Laparoscopic hepatectomy, a systematic review

Laparoscopic and Robot-Assisted Hepatic Surgery: An Historical Review

Hepatic surgery is a rapidly expanding component of abdominal surgery and is performed for a wide range of indications. The introduction of laparoscopic cholecystectomy in 1987 was a major change in abdominal surgery. Laparoscopic surgery was widely and rapidly adopted throughout the world for cholecystectomy initially and then applied to a variety of other procedures. Laparoscopic surgery became regularly applied to hepatic surgery, including segmental and major resections as well as organ donation. Many operations progressed from open surgery to laparoscopy to robot-assisted surgery, including colon resection, pancreatectomy, splenectomy thyroidectomy, adrenalectomy, prostatectomy, gastrectomy, and others. It is difficult to prove a data-based benefit using robot-assisted surgery, although laparoscopic and robot-assisted surgery of the liver are not inferior regarding major outcomes. When laparoscopic surgery initially became popular, many had concerns about its use to treat malignancies. Robot-assisted surgery is being used to treat a variety of benign and malignant conditions, and studies have shown no deterioration in outcomes. Robot-assisted surgery for the treatment of malignancies has become accepted and is now being used at more centers. The outcomes after robot-assisted surgery depend on its use at specialized centers, the surgeon's personal experience backed up by extensive training and maintenance of international registries. Robot-assisted hepatic surgery has been shown to be associated with slightly less intraoperative blood loss and shorter hospital lengths of stay compared to open surgery. Oncologic outcomes have been maintained, and some studies show higher rates of R0 resections. Patients who need surgery for liver lesions should identify a surgeon they trust and should not be concerned with the specific operative approach used. The growth of robot-assisted surgery of the liver has occurred in a stepwise approach which is very different from the frenzy that was seen with the introduction of laparoscopic cholecystectomy. This approach allowed the identification of areas for improvement, many of which are at the nexus of engineering and medicine. Further improvements in robot-assisted surgery depend on the combined efforts of engineers and surgeons.

The cost-effectiveness analysis of laparoscopic hepatectomy compared with open liver resection in the early stage of hepatocellular carcinoma: a decision-analysis model in Thailand

BACKGROUND

Laparoscopic liver resection is increasing operate. In the early stage of hepatocellular carcinoma (HCC), many studies supported that laparoscopic liver resection was a safe procedure and showed some clinical benefits. However, the full economic evaluation has not been fully investigated.

METHODS

A hybrid model of decision tree and Markov state transition model was constructed. Health outcomes were life-year gained (LYs), and quality-adjusted life years (QALYs). A deterministic sensitivity analysis was performed and a probabilistic sensitivity analysis was conducted by 1,000 micro-simulation. The incremental cost-effectiveness ratio (ICER) was reported and the willingness to pay (WTP) was defined at 160,000 THB per QALY gained.

RESULTS

Laparoscopic liver resection in the early stage of HCC was not cost-effective. In the base-case analysis, the total lifetime cost of laparoscopic approach was an average of 413,377 THB (US$13,214) higher than open approach by 55,474 THB (US$1,773) with a small QALY gained. The resulting ICER was 1,356,521 THB (US$43,362) per QALY gained.

CONCLUSION

Laparoscopic liver resection is not considered as a cost-effective alternative to open liver surgery in the early stage of HCC. In the Thai healthcare perspective, the results from this study may inform policymakers for the future policy implementation and healthcare resource allocation.

Robotic major liver resections: Surgical outcomes compared with open major liver resections

Backgrounds/Aims

Laparoscopic major liver resections are still considered innovative procedures despite the recent development of laparoscopic liver surgery. Robotic surgery has been introduced as an innovative system for laparoscopic surgery. In this study, we investigated surgical outcomes after major liver resections using robotic systems.

Methods

From January 2009 to October 2018, 70 patients underwent robotic major liver resections, which included conventional major liver resections and right sectionectomy. The short-term and long-term outcomes were compared with 252 open major resections performed during the same period.

Results

Operative time was longer in the robotic group (472 min vs. 349 min, p<0.001). However, estimated blood loss was lower in the robotic group compared with the open resection group (269 ml vs. 548 ml, p=0.009). The overall postoperative complication rate of the robotic group was lower than that of the open resection group (31.4% vs. 58.3%, p<0.001), but the major complication rate was similar between the two groups. Hospital stay was shorter in the robotic group (9.5 days vs. 15.1 days, p=0.006). Among patients with HCC, cholangiocarcinoma, and colorectal liver metastasis, there was no difference in overall and disease-free survival between the two groups. After propensity score matching in 37 patients with HCC for each group, the robotic group still showed a shorter hospital stay and comparable long-term outcomes.

Conclusions

Robotic major liver resections provided improved perioperative outcomes and comparable long-term oncologic outcome compared with open resections. Therefore, robotic surgery should be considered one of the options for minimally invasive major liver resections.

Emergency laparoscopic resection of spontaneous rupture of hepatocellular carcinoma: A case report

INTRODUCTION

Laparoscopic liver resection is currently performed as a therapeutic modality in hepatocellular carcinoma (HCC). In an emergency setting such as bleeding or rupture, however it has not been well documented.

PRESENTATION OF CASE

We describe a 55-year-old lady who presented to the emergency department with epigastric pain and symptoms of anaemia for one day duration. She was normotensive but tachycardic. Blood investigations revealed haemoglobin level of 6.5 g/dL and serum alpha-fetoprotein of 3136 g/dL. Contrast enhanced computed tomography scan revealed ruptured HCC of segment 2 and 3. She underwent emergency laparoscopic resection of the ruptured HCC. The postoperative recovery was uneventful and she was discharged well on postoperative day 7. Histology confirmed a 10 cm ruptured HCC with 3 mm tumour-free resection margin.

