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Liu Q, Li J, Zhou L, Gu H, Wu K, You N, Wang Z, Wang L, Zhu Y, Gan H, Zheng L. Liver Parenchyma Transection-First Approach for Laparoscopic Left Hemihepatectomy: A Propensity Score Matching Analysis. World J Surg 2020; 45:615-623. [PMID: 33140119 DOI: 10.1007/s00268-020-05846-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Laparoscopic major liver resection, such as laparoscopic left hemihepatectomy (LLH), is still perceived as a complicated procedure due to technical difficulties and slow learning curve. The study introduced an optimized procedure using the liver parenchyma transection-first approach and investigated its advantages on surgical outcomes by comparison with the conventional hilar dissection approach for LLH. METHODS Between January 2015 and May 2019, 96 patients who underwent laparoscopic left hemihepatectomy for hepatocellular carcinoma (HCC) were enrolled in the study. Among these, 41 patients underwent the liver parenchyma transection-first approach (LP-first group) and the other 55 underwent the conventional hilar dissection approach (conventional group). A 1:1 propensity score matching (PSM) was performed to compare the perioperative and long-term oncological outcomes of the two groups. RESULTS After 1:1 PSM, 37 patients in each group were selected for further analysis. The LP-first group was associated with shorter median operative time (210 vs 235 min, P = 0.035) and less blood loss (200 vs 300 mL, P = 0.410). In addition, no statistical differences were found in overall complications between the two groups (8.1% vs 24.3%, P = 0.058). There were no significant differences between the two groups in terms of 1-year and 3-year disease-free survival (DFS, P = 0.608) and overall survival (OS, P = 0.414). CONCLUSION The prior liver parenchyma approach for LLH is safe and reproducible in selected patients, which showed improved perioperative outcomes and comparable long-term oncological outcomes compared with the conventional approach.
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Affiliation(s)
- Qinqin Liu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, No. 183 Xinqiao High Street, Shapingba District, Chongqing, 400037, China
| | - Jing Li
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, No. 183 Xinqiao High Street, Shapingba District, Chongqing, 400037, China
| | - Ledu Zhou
- Department of Liver Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Huiying Gu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, No. 183 Xinqiao High Street, Shapingba District, Chongqing, 400037, China
| | - Ke Wu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, No. 183 Xinqiao High Street, Shapingba District, Chongqing, 400037, China
| | - Nan You
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, No. 183 Xinqiao High Street, Shapingba District, Chongqing, 400037, China
| | - Zheng Wang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, No. 183 Xinqiao High Street, Shapingba District, Chongqing, 400037, China
| | - Liang Wang
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, No. 183 Xinqiao High Street, Shapingba District, Chongqing, 400037, China
| | - Yinan Zhu
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, No. 183 Xinqiao High Street, Shapingba District, Chongqing, 400037, China
| | - Hui Gan
- Department of Radiology, The Second Affiliated Hospital of Army Medical University, Chongqing, China
| | - Lu Zheng
- Department of Hepatobiliary Surgery, The Second Affiliated Hospital of Army Medical University, No. 183 Xinqiao High Street, Shapingba District, Chongqing, 400037, China.
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Hobeika C, Fuks D, Cauchy F, Goumard C, Gayet B, Laurent A, Soubrane O, Salamé E, Cherqui D, Regimbeau JM, Mabrut JY, Scatton O, Vibert E. Benchmark performance of laparoscopic left lateral sectionectomy and right hepatectomy in expert centers. J Hepatol 2020; 73:1100-1108. [PMID: 32407812 DOI: 10.1016/j.jhep.2020.05.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/01/2020] [Accepted: 05/05/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Herein, we aimed to establish benchmark values - based on a composite indicator of healthcare quality - for the performance of laparoscopic left lateral sectionectomy (LLLS) and laparoscopic right hepatectomy (LRH) using data from expert centers. METHODS Data from a nationwide multicenter survey including all patients undergoing LLLS and LRH between 2000 and 2017 were analyzed. Textbook outcome (TO) completion was considered in patients fulfilling all 6 of the following characteristics: negative margins, no transfusion, no complication, no prolonged hospital stay, no readmission and no mortality. For each procedure, a cut-off laparoscopic liver resection (LLR) volume by center was associated with TO on multivariable analysis. These cut-offs defined the expert centers. The benchmark values were set at the 75th percentile of median outcomes among these expert centers. RESULTS Among 4,400 LLRs performed in 29 centers, 855 patients who underwent LLLS and 488 who underwent LRH were identified. The overall incidences of TO after LLLS and LRH were 43.7% and 23.8%, respectively. LLR volume cut-offs of 25 LLR/year (odds ratio [OR] 2.45; bootstrap 95% CI 1.65-3.69; p = 0.001) and 35 LLR/year (OR 2.55; bootstrap 95% CI 1.34-5.63; p = 0.003) were independently associated with completion of TO after LLLS and LRH, respectively. Eight centers for LLLS and 6 centers for LRH, including 516 and 346 patients undergoing LLLS/LRH respectively, reached these cut-offs and were identified as expert centers. After LLLS, benchmark values of severe complication, mortality and TO completion were defined as ≤5.3%, ≤1.2% and ≥46.6%, respectively. After LRH, benchmark values of severe complication, mortality and TO completion were ≤20.4%, ≤2.8% and ≥24.2%, respectively. CONCLUSIONS This study provides an up-to-date reference on the benchmark performance of LLLS and LRH in expert centers. LAY SUMMARY In a nationwide French survey of laparoscopic liver resection, expert centers were defined according to the completion of a textbook outcome, which is a composite indicator of healthcare quality. Benchmark values regarding intra-operative details and outcomes were established using data from 516 patients with laparoscopic left lateral sectionectiomy and 346 patients with laparoscopic right hepatectomy from expert centers. These values should be used as a reference point to improve the quality of laparoscopic resections.
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Affiliation(s)
- Christian Hobeika
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation - Sorbonne Université, CRCA Saint Antoine, Hôpital Pitié Salpétrière, 47 boulevard de l'hôpital, 75013, Paris, France.
| | - David Fuks
- Department of Digestive, Oncologic and Metabolic Surgery - Institut Mutualiste Montsouris, University Paris Descartes, 42 Boulevard Jourdan, 75014 Paris, France
| | - François Cauchy
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation - Hôpital Beaujon, 100 Boulevard Général Leclerc, 92118 Clichy, France
| | - Claire Goumard
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation - Sorbonne Université, CRCA Saint Antoine, Hôpital Pitié Salpétrière, 47 boulevard de l'hôpital, 75013, Paris, France
| | - Brice Gayet
- Department of Digestive, Oncologic and Metabolic Surgery - Institut Mutualiste Montsouris, University Paris Descartes, 42 Boulevard Jourdan, 75014 Paris, France
| | - Alexis Laurent
- Department of Digestive Surgery, APHP, Henri Mondor Hospital, Créteil, Île-de-France, France
| | - Olivier Soubrane
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation - Hôpital Beaujon, 100 Boulevard Général Leclerc, 92118 Clichy, France
| | - Ephrem Salamé
- Department of Digestive, Oncological, Endocrine, Hepato-Biliary and Pancreatic Surgery, and Liver Transplantation, Trousseau Hospital, University Hospital of Tours, France
| | - Daniel Cherqui
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation - Centre hépato-biliaire de Paul Brousse, 38 rue de la Chapelle, 94800, Villejuif, France
| | - Jean-Marc Regimbeau
- Department of Digestive Surgery, Amiens, France; SSPC (Simplification des Soins des Patients Complexes) - Unit of Clinical Research, University of Picardie Jules Verne, Amiens, France
| | - Jean-Yves Mabrut
- Department of General Surgery and Liver Transplantation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Olivier Scatton
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation - Sorbonne Université, CRCA Saint Antoine, Hôpital Pitié Salpétrière, 47 boulevard de l'hôpital, 75013, Paris, France
| | - Eric Vibert
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation - Centre hépato-biliaire de Paul Brousse, 38 rue de la Chapelle, 94800, Villejuif, France
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Keyt LK, Jensen AR, O'Driscoll SW, Sanchez-Sotelo J, Morrey ME, Camp CL. Establishing the learning curve for elbow arthroscopy: surgeon and trainee perspectives on number of cases needed and optimal methods for acquiring skill. J Shoulder Elbow Surg 2020; 29:e434-e442. [PMID: 32778381 DOI: 10.1016/j.jse.2020.04.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 04/06/2020] [Accepted: 04/12/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Elbow arthroscopy has increased in frequency as its indications have widened. Despite this growth, a learning curve has not yet been defined. HYPOTHESIS We hypothesized that there would be significant differences in perspective between trainees and established surgeons for the number of cases needed to reach each skill level and what they felt are the most valuable training tools. METHODS Orthopedic attending physicians and trainees were asked to complete a questionnaire assessing participant demographics, case volumes required to reach defined skill levels (novice, safe, competent, proficient, and expert), and the efficacy of various learning methodologies for elbow arthroscopy. The value of educational methods was assessed using a 5-point Likert scale (1 = not at all valuable; 5 = extremely valuable). RESULTS The study population consisted of 323 total participants, of whom 224 (69.3%) were attending surgeons and 99 (30.7%) were trainees (resident or fellow physicians). According to the attending physicians, the mean numbers of cases needed to reach each skill level were 19 to be safe, 42 to be competent, 93 to be proficient, and 230 to be expert. These case numbers were not significantly different from the perspectives of trainees. Across the respondents, there were no significant differences in the number of cases needed to reach each level of skill based on the respondents' level of training, years of experience, type of fellowship, or self-reported skill level.Although both groups highly valued live surgery (4.7 of 5) and cadaveric practice (4.6 of 5) for acquiring skill, attendings placed higher value on reading (4.0 vs. 3.3, P < .001), videos/live demos (4.2 vs. 3.6, P < .001), and formal courses (4.5 vs. 4.1, P < .001) than trainees. Both groups place relatively low value on surgical simulators (2.8-3.6). CONCLUSIONS There was considerable agreement among attending surgeons and trainees in terms of the number of cases needed to attain various skill levels of elbow arthroscopy, which was consistent regardless of fellowship background, self-reported skill level, career length, and elbow arthroscopy case volume. However, there was some disagreement between attending surgeons and trainees over the most valuable methods for acquiring surgical skill with trainees placing less value on textbooks, surgical videos, and formal courses compared with attending surgeons. An understanding of the elbow arthroscopy learning curve will help trainees and their training programs establish case volume targets before safe, independent practice. Future studies should aim to clinically validate this learning curve.
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Affiliation(s)
- Lucas K Keyt
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Andrew R Jensen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Mark E Morrey
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Annie Lo HY, Young S, Andrew DiFronzo L. Laparoscopic Liver Resection: A 7-Year Experience of 123 Resections in a Single Institution. Am Surg 2020; 86:1330-1336. [PMID: 33124880 DOI: 10.1177/0003134820964442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
There has been a significant increase in the use of laparoscopic liver resection (LLR) over the past 2 decades. This study aimed to analyze the outcomes associated with LLR at a single tertiary care hospital. Patients with benign or malignant tumors who underwent LLR by a single surgeon from January 2012 to November 2019 were identified. There were 123 patients who underwent LLR in the study period; 52% were men, and the median age was 61 (24-90) years. Five patients (4.1%) had unplanned conversion to open resection. Ninety-five patients (77.2%) had a wedge resection or single segmentectomy, and 28 (22.8%) underwent resection of 2+ liver segments. Seventy-one cases (57.7%) were for hepatocellular carcinoma (HCC), 24 (19.5%) for colorectal metastasis, and 28 (22.8%) were for other benign and malignant tumors. Median operative time was 239 (range 89-526) minutes. Mean estimated blood loss was 192 (range 0-1800) mL. The median length of stay (LOS) overall was 2 (range 0-9) days. From 2017 to 2019, the mean LOS was 1.2 days, compared to a mean LOS of 3.3 days from 2012 to 2016. More cases were performed as same-day surgery from 2017 onward; 19 patients (33.9%) had same-day surgery from 2017 to 2019, in comparison to only 1 patient (1.5%) in the period of 2012-2016 (P < .0001). Overall, 28 patients (22.8%) experienced postoperative morbidity; major postoperative morbidity occurred in 4 patients (3.3%). The 90-day mortality was .8%, and the 30-day readmission rate was 5.7%. In conclusion, LLR can be performed safely to treat liver tumors, and LOS decreased over time. Although overall morbidity is moderate, serious morbidity is low, as was the readmission rate. Laparoscopic wedge resection may be a feasible option as an outpatient procedure in select patients.
