROUND

Minimally invasive approaches for major hepatectomy have been marred by significant rates of conversion and associated morbidity. This study aimed to determine risk factors for conversion as well as postoperative morbidity in patients undergoing minimally invasive right-sided hepatectomy (MIRH).

METHODS

Data for patients undergoing MIRH between 2008 and 2017 at Emory University were reviewed. Risk factors for conversion were determined using multivariate regression analysis. Outcomes of conversion patients were compared with those who underwent successful MIRH or elective open surgery.

RESULTS

Unplanned conversion occurred in 7 (6.25%) of 112 patients undergoing MIRH. Primary reason for conversion was difficult dissection secondary to inflammation and severe adhesions. No preoperative clinical factor was identified that predicted conversions. Converted cases had higher EBL and pRBC transfusion compared to non-converted cases however morbidity was similar to those undergoing primary open surgery.

CONCLUSION

Difficult dissection and adhesions remained the only clinically applicable parameter leading to unplanned conversions. While these did offset benefits of a successful minimally invasive approach, it did not increase risk of postoperative complications compared with planned open surgery.

Laparoscopic extended liver resection: are postoperative outcomes different?

BACKGROUND

Although laparoscopic major hepatectomy (LMH) is becoming increasingly common in specialized centers, data regarding laparoscopic extended major hepatectomies (LEMH) and their outcomes are limited. The aim of this study was to compare the perioperative characteristics and postoperative outcomes of LEMH to standard LMH.

METHODS

All patients who underwent purely laparoscopic anatomical right or left hepatectomy and right or left trisectionectomy between February 1998 and January 2016 are enrolled. Demographic, clinicopathological, and perioperative factors were collected prospectively and analyzed retrospectively. Perioperative characteristics and postoperative outcomes in LEMH were compared to those of standard LMH.

RESULTS

Among 195 patients with LMH, 47 (24.1%) underwent LEMH, colorectal liver metastases representing 66.7% of all indications. Preoperative portal vein embolization was undertaken in 31 (15.9%) patients. Despite more frequent vascular clamping, blood loss was higher in LEMH group (400 vs. 214 ml; p = 0.006). However, there was no difference in intraoperative transfusion requirements. Thirty-one patients experienced liver failure with no differences between LMH and LEMH groups. Postoperative mortality was comparable in the two groups [3 (2.5%) LMH patients vs. 2 (5%) LEMH patients (p = 0.388)]. Overall morbidity was higher in the LEMH group [49 LMH patients (41.5%) vs. 24 LEMH patients (60%) (p = 0.052)]. Patients treated with left LEMH experienced more biliary leakage (p = 0.011) and more major pulmonary complications (p = 0.015) than left LMH.

CONCLUSION

LEMH is feasible at the price of important morbidity, with manageable and acceptable outcomes. These exigent procedures require high-volume centers with experienced surgeons.

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.

Considering the cost of a simultaneous versus staged approach to resection of colorectal cancer with synchronous liver metastases in a publicly funded healthcare model

BACKGROUND

Simultaneous resection for colorectal cancer with synchronous liver metastases is an established alternative to a staged approach. This study aimed to compare these approaches with regards to economic parameters and short-term outcomes.

METHODS

A retrospective cohort analysis was conducted between 2005 and 2016. The primary outcome was cost per episode of care. Secondary measures included 30-day clinical outcomes. A multivariate analysis was performed to determine the adjusted effect of a simultaneous surgical approach on total cost of care.

RESULTS

Fifty-three cases were identified; 27 in the staged approach, and 26 in the simultaneous group. Age (P = 0.49), sex (P = 0.20), BMI (P = 0.74), and ASA class (P = 0.44) were comparable between groups. Total cost ($20297 vs $27522), OR ($6830 vs $10376), PACU ($675 vs $1182), ward ($7586 vs $11603) and pharmacy costs ($728 vs $1075) were significantly less for the simultaneous group (P < 0.05). The adjusted rate ratio for total cost of care in the staged group compared to simultaneous group was 1.51 (95%CI: 1.16-1.97, P < 0.05). The groups had comparable Clavien-Dindo scores (P = 0.89), 30-day readmissions (P = 0.44), morbidity (P = 0.50) and mortality (P = 1.00).

CONCLUSIONS

Our study demonstrates that a simultaneous approach is associated with a significantly lower total cost while maintaining comparable short-term outcomes.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Perioperative fluid management in major hepatic resection: an integrative review

BACKGROUND

Fluid intervention and vasoactive pharmacological support during hepatic resection depend on the preference of the attending clinician, institutional resources, and practice culture. Evidence-based recommendations to guide perioperative fluid management are currently limited. Therefore, we provide a contemporary clinical integrative overview of the fundamental principles underpinning fluid intervention and hemodynamic optimization for adult patients undergoing major hepatic resection.

DATA SOURCES

A literature review was performed of MEDLINE, EMBASE and the Cochrane Central Registry of Controlled Trials using the terms "surgery", "anesthesia", "starch", "hydroxyethyl starch derivatives", "albumin", "gelatin", "liver resection", "hepatic resection", "fluids", "fluid therapy", "crystalloid", "colloid", "saline", "plasma-Lyte", "plasmalyte", "hartmann's", "acetate", and "lactate". Search results for MEDLINE and EMBASE were additionally limited to studies on human populations that included adult age groups and publications in English.

RESULTS

A total of 113 articles were included after appropriate inclusion criteria screening. Perioperative fluid management as it relates to various anesthetic and surgical techniques is discussed.

