Total anatomical laparoscopic liver resection of segment 4 (S4), extended S4, and subsegments S4a and S4b for hepatocellular carcinoma

Trans-arterial positive ICG staining-guided laparoscopic liver watershed resection for hepatocellular carcinoma

Introduction

Anatomical liver resection is the optimal treatment for patients with resectable hepatocellular carcinoma (HCC). Laparoscopic Couinaud liver segment resection could be performed easily as liver segments could be stained by ultrasound-guided indocyanine green (ICG) injection into the corresponding segment portal vein. Several smaller liver anatomical units (liver watersheds) have been identified (such as S8v, S8d, S4a, and S4b). However, since portal veins of liver watersheds are too thin to be identified under ultrasound, the boundaries of these liver watersheds could not be stained intraoperatively, making laparoscopic resection of these liver watersheds demanding. Digital subtraction angiography (DSA) could identify arteries of liver watersheds with a diameter of less than 2 mm. Yet, its usage for liver watershed staining has not been explored so far.

Purpose

The aim of this study is to explore the possibility of positive liver watershed staining via trans-arterial ICG injection under DSA examination for navigating laparoscopic watershed-oriented hepatic resection.

Methods

We describe, in a step-by-step approach, the application of trans-arterial ICG injection to stain aimed liver watershed during laparoscopic anatomical hepatectomy. The efficiency and safety of the technique are illustrated and discussed in comparison with the laparoscopic anatomical liver resection via ultrasound-guided liver segment staining.

Results

Eight of 10 HCC patients received successful trans-arterial liver watershed staining. The success rate of the trans-artery staining approach was 80%, higher than that of the ultrasound-guided portal vein staining approach (60%). Longer surgical duration was found in patients who underwent the trans-artery staining approach (305.3 ± 23.2 min vs. 268.4 ± 34.7 min in patients who underwent the ultrasound-guided portal vein staining approach, p = 0.004). No significant difference was found in major morbidity, reoperation rate, hospital stay duration, and 30-day and 90-day mortality between the 2 groups.

Conclusions

Trans-arterial ICG staining is safe and feasible for staining the aimed liver watershed, navigating watershed-oriented hepatic resection under fluorescence laparoscopy for surgeons.

Long-Term Outcomes of Laparoscopic Liver Resection for Centrally Located Hepatocellular Carcinoma

Background and Objectives: The feasibility of laparoscopic liver resection (LLR) for centrally located hepatocellular carcinoma (cHCC 1 cm of the hilum, major hepatic veins, and inferior vena cava) is still controversial. This study aims to evaluate the feasibility and safety of LLR for cHCC and compare the perioperative outcomes with those of open liver resection (OLR). Materials and Methods: This retrospective study included 110 patients who underwent LLR (n = 59) or open liver resection (OLR) (n = 51) for cHCC between January 2004 and September 2018. LLR group was divided into the following two subgroups according to the date of operation: Group 1 (n = 19) and Group 2 (n = 40), to account for the advancement in the laparoscopic techniques. Results: No mortality within 3 months was observed. There were no significant differences in operation time (285 vs. 280 min; p = 0.938) and postoperative complication rate (22.0% vs. 27.5%; p = 0.510) between both groups. However, intraoperative blood loss (500 vs. 700 mL; p < 0.001), transfusion rate (10.2% vs. 31.4%; p = 0.006), and hospital stay (6 vs. 10 days; p < 0.001) were significantly lower in the LLR group than in the OLR group. In the LLR group, Group 2, showed a shorter hospital stay than Group 1 (6 vs. 8 days; p = 0.006). There were improvements in the operation time (280 vs. 360 min; p = 0.036) and less intraoperative blood loss (455 vs. 500 mL; p = 0.075) in Group 2. Conclusions: We demonstrated that LLR can be safely performed in highly selected patients with cHCC.