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Affiliation(s)
- Hoi Y Annie Lo
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Stephanie Young
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
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Duarte VC, Coelho FF, Valverde A, Danoussou D, Kruger JAP, Zuber K, Fonseca GM, Jeismann VB, Herman P, Lupinacci RM. Minimally invasive versus open right hepatectomy: comparative study with propensity score matching analysis. BMC Surg 2020; 20:260. [PMID: 33126885 PMCID: PMC7602349 DOI: 10.1186/s12893-020-00919-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 10/20/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Minimally invasive liver resections (MILRs) have been increasingly performed in recent years. However, the majority of MILRs are actually minor or limited resections of peripheral lesions. Due to the technical complexity major hepatectomies remain challenging for minimally invasive surgery. The aim of this study was to compare the short and long-term outcomes of patients undergoing minimally invasive right hepatectomies (MIRHs) with contemporary patients undergoing open right hepatectomies (ORHs) METHODS: Consecutive patients submitted to anatomic right hepatectomies between January 2013 and December 2018 in two tertiary referral centers were studied. Study groups were compared on an intention-to-treat basis after propensity score matching (PSM). Overall survival (OS) analyses were performed for the entire cohort and specific etiologies subgroups RESULTS: During study period 178 right hepatectomies were performed. After matching, 37 patients were included in MIRH group and 60 in ORH group. The groups were homogenous for all baseline characteristics. MIRHs had significant lower blood loss (400 ml vs. 500 ml, P = 0.01), lower rate of minor complications (13.5% vs. 35%, P = 0.03) and larger resection margins (10 mm vs. 5 mm, P = 0.03) when compared to ORHs. Additionally, a non-significant decrease in hospital stay (ORH 9 days vs. MIRH 7 days, P = 0.09) was observed. No differences regarding the use of Pringle's maneuver, operative time, overall morbidity or perioperative mortality were observed. OS was similar between the groups (P = 0.13). Similarly, no difference in OS was found in subgroups of patients with primary liver tumors (P = 0.09) and liver metastasis (P = 0.80). CONCLUSIONS MIRHs are feasible and safe in experienced hands. Minimally invasive approach was associated with less blood loss, a significant reduction in minor perioperative complications, and did not negatively affect long-term outcomes.
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Affiliation(s)
- Vinícius Campos Duarte
- Liver Surgery Unit, Digestive Surgery Division, Department of Gastroenterology, University of São Paulo School of Medicine, Rua Dr. Enéas de Carvalho Aguiar, 255-9º Andar-sala 9025, São Paulo, SP, CEP 05403-900, Brazil.
| | - Fabricio Ferreira Coelho
- Liver Surgery Unit, Digestive Surgery Division, Department of Gastroenterology, University of São Paulo School of Medicine, Rua Dr. Enéas de Carvalho Aguiar, 255-9º Andar-sala 9025, São Paulo, SP, CEP 05403-900, Brazil
| | - Alain Valverde
- Digestive Surgery Unit, Diaconesses Croix Saint Simon Hospital, 125, Rue d'Avron, 75020, Paris, France
| | - Divia Danoussou
- Digestive Surgery Unit, Diaconesses Croix Saint Simon Hospital, 125, Rue d'Avron, 75020, Paris, France
| | - Jaime Arthur Pirola Kruger
- Liver Surgery Unit, Digestive Surgery Division, Department of Gastroenterology, University of São Paulo School of Medicine, Rua Dr. Enéas de Carvalho Aguiar, 255-9º Andar-sala 9025, São Paulo, SP, CEP 05403-900, Brazil
| | - Kevin Zuber
- Research and Biostatistics Unit, Rothschild Foundation Hospital, Paris, France
| | - Gilton Marques Fonseca
- Liver Surgery Unit, Digestive Surgery Division, Department of Gastroenterology, University of São Paulo School of Medicine, Rua Dr. Enéas de Carvalho Aguiar, 255-9º Andar-sala 9025, São Paulo, SP, CEP 05403-900, Brazil
| | - Vagner Birk Jeismann
- Liver Surgery Unit, Digestive Surgery Division, Department of Gastroenterology, University of São Paulo School of Medicine, Rua Dr. Enéas de Carvalho Aguiar, 255-9º Andar-sala 9025, São Paulo, SP, CEP 05403-900, Brazil
| | - Paulo Herman
- Liver Surgery Unit, Digestive Surgery Division, Department of Gastroenterology, University of São Paulo School of Medicine, Rua Dr. Enéas de Carvalho Aguiar, 255-9º Andar-sala 9025, São Paulo, SP, CEP 05403-900, Brazil
| | - Renato Micelli Lupinacci
- Digestive Surgery Unit, Diaconesses Croix Saint Simon Hospital, 125, Rue d'Avron, 75020, Paris, France.,AP-HP, Department of Digestive, Oncologic and Metabolic Surgery, Ambroise Paré Hospital, Boulogne-Billancourt, France.,Versailles St-Quentin-en-Yvelines/Paris Saclay University, UFR des Sciences de la Santé Simone Veil, Montigny-Le-Bretonneux, France
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Hasegawa Y, Nitta H, Takahara T, Katagiri H, Kanno S, Umemura A, Akiyama Y, Iwaya T, Otsuka K, Sasaki A. Surgical outcomes of 118 complex laparoscopic liver resections: a single- center experience. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2020; 27:942-949. [PMID: 33058554 DOI: 10.1002/jhbp.848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/09/2020] [Accepted: 09/20/2020] [Indexed: 12/07/2022]
Abstract
BACKGROUND Indications for laparoscopic liver resection (LLR) are continuously expanding. The Japanese Society of Hepato-Biliary-Pancreatic Surgery defines highly difficult hepatectomy as a procedure involving one or more sections (except for left lateral sectionectomy) or anatomical segmentectomy. This study aimed to assess the outcomes of complex LLR procedures and compare their technical difficulties, about which only a little is known to date. METHODS We performed a retrospective review of the operative outcomes of 118 consecutive patients who underwent pure laparoscopic complex hepatectomy. The surgical outcomes, including operative times, blood loss amounts, and postoperative morbidity rates, were compared among complex LLR procedures. RESULTS The overall median operative time was 280 minutes, and the median intraoperative blood loss was 86 mL. Two patients required conversion to open laparotomy (1.7%). The postoperative major morbidity rate was 11.0% Posterosuperior segmentectomy, right hemihepatectomy, and anterior sectionectomy required the longest operative times. Anterior and posterior sectionectomy resulted in the highest blood loss, and right hemihepatectomy and anterior sectionectomy resulted in the most complications. CONCLUSIONS The surgical difficulties associated with complex LLR procedures vary. It is critical to recognize the specific risks and cautionary points to ensure patient safety and provide proper systemic training to surgeons.
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Affiliation(s)
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University, Yahaba, Japan
| | | | | | - Shoji Kanno
- Department of Surgery, Iwate Medical University, Yahaba, Japan
| | - Akira Umemura
- Department of Surgery, Iwate Medical University, Yahaba, Japan
| | - Yuji Akiyama
- Department of Surgery, Iwate Medical University, Yahaba, Japan
| | - Takeshi Iwaya
- Department of Surgery, Iwate Medical University, Yahaba, Japan
| | - Koki Otsuka
- Department of Surgery, Iwate Medical University, Yahaba, Japan
| | - Akira Sasaki
- Department of Surgery, Iwate Medical University, Yahaba, Japan
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Taesombat W, Kanjanasilp P, Nonthasoot B, Sutherasan M, Vorasittha A, Sirichindakul B. Benefits of simultaneous laparoscopic colorectal surgery and liver resection for colorectal cancer with synchronous liver metastases: Retrospective case-matched study. Ann Med Surg (Lond) 2020; 58:120-123. [PMID: 32983430 PMCID: PMC7494584 DOI: 10.1016/j.amsu.2020.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/01/2020] [Accepted: 09/01/2020] [Indexed: 01/22/2023] Open
Abstract
Introduction Laparoscopic surgery for colorectal cancer and liver tumors are accepted as alternative procedure to open surgery. However, few studies reported outcomes of simultaneous laparoscopic surgery of these two procedures. The aim of this study was to compare short-term outcomes between laparoscopic and open approach. Materials and methods Between June 2010 to December 2019, simultaneous laparoscopic cases were retrospectively matched (1:2) to open cases. Peri-operative and short-term outcomes were compared between both groups. Results Twelve patients in laparoscopic group were matched to 24 patients in open group according to age, gender, body mass index, american society of anesthesiologists physical status, preoperative laboratory data, number and size of liver metastases and extent of colorectal and liver resection, Most patients in each group had left-sided colon or rectal cancer and underwent wedge liver resection. The mean number of liver metastases was 1.3 vs 1.5 and size of liver metastases was 2.2 ± 1.4 vs 2.7 ± 1.1 cm in laparoscopic compared to open group. Estimated blood loss and length of hospital stay were significantly lower in laparoscopic group. However, operative time was significantly longer in laparoscopic group. Peri-operative complication was not significant difference between both groups and there was no mortality. Conclusion Simultaneous laparoscopic colorectal surgery and minor liver resection is feasible and safe. Laparoscopic approach has better peri-operative outcome in term of shorter length of hospital stay compared to open approach. Outcome of simultaneous laparoscopic surgery for colorectal cancer with synchronous liver metastases remains controversy. This study showed comparable peri-operative outcomes of simultaneous laparoscopic compared to open surgery. Simultaneous laparoscopic surgery had shorter length of hospital stay and less operative blood loss.
