Transumbilical single-incision laparoscopic hepatectomy using precoagulation and clipless technique in a patient with combined hepatocellular-cholangiocarcinoma: a case report. Surg Laparosc Endosc Percutan Tech. 2013;23:e194-e199. [PMID: 24105295 DOI: 10.1097/sle.0b013e31828b8602]

New Bipolar Electrosurgical Vessel Sealing Device Provides Improved Performance and Procedural Efficiency

Purpose

This study compared the performance of the new LigaSure™ XP Maryland Jaw Sealer/Divider (XP Maryland) to that of LigaSure Atlas™ (Atlas) and LigaSure™ Dolphin Tip (Dolphin Tip), two early LigaSure™ (LigaSure) devices characterized by consistent and reliable clinical performance.

Methods

Ex vivo bench testing on porcine renal arteries compared burst pressures, seal times, and rates of sticking, incomplete cuts, and charring between XP Maryland and Atlas and between XP Maryland and Dolphin Tip. In vivo acute testing on a porcine model compared thermal spread, seal times, and rates of hemostasis, sticking, and incomplete cuts between XP Maryland and the two early LigaSure devices.

Results

Ex vivo, XP Maryland showed a significantly faster mean seal time compared to Dolphin Tip (P < 0.0001) and Atlas (P < 0.0001). XP Maryland had fewer incomplete cuts than Dolphin Tip (P < 0.0001) and fewer sticking incidents than Atlas (P = 0.0019). Atlas had a statistically higher average burst pressure compared to XP Maryland (P < 0.0001). As with ex vivo results, XP Maryland had a significantly faster mean seal time in vivo compared to Dolphin Tip (P = 0.0168) and Atlas (P < 0.0001). Other in vivo results showed XP Maryland had fewer incomplete cuts compared to Dolphin Tip (P < 0.0001) and statistically less lateral thermal spread than Atlas (P = 0.0010). For all other ex vivo and in vivo performance characteristics, no statistically significant differences were found between XP Maryland and the other devices.

Conclusion

The study demonstrated the consistent and reliable performance of XP Maryland and the two early LigaSure devices. In addition, the studies showed XP Maryland has some improved performance characteristics when compared to Atlas and Dolphin Tip that may result in improved procedural efficiency and may reduce potential surgical risks.

Single incision laparoscopic surgery for hepatocellular carcinoma

Single incision laparoscopic liver resection (SILLR) is the most recent development in the laparoscopic approach to the liver. SILLR for hepatocellular carcinoma (HCC) has developed much more slowly than multiport LLR. So far, 195 patients completed SILLR for HCC. In this paper, we reviewed all published papers about SILLR for HCC and discussed the feasibility of the SILLR, peri and postoperative findings, tricks of patient selection and whether SILLR compromise the oncological principles.

The Current Role of Single-Site Robotic Approach in Liver Resection: A Systematic Review

BACKGROUND

Liver resection is a critical surgical procedure for treating various hepatic pathologies. Minimally invasive approaches have gradually gained importance, and, in recent years, the introduction of robotic surgery has transformed the surgical landscape, providing potential advantages such as enhanced precision and stable ergonomic vision. Among robotic techniques, the single-site approach has garnered increasing attention due to its potential to minimize surgical trauma and improve cosmetic outcomes. However, the full extent of its utility and efficacy in liver resection has yet to be thoroughly explored.

METHODS

We conducted a comprehensive systematic review to evaluate the current role of the single-site robotic approach in liver resection. A detailed search of PubMed was performed to identify relevant studies published up to January 2024. Eligible studies were critically appraised, and data concerning surgical outcomes, perioperative parameters, and post-operative complications were extracted and analyzed.

RESULTS

Our review synthesizes evidence from six studies, encompassing a total of seven cases undergoing robotic single-site hepatic resection (SSHR) using various versions of the da Vinci© system. Specifically, the procedures included five left lateral segmentectomy, one right hepatectomy, and one caudate lobe resection. We provide a summary of the surgical techniques, indications, selection criteria, and outcomes associated with this approach.

CONCLUSION

The single-site robotic approach represents an option among the minimally invasive approaches in liver surgery. However, although the feasibility has been demonstrated, further studies are needed to elucidate its optimal utilization, long-term outcomes, and comparative effectiveness against the other techniques. This systematic review provides valuable insights into the current state of single-site robotic liver resection and underscores the need for continued research in this rapidly evolving field.