Timing for Introduction of Total Laparoscopic Living Donor Right Hepatectomy; Initial Experience Based on the Data of Laparoscopic Major Hepatectomy

BACKGROUND

This study evaluated the timing of safe introduction of total laparoscopic donor right hepatectomy (TLDRH) based on outcomes of laparoscopic major hepatectomy (LMH).

METHODS

The data of 1013 consecutive patients who underwent laparoscopic liver resection from 2003 to 2017 were reviewed; the cumulative sum method was used to evaluate the learning curve of LMH. Patients were divided into 3 groups according to the timing of introduction of TLDRH (since 2010) and learning curve of LMH. Surgical outcomes of LMH and TLDRH were evaluated.

RESULTS

Cumulative sum analysis demonstrated a learning curve of approximately 73 cases of LMH. In phase I (before the introduction of TLDRH, 2003-2009), 38 cases of LMH were performed. Phase II (after the introduction of TLDRH until learning curve of LMH, 2010-2014), 35 and 15 cases of LMH and TLDRH were performed, respectively. Phase III (after learning curve of LMH until 2017, 2014-2017), 59 and 20 cases of LMH and TLDRH were performed, respectively. In cases of LMH, there was significant improvement in the operation time 398.9 ± 140.9 versus 403.7 ± 165.2 versus 265.5 ± 91.7; P < 0.001), estimated blood loss (1122.9 ± 1460.2 versus 1209.3 ± 1409.1 versus 359.8 ± 268.8; P < 0.001), and open conversion rate (26.3% versus 22.9% versus 13.6%; P = 0.026) between phases I versus II versus III. In cases of TLDRH, the operation time (567.8 ± 117.9 versus 344.2 ± 71.8; P < 0.001), estimated blood loss (800.7 ± 514.8 versus 439.4 ± 347.0; P = 0.004), and hospital stay (12.5 ± 4.36 versus 9.15 ± 4.84; P = 0.025) significantly improved in phase III.

CONCLUSIONS

Overcoming the learning curve of LMH before starting TLDRH is advisable to ensure donor's surgical outcomes.

Laparoscopic Living Donor Right Hepatectomy Regarding the Anatomical Variation of the Portal Vein: A Propensity Score-Matched Analysis

This study is designed to analyze the feasibility of laparoscopic living donor right hemihepatectomy in living donors with portal vein variation. Living donor liver transplantation cases using a right liver graft during the period of January 2014 to September 2019 were included. Computed tomographic angiographies of the donor were 3-dimensionally reconstructed, and the anatomical variation of the portal vein was classified. To reduce selection bias, a 1:1 ratio propensity score-matched analysis between the laparoscopy group and the open group was performed. Surgical and recovery-related outcomes as well as portal vein complication-free survival, graft survival, and overall survival rates were analyzed. After matching, 171 cases in each group from 444 original cases were compared. The laparoscopy group had a shorter operation time (P < 0.001), a smaller number of additional opioids required by the donor (P < 0.001), and a shorter hospital stay (P < 0.001). There were no differences in the portal vein complication-free survival (P = 0.16), graft survival (P = 0.26), or overall survival rates (P = 0.53). Although portal vein complication-free survival was inferior in portal veins other than type I (P = 0.01), the laparoscopy group showed similar portal vein complication-free survival regardless of the anatomical variation of portal vein (P = 0.35 in type I and P = 0.30 in other types). Laparoscopic living donor right hemihepatectomy can be performed as safely as open surgery regardless of the anatomical variation of the portal vein.