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Affiliation(s)
- Wipusit Taesombat
- Department of Surgery, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Prapon Kanjanasilp
- Department of Surgery, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Bunthoon Nonthasoot
- Department of Surgery, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Methee Sutherasan
- Department of Surgery, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Athaya Vorasittha
- Department of Surgery, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Boonchoo Sirichindakul
- Department of Surgery, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
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Ziogas IA, Giannis D, Esagian SM, Economopoulos KP, Tohme S, Geller DA. Laparoscopic versus robotic major hepatectomy: a systematic review and meta-analysis. Surg Endosc 2020; 35:524-535. [DOI: 10.1007/s00464-020-08008-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 09/16/2020] [Indexed: 02/08/2023]
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Antoun A, Chau J, Alsharqawi N, Kaneva P, Feldman LS, Mueller CL, Lee L. P338: summarizing measures of proficiency in transanal total mesorectal excision—a systematic review. Surg Endosc 2020; 35:4817-4824. [DOI: 10.1007/s00464-020-07935-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/25/2020] [Indexed: 01/01/2023]
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Short-term Outcomes of "Difficult" Laparoscopic Liver Resection at Specialized Centers: Report From INSTALL (International Survey on Technical Aspects of Laparoscopic Liver Resection)-2 on 4478 Patients. Ann Surg 2020; 275:940-946. [PMID: 32889884 DOI: 10.1097/sla.0000000000004434] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To define the current status of "difficult" LLR, a global database was created and investigated. BACKGROUND In the Second International Consensus Conference in 2014, minor LLR was considered as a standard practice and major LLR remained an innovative procedure. Since then, no updates on worldwide trends have been available. METHODS A questionnaire on all consecutive patients who underwent difficult LLR (major hepatectomy, posterosuperior segmentectomy, sectionectomy, living donor hepatectomy, tumor size ≥10 cm, Child-Pugh grade ≥B, combined with biliary reconstruction, and Iwate criteria difficulty score ≥7) in 2014-2018 was distributed via email to 65 high-volume LLR centers worldwide. Individual data on patient and tumor demographics, surgical information, and short-term outcomes were obtained to create a large-scale international registry for analyses. RESULTS Overall, 58 centers in 19 countries performed 4478 difficult LLR (median, 58.5; range, 5-418) during the study period. Hepatocellular carcinoma accounted for ≥40% of all indications. Half of the patients underwent major hepatectomy, followed by sectionectomy, posterosuperior segmentectomy, and living donor hepatectomy. In the vast majority of procedures, Clavien-Dindo grade ≥IIIa complication rates of ≈10% and 90-day mortality rates of ≈1% were achieved. Left or right trisectionectomy had the worst Clavien-Dindo grade ≥IIIa complication rate of ≥10% and 90-day mortality rate of 5%-10%. No significant correlation was observed between center volume and short-term outcomes. CONCLUSIONS Total 4478 patients underwent difficult LLR worldwide in 2014-2018. Most procedures are safe and feasible when conducted in specialized centers.
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Pure laparoscopic right hepatectomy: A risk score for conversion for the paradigm of difficult laparoscopic liver resections. A single centre case series. Int J Surg 2020; 82:108-115. [PMID: 32861891 DOI: 10.1016/j.ijsu.2020.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/23/2020] [Accepted: 08/01/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Converted laparoscopic hepatectomies are known to lose some advantages of the minimally-invasiveness, and factors are identified to predict patients at risk. Specific evidence for laparoscopic right hepatectomy is expected of usefulness in clinical practice, given its technical peculiarities. The purpose of the study was the identification of risk factors and the development of a risk score for conversion of laparoscopic right hepatectomy. MATERIALS AND METHODS Laparoscopic right hepatectomy performed at a single hepatobiliary surgical center were analyzed. The cohort was split in half to obtain a derivation and a validation set. Risk factors for conversion were identified by uni- and multivariable analysis. A "conversion risk score" was built assigning each factor 1 point and comparing the score with the conversion status for each patient. The accuracy was assessed by the area-under-the-receiver-operator-characteristic-curve. RESULTS Among 130 operations, 22 were converted (16.9%). Reasons were: 45.5% oncologic inadequacy, 31.8% bleeding, 9.1% adhesions, 9.1% biliostasis, 4.5% anaesthesiological problems. Independent risk factors for conversion were: previous laparoscopic liver surgery (Hazard Ratio 4.9, p 0.011), preoperative chemotherapy ( Hazard Ratio 6.2, p 0.031), malignant diagnosis (Hazard Ratio 3.3, p 0.037), closeness to hepatocaval confluence or inferior vena cava (Hazard Ratio 4.1, p 0.029), tumor volume (Hazard Ratio 2.9, p 0.024). Conversion rates correlated positively with the score, raising from 0 to 100% when the score increased from 0 to 5 (Spearman: p 0.032 in the derivation set, p 0.020 in the validation set). The risk of conversion showed a sharp increase passing from class 3 to 4, reaching a probability estimated between 60 and 71.4%. The score showed good accuracy (area-under-the-receiver-operator-characteristic-curve 0.82). CONCLUSION Specific risk factors for conversion are identified for laparoscopic right hepatectomy. This score may help in standardizing the choice of a pure laparoscopic or open approach for such challenging resections.
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Comparison of the learning curves for robotic left and right hemihepatectomy: A prospective cohort study. Int J Surg 2020; 81:19-25. [PMID: 32739547 DOI: 10.1016/j.ijsu.2020.07.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/11/2020] [Accepted: 07/07/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Robotic hepatectomy has been continuously improving and shown to be safe and reliable. The learning curve of robotic hemihepatectomy is required which enable beginners to benefit from previous experience. The aim of this study was to assess the learning curve of robotic left (RLH) and right hemihepatectomy (RRH) in terms of operative time (OT) to determine which procedure has an easier learning curve for beginners. METHODS Data records for each 100 consecutive patients who underwent RLH and RRH between July 2012 and May 2019 were collected prospectively and analyzed retrospectively. The data included demographics, OT, estimated blood loss (EBL), postoperative hospital stay (PHS), and rates of morbidity and mortality. The cumulative sum method was used to evaluate the learning curve of OT. RESULTS All patients underwent the RRH and RLH procedure performed by the same surgical team. RRH and RLH learning curve consisted of two phases: the first and second phase. The first phase of RRH included 45 patients, while RLH outcomes were optimized after 35 cases were completed. Compared with the first phase, the mean OT and the median blood loss were decreased significantly in the second phase in both learning curves. No significant decrease in the rates of morbidity and conversion to laparotomy or PHS was observed. CONCLUSIONS This study demonstrated the safety and feasibility of RLH and RRH. The surgeons who previously lacked robotic experience are able to overcome the learning curve for RLH faster than RRH.
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Stepwise development of laparoscopic liver resection skill using rubber traction technique. HPB (Oxford) 2020; 22:1174-1184. [PMID: 31786055 DOI: 10.1016/j.hpb.2019.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 10/17/2019] [Accepted: 11/04/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND To improve patient safety, we standardized our surgical technique and implemented a stepwise strategy for surgeons learning to perform laparoscopic liver resection (LLR). The aim of the study is to describe how the stepwise training approach and standardized LLR affects surgical outcomes. METHODS Data from 272 consecutive patients who underwent LLR from January 2009 to December 2017 were retrospectively reviewed. The risk-adjusted cumulative sum (RA-CUSUM) of surgical failures (conversion to laparotomy, blood transfusion, or Clavien-Dindo grade ≥3) and the CUSUM of operative time were used to determine optimal number of operations needed to achieve the best surgical outcome. RESULTS As the surgeon moved from simple to complex procedures, the complication rates, need for transfusions, and conversion rates did not increase over time. After 53 cases of minor LLR, a learning curve of 21 cases was achieved for right hepatectomy. Blood loss and operative time significantly improved thereafter. For minor anterolateral and posterosuperior segment resections, blood loss, and operative time significantly improved at the 37th and 31st case, respectively, given that the anterolateral segments had more complex surgeries performed. CONCLUSION Standardization of the operative technique and the implementation of a stepwise approach to training surgeons to perform LLRs could considerably improve surgical outcomes.
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Sucandy I, Luberice K, Lippert T, Castro M, Krill E, Ross S, Rosemurgy A. Robotic Major Hepatectomy: An Institutional Experience and Clinical Outcomes. Ann Surg Oncol 2020; 27:4970-4979. [DOI: 10.1245/s10434-020-08845-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/28/2020] [Indexed: 12/15/2022]
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Learning Curve in Laparoscopic Liver Resection, Educational Value of Simulation and Training Programmes: A Systematic Review. World J Surg 2020; 43:2710-2719. [PMID: 31384997 DOI: 10.1007/s00268-019-05111-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The laparoscopic approach is widely accepted as the procedure of choice for abdominal surgery. However, laparoscopic liver resection (LLR) has advanced slowly due to the significant learning curve (LC), and only few publications have dealt with advanced training in LLR. METHODS Two reviewers conducted systematic research through MEDLINE and EMBASE with combinations of the following keywords: (learning curve OR teaching OR training OR simulation OR education) AND (liver OR hepatic) AND (laparoscopic OR laparoscopy). Robotic-assisted, hand-assisted and hybrid LLRs were excluded. RESULTS Nineteen studies were retrieved. Overall, the level of evidence was low. Thirteen articles assessed the LC during real-life LLR, and six articles focussed on simulation and training programmes in LLR. The LC in minor LLR comprised 60 cases overall, and 15 cases for standardised left lateral sectionectomy. For major LLR (MLLR), the LC was 50 cases for most studies, but was reported to be 15-20 cases in more recent studies, provided MLLR is performed progressively in selected patients. However, there was heterogeneity in the literature regarding the number of minor LLRs required before MLLR, with 60 minor LLRs reported as the minimum. Six studies showed a potential benefit of simulation and training programmes in this field. The gradual implementation of LLR combined with simulation-based training programmes could reduce the clinical impact of LC. CONCLUSIONS The LC in LLR is a long process, and MLLR should be gradually implemented under the supervision of experienced surgeons. Training outside the operating room may reduce the LC in real-life situations.
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Navarro JG, Kang I, Rho SY, Choi GH, Han DH, Kim KS, Choi JS. Major Laparoscopic Versus Open Resection for Hepatocellular Carcinoma: A Propensity Score-Matched Analysis Based on Surgeons' Learning Curve. Ann Surg Oncol 2020; 28:447-458. [PMID: 32602059 DOI: 10.1245/s10434-020-08764-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical complications for surgeons still in the learning phase of major laparoscopic liver resection (LLR) have been frequently observed. We aimed to compare perioperative and long-term outcomes of laparoscopic and open surgery based on the surgeons' learning curve for LLR after propensity score-matched (PSM) analysis. METHODS This was a retrospective study of all patients with a histologic diagnosis of hepatocellular carcinoma who underwent major hepatectomy between January 2013 and December 2018. A PSM analysis was used to compare the groups of patients who underwent LLR and open major liver resection (OLR) before and after the learning curve was maximized. RESULTS Among 405 patients, 106 underwent LLR and 299 underwent OLR. The learning curve was maximized after 42 cases. Compared with OLR, LLR had more liver-related injury and grade III or higher complications during the learning phase. The LLR group had less blood loss, fewer transfusion requirements, and fewer liver-related complications during the 'experienced' phase. Hospital stay was significantly shorter during and after maximization of the learning curve in LLR compared with OLR. Operative time was comparable in the two phases. Overall, LLR was associated with less blood loss, fewer complications, and shorter hospital stay compared with open surgery. There was no significant difference in long-term survival outcomes between the two groups. CONCLUSIONS LLR had a higher incidence of liver-related complications during the surgeon's learning phase compared with OLR. This association was significantly diminished with surgeon experience. Overall perioperative outcomes such as estimated blood loss, surgical complications, and hospital stay remained better for LLR compared with OLR.
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Affiliation(s)
- Jonathan Geograpo Navarro
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.,Division of Surgical Oncology, Department of Surgery, Vicente Sotto Memorial Medical Center, Cebu City, Cebu, Philippines
| | - Incheon Kang
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seoung Yoon Rho
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Gi Hong Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.
| | - Dai Hoon Han
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Sik Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Sub Choi
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Prevention of intra-thoracic recurrent laryngeal nerve injury with robot-assisted esophagectomy. Langenbecks Arch Surg 2020; 405:533-540. [PMID: 32494883 DOI: 10.1007/s00423-020-01904-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/25/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE Transthoracic esophagectomy for esophageal cancer is one of the most invasive procedures in surgery for gastrointestinal cancer. Serious complications sometimes occur after esophageal cancer surgery, including recurrent laryngeal nerve injury and pneumonia. The purpose of this study was to access the possibility of robot-assisted thoracoscopic esophagectomy for esophageal cancer in terms of preventing recurrent laryngeal nerve injury. METHODS Operations in thoracic part were performed in prone position with bilateral ventilation. During dissection of the recurrent laryngeal nerve lymph nodes, thin blood vessels were coagulated with Maryland bipolar forceps in the left hand and then dissected with monopolar scissors in the right hand. Especially when dissecting left recurrent laryngeal nerve lymph nodes, the nerve was left unisolated from the vascular sheath that involves the aortic arch. Short-term outcomes including operative time, estimated blood loss, and postoperative complications including recurrent laryngeal nerve injury were accessed. RESULTS From November 2018 to January 2020, 20 patients underwent robot-assisted thoracoscopic esophagectomy for esophageal cancer. Thoracic operative time was 242 min, estimated blood loss in the thoracic part was minimal, the number of dissected mediastinal lymph nodes was 19 (all median), and the incidence rates of recurrent laryngeal nerve injury and pneumonia were 10% (2 case) and 10% (2 cases), respectively. CONCLUSION Robot-assisted thoracoscopic esophagectomy for esophageal cancer has the possibility of reducing recurrent laryngeal nerve injury even in the introductory period. Randomized controlled trials are required to confirm this advantage of the robotic surgery.