DISCUSSION

Ruptured HCC is associated with a high mortality rate of 25-75 %. Traditional treatment involves initial stabilization and hemostasis through transarterial embolization followed by staged hepatic resection. However, laparoscopic liver resection has been shown to be superior than open surgery in terms of postoperative outcomes.

CONCLUSION

Laparoscopic resection of bleeding HCC is achievable and can be considered in the treatment algorithm of selected patients.

Laparoscopic Versus Open Hepatic Resection for Solitary Hepatocellular Carcinoma Less Than 5 cm in Cirrhotic Patients: A Randomized Controlled Study

BACKGROUND

Current literature is lacking level 1 evidence for surgical and oncologic outcomes of hepatocellular carcinoma (HCC) undergoing laparoscopic versus open hepatectomy. Aim was to compare feasibility, safety, and surgical and oncologic efficiency of laparoscopic versus open liver resection (OLR) in management of solitary small (<5 cm) peripheral HCC in Child A cirrhotic patients.

METHODS

Patients were randomly assigned to either OLR group (25 patients) or laparoscopic liver resection (LRR) group (LRR: 25 patients). All were treated with curative intent aiming at achieving R0 resection using radiofrequency-assisted technique.

RESULTS

LLR had significantly less operative time (120.32 ± 21.58 versus 146.80 ± 16.59 minutes, P < .001) and shorter duration of hospital stay (2.40 ± 0.58 versus 4.28 ± 0.79 days, P < .001), with comparable overall complications (25 versus 28%, P = .02). LLR had comparative resection time (66.56 ± 23.80 versus 59.56 ± 14.74 minutes, P = .218), amount of blood loss (250 versus 230 mL, P = .915), transfusion rate (P = 1.00), and R0 resection rate when compared with OLR. After median follow-up of 34.43 (31.67-38.60) months, LLR achieved similar adequate oncological outcome of OLR, no local recurrence, with no significant difference in early recurrence or number of de novo lesions (P = .49). One-year and 3-year disease free survival (DFS) rates, 88% and 59%, in the LLR were comparable to corresponding rates of 84% and 54% in OLR (P = .9).

CONCLUSION

LLR is superior to the OLR with significantly shorter duration of hospital stay and does not compromise the oncological outcomes.

The Effectiveness of a Systematic Algorithm for the Management of Vascular Injuries during the Laparoscopic Surgery

OBJECTIVES

Currently, there is no standardized training protocol to teach surgeons how to deal with vascular injuries during laparoscopic procedures. The purpose of this study is to develop and evaluate the effectiveness of a standardized algorithm for managing vascular injury during laparoscopic nephrectomies.

MATERIALS AND METHODS

The performance of 6 surgeons was assessed during 10 laparoscopic nephrectomies in a porcine model. During the first and tenth operations, an injury was made in the renal vein without warning the surgeon. After the first procedure, the surgeons were instructed on how to proceed in dealing with the vascular injury, according to an algorithm developed by the designers of this study. The performance of each surgeon before and after learning the algorithm was assessed.

RESULTS

After learning the algorithm there was a decreased blood loss from 327 ± 403.11 ml to 37 ± 18.92 ml (p = 0.031) and decreased operative time from 43 ± 14.53 min to 27 ± 8.27 min (p = 0.015). There was also improvement in the time to start lesion repair from 147 ± 117.65 sec to 51 ± 39.09 sec (p = 0.025). There was a trend toward improvement in the reaction time to the injury (22 ± 21.55 sec vs. 14 ± 6.39, p = 0.188), the time required to control the bleeding (50 ± 94.2 sec vs. 14 ± 6.95 sec, p = 0.141), and the total time required to completely repair of the vascular injury (178 ± 170.4 sec vs. 119 ± 183.87 sec, p = 0.302).

CONCLUSION

A standardized algorithm may help to reduce the potential risks associated with laparoscopic surgery. Further studies will help to refine and determine the benefits of standardized protocols such as that developed in this study for the management of life-threatening laparoscopic complications.

Long-term survival in laparoscopic vs open resection for colorectal liver metastases: inverse probability of treatment weighting using propensity scores

BACKGROUND

This study compares long-term outcomes between intention-to-treat laparoscopic and open approaches to colorectal liver metastases (CLM), using inverse probability of treatment weighting (IPTW) based on propensity scores to control for selection bias.

METHOD

Patients undergoing liver resection for CLM by 5 surgeons at 3 institutions from 2000 to early 2014 were analysed. IPTW based on propensity scores were generated and used to assess the marginal treatment effect of the laparoscopic approach via a weighted Cox proportional hazards model.

RESULTS

A total of 298 operations were performed in 256 patients. 7 patients with planned two-stage resections were excluded leaving 284 operations in 249 patients for analysis. After IPTW, the population was well balanced. With a median follow up of 36 months, 5-year overall survival (OS) and recurrence-free survival (RFS) for the cohort were 59% and 38%. 146 laparoscopic procedures were performed in 140 patients, with weighted 5-year OS and RFS of 54% and 36% respectively. In the open group, 138 procedures were performed in 122 patients, with a weighted 5-year OS and RFS of 63% and 38% respectively. There was no significant difference between the two groups in terms of OS or RFS.

CONCLUSION

In the Brisbane experience, after accounting for bias in treatment assignment, long term survival after LLR for CLM is equivalent to outcomes in open surgery.