Anatomic Laparoscopic Liver Resection in the Scenario of the Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

Aim: To assess the impact of the laparoscopic anatomic resections (LARs) on hepatocellular carcinoma (HCC) patients, analyzing the pooled short- and long-term outcomes of this technique and comparing it with the standard open approach [open anatomic resections (OAR)]. Material and Methods: A systematic literature search was performed in PubMed, Embase, and Scopus for studies published between 2010 and 2020 concerning LAR for HCC. Results: After screening 311 articles, 10 studies with a total of 398 patients who underwent LAR for HCC were included. The pooled cohort included mostly male (76.6%), Child A (98.2%), with hepatitis B virus (HBV)-related disease (60.5%). The pooled conversion rate was 7.3%. The pooled overall complication rate was 10.2 with a mortality rate of 1.0%. In the pooled analyses of only comparative studies, LAR group included 378 versus 455 in OAR. Operative time was longer in the LAR group (329 minutes versus 248; P = .001). Blood loss (179 versus 331 mL; P = .018) was lower in the LAR group. The pooled mean length of hospital stay was 8.4 days in LARs and 11.3 in OARs (P = .002). The pooled rate of postoperative complications was higher in the OAR group (25.3 versus 13.8; P = .009), while mortality rates were similar. The LAR group had a pooled 3- and 5-year overall survival of 90.1 and 81.9 versus 83.5 and 80.7 of the OARs (P > .05), respectively. Conclusions: In conclusion, the LAR for HCC is safe and associated with decreased blood loss and length of hospital stay. Survival rates are comparable with those of the conventional open approach.

Pure Laparoscopic Anatomical Resection of the Ventral Area of the Right Anterior Section Using the Transfissural Glissonean Approach

The introduction of the anatomical concept of classifying the right anterior section (RAS) into the ventral and dorsal areas enabled the development of limited resection of the ventral or dorsal area. Anatomical resection of the ventral area of the RAS is technically demanding because it requires determination of the boundary of the ventral area and two large of transection planes. We present a technique for laparoscopic anatomical resection of the ventral area of the RAS using a transfissural Glissonean approach.In the transfissural Glissonean approach, the portal or umbilical fissure is opened after liver parenchymal dissection, and then, the surgeon can confirm the Glissonean pedicles and territory. The procedure was as follows: (1) dissection of the right anterior portal pedicle (RAPP) for the identification of the main portal fissure, (2) opening of the main portal fissure, (3) dissection and clamping of the ventral branch of the RAPP, and (4) transection of the borderline of the ventral and dorsal areas.The transfissural Glissonean approach is a feasible and effective technique for laparoscopic anatomical resection of the ventral area of the RAS. Opening the main portal fissure allows easy and direct access to the ventral branch of the RAPP.

Laparoscopic Anatomic Spiegel Lobectomy With the Extrahepatic Glissonean Approach

BACKGROUND

Laparoscopic Spiegel lobectomy is difficult due to its deep location and being surrounded by gross vessels. Extrahepatic Glissonean pedicle transection method has been proposed by Takasaki during open liver resections. This approach can be successfully performed during laparoscopic anatomic hepatectomy. Here we describe pure laparoscopic Spiegel lobectomy using the extrahepatic Glissonean approach.

METHODS

The patient was a 25-year-old male with a background of hepatitis B. A 1.5 cm×1.7 cm mass was detected in liver Spiegel lobe and highly suspected to be an hepatocellular carcinoma. The liver function was normal (Child-pugh 5), and alpha-fetoprotein was within the normal ranges. Laparoscopic Spiegel lobectomy using extrahepatic Glissonean approach was proposed. The hilar plate was partly detached from liver parenchyma, and 2 Glissonean pedicles of the Spiegel lobe were dissected, clamped and divided. Liver parenchymal transection was performed using the harmonic scalpel.

RESULTS

The operation time was 196 minutes without Pringle's maneuver. Estimated blood loss was <50 mL, and no blood transfusion was required. The patient recovered well and was discharged on postoperative day 6. There was no complication. Pathologic findings support the diagnosis of hepatocellular carcinoma.

CONCLUSIONS

Laparoscopic Spiegel lobectomy using the extrahepatic Glissonean approach is safe and feasible.

Laparoscopic caudate lobe resection for the treatment of hepatolithiasis

Background

To explore the safety and feasibility of laparoscopic caudate lobe (CL) resection for the treatment of hepatolithiasis.