Single-incision laparoscopic surgery to treat hepatopancreatobiliary cancer: A technical review

Single-incision laparoscopic surgery (SILS), or laparoendoscopic single-site surgery, was launched to minimize incisional traumatic effects in the 1990s. Minor SILS, such as cholecystectomies, have been gaining in popularity over the past few decades. Its application in complicated hepatopancreatobiliary (HPB) surgeries, however, has made slow progress due to instrumental and technical limitations, costs, and safety concerns. While minimally invasive abdominal surgery is pushing the boundaries, advanced laparoscopic HPB surgeries have been shown to be comparable to open operations in terms of patient and oncologic safety, including hepatectomies, distal pancreatectomies (DP), and pancreaticoduodenectomies (PD). In contrast, advanced SILS for HPB malignancy has only been reported in a few small case series. Most of the procedures involved minor liver resections and DP; major hepatectomies were rarely described. Single-incision laparoscopic PD has not yet been reported. We herein review the published SILS for HPB cancer in the literature and our three-year experience focusing on the technical aspects.

Long-term outcomes of laparoscopic versus open liver resection for intrahepatic combined hepatocellular-cholangiocarcinoma with propensity score matching

Background

Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is a rare primary hepatic neoplasm. Currently, there are no well-structured studies that analyze the feasibility of laparoscopic liver resection in cHCC-CCA alone. This retrospective cohort study aimed to compare the long-term survival of laparoscopic liver resection with open liver resection in cHCC-CCA.

Methods

Patients with a postoperative pathologic report of cHCC-CCA who underwent liver resection from August 2004 to December 2017 were included in this study. Kaplan-Meier survival analysis was performed to analyze the 3-y disease-free survival and 3-y overall survival. Propensity score matching was done to reduce the influence of confounding variables.

Results

A total of 145 patients were pathologically confirmed to have cHCC-CCA, of which 10 patients were excluded due to having received palliative surgery. Of the remaining 135 patients, 43 underwent laparoscopic and 92 underwent open liver resection; propensity score matching yielded 30 patients for each group. The 3-y overall survival was 38 (88.4%) in the laparoscopic group and 84 (91.3%) in the open group before propensity score matching (P = .678), and 25 (83.3%) and 28 (93.3%), respectively, after matching (P = .257). The 3-y disease-free survival was 24 (55.8%) in the laparoscopic group and 32 (34.8%) in the open group before matching (P = .040), and 17 (56.7%) and 16 (53.3%), respectively, after matching (P = .958). The hospital stay was shorter in the laparoscopic group before and after matching, while other operative outcomes were similar in both groups.

Conclusion

Laparoscopic liver resection for cHCC-CCA is technically feasible and safe, having a shorter hospital stay without compromising oncological outcomes.

Feasibility of Solo Single-Incision Laparoscopic Surgery in Non-anatomical Minor Liver Resection: a Propensity Score-Matched Analysis

BACKGROUND

We introduced solo surgery using a laparoscopic scope holder to wide an operator's activity range and reduce instrument crowding and clashing in single incisional surgery. This study aimed to compare the surgical outcomes of solo single-incision laparoscopic surgery (SILS) and conventional multiport laparoscopic surgery (MULS) for hepatocellular carcinoma (HCC).

METHODS

Among 477 consecutive patients between January 2004 and December 2017, 214 patients were included. To overcome selection bias, we performed 1:1 match using propensity score matching between SILS and MULS. Baseline characteristics, operative outcomes, and postoperative complications were compared.

RESULTS

No significant differences in baseline characteristics and pathologic features were found between the two groups. Operation time, estimated blood loss, and postoperative major complication were not significantly different (119.0 min vs 141.6 min, p = 0.275; 200.0 mL min vs 373.3 min, p = 0.222; 0 vs 0, p = 1.000). However, postoperative hospital stay was significantly shorter in SILS (2.73 days vs 7.67 days, p = 0.005).

CONCLUSIONS

Solo SILS had comparable postoperative complications and feasibility in the aspect of operation time and hospital stay compared with conventional MULS for a favorable located single HCC.

Is Single-Incision Laparoscopic Liver Surgery Safe and Efficient for the Treatment of Malignant Hepatic Tumors? A Systematic Review

PURPOSE

The objective of this review was to evaluate the safety and efficiency of single-incision laparoscopic liver surgery (SILLS) for malignant liver lesions.

METHODS

A retrospective review of the Medline database was performed, including studies published up to February 2019.