The laparoscopic liver resections-an initial experience and the literature review

The laparoscopic liver resection (LLR) represents a new pathway in hepatic surgery. Several studies have reported its application in both malignant and benign liver diseases. The most common liver resections performed laparoscopically are wedge, segmental resections and metastasectomy; although in large centers the laparoscopic right and left hepatectomies have begun to perform more frequently. We report the initial experience in LLRs at our department including a case of the first laparoscopic left lateral liver bisegmentectomy performed in patient with follicular nodular hyperplasia and the 15 cases of wedge laparoscopic resections of echinococcic liver cysts. According to literature the mortality rate in LLRs is up to 0.3% and morbidity rate up to 10.5%. The most common cause of the death is liver failure, while the most frequent complication is the bile leakage. Advantages for patients include smaller incisions, less blood loss, and shorter lengths of hospital stay. The LLRs in experienced hands were shown to be safe with acceptable morbidity and mortality for both minor and major hepatic resections in benign and malignant diseases.

Laparoscopic left hepatectomy in swine: a safe and feasible technique

A purely laparoscopic four-port approach was created for left hepatectomy in pigs. A polyethylene loop was placed on the left two hepatic lobes for traction and lift. Next, penetrating ligation of the lobes using of a double row of silk sutures was performed to control bleeding. A direct hepatic transection was completed using a monopolar hook electrode without meticulous dissection of the left hepatic vein. The raw surface of the liver was coagulated and sealed with fibrin glue. Lobes were retrieved through an enlarged portal. Laparoscopic hepatic lobectomy was completed in all pigs without the use of specialized instruments and with a mean operative time of 179 ± 9 min. No significant perioperative complications were observed. The average weight of each resected lobe was 180 ± 51 g. Complete blood count as well as serum organics and enzyme levels normalized after about 2 weeks. During necropsy, adhesion of the hepatic raw surface to the gastric wall and omentum were observed. No other abnormalities were identified. This minimally invasive left hepatectomy technique in swine could serve as a useful model for investigating liver diseases and regeneration, and offer preclinical information to improve hepatobiliary surgical procedures.

Laparoscopic approach to gastrointestinal malignancies: toward the future with caution

After the rapid acceptance of laparoscopy to manage multiple benign diseases arising from gastrointestinal districts, some surgeons started to treat malignancies by the same way. However, if the limits of laparoscopy for benign diseases are mainly represented by technical issues, oncologic outcomes remain the foundation of any procedures to cure malignancies. Cancerous patients represent an important group with peculiar aspects including reduced survival expectancy, worsened quality of life due to surgery itself and adjuvant therapies, and challenging psychological impact. All these issues could, potentially, receive a better management with a laparoscopic surgical approach. In order to confirm such aspects, similarly to testing the newest weapons (surgical or pharmacologic) against cancer, long-term follow-up is always recommendable to assess the real benefits in terms of overall survival, cancer-free survival and quality of life. Furthermore, it seems of crucial importance that surgeons will be correctly trained in specific oncologic principles of surgical oncology as well as in modern miniinvasive technologies. Therefore, laparoscopic treatment of gastrointestinal malignancies requires more caution and deep analysis of published evidences, as compared to those achieved for inflammatory bowel diseases, gastroesophageal reflux disease or diverticular disease. This review tries to examine the evidence available to date for the use of laparoscopy and robotics in malignancies arising from the gastrointestinal district.

Current status of robotic liver resection: a systematic review

Robotic surgery is an emerging technique for the management of patients with liver disease, and only a limited number of reports are available. A systematic search of electronic databases (PubMed, Embase and Cochrane), including only case series with more than five patients, identified nine series (with one from our institution), which totaled to 232 patients. Overall, the peri-operative outcomes of the reported patients are similar to those utilizing the laparoscopic and open approaches. Robotic surgery appears to be a valid option for selected hepatic resections in experienced hands. It could represent a bridge toward minimally invasive approaches for confirmed liver surgeons. By contrast, the long-term oncological outcomes remain uncertain and need further studies.

A survey in the hepatopancreatobiliary community on ways to enhance patient recovery

OBJECTIVES

Both laparoscopic techniques and multimodal enhanced recovery programmes have been shown to improve recovery and reduce length of hospital stay. Interestingly, evidence-based care programmes are not widely implemented, whereas new, minimally invasive surgical procedures are often adopted with very little evidence to support their effectiveness. The present survey aimed to shed light on experiences of the adoption of both methods of optimizing recovery.

METHODS

An international, web-based, 18-question, electronic survey was composed in 2010. The survey was sent out to 673 hepatopancreatobiliary (HPB) centres worldwide in June 2010 to investigate international experiences with laparoscopic liver surgery, fast-track recovery programmes and surgery-related equipoise in open and laparoscopic techniques and to assess opinions on strategies for adopting laparoscopic liver surgery in HPB surgical practice.

RESULTS

A total of 507 centres responded (response rate: 75.3%), 161 of which finished the survey completely. All units reported performing open liver resections, 24.2% performed open living donor resections, 39.1% carried out orthotopic liver transplantations, 87.6% had experience with laparoscopic resections and 2.5% performed laparoscopic living donor resections. A median of 50 (range: 2-560) open and 9.5 (range: 1-80) laparoscopic liver resections per surgical unit were performed in 2009. Patients stayed in hospital for a median of 7 days (range: 2-15 days) after uncomplicated open liver resection and a median of 4 days (range: 1-10 days) after uncomplicated laparoscopic liver resection. Only 28.0% of centres reported having experience with fast-track programmes in liver surgery. The majority considered the instigation of a randomized controlled trial or a prospective register comparing the outcomes of open and laparoscopic techniques to be necessary.