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Kose E, Karahan SN, Berber E. Robotic Liver Resection: Recent Developments. CURRENT SURGERY REPORTS 2020. [DOI: 10.1007/s40137-020-00254-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Hołówko W, Triantafyllidis I, Neuberg M, Tabchouri N, Beaussier M, Bennamoun M, Sarran A, Lefevre M, Louvet C, Gayet B, Fuks D. Does the difficulty grade of laparoscopic liver resection for colorectal liver metastases correlate with long-term outcomes? Eur J Surg Oncol 2020; 46:1620-1627. [PMID: 32561203 DOI: 10.1016/j.ejso.2020.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 05/20/2020] [Accepted: 05/25/2020] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Prognosis of patients with colorectal liver metastases (CRLM) is strongly correlated with the oncological outcome after liver resection. The aim of this study was to analyze the impact of laparoscopic liver resection (LLR) difficulty score (IMM difficulty score) on the oncological results in patients treated for CRLM. METHODS All patients who underwent LLRs for CRLM from 2000 to 2016 in our department, were retrospectively reviewed. Data regarding difficulty classification, -according to the Institute Mutualiste Montsouris score (IMM)-, recurrence rate, recurrence-free survival (RFS), overall survival (OS) and data regarding margin status were analyzed. RESULTS A total of 520 patients were included. Patients were allocated into 3 groups based on IMM difficulty score of the LLR they underwent: there were 227 (43,6%), 84 (16,2%) and 209 (40,2%) patients in groups I, II and III, respectively. The R1 resection rate in group I, II and III were 8,8% (20/227), 11,9% (10/84) and 12,4% (26/209) respectively (p = 0.841). Three- and 5-year RFS rates were 77% and 73% in group I, 58% and 51% in group II, 61% and 53% in group III, respectively (p = 0.038). Three and 5-year OS rates were 87% and 80% for group I, 77% and 66% for group II, 80% and 69% for group III respectively (p = 0.022). CONCLUSION The higher LLR difficulty score correlates with significant morbidity and worse RFS and OS, although the more technically demanding and difficult cases are not associated with increased rates of positive resection margins and recurrence.
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Affiliation(s)
- Wacław Hołówko
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, Université Paris Descartes, France; Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Ioannis Triantafyllidis
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, Université Paris Descartes, France; Department of General Surgery, General Hospital of Veria, Greece
| | - Maud Neuberg
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, Université Paris Descartes, France
| | - Nicolas Tabchouri
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, Université Paris Descartes, France
| | - Marc Beaussier
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, Université Paris Descartes, France
| | - Mostefa Bennamoun
- Department of Oncology, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, France
| | - Anthony Sarran
- Department of Radiology, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, France
| | - Marine Lefevre
- Department of Pathology, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, France
| | - Christophe Louvet
- Department of Oncology, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, France
| | - Brice Gayet
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, Université Paris Descartes, France
| | - David Fuks
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014, Paris, Université Paris Descartes, France.
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Assis BSD, Coelho FF, Jeismann VB, Kruger JAP, Fonseca GM, Cecconello I, Herman P. Total laparoscopic vs. open liver resection: comparative study with propensity score matching analysis. ACTA ACUST UNITED AC 2020; 33:e1494. [PMID: 32428137 PMCID: PMC7236330 DOI: 10.1590/0102-672020190001e1494] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 01/28/2020] [Indexed: 02/07/2023]
Abstract
Background:
There have been an increasing number of articles that demonstrate the
potential benefits of minimally invasive liver surgery in recent years. Most
of the available evidence, however, comes from retrospective observational
studies susceptible to bias, especially selection bias. In addition, in many
series, several modalities of minimally invasive surgery are included in the
same comparison group. Aim:
To compare the perioperative results (up to 90 days) of patients submitted
to total laparoscopic liver resection with those submitted to open liver
resection, matched by propensity score matching (PSM). Method: Consecutive adult patients submitted to liver resection were included. PSM
model was constructed using the following variables: age, gender, diagnosis
(benign vs. malignant), type of hepatectomy (minor vs. major), and presence
of cirrhosis. After matching, the groups were redefined on a 1:1 ratio, by
the nearest method. Results:
After matching, 120 patients were included in each group. Those undergoing
total laparoscopic surgery had shorter operative time (286.8±133.4 vs.
352.4±141.5 minutes, p<0.001), shorter ICU stay (1.9±1.2 vs. 2.5±2.2days,
p=0.031), shorter hospital stay (5.8±3.9 vs. 9.9±9.3 days, p<0.001) and a
45% reduction in perioperative complications (19.2 vs. 35%, p=0.008). Conclusion:
Total laparoscopic liver resections are safe, feasible and associated with
shorter operative time, shorter ICU and hospital stay, and lower rate of
perioperative complications.
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Affiliation(s)
- Bruno Silva de Assis
- Postgraduate Course in Digestive Surgery, Colégio Brasileiro de Cirurgia Digestiva, São Paulo, Brazil
| | - Fabricio Ferreira Coelho
- Postgraduate Course in Digestive Surgery, Colégio Brasileiro de Cirurgia Digestiva, São Paulo, Brazil
| | - Vagner Birk Jeismann
- Postgraduate Course in Digestive Surgery, Colégio Brasileiro de Cirurgia Digestiva, São Paulo, Brazil
| | | | - Gilton Marques Fonseca
- Postgraduate Course in Digestive Surgery, Colégio Brasileiro de Cirurgia Digestiva, São Paulo, Brazil
| | - Ivan Cecconello
- Department of Gastroenterology, School of Medicine, Universityof São Paulo, São Paulo, Brazil
| | - Paulo Herman
- Department of Gastroenterology, School of Medicine, Universityof São Paulo, São Paulo, Brazil
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Learning Curve Under Proctorship of Pure Laparoscopic Living Donor Left Lateral Sectionectomy for Pediatric Transplantation. Ann Surg 2020; 271:542-548. [PMID: 29995683 DOI: 10.1097/sla.0000000000002948] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the learning curve of an expert liver transplantation surgeon approaching fully laparoscopic living donor left lateral sectionectomy (L-LLS) under proctorship. BACKGROUND Laparoscopic liver resections necessitate a long learning curve trough a stepwise fulfillment of difficulties. L-LLS requires expertise in both living donor liver transplantation and advanced laparoscopic liver surgery. There is currently no data about the learning curve of L-LLS. METHODS A total of 72 pure L-LLS were included in this study. A Broken line model was used to identify the periods of the learning curve. A CUSUM analysis of the operative time was performed to evaluate improvements of outcomes with time. To evaluate the relationship between operative time and progressive number of procedures, a linear regression model was applied. A receiver operating characteristic (ROC) curve was carried out to identify the cutoff for completion of the learning curve. RESULTS Operative time decreased with the progressive increase of procedures. Two cutoffs and 3 different periods were identified: cases 1 to 22, cases 23 to 55, and cases 56 to 72. A significant decrease in blood loss and operative time was noted. The CUSUM analysis showed an increase in operative time in the first period, a stable duration in the second period, and a decrease in the last. Blood loss was significantly associated with an increase in operative time (P = 0.003). According to the ROC curve, the learning curve was completed after 25 procedures. CONCLUSIONS L-LLS is a safe procedure that can be standardized and successfully taught to surgeons with large experience in donor hepatectomy through a proctored learning curve.
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Mosteanu BI, Han HS, Cho JY, Lee B. When should we choose a laparoscopic approach? A high-volume center recommendation score. Surg Oncol 2020; 34:208-211. [PMID: 32891332 DOI: 10.1016/j.suronc.2020.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/19/2020] [Accepted: 04/25/2020] [Indexed: 02/07/2023]
Abstract
Laparoscopic liver resection is a demanding procedure that is undergoing continuous development. The surgeon's skill is constantly improving, new surgical instruments are being introduced, and the indications for this procedure are expanding. However, there is still great concern about patient safety during the procedure and it is not commonly performed in many centers, although numerous studies have confirmed the safety and feasibility of laparoscopic liver techniques. Our center tries to use laparoscopy routinely for most cases and we do not consider conversion to open surgery to be a complication. We present our current opinion on patient selection for laparoscopic liver resection in the hope of encouraging more centers to adopt and develop this technique. Although laparoscopic liver resection is not an official standard of care, it should be considered according to the surgeon's experience and available resources.
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Affiliation(s)
- Benone-Iulian Mosteanu
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, South Korea; Department of Surgery, Fundeni Clinical Institute, Bucharest, Romania
| | - Ho-Seong Han
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, South Korea.
| | - Jai Young Cho
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Boram Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, South Korea
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Park HM, Han SS, Park SJ, Kim SW. Learning curve for pancreatoduodenectomy: can it be generalized? ANZ J Surg 2020; 90:1414-1421. [PMID: 32255265 DOI: 10.1111/ans.15874] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 02/25/2020] [Accepted: 03/12/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND We hypothesized that a learning curve exists for pancreatoduodenectomy (PD) and that the factors that show a learning curve and the degree of improvement over time differ among surgeons. METHODS We analysed the outcomes of PD in 300 patients operated by two surgeons between 2001 and 2014; these comprised the first 150 patients operated by each surgeon. Patients operated by each surgeon were classified into three groups according to the chronological sequence of operation (50 patients per group). RESULTS For surgeon A, the median operation time (496 versus 454 versus 418 min, P < 0.001) and the mean amount of red blood cell transfusion (3.76 versus 2.76 versus 1.26 packs, P < 0.001) showed a slight but progressive decrease from the first 50 cases to the second and the third 50 cases. For surgeon B, only the operation time, which decreased and ultimately plateaued at approximately case 100, was significantly different among the groups. There was no improvement in post-operative complications, re-operation rates, mortality, length of stay and re-admission rates over time for both surgeons. CONCLUSION We demonstrated that a learning curve for PD exists with respect to various factors. However, the factors for which learning curves were exhibited and the degree of improvement over time were different between the two surgeons.