Methods

A retrospective study of nine patients who received laparoscopic CL resection for treatment of hepatolithiasis in our hospital from January 2013 to April 2017. Of these cases, we studied the patients' demographic data, the operation time, blood loss, post-operative hospital stay, post-operative complications and prognosis.

Results

All the nine cases are performed successfully; the post-operative recovery was symptom free except for one case of post-operative bile leakage. Among them, there were six cases of CL resection in combination with other lobe, three cases of separate CL resection, and three cases of whole CL resection. The average operative time was 310 min (Range: 180-450 min), the average intraoperative blood loss was 530 ml (Range: 100-1000 ml), average post-operative hospital stay was 9 days (Range: 6-13 days), average total hospital stay was 10 days (Range: 9-19 days). Intraoperative calculi exhaustion rate was 66.7% (6/9), which at the end of treatment was 88.9% (8/9). No cases had calculi recurrence.

Conclusion

The application of laparoscopic CL resection is feasible and safe.

Laparoscopic hepatectomy versus open hepatectomy in the management of posterosuperior segments of the Liver: A systematic review and meta-analysis

BACKGROUND

Previous guidance and consensus have well-addressed the advantages of laparoscopic procedures in the anterolateral segments of II, III, IVb and V of the liver, as for lesions located in the posterosuperior segments of I, IVa, VII and VIII is challenging but has become more practical recently due to progress in operative techniques.

METHODS

A systematic review and meta-analysis was conducted to evaluate the safety and efficacy of LH and OH patients with tumors located in posterosuperior segments. The primary sources of the reviewed studies through April 2018, with restriction on the language of English, were Pubmed and Embase.

RESULTS

A total of 5 studies qualified for inclusion in this quantified meta-analysis with a total of 647 patients. LH was associated with significantly less overall complication (OR = 0.43, 95%CI: 0.28-0.65; P < 0.0001, I² = 0%) and non-significantly less severe complication significantly (P = 0.06) compared with OH. Shorter length of hospital stay of 2.08day (95%CI: -3.68day to -0.49day; P = 0.01, I² = 81%) was observed in LH. As for mortality, transfusion, R0 resection, tumor-free margin and operative time the pooled outcomes were comparable. Long-term survivals were similar between LH and OH for the posterosuperior segments.

CONCLUSION

Laparoscopic hepatectomy could be the preferred option for posterosuperior segments for selected patients. Future well designed and large studies should focus on the impacts of underlined liver chronic diseases such as cirrhosis on patient prognosis.

Efficacy and safety of anatomic resection versus nonanatomic resection in patients with hepatocellular carcinoma: A systemic review and meta-analysis

BACKGROUND

The surgical decision of performing anatomic resection (AR) or nonanatomic resection (NAR) in patients with hepatocellular carcinoma remains controversial. The aim of the current study is to conduct a meta-analysis on published results to compare surgical outcomes after AR and NAR.

METHODS

A comprehensive search of the Pubmed, Ovid-Medline, Embase, Cochrane library, and Science Citation indexes was performed. Overall and disease free survival (DFS), perioperative mortality and morbidity were the main outcomes. The meta-analysis was performed using Revman 5.3 statistical software, and the results are expressed as the relative risk (RR) or weighted mean differences with 95% of confidence intervals.