CONCLUSIONS

Worldwide dissemination of laparoscopic liver resection is substantial, although laparoscopic volumes are low in the majority of HPB centres. The adoption of enhanced recovery programmes in liver surgery is limited and should be given greater attention.

Enhanced recovery programmes in hepatobiliary and pancreatic surgery: a systematic review

INTRODUCTION

The terms ‘enhanced recovery after surgery’, ‘enhanced recovery programme’ (ERP) and ‘fast track surgery’ refer to multimodal strategies aiming to streamline peri-operative care pathways, to maximise effectiveness and minimise costs. While the results of ERP in colorectal surgery are well reported, there have been no reviews examining if these concepts could be applied safely to hepatopancreatobiliary (HPB) surgery. The aim of this systematic review was to appraise the current evidence for ERP in HPB surgery.

METHODS

A MEDLINE® literature search was undertaken using the keywords ‘enhanced recovery’, ‘fast-track’, ‘peri-operative’, ‘surgery’, ‘pancreas’ and ‘liver’ and their derivatives such as ‘pancreatic’ or ‘hepatic’. The primary endpoint was length of post-operative hospital stay. Secondary endpoints were morbidity, mortality and readmission rate.

RESULTS

Ten articles were retrieved describing an ERP. ERP protocols varied slightly between studies. A reduction in length of stay was a consistent finding following the incorporation of ERP when compared with historical controls. This was not at the expense of increased rates of readmission, morbidity or mortality in any study.

CONCLUSIONS

The introduction of an ERP in HPB surgery appears safe and feasible. Currently, many of the principles of the multimodal pathway are derived from the colorectal ERP and distinct differences exist, which may impede its implementation in HPB surgery.

Laparoscopic hepatectomy is associated with a higher incident frequency in hepatolithiasis patients

PURPOSES

The primary concern regarding laparoscopic hepatectomy in hepatolithiasis patients is surgical safety, which may be high in current practice.

METHODS

Hepatolithiasis patients who underwent laparoscopic and laparotomic hepatectomies were retrospectively studies after being matched for age, location of gallstones, liver resection and underlying liver conditions at a ratio of 1:1 (n = 44 in each group). The rates of intraoperative incidents and postoperative complications were examined using validated classification and grading systems. The primary outcome measure was the procedure-related complication/mortality rate.

RESULTS

Laparoscopy was converted to open surgery in three patients (6.8 %). The length of the operation for laparoscopic hepatectomy was significantly longer than that for laparotomic hepatectomy (277.5 min [range, 190-410 min] vs. 212.5 min [140-315 min], P < 0.001). The two groups had similar intraoperative blood loss (367.5 mL [150-1200 mL] vs. 392.5 mL [200-1400 mL], P > 0.05) and transfusion frequencies (13.6 vs. 18.2 %, P > 0.05). The laparoscopy group had a higher percentage of patients with at least one intraoperative incident compared with the laparotomy group (22.7 vs. 6.8 %; P < 0.05). Vascular events occurred in nine patients (20.5 %) undergoing laparoscopy and two patients (4.5 %) undergoing laparotomy (OR 5.4 [95 %CI, 1.1-26.7], P < 0.05).

CONCLUSIONS

Laparoscopic hepatectomy is associated with a higher risk of intraoperative vascular incidents in hepatolithiasis patients compared wit laparotomy.

The introduction of a laparoscopic liver surgery programme: a cost analysis of initial experience in a university hospital

BACKGROUND AND AIMS

In the era of expanding costs of healthcare, this study was conducted to perform a cost analysis of introducing a laparoscopic liver surgery programme for left sided liver lesions.

MATERIALS AND METHODS

Consecutive patients treated by laparoscopic liver resections of left lateral segments were included. Controls were a group of 14 patients undergoing open resection for similar pathology. Primary outcomes were costs. Secondary outcomes were complications, conversions, blood loss, length of operation, and length of hospital stay.

RESULTS

The laparoscopic approach for hepatic left lateral resection (bisegmentectomy 2 and 3) was performed in fourteen patients (group I, median age 54 [range 26-82] years). In the open group, fourteen patients from a prospectively collected database with the same type of resection were selected (group II, median age 64 [range 29-76] years). Costs of theatre usage in the laparoscopic group were significantly lower (p=0.031). No significant differences in costs of disposable instruments, ward stay and total costs were observed between the two groups. There were three complications in the laparoscopic group compared with two complications in the open group. In the laparoscopic group there were 2 conversions (14%). Median blood loss was significantly lower in the laparoscopic group (50 mls [range 0-750], (p=0.001) versus the open group (500 mls [range 150-750]). Furthermore, operation time was also significantly lower in the laparoscopic group (116 [range 85-261] minutes) versus the open group (165 [range 96-217] minutes, p=0.016). Median length of stay was 6 [range 4-11] days in group I versus 6 [range 5-13] days in group II (p=0.508).

CONCLUSION

Costs of laparoscopic liver resections proved to be equivalent to open surgery. Furthermore, implementation of a laparoscopic liver resection programme seems feasible and safe with reduced blood loss and operation time and comparable morbidity and length of stay.

Open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery ERAS® programme (ORANGE II-trial): study protocol for a randomised controlled trial

Background

The use of lLaparoscopic liver resection in terms of time to functional recovery, length of hospital stay (LOS), long-term abdominal wall hernias, costs and quality of life (QOL) has never been studied in a randomised controlled trial. Therefore, this is the subject of the international multicentre randomised controlled ORANGE II trial.