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Affiliation(s)
- Hyeong Min Park
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang-si, South Korea
| | - Sung-Sik Han
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang-si, South Korea
| | - Sang-Jae Park
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang-si, South Korea
| | - Sun-Whe Kim
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang-si, South Korea
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Kuge H, Yokoo T, Uchida H, Yamaoka K, Yoshikawa S. Learning curve for laparoscopic transabdominal preperitoneal repair: A single-surgeon experience of consecutive 105 procedures. Asian J Endosc Surg 2020; 13:205-210. [PMID: 31282102 DOI: 10.1111/ases.12724] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 05/13/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Based on previously published papers, the learning curve for laparoscopic groin hernia repair is controversial. The purpose of the present study was to evaluate the learning curve for laparoscopic surgery for groin hernia in a local hospital setting. METHOD We analyzed 100 consecutive cases of laparoscopic transabdominal preperitoneal repair performed by a single surgeon at a single facility from April 2013 to December 2015. The total operative time was divided into three parts: (a) preparing the peritoneal flap, (b) unfolding the mesh, and (c) suturing the peritoneum. A cumulative sum method for the total operative time and duration of the three parts was used to determine the learning curve. RESULTS The learning curve was overcome after 75 cases based on cumulative sum analysis of the total operative time. The cumulative sum analysis of the times to unfold mesh and to suture the peritoneum indicated that the learning curve was overcome after 22 and 32 cases, respectively. The learning curve for preparing the peritoneal space was correlated with that for the entire procedure. No cases of recurrence were encountered. CONCLUSION At least 75 cases were needed to overcome the learning curve for laparoscopic transabdominal preperitoneal repair.
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Affiliation(s)
- Hiroyuki Kuge
- Department of Coloproctology, Kenseikai Nara Coloproctology Center, Nara, Japan.,Department of Surgery, Nara Medical University, Nara, Japan
| | - Takashi Yokoo
- Department of Coloproctology, Kenseikai Nara Coloproctology Center, Nara, Japan
| | - Hideki Uchida
- Department of Coloproctology, Kenseikai Nara Coloproctology Center, Nara, Japan
| | - Kentaro Yamaoka
- Department of Coloproctology, Kenseikai Nara Coloproctology Center, Nara, Japan
| | - Shusaku Yoshikawa
- Department of Coloproctology, Kenseikai Nara Coloproctology Center, Nara, Japan
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Görgec B, Suhool A, Al-Jarrah R, Fontana M, Tehami NA, Modi S, Abu Hilal M. Surgical technique and clinical results of one- or two-stage laparoscopic right hemihepatectomy after portal vein embolization in patients with initially unresectable colorectal liver metastases: A case series. Int J Surg 2020; 77:69-75. [PMID: 32171801 DOI: 10.1016/j.ijsu.2020.03.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/21/2020] [Accepted: 03/04/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The use of the laparoscopic approach in one-stage or second-step of two-stage right hemihepatectomy (RHH) after portal vein embolization (PVE) in patients with initially unresectable colorectal liver metastases (CRLMs) is technically demanding. Currently, there is limited published data regarding the technique and results required to better understand its safety and feasibility. This paper reports our experience, results, techniques and variety of tips and tricks (highlighted in the attached video), to facilitate this resection. METHODS A prospectively maintained database of laparoscopic liver surgery within our unit at a tertiary referral centre between August 2003 and March 2019 was reviewed. Patients with initially unresectable CRLMs who underwent laparoscopic RHH or extended RHH after PVE in the context of a one or two-stage procedure were included. RESULTS Between August 2003 and March 2019, 19 patients with initially unresectable CRLMs underwent laparoscopic RHH after PVE. Twelve patients (63.2%) had RHH in the context of a two-stage hepatectomy and 7 as a one-stage procedure. Median time interval between PVE and surgery was 42.5 days (IQR, 34.5-60.0 days). Mean operating time was 351.8 ± 80.5 minutes. Median blood loss was 850 mL (IQR, 475-1350 mL). Conversion to open surgery occurred in 2 of 19 cases (10.5%). Severe postoperative morbidity occurred in 2 patients. The mortality rate was 5.3%. Median postoperative hospital stay was 5 days (IQR, 4-7 days). Radical resection was obtained in eighteen patients (94.7%). CONCLUSION Laparoscopic RHH after PVE in the context of a one- or two-stage resection in patients with initially unresectable CRLMs is a safe and feasible procedure with favourable oncological outcomes.
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Affiliation(s)
- Burak Görgec
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Tremona Road, SO16 2YD, Southampton, UK; Department of Surgery, Fondazione Poliambulanza, Istituto Ospedaliero, Via Bissolati 57, Brescia, Italy
| | - Amal Suhool
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Tremona Road, SO16 2YD, Southampton, UK
| | - Ra'ed Al-Jarrah
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Tremona Road, SO16 2YD, Southampton, UK
| | - Martina Fontana
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Tremona Road, SO16 2YD, Southampton, UK; Department of Surgery, University Hospital of Verona, Piazzale Aristide Stefani 1, Verona, Italy
| | - Nadeem A Tehami
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Tremona Road, SO16 2YD, Southampton, UK
| | - Sachin Modi
- Department of Radiology, University Hospital Southampton NHS Foundation Trust, Tremona Road, SO16 2YD, Southampton, UK
| | - Mohammad Abu Hilal
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Tremona Road, SO16 2YD, Southampton, UK; Department of Surgery, Fondazione Poliambulanza, Istituto Ospedaliero, Via Bissolati 57, Brescia, Italy.
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76
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Cai M, Syn NLX, Koh YX, Teo JY, Lee SY, Cheow PC, Chow PKH, Chung AYF, Chan CY, Goh BKP. Impact of First Assistant Surgeon Experience on the Perioperative Outcomes of Laparoscopic Hepatectomies. J Laparoendosc Adv Surg Tech A 2020; 30:423-428. [PMID: 32109190 DOI: 10.1089/lap.2019.0701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Introduction: This study aims to evaluate the impact of first assistant surgeon experience on the outcomes of laparoscopic hepatectomies in a university-affiliated teaching hospital. Methods: This is a retrospective study comparing outcomes of laparoscopic hepatectomies with first assistant surgeons of varying experience levels. Three hundred and eighty-five consecutive laparoscopic hepatectomies performed in a tertiary university-affiliated teaching hospital from 2012 to 2018 were included and stratified into three cohorts-Group 1 in which assistants were residents, Group 2 for fellows, and Group 3 for attendings. Baseline clinicopathologic variables and outcome measures were analyzed using the augmented inverse probability of treatment weighting approach, which is a propensity score-based method that combines aspects of covariate adjustment and inverse probability weighting. Results: Group 3 comprised a greater proportion of advanced- and expert-level surgeries based on the Iwate criteria; 33.8%, 32.2%, and 46.0% of patients underwent advanced- and expert-level surgeries in Groups 1, 2, and 3, respectively. Group 3 had consistently higher operative times as well as more frequent use and longer duration of Pringle's maneuver (P < .05). The median operative times for Groups 1, 2, and 3 were 195, 195, and 290 minutes, respectively. Pringle's maneuver was applied in 26.9%, 33.9%, and 60.2% of patients with a corresponding median duration of 35, 36, and 45 minutes, respectively. None of the other perioperative and postoperative outcomes demonstrated statistically significant differences. Conclusion: With an appropriate selection of cases, participation of residents as first assistants in laparoscopic hepatectomies can be encouraged without compromise in perioperative outcomes.
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Affiliation(s)
- Mingzhe Cai
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Nicholas L X Syn
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Ye-Xin Koh
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Jin-Yao Teo
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Ser-Yee Lee
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Peng-Chung Cheow
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Pierce K H Chow
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
| | - Alexander Y F Chung
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Chung-Yip Chan
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore
| | - Brian K P Goh
- Department of Hepato-Pancreato-Biliary and Transplant Surgery, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Medical School, National University of Singapore, Singapore, Singapore
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77
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Goh BKP, Prieto M, Syn N, Koh Y, Lim K. Critical appraisal of the learning curve of minimally invasive hepatectomy: experience with the first 200 cases of a Southeast Asian early adopter. ANZ J Surg 2020; 90:1092-1098. [DOI: 10.1111/ans.15683] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 12/17/2019] [Accepted: 12/22/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Brian K. P. Goh
- Department of Hepatopancreatobiliary and Transplant SurgerySingapore General Hospital Singapore
- Duke‐National University of Singapore Medical School Singapore
| | - Mikel Prieto
- Hepatobiliary Surgery and Liver Transplantation UnitCruces University Hospital Bilbao Spain
| | - Nicholas Syn
- Yong Loo Lin School of MedicineNational University of Singapore Singapore
| | - Ye‐Xin Koh
- Department of Hepatopancreatobiliary and Transplant SurgerySingapore General Hospital Singapore
| | - Kai‐Inn Lim
- Department of AnaesthesiologySingapore General Hospital Singapore
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78
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Long-term outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma: Retrospective case-matched study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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79
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Schneider C, Thompson S, Totz J, Song Y, Allam M, Sodergren MH, Desjardins AE, Barratt D, Ourselin S, Gurusamy K, Stoyanov D, Clarkson MJ, Hawkes DJ, Davidson BR. Comparison of manual and semi-automatic registration in augmented reality image-guided liver surgery: a clinical feasibility study. Surg Endosc 2020; 34:4702-4711. [PMID: 32780240 PMCID: PMC7524854 DOI: 10.1007/s00464-020-07807-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 07/10/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The laparoscopic approach to liver resection may reduce morbidity and hospital stay. However, uptake has been slow due to concerns about patient safety and oncological radicality. Image guidance systems may improve patient safety by enabling 3D visualisation of critical intra- and extrahepatic structures. Current systems suffer from non-intuitive visualisation and a complicated setup process. A novel image guidance system (SmartLiver), offering augmented reality visualisation and semi-automatic registration has been developed to address these issues. A clinical feasibility study evaluated the performance and usability of SmartLiver with either manual or semi-automatic registration. METHODS Intraoperative image guidance data were recorded and analysed in patients undergoing laparoscopic liver resection or cancer staging. Stereoscopic surface reconstruction and iterative closest point matching facilitated semi-automatic registration. The primary endpoint was defined as successful registration as determined by the operating surgeon. Secondary endpoints were system usability as assessed by a surgeon questionnaire and comparison of manual vs. semi-automatic registration accuracy. Since SmartLiver is still in development no attempt was made to evaluate its impact on perioperative outcomes. RESULTS The primary endpoint was achieved in 16 out of 18 patients. Initially semi-automatic registration failed because the IGS could not distinguish the liver surface from surrounding structures. Implementation of a deep learning algorithm enabled the IGS to overcome this issue and facilitate semi-automatic registration. Mean registration accuracy was 10.9 ± 4.2 mm (manual) vs. 13.9 ± 4.4 mm (semi-automatic) (Mean difference - 3 mm; p = 0.158). Surgeon feedback was positive about IGS handling and improved intraoperative orientation but also highlighted the need for a simpler setup process and better integration with laparoscopic ultrasound. CONCLUSION The technical feasibility of using SmartLiver intraoperatively has been demonstrated. With further improvements semi-automatic registration may enhance user friendliness and workflow of SmartLiver. Manual and semi-automatic registration accuracy were comparable but evaluation on a larger patient cohort is required to confirm these findings.