RESULTS

After application of the exclusion and inclusion criteria, 25 studies published between 1996~2015 that compared outcomes after AR and NAR in patients with HCC were identified. A total of 10216 patients were included in the meta-analysis, 4576 in the AR group and 5640 in the NAR group. Liver cirrhosis was found in 54.8% (range from 18.8% to 100%) of patients in the AR group and 67.8% (range from 34.3% to 100%) of patients in the NAR group, resulting in a RR of 0.45 (I2 = 18%, fixed model, 95% CI 0.39-0.52; Z = 10.31; P = <0.00001). The meta-analysis revealed a statistically significant 5-year survival (RR of 1.10, 95% CI 1.03-1.17; Z = 2.92, P = 0.004) and DFS (RR: 1.33, 95% CI 1.18-1.51; Z = 4.46, P <0.00001) advantage for patients undergoing AR resection compared to NAR. In regards to safety, no statistical significance was found in mortality and morbidity between the two groups. Eight studies including 1812 patients with small (<5 cm) solitary HCC indicated a better 5-year DFS in the AR group (41.4%) than in the NAR group (28.6%), with a RR of 1.32 (I2 = 42, fixed model, 95%CI: 1.15-1.52, Z = 3.86, P = 0.0001).

CONCLUSION

The current study demonstrates better surgical outcomes after AR than NAR in patients with HCC. Therefore, AR is recommended in resectable HCC, especially with small (<5 cm) solitary tumours.

Laparoscopic liver resection of hepatocellular carcinoma located in segments 7 or 8

BACKGROUND

Many centers consider hepatocellular carcinoma (HCC) located in segments 7 or 8 to be unsuitable for laparoscopic liver resection (LLR). We evaluated the safety of LLR of HCC in segments 7 or 8 following the introduction of new laparoscopic techniques.

METHODS

This retrospective study included 104 patients who underwent LLR (n = 46) or open liver resection (OLR) (n = 58) for HCC located in segments 7 or 8 between October 2004 and June 2015. The LLR group was subdivided into two subgroups according to whether LLR was performed before (Lap1; n = 29) or after (Lap2; n = 17) the introduction of the Pringle maneuver, intercostal trocars, and semi-lateral patient positioning.

RESULTS

Non-anatomical resection was more frequent (63.0 vs. 29.3%; P < 0.001) and tumor size was smaller (2.8 vs. 4.7 cm; P < 0.001) in the LLR group than in the OLR group. Blood transfusion (P = 0.526), operation time (P = 0.267), postoperative complications (P = 0.051), and resection margin (P = 0.705) were similar in both groups. LLR was associated with less blood loss (550 vs. 700 ml, P = 0.030) and shorter hospital stay (8 vs. 10 days; P = 0.001). The 3-year overall (90.2 vs. 81.2%, P = 0.096) and disease-free survival (15.1 vs. 12.1%; P = 0.857) rates were similar in both groups. The Lap2 group has less blood loss (230 vs. 500 ml; P = 0.005) and shorter hospital stay (7 vs. 9 days; P = 0.038) compared with the Lap1 group.

CONCLUSION

LLR can be safely performed for HCC located in segments 7 or 8 with recent improvements in surgical techniques and accumulated experience.

Segmentectomy: is minimally invasive surgery going to change a liver dogma?

Nowadays, the respective approach to hepatic resections (for malignant or benign liver lesions) is oriented toward minimal parenchymal resection. This surgical behavior is sustained by several observations that surgical margin width is not correlated with recurrence of malignancies. Parenchymal-sparing resection reduces morbidity without changing long-term results and allows the possibility of re-do liver resection in case of recurrence. Minimally invasive liver surgery (MILS) is performed worldwide and is considered a standard of care for many surgical procedures. MILS is associated with less blood loss, less analgesic requirements, and shorter length of hospital with a better quality of life. One of the more frequent criticisms to MILS is that it represents a more challenging approach for anatomical segmentectomies and that in most cases a non-anatomical resection could be performed with thinner resection margins compared with open surgery. But even in the presence of reduced surgical margins, oncological results in the short- and long-term follow-up seem to be the same such as open surgery. The purpose of this review is to try to understand whether chasing at any cost laparoscopic anatomical segmentectomies is still necessary whereas non-anatomical resections, with a parenchymal-sparing behavior, are feasible and overall recommended also in a laparoscopic approach. The message coming from this review is that MILS is opening more and more new frontiers that are still need to be supported by further experience.