Methods

Patients eligible for left lateral sectionectomy (LLS) of the liver will be recruited and randomised at the outpatient clinic. All randomised patients will undergo surgery in the setting of an ERAS programme. The experimental design produces two randomised arms (open and laparoscopic LLS) and a prospective registry. The prospective registry will be based on patients that cannot be randomised because of the explicit treatment preference of the patient or surgeon, or because of ineligibility (not meeting the in- and exclusion criteria) for randomisation in this trial. Therefore, all non-randomised patients undergoing LLS will be approached to participate in the prospective registry, thereby allowing acquisition of an uninterrupted prospective series of patients. The primary endpoint of the ORANGE II trial is time to functional recovery. Secondary endpoints are postoperative LOS, percentage readmission, (liver-specific) morbidity, QOL, body image and cosmetic result, hospital and societal costs over 1 year, and long-term incidence of incisional hernias. It will be assumed that in patients undergoing laparoscopic LLS, length of hospital stay can be reduced by two days. A sample size of 55 patients in each randomisation arm has been calculated to detect a 2-day reduction in LOS (90% power and α = 0.05 (two-tailed)).

The ORANGE II trial is a multicenter randomised controlled trial that will provide evidence on the merits of laparoscopic surgery in patients undergoing LLS within an enhanced recovery ERAS programme.

Trial registration

ClinicalTrials.gov NCT00874224.

Laparoscopic approach for treatment of multiple hepatocellular carcinomas

BACKGROUND

The aim of this study is to evaluate clinical and oncologic outcomes after laparoscopic surgery for patients with multiple hepatocellular carcinoma (HCC).

METHODS

Among the 260 patients who underwent laparoscopic procedures, including laparoscopic liver resection and laparoscopic radiofrequency ablation (LRFA), between September 2003 and December 2009, 107 patients with HCC were included in this retrospective study. According to tumor multiplicity, patients were divided into multiple lesion (n = 23) and single lesion (n = 84) groups. We compared the operative outcomes after the laparoscopic procedures between the single and multiple tumor groups.

RESULTS

There was no difference in the clinicopathologic characteristics between the two groups, except the multiple group had more frequent previous history of preoperative transarterial chemoembolization. LRFA was more frequently used in the multiple group as compared with the single group. There was no postoperative mortality in either group. Application of laparoscopic surgery in the multiple group did not increase the operative time, rate of intraoperative transfusion, length of postoperative hospital stay, or postoperative complications, as compared with the single group. After median follow-up of 33.7 months, there was no statistically significant difference of the survival rates between the two groups, although there was a better disease-free survival rate in the single group.

CONCLUSIONS

This study shows that laparoscopic surgery, including LH and LRFA, can be safely applied to patients with multiple HCCs, and the survival outcomes are acceptable.

Laparoscopic resection of colorectal liver metastases: surgical and long-term oncologic outcome

OBJECTIVE

To analyze the immediate and long-term outcome after laparoscopic resection of colorectal liver metastases and difference between observed and predicted [Fong's and Basingstoke Predictive Index (BPI) scores] survivals.

BACKGROUND

: Laparoscopic liver resection has been reported safe and feasible and improves postoperative course. The oncologic outcomes after resection of colorectal metastases are poorly reported.

METHODS

Between August 1998 and January 2010, 122 patients underwent laparoscopic resection for colorectal liver metastases during 135 procedures at Rikshospitalet. Patients undergoing surgery between August 1998 and June 2009 were included in research analysis. The patients had median Fong's and BPI's scores of 2 (0-5) and 7 (0-23), respectively. Mainstream analysis of hospital data was done on intent-to-treat basis. Intraoperative incidents and postoperative complications were analyzed according to the Satava and Clavien-Dindo classifications. Median follow-up was 24 (0-100) months.

RESULTS

One hundred fifty-one liver resections were performed in 107 patients during 118 procedures: 117 nonanatomic and 34 anatomic liver resections. There were 5 conversions to laparotomy (4.2%). The resection margin was free of tumor tissue in 141 (93.4%) of 151 specimens, and the distance between the resection margin and tumor tissue was median 6 (0-40) mm. Intraoperative incidents occurred in 14 cases (11.9%), including 5 (4.2%), 8 (6.8%), and 1 (0.8%) cases of grades I, II, and III, respectively. Postoperative complications were observed in 16 cases (14.3%), including 2, 3, 7, 3, 0, and 1 cases of grades I, II, IIIa, IIIb, IV, and V, respectively. During follow-up, 21 patients received repeat liver resection of recurrences (11 by laparoscopy and 10 by laparotomy). The 5-year overall survival rates were 51% as laparoscopically completed cases and 47% as intent-to-treat. The observed actuarial survival values exceeded the values expected by Fong's and BPI's score, with 10.2% and 6.7% as laparoscopically completed cases and with 3.8% and 2.4% as intent-to-treat, respectively.

CONCLUSIONS

Laparoscopic resection is a favorable alternative to open liver resection for patients with colorectal liver metastases. The observed actuarial survival values after laparoscopic resection surpass the values expected by major scoring systems.

Laparoscopic vs open left hepatectomy for hepatolithiasis

AIM

To explore the feasibility and therapeutic effect of total laparoscopic left hepatectomy (LLH) for hepatolithiasis.

METHODS

From June 2006 to October 2009, 61 consecutive patients with hepatolithiasis who met the inclusion criteria for LLH were treated in our institute. Of the 61 patients with hepatolithiasis, 28 underwent LLH (LLH group) and 33 underwent open left hepatectomy (OLH group). Clinical data including operation time, intraoperative blood loss, postoperative complication rate, postoperative hospital stay time, stone clearance and recurrence rate were retrospectively analyzed and compared between the two groups.