CONCLUSIONS

Clinicians should have a fundamental understanding of the surgical phases of the resection, hemodynamic goals, and anesthesia challenges in attempts to individualize therapy to the patient's underlying pathophysiological condition. Therefore, an ideal approach for perioperative fluid therapy is always individualized. Planning and designing large-scale clinical trials are imperative to define the optimal type and amount of fluid for patients undergoing major hepatic resection. Further clinical trials evaluating different intraoperative goal-directed strategies are also eagerly awaited.

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.

Cost-Effective Surgical Management of Liver Disease Amidst a Financial Crisis

BACKGROUND

Intraoperative use of specialized equipment and disposables contributes to the increasing cost of modern liver surgery. As a response to the recent severe financial crisis in our country we have employed a highly standardized protocol of liver resection that minimizes intraoperative and postoperative costs. Our goal is to evaluate cost-effectiveness of this protocol.

STUDY DESIGN

We evaluated retrospectively all patients who underwent open hepatic resections for 4 years. All resections were performed by the same surgical team under selective hepatic vascular exclusion, i.e., occlusion of the hepatoduodenal ligament and the major hepatic veins, occasionally combined with extrahepatic ligation of the ipsilateral portal vein. Sharp parenchymal transection was performed with a scalpel and hemostasis was achieved with sutures without the use of energy devices. In each case we performed a detailed analysis of costs and surgical outcomes.

RESULTS

Our cohort included 146 patients (median age 63 years). 113 patients were operated for primary or metastatic malignancies and 33 for benign lesions. Operating time was 121 ± 21 min (mean ± SD), estimated blood loss was 310 ± 159 ml (mean ± SD), and hospital stay was 7 ± 5 days (mean ± SD). Six patients required admission in the ICU postoperatively. 90-day mortality was 2.74 %, and 8.9 % of patients developed grade III/IV postoperative complications (Clavien-Dindo classification). Total in-hospital cost excluding physician fees was 6987.63 ± 3838.51 USD (mean ± SD).

CONCLUSIONS

Our analysis suggests that, under pressing economic conditions, the proposed surgical protocol can significantly lessen the financial burden of liver surgery without compromising patient outcomes.

Can retrohepatic tunnel be quickly and easily established for laparoscopic liver hanging maneuver by Goldfinger dissector in laparoscopic right hepatectomy?

OBJECTIVE

The liver hanging maneuver (LHM) is rarely applied in laparoscopic right hepatectomy (LRH) because of the difficulty encountered in retrohepatic tunnel (RT) dissection and tape positioning. Thus far no report has detailed how to quickly and easily establish RT for laparoscopic LHM in LRH, nor has employment of the Goldfinger dissector to create a total RT been reported. This study's aim was to evaluate the safety and feasibility of establishing RT for laparoscopic LHM using the Goldfinger dissector in LRH.

METHODS

Between March 2015 and July 2015, five consecutive patients underwent LRH via the caudal approach with laparoscopic LHM. A five-step strategy using the Goldfinger dissector to establish RT for laparoscopic LHM was adopted. Perioperative data were analyzed.

RESULTS

The median age of patients was 58 (range, 51-65) years. Surgery was performed for one intrahepatic lithiasis and four hepatocellular carcinomas with a median size of 90 (40-150) mm. The median operative time was 320 (282-358) min with a median blood loss of 200 (200-600) ml. Laparoscopic LHM was achieved in a median of 31 (21-62) min, and the median postoperative hospital stay was 14 (9-16) d. No transfusion or conversion was required, and no severe liver-related morbidity or death was observed.

CONCLUSIONS

The Goldfinger dissector is a useful instrument for the establishment of RT. A five-step strategy using the Goldfinger dissector can quickly and easily facilitate an RT for a laparoscopic LHM in LRH.

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.

The comparative costs of laparoscopic and open liver resection: a report for the 2nd International Consensus Conference on Laparoscopic Liver Resection

BACKGROUND

The techniques of laparoscopic liver resection (LLR) have developed rapidly in selected centers, while global adoption of this approach has been cautious. The costs of LLR compared to open resection (OLR) are considered an important metric in evaluating this approach and may be a barrier to adoption in some centers.

METHODS

To formulate a consensus statement using the Zurich-Danish consensus model to the question of "What are the comparative outcomes of cost for LLR and OLR, minor and major?" a systematic search of the literature was conducted. Results were presented to the jury in September 2014 and updated in August 30, 2015. Adjustments for currency conversions and inflation were not performed due to limitations in available data.

RESULTS

Thirty-four studies were reviewed, and 11 relevant papers were selected for inclusion. No randomized control studies were found. Five studies were case-matched comparisons, while the remaining studies were retrospective reviews. The number of patients in each study ranged from 28 to 74, and the cumulative number of patients was 643 comparing 350 OLR to 293 LLR. Overall median hospital stay was lower for LLR at 4.6 versus 7.4 days. This remained valid when only the case-matched studies were analyzed, 4.6 (n = 178) versus 6.6 days (n = 266). The median overall total costs were 16.3 % lower (range 0 to -22 %) for LLR compared to OLR. This remained valid in the subgroup analysis of the case-matched studies, with a median 17.4 % lower costs for the LLR. Median OR costs were 3 % higher for LLR (range -9 to 40 %) but 32.9 % lower for hospital ward costs (range 0 to -60 %) when compared to OLR.

CONCLUSIONS

Currently, the published literature indicates that overall hospital costs are less for LLR when compared to OLR (Level of evidence 3a and 3b). This evidence is strongest for minor hepatic resections. The decreased cost is based on savings in hospital ward costs and likely related to a significantly shorter hospital stay for LLR.