RESULTS

Overall, 69 patients (50 males) with a median age of 61 years (range, 31-90) from 16 studies underwent SILLS for malignant liver disease and were included in this review. The majority of patients underwent resection for hepatocellular carcinoma (n = 52, 75 %), followed by metastatic disease (n = 15, 22 %). The hepatic lesions were located in anterolateral liver segments in 62 patients (90 %) and in posterosuperior liver segments in 7 patients (10 %). Sixty-five patients (94 %) underwent minor liver resection. The median blood loss was 200 mL (range 0-2500), while 4 patients that underwent single-port resection were converted to either conventional laparoscopy or open resections. Two cases were reported to be associated with postoperative complications in the single-port group (1 [1.7 %] grade Dindo-Clavien I-II, 1 [1.7 %] grade Dindo-Clavien III-IV), while no complications were noted in the multiport group. All patients successfully underwent R0 resection.

CONCLUSIONS

SILLS seems to be a safe and efficient treatment modality for malignant liver disease when performed by experienced surgeons in carefully selected patients. More studies are needed to better identify which patients may benefit from such an operative approach.

The Role of the Single Incision Laparoscopic Approach in Liver and Pancreatic Resectional Surgery

Introduction. Single incision laparoscopic surgery (SILS) has gained increasing support over the last few years. The aim of this narrative review is to analyse the published evidence on the use and potential benefits of SILS in hepatic and pancreatic resectional surgery for benign and malignant pathology. Methods. Pubmed and Embase databases were searched using the search terms "single incision laparoscopic", "single port laparoscopic", "liver surgery", and "pancreas surgery". Results. Twenty relevant manuscripts for liver and 9 for pancreatic SILS resections were identified. With regard to liver surgery, despite the lack of comparative studies with other minimal invasive techniques, outcomes have been acceptable when certain limitations are taken into account. For pancreatic resections, when compared to the conventional laparoscopic approach, SILS produced comparable results with regard to intra- and postoperative parameters, including length of hospitalisation and complications. Similarly, the results were comparable to robotic pancreatectomies, with the exception of the longer operative time reported with the robotic approach. Discussion. Despite the limitations, the published evidence supports that SILS is safe and feasible for liver and pancreatic resections when performed by experienced teams in the tertiary setting. However, no substantial benefit has been identified yet, especially compared to other minimal invasive techniques.

Application of stapling devices in liver surgery: Current status and future prospects

The liver is a vascular-rich solid organ. Safe and effective dissection of the vessels and liver parenchyma, and control of intraoperative bleeding are the main concerns when performing liver resection. Several studies have confirmed that intraoperative blood loss and postoperative transfusion are predictors of postoperative morbidity and mortality in liver surgery. Various methods and instruments have been developed during hepatectomy. Stapling devices are crucial for safe and rapid anastomosis. They are used to divide hepatic veins and portal branches, and to transect liver parenchyma in open liver resection. In recent years, laparoscopic liver surgery has developed rapidly, and is now preferred by many surgeons. Stapling devices have also been gradually introduced in laparoscopic liver surgery, from dividing vascular and biliary structures to parenchymal transection. This may be because staplers make manipulation more simple, rapid and safe. Even in single incision laparoscopic surgery, which is recognized as a new minimally invasive technique, staplers are also utilized, especially in left lateral hepatectomy. For safe application of stapling devices in liver surgery, more related designs and modifications, such as application of a suitable laparoscopic articulating liver tissue crushing device, a staple line reinforcement technique with the absorbable polymer membrane or radiofrequency ablation assistance, are still needed. More randomized studies are needed to demonstrate the benefits and find broader indications for the use of stapling devices, to help expand their application in liver surgery.

Single port laparoscopic liver surgery: A minireview

Nowadays, the trend is to perform surgeries with "scarless" incisions. In light of this, the single-port laparoscopic surgery (SPLS) technique is rapidly becoming widespread due to its lack of invasiveness and its cosmetic advantages, as the only entry point is usually hidden in the umbilicus. The interest in "scarless" liver resections did not grow as rapidly as the interest in other scarless surgeries. Hepatopancreatobiliary surgeons are reluctant to operate a malignant lesion through a narrow incision with limited exposure. There are concerns over adverse oncological outcomes for single-port laparoscopic liver resections (SPL-LR) for hepatocellular carcinoma or metastatic colorectal cancer. In addition, getting familiar with using the operating instruments through a narrow incision with limited exposure is very challenging. In this article, we reviewed the published literature to describe history, indications, contraindications, ideal patients for new beginners, technical difficulty, advantages, disadvantages, oncological concern and the future of SPL-LR.