RESULTS

LLH was successfully performed in 28 patients. The operation time of LLH group was longer than that of OLH group (158 +/- 43 min vs 132 +/- 39 min, P < 0.05) and the hospital stay time of LLH group was shorter than that of OLH group (6.8 +/- 2.8 d vs 10.2 +/- 3.4 d, P < 0.01). No difference was found in intraoperative blood loss (180 +/- 56 mL vs 184 +/- 50 mL), postoperative complication rate (14.2% vs 15.2%), and stone residual rate (intermediate rate 17.9% vs 12.1% and final rate 0% vs 0%) between the two groups. No perioperative death occurred in either group. Fifty-seven patients (93.4%) were followed up for 2-40 mo (mean 17 mo), including 27 in LLH group and 30 in OLH group. Stone recurrence occurred in 1 patient of each group.

CONCLUSION

LLH for hepatolithiasis is feasible and safe in selected patients with an equal therapeutic effect to that of traditional open hepatectomy.

Laparoscopic vs open left hepatectomy for hepatolithiasis

AIM: To explore the feasibility and therapeutic effect of total laparoscopic left hepatectomy (LLH) for hepatolithiasis.

METHODS: From June 2006 to October 2009, 61 consecutive patients with hepatolithiasis who met the inclusion criteria for LLH were treated in our institute. Of the 61 patients with hepatolithiasis, 28 underwent LLH (LLH group) and 33 underwent open left hepatectomy (OLH group). Clinical data including operation time, intraoperative blood loss, postoperative complication rate, postoperative hospital stay time, stone clearance and recurrence rate were retrospectively analyzed and compared between the two groups.

RESULTS: LLH was successfully performed in 28 patients. The operation time of LLH group was longer than that of OLH group (158 ± 43 min vs 132 ± 39 min, P < 0.05) and the hospital stay time of LLH group was shorter than that of OLH group (6.8 ± 2.8 d vs 10.2 ± 3.4 d, P < 0.01). No difference was found in intraoperative blood loss (180 ± 56 mL vs 184 ± 50 mL), postoperative complication rate (14.2% vs 15.2%), and stone residual rate (intermediate rate 17.9% vs 12.1% and final rate 0% vs 0%) between the two groups. No perioperative death occurred in either group. Fifty-seven patients (93.4%) were followed up for 2-40 mo (mean 17 mo), including 27 in LLH group and 30 in OLH group. Stone recurrence occurred in 1 patient of each group.

CONCLUSION: LLH for hepatolithiasis is feasible and safe in selected patients with an equal therapeutic effect to that of traditional open hepatectomy.

Open liver resection for colorectal metastases: better short- and long-term outcomes in patients potentially suitable for laparoscopic liver resection

BACKGROUND

There is no prospective randomized data comparing laparoscopic to open hepatectomy. This study compared short- and long-term outcomes in patients undergoing hepatectomy for colorectal metastases (CRM), who were suitable for either laparoscopic or open surgery.

METHODS

Data were prospectively collected from consecutive patients undergoing hepatic resection of CRM at a single centre (1987-2007). Patients who were suitable for laparoscopic resection (Group 1) were compared with patients whose tumour characteristics would best be considered for open resection (Group 2).

RESULTS

Out of 1152 hepatectomies, 266 (23.1%) were deemed suitable for a laparoscopic approach. The median (IQR) number of metastases was greater in Group 2 [2(1-20) vs. 1(1-10), P < 0.001], as was the mean (SD) tumour size [5.3(3.6) cm vs. 3.3(1.2) cm, P < 0.001]. The median (IQR) operation time [210 (70) min vs. 240 (90) min, P < 0.001] and blood loss [270 (265) ml vs. 355 (320) ml, P < 0.001] were less in Group 1. There was no difference in length of stay, morbidity or mortality. Patients in Group 2 had a higher R1 resection rate (14.9%) compared with Group 1 (4.5%, P < 0.001) and lower 5-year survival (37.8% vs. 44.2%, P= 0.005).

DISCUSSION

Current criteria for laparoscopic hepatectomy selects patients who have more straight-forward surgery, with less risk of an involved resection margin and better long-term survival, compared with patients unsuited to a laparoscopic approach. Clearly defined criteria for laparoscopic hepatectomy are essential to allow meaningful analysis of outcomes and the results of unrandomized series of laparoscopic hepatectomies must be interpreted with caution.

Fast track liver resection: the effect of a comprehensive care package and analgesia with single dose intrathecal morphine with gabapentin or continuous epidural analgesia

BACKGROUND

A comprehensive care package for patients undergoing hepatectomy was developed with the aim of minimal physiological disturbance in the peri-operative period. Peri-operative analgesia with few gastrointestinal effects and reduced requirement for intravenous (IV) fluid therapy was central to this plan.

METHODS

Data on 100 consecutive patients managed with continuous epidural infusion (n = 50; bupivicaine 0.125% and fentanyl 2 microg/mL at 0.1 mL/kg/hr) or intrathecal morphine (n = 50; 300 microg in combination with oral gabapentin 1200 mg preoperatively and 400 mg bd postoperatively) was compared.

RESULTS

The epidural and intrathecal morphine groups were equivalent in terms of patient demographics, procedures and complications. Patients receiving intrathecal morphine received less intra-operative IV fluids (median 1500 mL versus 2200 mL, P = .06), less postoperative IV fluids (median 1200 mL versus 4300 mL, P = .03) than patients receiving epidural infusion. Patients managed with intrathecal morphine established a normal dietary intake sooner (16 hours versus 20 hours, P = .05) and had shorter hospital stays than those managed with epidural infusions (4.7 +/- 0.9 days versus 6.8 +/- 1.2 days, P = .02).