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Affiliation(s)
- C. Schneider
- Division of Surgery & Interventional Science, Royal Free Campus, University College London, Pond Street, London, NW3 2QG UK
| | - S. Thompson
- Wellcome / EPSRC Centre for Surgical and Interventional Sciences (WEISS), University College London, London, UK ,Centre for Medical Image Computing (CMIC), University College London, London, UK ,Department of Medical Physics and Bioengineering, University College London, London, UK
| | - J. Totz
- Wellcome / EPSRC Centre for Surgical and Interventional Sciences (WEISS), University College London, London, UK ,Centre for Medical Image Computing (CMIC), University College London, London, UK ,Department of Medical Physics and Bioengineering, University College London, London, UK
| | - Y. Song
- Wellcome / EPSRC Centre for Surgical and Interventional Sciences (WEISS), University College London, London, UK ,Centre for Medical Image Computing (CMIC), University College London, London, UK ,Department of Medical Physics and Bioengineering, University College London, London, UK
| | - M. Allam
- Division of Surgery & Interventional Science, Royal Free Campus, University College London, Pond Street, London, NW3 2QG UK
| | - M. H. Sodergren
- Centre for Medical Image Computing (CMIC), University College London, London, UK
| | - A. E. Desjardins
- Wellcome / EPSRC Centre for Surgical and Interventional Sciences (WEISS), University College London, London, UK ,Department of Medical Physics and Bioengineering, University College London, London, UK
| | - D. Barratt
- Wellcome / EPSRC Centre for Surgical and Interventional Sciences (WEISS), University College London, London, UK ,Centre for Medical Image Computing (CMIC), University College London, London, UK ,Department of Medical Physics and Bioengineering, University College London, London, UK
| | - S. Ourselin
- Wellcome / EPSRC Centre for Surgical and Interventional Sciences (WEISS), University College London, London, UK ,Centre for Medical Image Computing (CMIC), University College London, London, UK ,Department of Medical Physics and Bioengineering, University College London, London, UK
| | - K. Gurusamy
- Division of Surgery & Interventional Science, Royal Free Campus, University College London, Pond Street, London, NW3 2QG UK ,Wellcome / EPSRC Centre for Surgical and Interventional Sciences (WEISS), University College London, London, UK ,Department of Hepatopancreatobiliary and Liver Transplant Surgery, Royal Free Hospital, London, UK
| | - D. Stoyanov
- Wellcome / EPSRC Centre for Surgical and Interventional Sciences (WEISS), University College London, London, UK ,Centre for Medical Image Computing (CMIC), University College London, London, UK ,Department of Computer Science, University College London, London, UK
| | - M. J. Clarkson
- Wellcome / EPSRC Centre for Surgical and Interventional Sciences (WEISS), University College London, London, UK ,Centre for Medical Image Computing (CMIC), University College London, London, UK ,Department of Medical Physics and Bioengineering, University College London, London, UK
| | - D. J. Hawkes
- Wellcome / EPSRC Centre for Surgical and Interventional Sciences (WEISS), University College London, London, UK ,Centre for Medical Image Computing (CMIC), University College London, London, UK ,Department of Medical Physics and Bioengineering, University College London, London, UK
| | - B. R. Davidson
- Division of Surgery & Interventional Science, Royal Free Campus, University College London, Pond Street, London, NW3 2QG UK ,Wellcome / EPSRC Centre for Surgical and Interventional Sciences (WEISS), University College London, London, UK ,Department of Hepatopancreatobiliary and Liver Transplant Surgery, Royal Free Hospital, London, UK
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80
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Xu H, Liu F, Hao X, Wei Y, Li B, Wen T, Wang W, Yang J. Laparoscopically anatomical versus non-anatomical liver resection for large hepatocellular carcinoma. HPB (Oxford) 2020; 22:136-143. [PMID: 31320241 DOI: 10.1016/j.hpb.2019.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 06/03/2019] [Accepted: 06/20/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND The role of laparoscopically anatomical resection (LAR) for hepatocellular carcinoma (HCC) remains unclear due to the more demanding technique required in laparoscopy. This study is to analyze the clinical impact of LAR compared to laparoscopically non-anatomical resection (LNAR) for HCC. METHODS All patients received laparoscopic hepatectomy for HCC (diameter 5-10 cm) from January 2015 to December 2018 were retrospectively enrolled in this study. Patients were divided into LAR and LNAR groups. The perioperative and oncological outcomes were evaluated based on propensity score matching (PSM) method. RESULTS After PSM, 51 patients in each group were enrolled. The operative time in LAR group was longer (240 vs 195.0 min, p = 0.012) and blood loss was more (200.0 vs 150.0 mL, p = 0.030) than those of LNAR group, respectively. The total complication rates were comparable between them (21.6% vs 17.6%, p = 0.500). The 3-year overall survival rates were 59.4% in LAR group and 38.7% in LNAR group, respectively (p = 0.045). The 3-year disease-free survival rates were 52.3% in LAR group and 27.0% in LNAR group, respectively (p = 0.042). CONCLUSION LAR could be feasibly performed with comparable perioperative outcomes and contributed to improve long-term survival in patients with HCC (diameter 5-10 cm) when compared to LNAR.
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Affiliation(s)
- HongWei Xu
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - Fei Liu
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - XiangYong Hao
- Department of General Surgery, Gansu Provincial Hospital, Lanzhou, Gansu Province, China
| | - YongGang Wei
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
| | - Bo Li
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China.
| | - TianFu Wen
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - WenTao Wang
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
| | - JiaYin Yang
- Department of Liver Surgery, Center of Liver Transplantation, West China Hospital of Sichuan University, Chengdu, Sichuan Province, China
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81
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van der Poel MJ, Fichtinger RS, Bemelmans M, Bosscha K, Braat AE, de Boer MT, Dejong CHC, Doornebosch PG, Draaisma WA, Gerhards MF, Gobardhan PD, Gorgec B, Hagendoorn J, Kazemier G, Klaase J, Leclercq WKG, Liem MS, Lips DJ, Marsman HA, Mieog JSD, Molenaar QI, Nieuwenhuijs VB, Nota CL, Patijn GA, Rijken AM, Slooter GD, Stommel MWJ, Swijnenburg RJ, Tanis PJ, Te Riele WW, Terkivatan T, van den Tol PM, van den Boezem PB, van der Hoeven JA, Vermaas M, Abu Hilal M, van Dam RM, Besselink MG. Implementation and outcome of minor and major minimally invasive liver surgery in the Netherlands. HPB (Oxford) 2019; 21:1734-1743. [PMID: 31235430 DOI: 10.1016/j.hpb.2019.05.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/25/2019] [Accepted: 05/07/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND While most of the evidence on minimally invasive liver surgery (MILS) is derived from expert centers, nationwide outcomes remain underreported. This study aimed to evaluate the implementation and outcome of MILS on a nationwide scale. METHODS Electronic patient files were reviewed in all Dutch liver surgery centers and all patients undergoing MILS between 2011 and 2016 were selected. Operative outcomes were stratified based on extent of the resection and annual MILS volume. RESULTS Overall, 6951 liver resections were included, with a median annual volume of 50 resections per center. The overall use of MILS was 13% (n = 916), which varied from 3% to 36% (P < 0.001) between centers. The nationwide use of MILS increased from 6% in 2011 to 23% in 2016 (P < 0.001). Outcomes of minor MILS were comparable with international studies (conversion 0-13%, mortality <1%). In centers which performed ≥20 MILS annually, major MILS was associated with less conversions (14 (11%) versus 41 (30%), P < 0.001), shorter operating time (184 (117-239) versus 200 (139-308) minutes, P = 0.010), and less overall complications (37 (30%) versus 58 (42%), P = 0.040). CONCLUSION The nationwide use of MILS is increasing, although large variation remains between centers. Outcomes of major MILS are better in centers with higher volumes.
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Affiliation(s)
- Marcel J van der Poel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Robert S Fichtinger
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands; RWTH Aachen, Germany
| | - Marc Bemelmans
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands; RWTH Aachen, Germany
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Andries E Braat
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke T de Boer
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands; RWTH Aachen, Germany
| | - Pascal G Doornebosch
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - Werner A Draaisma
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands; Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
| | | | | | - Burak Gorgec
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - Joost Klaase
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands; Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | | | - Mike S Liem
- Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | - Daan J Lips
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands; Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | | | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Quintus I Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Carolijn L Nota
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala, Zwolle, the Netherlands
| | - Arjen M Rijken
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Gerrit D Slooter
- Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands; Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Wouter W Te Riele
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Türkan Terkivatan
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Petrousjka M van den Tol
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | | | | | - Maarten Vermaas
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - Moh'd Abu Hilal
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands; RWTH Aachen, Germany
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
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A Comparison of the Learning Curves of Laparoscopic Liver Surgeons in Differing Stages of the IDEAL Paradigm of Surgical Innovation: Standing on the Shoulders of Pioneers. Ann Surg 2019; 269:221-228. [PMID: 30080729 DOI: 10.1097/sla.0000000000002996] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To compare the learning curves of the self-taught "pioneers" of laparoscopic liver surgery (LLS) with those of the trained "early adopters" in terms of short- and medium-term patient outcomes to establish if the learning curve can be reduced with specific training. SUMMARY OF BACKGROUND DATA It is expected that a wider adoption of a laparoscopic approach to liver surgery will be seen in the next few years. Current guidelines stress the need for an incremental, stepwise progression through the learning curve in order to minimize harm to patients. Previous studies have examined the learning curve in Stage 2 of the IDEAL paradigm of surgical innovation; however, LLS is now in stage 3 with specific training being provided to surgeons. METHODS Using risk-adjusted cumulative sum analysis, the learning curves and short- and medium-term outcomes of 4 "pioneering" surgeons from stage 2 were compared with 4 "early adapting" surgeons from stage 3 who had received specific training for LLS. RESULTS After 46 procedures, the short- and medium-term outcomes of the "early adopters" were comparable to those achieved by the "pioneers" following 150 procedures in similar cases. CONCLUSIONS With specific training, "early adapting" laparoscopic liver surgeons are able to overcome the learning curve for minor and major liver resections faster than the "pioneers" who were self-taught in LLS. The findings of this study are applicable to all surgical specialties and highlight the importance of specific training in the safe expansion of novel surgical practice.
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83
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Kim JH, Kim H. Modified liver hanging maneuver in laparoscopic major hepatectomy: the learning curve and evolution of indications. Surg Endosc 2019; 34:2742-2748. [PMID: 31712899 DOI: 10.1007/s00464-019-07248-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 11/03/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Laparoscopic major hepatectomy is a technically challenging procedure requiring a steep learning curve. The liver hanging maneuver is a useful technique in liver resection, especially for large or invasive tumors, a relative contraindication of the laparoscopic approach. Therefore, this study aimed to evaluate the learning curve for laparoscopic major hepatectomy using the liver hanging maneuver and extended indications. METHODS Patients who underwent laparoscopic major hepatectomy using the liver hanging maneuver by a single surgeon from January 2013 and September 2018 were retrospectively reviewed. Our hanging technique involves placing the hanging tape along the inferior vena cava for right-sided hepatectomy or the ligamentum venosum for left-sided hepatectomy. The upper end of the tape was placed at the lateral side of the major hepatic veins. The learning curve for operating time and blood loss was evaluated using the cumulative sum (CUSUM) method. RESULTS Among 53 patients, 18 underwent right hepatectomy, 26 underwent left hepatectomy, and 9 underwent right posterior sectionectomy. CUSUM analysis showed that operative time and blood loss improved after the 30th laparoscopic major hepatectomy. The 53 consecutive patients were divided into two groups (early, patients 1-30; late, patients 31-53). The median operative time was lower in the late group, but the difference was not statistically significant (270 vs. 245 min, p = 0.261). The median blood loss was also significantly lower in the late group (350 vs. 150 ml, p < 0.001). Large tumors (measuring > 10 cm) and tumors in proximity to major vessels were significantly higher in the late group (0 vs. 17.4%, p = 0.018; 3.3 vs. 21.7%, p = 0.036; respectively). CONCLUSION This study shows that laparoscopic major hepatectomy using the modified liver hanging maneuver has a learning curve of 30 cases. After procedure standardization, the indications have gradually been extended to large or invasive tumors.