Thermal tissue change induced by a microwave surgical instrument in a rat hepatectomy model

BACKGROUND

Microwaves exhibit great potential in tissue heating, which causes effective coagulation. Using this energy, we have developed the microwave coagulation surgical instrument (MWCX) for clinical application. Here, we characterized the impact of MWCX on tissues including heating property, tissue change, and spread of thermal injury.

METHODS

Hepatectomy was performed with MWCX using a rat model. The resections were completed using various energy levels and powers. Tissue temperature during radiation was recorded. Tissue change and lateral thermal injury (LTI) was assessed immediately, 7 days, 3 months, and 6 months after resection.

RESULTS

All cutting and hemostasis procedures were successfully accomplished. Major histologic findings consisted of deformation or destruction of hepatocytes, tissue edema, and peripheral hemorrhage. At various energy levels, 200 to 1000 J, the tissue was heated up to approximately 80°C to 140°C causing 2.7- to 6.5-mm LTI on the 7th day. LTI was then decreased gradually in the following term. At certain energy levels, the application of neither 20 W nor 40 W induced significant difference in both heating and LTI.

CONCLUSIONS

MWCX achieved effective tissue coagulation with relevant tissue injury, and it should be a good candidate for clinical application.

Laparoscopic hepatectomy: Recent advances and current thought

The development of laparoscopic hepatectomy is rapid in recent years. Preliminary clinical studies have shown that the postoperative morbidity of laparoscopic hepatectomy has no significant difference compared with open hepatectomy. Laparoscopic hepatectomy has many advantages such as minimal invasiveness, faster recovery and less impairment to immune function. Both the short- and long-term effects of laparoscopic hepatectomy for liver cancer patients are similar to those of open hepatectomy. There are still many issues worthy of discussion about laparoscopic hepatectomy due to the clinical and pathological features of liver cancer such as how to evaluate patients' condition preoperatively, how to follow the principle of intraoperative non-tumor touch, how to locate the tumor within the liver parenchyma, how to optimize the surgical approach, and how to control bleeding. It is anticipated that laparoscopic hepatectomy will be more widely used once these issues are resolved.

What is the best technique in parenchymal transection in laparoscopic liver resection? Comprehensive review for the clinical question on the 2nd International Consensus Conference on Laparoscopic Liver Resection

The continuing evolution of technique and devices used in laparoscopic liver resection (LLR) has allowed successful application of this minimally invasive surgery for the treatment of liver disease. However, the type of instruments by energy sources and technique used vary among each institution. We reviewed the literature to seek the best technique for parenchymal transection, which was proposed as one of the important clinical question in the 2nd International Consensus Conference on LLR held on October 2014. While publications have described transection techniques used in LLR from 1991 to June 2014, it is difficult to specify the best technique and device for laparoscopic hepatic parenchymal transection, owing to a lack of randomized trials with only a small number of comparative studies. However, it is clear that instruments should be used in combination with others based on their functions and the depth of liver resection. Most authors have reported using staplers to secure and divide major vessels. Preparation for prevention of unexpected hemorrhaging particularly in liver cirrhosis, the Pringle's maneuver and prompt technique for hemostasis should be performed. We conclude that hepatobiliary surgeons should select techniques based on their familiarity with a concrete understanding of instruments and individualize to the procedure of LLR.

Transumbilical glove port: A cost-effective method for single-incision laparoscopic hepatectomy

Objectives:

Emerging concepts of “reduced port surgery” have gained considerable attention from laparoscopic surgeons, including the field of liver resection. To date, 86 cases of single-incision laparoscopic hepatectomy (SILH) have been reported, with commercially available access devices being used in most of these cases. We report herein a use of homemade transumbilical glove port for SILH.

Methods:

A 39-year-old woman represented giant hepatic hemangioma (9-cm in size) located at the left lateral segment (S2/3). Partial hepatectomy was performed by the glove method via single port access with conventional laparoscopic bipolar forceps, grasper and scissors without the need of any single-port specific devices.

Results:

The operative time was 77 minutes, and intraoperative blood loss was 50 mL. The postoperative course was uneventful.

Conclusions:

Glove method not only has significant advantages in terms of cost, but also is superior in its versatility, allowing wider range of movements compared to conventional access devices. Taking in consideration its cost effectiveness and versatility, glove method may be a good option for SILH.