CONCLUSIONS

Single dose intrathecal morphine is a safe and effective means of providing peri-operative analgesia. Patients managed with intrathecal morphine have reduced peri-operative physiological disturbance and return home within a few days of hepatic resection.

World review of laparoscopic liver resection-2,804 patients

OBJECTIVE

To provide a review of the world literature on laparoscopic liver resection.

SUMMARY BACKGROUND DATA

Initially described for peripheral, benign tumors resected by nonanatomic wedge resections, minimally invasive liver resections are now being performed more frequently, even for larger, malignant tumors located in challenging locations. Although a few small review articles have been reported, a comprehensive review on laparoscopic liver resection has not been published.

METHODS

We conducted a literature search using Pubmed, screening all English publications on laparoscopic liver resections. All data were analyzed and apparent case duplications in updated series were excluded from the total number of patients. Tumor type, operative characteristics, perioperative morbidity, and oncologic outcomes were tabulated.

RESULTS

A total of 127 published articles of original series on laparoscopic liver resection were identified, and accounted for 2,804 reported minimally invasive liver resections. Fifty percent were for malignant tumors, 45% were for benign lesions, 1.7% were for live donor hepatectomies, and the rest were indeterminate. Of the resections, 75% were performed totally laparoscopically, 17% were hand-assisted, and 2% were laparoscopic-assisted open hepatic resection (hybrid) technique, with the remainder being other techniques or conversions to open hepatectomies. The most common laparoscopic liver resection was a wedge resection or segmentectomy (45%) followed by anatomic left lateral sectionectomy (20%), right hepatectomy (9%), and left hepatectomy (7%). Conversion from laparoscopy to open laparotomy and from laparoscopy to hand-assisted approach occurred in 4.1% and 0.7% of reported cases, respectively. Overall mortality was 9 of 2,804 patients (0.3%), and morbidity was 10.5%, with no intraoperative deaths reported. The most common cause of postoperative death was liver failure. Postoperative bile leak was observed in 1.5% of cases. For cancer resections, negative surgical margins were achieved in 82% to 100% of reported series. The 5-year overall and disease-free survival rates after laparoscopic liver resection for hepatocellular carcinoma were 50% to 75% and 31% to 38.2%, respectively. The 3-year overall and disease-free survival rates after laparoscopic liver resection for colorectal metastasis to the liver were 80% to 87% and 51%, respectively.

CONCLUSION

In experienced hands, laparoscopic liver resections are safe with acceptable morbidity and mortality for both minor and major hepatic resections. Oncologically, 3- and 5-year survival rates reported for hepatocellular carcinoma and colorectal cancer metastases are comparable to open hepatic resection, albeit in a selected group of patients.

Total laparoscopic liver resection in 78 patients

AIM: To summarize the clinical experience of laparoscopic hepatectomy at a single center.

METHODS: Between November 2003 and March 2009, 78 patients with hepatocellular carcinoma (n = 39), metastatic liver carcinoma (n = 10), and benign liver neoplasms (n = 29) underwent laparoscopic hepatectomy in our unit. A retrospective analysis was done on the clinical outcomes of the 78 patients.

RESULTS: The lesions were located in segments I (n = 3), II (n = 16), III (n = 24), IV (n = 11), V (n = 11), VI (n = 9), and VIII (n = 4). The lesion sizes ranged from 0.8 to 15 cm. The number of lesions was three (n = 4), two (n = 8) and one (n = 66) in the study cohort. The surgical procedures included left hemi-hepatectomy (n = 7), left lateral lobectomy (n = 14), segmentectomy (n = 11), local resection (n = 39), and resection of metastatic liver lesions during laparoscopic surgery for rectal cancer (n = 7). Laparoscopic liver resection was successful in all patients, with no conversion to open procedures. Only four patients received blood transfusion (400-800 mL). There were no perioperative complications, such as bleeding and biliary leakage. The liver function of all patients recovered within 1 wk, and no liver failure occurred.

CONCLUSION: Laparoscopic hepatectomy is a safe and feasible operation with minimal surgical trauma. It should be performed by a surgeon with sufficient experience in open hepatic resection and who is proficient in laparoscopy.

Open versus laparoscopic resection for liver tumours

BACKGROUND

The issue under debate is whether laparoscopic liver resections for malignant tumours produce outcomes which are comparable with conventional, open liver resections.

METHODS

Literature review on liver resection and laparoscopy.

RESULTS

There are no randomized controlled trials (RCTs) published that provide any evidence for the benefits of laparoscopic liver resections for liver tumours. In case-control series reporting short-term outcomes, laparoscopic liver resection has been shown to have the advantage of a reduced length of hospital stay. There are as yet, however, no adequate long-term survival studies demonstrating that laparoscopic liver resection is oncologically equivalent to open resection.

DISCUSSION

The challenge for the near future is to test the oncological integrity of laparoscopic liver resection in controlled trials in the same way that we have learned from the RCTs carried out in laparoscopic resection for colorectal cancer. It is likely that laparoscopic liver resection will then have to compete with fast-track, open liver resection. Already, concerns have been raised regarding the learning curve required to master the techniques of laparoscopic liver resection.

Laparoscopic hepatectomy is a safe procedure for cancer patients

BACKGROUND

Utilizing laparoscopy for major surgeries such as hepatectomy is a relatively new concept. Initially, benign pathologies dominated indications for resection. Our experience in an Australian setting with primarily malignant diagnoses is described.

METHODS

A review of patients' profiles, pathology, surgery and outcome was performed on 35 patients between December 2005 and August 2008. Data were collected and analysed retrospectively from medical records on a pre-designed datasheet.