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Affiliation(s)
- Ji Hoon Kim
- Department of Surgery, Eulji University College of Medicine, Dunsan 2(i)-dong, Seo-gu, Daejeon, Republic of Korea.
| | - Hyeyoung Kim
- Department of Surgery, Eulji University College of Medicine, Dunsan 2(i)-dong, Seo-gu, Daejeon, Republic of Korea
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84
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Goh BKP, Lee S, Koh Y, Kam J, Chan C. Minimally invasive major hepatectomies: a Southeast Asian single institution contemporary experience with its first 120 consecutive cases. ANZ J Surg 2019; 90:553-557. [DOI: 10.1111/ans.15563] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 10/12/2019] [Accepted: 10/14/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Brian K. P. Goh
- Department of Hepatopancreatobiliary and Transplant SurgerySingapore General Hospital Singapore
- Office of Clinical SciencesDuke‐NUS Medical School Singapore
| | - Ser‐Yee Lee
- Department of Hepatopancreatobiliary and Transplant SurgerySingapore General Hospital Singapore
- Office of Clinical SciencesDuke‐NUS Medical School Singapore
| | - Ye‐Xin Koh
- Department of Hepatopancreatobiliary and Transplant SurgerySingapore General Hospital Singapore
- Office of Clinical SciencesDuke‐NUS Medical School Singapore
| | - Juinn‐Huar Kam
- Department of Hepatopancreatobiliary and Transplant SurgerySingapore General Hospital Singapore
| | - Chung‐Yip Chan
- Department of Hepatopancreatobiliary and Transplant SurgerySingapore General Hospital Singapore
- Office of Clinical SciencesDuke‐NUS Medical School Singapore
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Sultana A, Nightingale P, Marudanayagam R, Sutcliffe RP. Evaluating the learning curve for laparoscopic liver resection: a comparative study between standard and learning curve CUSUM. HPB (Oxford) 2019; 21:1505-1512. [PMID: 30992198 DOI: 10.1016/j.hpb.2019.03.362] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/19/2018] [Accepted: 03/13/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND Laparoscopic liver resection (LLR) requires training in both hepatobiliary surgery and advanced laparoscopy. Available data on LLR learning curves are derived from pioneer surgeons. The aims of this study were to evaluate the LLR learning curve for second generation surgeons, and to compare different CUSUM methodology with and without risk adjustment. METHODS Retrospective analysis of a prospective database of 111 consecutive patients who underwent LLR by two surgeons at a single centre between 2011 and 2016. The LLR learning curve for minor hepatectomy (MH) was evaluated for each surgeon using standard CUSUM before and after risk-adjusting for operative difficulty using the Iwate index, and compared with Learning Curve (LC) CUSUM. The end points were operative time and conversion rate. RESULTS Standard CUSUM analysis identified a learning curve of 50-60 MH procedures. The corresponding learning curve reduced to 25-30 after risk-adjusting for operative difficulty, whilst LC-CUSUM identified a learning curve of 17-25 procedures. CONCLUSIONS The learning curve for laparoscopic minor liver resection by second generation surgeons is shorter than that for pioneer surgeons. Laparoscopic HPB fellowship programmes may further shorten the learning curve, facilitating safe expansion of LLR. The LC-CUSUM method is an alternative technique that warrants further study.
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Affiliation(s)
- Asma Sultana
- Department of HPB Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Peter Nightingale
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ravi Marudanayagam
- Department of HPB Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Robert P Sutcliffe
- Department of HPB Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.
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86
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Troisi RI, Pegoraro F, Giglio MC, Rompianesi G, Berardi G, Tomassini F, De Simone G, Aprea G, Montalti R, De Palma GD. Robotic approach to the liver: Open surgery in a closed abdomen or laparoscopic surgery with technical constraints? Surg Oncol 2019; 33:239-248. [PMID: 31759794 DOI: 10.1016/j.suronc.2019.10.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 10/24/2019] [Indexed: 02/07/2023]
Abstract
The application of the minimally invasive approach has shown to be safe and effective for liver surgery and is in constant growth. The indications for laparoscopic surgery are steadily increasing across the field. In the early 2000s, robotic surgery led to some additional improvements, such as tremor filtration, instrument stability, 3D view and more comfort for the surgeon. These techniques bring in some advantages compared to the traditional OLR: less blood loss, shorter admissions, fewer adhesions, and a faster postoperative recovery and better outcomes in case of further hepatectomy for tumor recurrence has been shown. Concerning which is the best minimally invasive approach between laparoscopic and robotic surgery, the evidence is still conflicting. The latter shows good potential, since the endo-wristed instruments work similarly to the surgeon's hands, even with an intact abdominal wall. However, the technique is still under development, burdened by important costs, and limited by the lack of some instruments available for the laparoscopic approach. The paucity of universally accepted and proven data, especially concerning long-term outcomes, hampers drawing univocal acceptance at present. Furthermore, the number of variables related both to the patient and the disease further complicates the decision leading to a treatment tailored to each patient with strict selection. This review aims to explore the main differences between laparoscopic and robotic surgery, focusing on indications, operative technique and current debated clinical issues in recent literature.
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Affiliation(s)
- Roberto Ivan Troisi
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy; Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium.
| | - Francesca Pegoraro
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | | | - Giammauro Berardi
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium
| | - Federico Tomassini
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium
| | - Giuseppe De Simone
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | - Giovanni Aprea
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | - Roberto Montalti
- Department of Public Health, Federico II University Naples, Italy
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
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87
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Triantafyllidis I, Gayet B, Tsiakyroudi S, Tabchouri N, Beaussier M, Bennamoun M, Sarran A, Lefevre M, Louvet C, Fuks D. Perioperative and long-term outcomes of laparoscopic liver resections for non-colorectal liver metastases. Surg Endosc 2019; 34:3833-3844. [PMID: 31586246 DOI: 10.1007/s00464-019-07148-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 09/24/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Liver is a common metastatic site not only of colorectal but of non-colorectal neoplasms, as well. However, resection of non-colorectal liver metastases (NCRLMs) remains controversial. The aim of this retrospective study was to analyze the short- and long-term outcomes of patients undergoing laparoscopic liver resection (LLR) for NCRLMs. METHODS From a prospectively maintained database between 2000 and 2018, patients undergoing LLR for colorectal liver metastases (CRLMs) and NCRLMs were selected. Clinicopathologic, operative, short- and long-term outcome data were collected, analyzed, and compared among patients with CRLMs and NCRLMs. RESULTS The primary tumor was colorectal in 354 (82.1%), neuroendocrine in 21 (4.9%), and non-colorectal, non-neuroendocrine in the remaining 56 (13%) patients. Major postoperative morbidities were 12.7%, 19%, and 3.6%, respectively (p = 0.001), whereas the mortality was 0.6% for patients with CRLMs and zero for patients with NCRLMs. The rate of R1 surgical margin was comparable (p = 0.432) among groups. According to the survival analysis, 3- and 5-year recurrence-free survival (RFS) rates were 76.1% and 64.3% in the CRLM group, 57.1% and 42.3% in the neuroendocrine liver metastase (NELM) group, 33% and 20.8% in the non-colorectal, non-neuroendocrine liver metastase (NCRNNELM) group (p = 0.001), respectively. Three- and 5-year overall survival (OS) rates were 88.3% and 82.7% in the CRLM group, 85.7% and 70.6% in the NELM group, 71.4% and 52.9% in the NCRNNELM group (p = 0.001), respectively. In total, 113 out of 354 (31.9%) patients with CRLMs, 2 out of 21(9.5%) with NELMs, and 8 out of 56 (14.3%) patients with NCRNNELMs underwent repeat LLR for recurrent metastatic tumors. CONCLUSION LLR is safe and feasible in the context of a multimodal management where an aggressive surgical approach, necessitating even complex procedures for bilobar multifocal metastases and repeat hepatectomy for recurrences, is the mainstay and may be of benefit in the long-term survival, in selected patients with NCRNNELMs.
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Affiliation(s)
- Ioannis Triantafyllidis
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, 42 Boulevard Jourdan, 75014, Paris, France.,Department of General Surgery, General Hospital of Veria, 59132, Veria, Greece
| | - Brice Gayet
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, 42 Boulevard Jourdan, 75014, Paris, France
| | - Sofia Tsiakyroudi
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, 42 Boulevard Jourdan, 75014, Paris, France
| | - Nicolas Tabchouri
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, 42 Boulevard Jourdan, 75014, Paris, France
| | - Marc Beaussier
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, 42 Boulevard Jourdan, 75014, Paris, France
| | - Mostefa Bennamoun
- Department of Oncology, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France
| | - Anthony Sarran
- Department of Radiology, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France
| | - Marine Lefevre
- Department of Pathology, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France
| | - Christophe Louvet
- Department of Oncology, Institut Mutualiste Montsouris, 42 Boulevard Jourdan, 75014, Paris, France
| | - David Fuks
- Department of Digestive Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université Paris Descartes, 42 Boulevard Jourdan, 75014, Paris, France.
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Peyton J, von Ungern-Sternberg BS. If you think you can do it, that's confidence: If you do it that's competence-Where are we in pediatric anesthesia? Paediatr Anaesth 2019; 29:981-982. [PMID: 31602742 DOI: 10.1111/pan.13720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 08/09/2019] [Indexed: 12/01/2022]
Affiliation(s)
- James Peyton
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Medicine, Perth Children's Hospital, Perth, Australia.,Medical School, The University of Western Australia, Perth, Australia.,Telethon Kids Institute, Perth, Australia
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89
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Chen TH, Yang HR, Jeng LB, Hsu SC, Hsu CH, Yeh CC, Yang MD, Chen WTL. Laparoscopic Liver Resection: Experience of 436 Cases in One Center. J Gastrointest Surg 2019; 23:1949-1956. [PMID: 30421118 DOI: 10.1007/s11605-018-4023-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 10/18/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND To report experience of laparoscopic liver resection (LLR) in one center. METHODS We retrospectively reviewed 436 consecutive LLRs in 411 patients between December 2010 and December 2016. On the basis of the 2008 Louisville Statement, we divided the 436 cases into two groups: Simple Group (n = 203) and Difficult Group (n = 233). RESULTS The indications were HCC (n = 194), colorectal cancer liver metastasis (n = 156), benign tumors (n = 62), hepatolithiasis (n = 2), and other malignant lesions (n = 22). The median tumor size was 24 mm (range 3 to 130). Procedures of LLR included wedge resection (n = 230), one segmentectomy (n = 8), two segmentectomies (n = 12), left lateral sectionectomy (n = 75), right hepatectomy (n = 52), left hepatectomy (n = 31), extended right hepatectomy (n = 2), extended left hepatectomy (n = 5), central bisectionectomy (n = 3), right posterior sectionectomy (n = 12), and right anterior sectionectomy (n = 6). The median operative time was 228 min (range 9-843) and median blood loss was 150 ml (range 2-3500). Twenty-five cases required blood transfusion (5.7%). Conversion to open surgery was required in six cases (1.4%). The mean length of stay was 6.4 ± 2.9 days. Overall complication rate was 9.4% and major complication rate was 5%. One patient died of liver failure on the thirtieth postoperative day after a right hepatectomy. We had higher median blood loss (200 vs. 100 ml; p < 0.001), higher transfusion rate (8.2 vs. 2.9%; p = 0.020), longer median operative time (297 vs. 164 min; p < 0.001), higher conversion rate (2.6 vs. 0%; p = 0.021), higher complication rate (14.2 vs. 3.9%; p < 0.001), and longer mean postoperative hospital stay (6.8 ± 2.9 vs. 5.9 ± 3.0 days; p < 0.001) in the Difficult Group. CONCLUSIONS Laparoscopic liver resection is safe for selected patients in the Difficult Group. On the basis of the 2008 Louisville Statement, selection criteria of LLR are helpful to predict the difficulty of the operation and the postoperative outcomes of LLR.