RESULTS

Commonest indication for resection was colorectal metastasis (54%), 71% of all resections were for malignancy. Average operating time was 2 h 31 min (range 30 min-7 h, 15 min). Major morbidity consisted of one bile leak, two subphrenic abscesses and one pulmonary embolus. There were no deaths. Conversion to open was required in 20% and two patients required intra-operative blood transfusions. Average length of stay overall was 6.1 days (range 1-27), but as low as 2 days for some left lateral sectionectomies. Cessation of parenteral analgesia, return to normal diet and full mobility were achieved on average at 2.4, 2.3 and 2.8 days. Significant post-operative liver dysfunction was seen in two patients, which returned to normal by discharge. One patient died of disease progression 4 months after surgery. There were two involved margins in 35 patients (6%).

CONCLUSIONS

Laparoscopic hepatectomy is a developing and safe technique in a select group of patients including those with malignancies, resulting in short hospital stays, rapid return to normal diet, full mobility and minimal morbidity with acceptable oncological parameters. This study is not comparative in nature, but provides evidence to support further investigation and establishment of this new technique for liver resection.

The association between central venous pressure, pneumoperitoneum, and venous carbon dioxide embolism in laparoscopic hepatectomy

BACKGROUND

Laparoscopic hepatectomy (LH) is increasingly used. However, the safety and outcomes of LH have yet to be elucidated. The risk of venous gas embolism is increased during liver parenchymal transection. This risk may be increased with positive pressure carbon dioxide (CO(2)) pneumoperitoneum (PP). This may be exacerbated further when low central venous pressure (CVP) anesthesia is used to minimize hemorrhage during liver resection.

METHODS

To determine the risk of CO(2) venous embolism, hand-assisted laparoscopic left hepatic lobectomy was performed for 26 domestic pigs. They were divided into three groups involving, respectively, positive gradient (normal-pressure PP of 12-14 mmHg and low CVP of 5-7 mmHg), negative gradient (low-pressure PP of 7-8 mmHg and normal CVP of 10-12 mmHg), and neutral gradient (normal-pressure PP and normal CVP or low-pressure PP and low CVP). Transesophageal echocardiography (TEE) was used intraoperatively to assess the presence of emboli in the suprahepatic vena cava and the right side of the heart. The TEE was recorded and analyzed by blinded observers. Carbon dioxide embolism also was monitored using end-tidal CO(2) and compared with TEE.

RESULTS

Carbon dioxide embolism was demonstrated in 19 of the 26 cases. The majority of gas emboli were small gas bubbles associated with dissection of the major hepatic veins. No statistically significant difference in the occurrence of gas emboli was observed between the groups. Of the 19 animals, 18 experienced no significant hemodynamic changes. One pig in the positive gradient group experienced hypotension in relation to gas embolism. The effects were only transient and did not preclude safe completion of the operation.

CONCLUSIONS

Carbon dioxide embolism during LH occurs frequently. Clinically, this finding appears to be nominal, but care must be taken when dissection around large veins is performed, and awareness by the surgical and anesthesiology teams of potential venous air embolism is essential. Further evaluation of this phenomenon is required.

Outcome for patients treated with laparoscopic versus open resection of hepatocellular carcinoma: case-matched analysis

INTRODUCTION

This is a case-matched analysis of patients undergoing laparoscopic versus open hepatectomy for hepatocellular carcinoma (HCC), with specific regard to margin status and survival.

METHODS

Laparoscopic cases were matched with open controls by cirrhosis and tumor size (within 10%). Data were evaluated by logistic regression using the generalized estimating equation method. Mixed linear regression models were used to assess operative duration in the groups. Overall and disease-free survival were compared using a Cox proportional frailty model.

RESULTS

Twenty laparoscopic cases were matched to 56 open resections. Thirty patients (39%) developed recurrence and 13 patients (17%) died, including one (1.3%) death within 30 days. There were no significant differences in age, gender, cirrhosis or tumor size. Paired univariate and multivariate analyses showed cases of laparoscopic resection had similar rates of transfusion and positive margins compared with open resection. Operative duration was similar in laparoscopic (mean 161 +/- 37 min) and open (mean 165 +/- 53 min) groups. The adjusted odds of length of stay > or = 6 days was significantly lower in patients with laparoscopic resection [odds ratio (OR) = 0.07, 95% confidence interval (CI) = 0.02-0.27]. Both unadjusted and adjusted analyses showed no significant association between type of resection and overall or disease-free survival.

DISCUSSION

Neither margin status, nor recurrence, nor survival was significantly different between the two cohorts. Laparoscopic resection for malignancy is safe, with a similar operative time as open hepatectomy. If tumor location is amenable, laparoscopic resection for HCC is a reasonable alternative to open resection with the added benefits of improved cosmesis and sooner discharge home.

Laparoscopic liver resection for cancer

The field of laparoscopic liver resection surgery has rapidly evolved, with more than 1000 cases now reported. Laparoscopic hepatic resection was initially described for small, peripheral, benign lesions. Experienced teams are now performing laparoscopic anatomic resections for cancer. Operative times improved with experience. When compared with open cases, blood loss was less in most laparoscopic series, but was the main indication for conversion to an open procedure. Patients undergoing laparoscopic resection had shorter length of hospital stay and quicker recovery. Perioperative complications were comparable between the two approaches. Importantly, basic oncologic principles were maintained in the laparoscopic liver resections. The purpose of this review is to summarize the data available on outcomes for laparoscopic hepatic resection for cancer. This includes primary hepatocellular carcinoma, as well as metastatic colorectal cancer to the liver. The evidence to date suggests that laparoscopic results are comparable with the open approach in cancer patients.