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Affiliation(s)
- Te-Hung Chen
- School of Medicine, China Medical University, No.2, Yude Rd., North Dist, Taichung City, 404, Taiwan.,Department of Surgery, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Horng-Ren Yang
- School of Medicine, China Medical University, No.2, Yude Rd., North Dist, Taichung City, 404, Taiwan.,Department of Surgery, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Long-Bin Jeng
- School of Medicine, China Medical University, No.2, Yude Rd., North Dist, Taichung City, 404, Taiwan. .,Department of Surgery, China Medical University Hospital, China Medical University, Taichung, Taiwan.
| | - Shih-Chao Hsu
- School of Medicine, China Medical University, No.2, Yude Rd., North Dist, Taichung City, 404, Taiwan.,Department of Surgery, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chia-Hao Hsu
- School of Medicine, China Medical University, No.2, Yude Rd., North Dist, Taichung City, 404, Taiwan.,Department of Surgery, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chun-Chieh Yeh
- School of Medicine, China Medical University, No.2, Yude Rd., North Dist, Taichung City, 404, Taiwan.,Department of Surgery, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Mei-Due Yang
- School of Medicine, China Medical University, No.2, Yude Rd., North Dist, Taichung City, 404, Taiwan.,Department of Surgery, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - William Tzu-Liang Chen
- School of Medicine, China Medical University, No.2, Yude Rd., North Dist, Taichung City, 404, Taiwan.,Department of Surgery, China Medical University Hospital, China Medical University, Taichung, Taiwan
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90
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Critical Appraisal of the Impact of the Systematic Adoption of Advanced Minimally Invasive Hepatobiliary and Pancreatic Surgery on the Surgical Management of Mirizzi Syndrome. World J Surg 2019; 43:3138-3152. [DOI: 10.1007/s00268-019-05164-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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91
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Berardi G, Aghayan D, Fretland ÅA, Elberm H, Cipriani F, Spagnoli A, Montalti R, Ceelen WP, Aldrighetti L, Abu Hilal M, Edwin B, Troisi RI. Multicentre analysis of the learning curve for laparoscopic liver resection of the posterosuperior segments. Br J Surg 2019; 106:1512-1522. [PMID: 31441944 DOI: 10.1002/bjs.11286] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 04/12/2019] [Accepted: 05/27/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic liver resection demands expertise and a long learning curve. Resection of the posterosuperior segments is challenging, and there are no data on the learning curve. The aim of this study was to evaluate the learning curve for laparoscopic resection of the posterosuperior segments. METHODS A cumulative sum (CUSUM) analysis of the difficulty score for resection was undertaken using patient data from four specialized centres. Risk-adjusted CUSUM analysis of duration of operation, blood loss and conversions was performed, adjusting for the difficulty score of the procedures. A receiver operating characteristic (ROC) curve was used to identify the completion of the learning curve. RESULTS According to the CUSUM analysis of 464 patients, the learning curve showed an initial decrease in the difficulty score followed by an increase and, finally, stabilization. More patients with cirrhosis or previous surgery were operated in the latest phase of the learning curve. A smaller number of wedge resections and a larger number of anatomical resections were performed progressively. Dissection using a Cavitron ultrasonic surgical aspirator and the Pringle manoeuvre were used more frequently with time. Risk-adjusted CUSUM analysis showed a progressive decrease in operating time. Blood loss initially increased slightly, then stabilized and finally decreased over time. A similar trend was found for conversions. The learning curve was estimated to be 40 procedures for wedge and 65 for anatomical resections. CONCLUSION The learning curve for laparoscopic liver resection of the posterosuperior segments consists of a stepwise process, during which accurate patient selection is key.
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Affiliation(s)
- G Berardi
- Department of Human Structure and Repair, Faculty of Medicine, Ghent University, Belgium
| | - D Aghayan
- Intervention Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Å A Fretland
- Intervention Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway
- Department of Hepatopancreatobiliary Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - H Elberm
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - F Cipriani
- Hepatobiliary Surgery, Department of Surgery, San Raffaele Hospital Milan, Milan, Italy
| | - A Spagnoli
- Department of Statistical Sciences, Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
| | - R Montalti
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - W P Ceelen
- Department of Human Structure and Repair, Faculty of Medicine, Ghent University, Belgium
| | - L Aldrighetti
- Hepatobiliary Surgery, Department of Surgery, San Raffaele Hospital Milan, Milan, Italy
| | - M Abu Hilal
- Hepatobiliary and Pancreatic Surgical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - B Edwin
- Intervention Centre, Oslo University Hospital - Rikshospitalet, Oslo, Norway
- Department of Hepatopancreatobiliary Surgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, Medical Faculty, University of Oslo, Oslo, Norway
| | - R I Troisi
- Department of Human Structure and Repair, Faculty of Medicine, Ghent University, Belgium
- Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
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92
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Rashidian N, Willaert W, Giglio MC, Scuderi V, Tozzi F, Vanlander A, D’Herde K, Alseidi A, Troisi RI. Laparoscopic Liver Surgery Training Course on Thiel-Embalmed Human Cadavers: Program Evaluation, Trainer’s Long-Term Feedback and Steps Forward. World J Surg 2019; 43:2902-2908. [DOI: 10.1007/s00268-019-05103-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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93
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Propensity Score-Matched Analysis of Pure Laparoscopic Versus Hand-Assisted/Hybrid Major Hepatectomy at Two Western Centers. World J Surg 2019; 43:2025-2037. [PMID: 30953196 DOI: 10.1007/s00268-019-04998-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic major hepatectomy is expanding, but little data exist comparing surgical approaches. The aim of this study was to test the hypothesis that pure laparoscopic liver resection (PLAP) has advantages over hand-assisted (HALS) or hybrid (HYB) resection for major hemi-hepatectomy at two western centers. METHODS Using propensity score matching, 65 cases of HALS + HYB (18 hand-assisted and 47 hybrid) were matched to 65 cases of PLAP. Baseline characteristics were well matched for gender, age, ASA score, Childs A cirrhosis, right/left hepatectomy, malignancy, tumor size, and type between the groups. RESULTS The HALS + HYB group had 27 right and 38 left major hepatectomies (n = 65) versus 29 right and 36 left (n = 65) in the PLAP group (p = NS). The median number of lesions resected was 1 in each group, with median size 5.6 cm (HALS + HYB) versus 6.0 cm (PLAP), (p = NS). The HALS + HYB group had shorter OR time (240 versus 330 min, p < 0.01), and less blood loss (EBL 150 ml vs. 300 ml, p < 0.01) versus the PLAP group, respectively. Median length of stay (LOS) was 4 days with HALS + HYB versus 5 days in the PLAP group (p = 0.02). There were no significant differences in use of the Pringle maneuver, transfusion rate, ICU stay, post-op morbidity, liver-specific complications, or R0 resection. Pain regimen/usage in each group is provided. There were no 30/90-day deaths in either group. CONCLUSION This is the first reported series of propensity score matching of HALS + HYB versus PLAP for major hepatectomy. The HALS + HYB group had non-inferior OR time, blood loss, and LOS versus the PLAP group, while the other perioperative parameters were comparable. We conclude that minimally invasive liver resection with either PLAP or HALS + HYB technique yields excellent results.
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94
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Shirasu T, Furuya T, Nagai M, Nomura Y. Learning Curve Analysis to Determine Operative Requirements for Young Vascular Surgeons Learning Open Abdominal Aortic Aneurysm Repair. Circ J 2019; 83:1868-1875. [PMID: 31353341 DOI: 10.1253/circj.cj-19-0386] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Since endovascular aneurysm repair has become predominant, the issue of training young vascular surgeons in open abdominal aortic aneurysm (AAA) surgery has received significant attention. Through learning curve analysis, we aimed to determine the number of cases needed for young surgeons to achieve satisfactory open surgical skills.Methods and Results:A total of 562 consecutive patients who underwent open repair either by an attending surgeon (group A) or 6 young vascular surgeons (group Y) were included and assessed with regards to the preparation, clamp, and total operation times. Although some of the patients' characteristics were different, the surgical procedures were comparable between the 2 groups. There was a clear trend towards a decrease in each 10 successive cases in group Y. The operation times in group A were constant at 72±30 (preparation), 48±10 (clamp), and 231±59 min (total), which were achieved by young vascular surgeons in 10, 30, and 10 cases, respectively. In the cumulative sum analysis, 25-27 cases were necessary for young vascular surgeons to enhance their surgical skills. The complication rate in group Y was no higher than that in group A. CONCLUSIONS Young vascular surgeons can safely learn open AAA repair without increasing operation time or complications. Approximately 30 cases would be necessary to gain satisfactory surgical skills.
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Affiliation(s)
- Takuro Shirasu
- Department of Surgery, Asahi General Hospital.,Division of Vascular Surgery, Department of Surgery, The University of Tokyo
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95
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Laparoscopic pancreaticoduodenectomy for periampullary tumors: lessons learned from 500 consecutive patients in a single center. Surg Endosc 2019; 34:1343-1352. [DOI: 10.1007/s00464-019-06913-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 06/11/2019] [Indexed: 12/22/2022]
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96
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Preoperative Prognosticators of Safe Laparoscopic Hepatocellular Carcinoma Resection in Advanced Cirrhosis: a Propensity Score Matching Population-Based Analysis of 1799 Western Patients. J Gastrointest Surg 2019; 23:1157-1165. [PMID: 30820798 DOI: 10.1007/s11605-019-04139-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 01/23/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The safety and oncologic outcomes of patients with advanced cirrhosis undergoing laparoscopic liver resection (LLR) compared to open resection (OLR) for hepatocellular carcinoma (HCC) remain unclear. METHODS Patients with HCC resection during 2010-2014 were identified from the National Cancer Database. Patients with severe fibrosis; single lesions; M0; and known grade, margin status, tumor size, length of hospital stay, 30- and 90-day mortality, 30-day readmission, surgical approach, and complete follow-up were included. A 1:1 propensity score matching analysis of LLR:OLR was performed. Prognostic effect of LLR was assessed by multivariable Cox proportional hazards model. RESULTS A total of 1799 hepatectomy patients (minor (n = 491, 27.3%); major (n = 1308, 72.7%)) were included. Of 193 (10.7%) LLR patients, 190 were eligible for matching. The LLR vs OLR did not differ for patient characteristics, resection margin status, and 30-day (p = 0.141), 90-day mortality (p = 0.121), or 30-day readmission (p = 0.784). Median hospital stay was shorter for LLR (6 vs 8 days, p = 0.001). Median overall survival (OS) was similar for LLR vs OLR (44.2 and 39.5 months, respectively, p = 0.064). Predictors of worse OS were older age (hazard ratio (HR) 1.04, p = 0.034), > 2 comorbidities (HR 1.29, p = 0.012), grade 3-4 disease (HR 1.81, p = 0.025), N1 disease (HR 1.04, p = 0.048), and R1 margins (HR 1.34, p = 0.002). After adjustment for confounders, LLR vs OLR was not a significant risk factor for OS (HR 1.14, 95% CI 0.76-1.71, p = 0.522). CONCLUSION While LLR in advanced cirrhosis for patients with HCC proved safe, optimal patient selection based on the preoperatively available factors comorbidities, age, degree of underlying liver disease, and high-quality oncologic surgery will determine long-term survival.
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97
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Baltatzis M, Mirza A, Stathakis P, Tyurkylmaz A, Jamdar S, Siriwardena AK, Sheen AJ. Comparison of Outcomes Between Open Major Hepatectomy Using CUSA and Laparoscopic Major Hepatectomy Using "Lotus" Liver Blade. A Propensity Score Matched Analysis. Front Surg 2019; 6:33. [PMID: 31214597 PMCID: PMC6554423 DOI: 10.3389/fsurg.2019.00033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 05/21/2019] [Indexed: 12/19/2022] Open
Abstract
Introduction: Evolution in laparoscopic liver surgery during the past two decades is an indisputable fact. According to the second international consensus conference for laparoscopic liver resection held in Morioka, Japan in 2014 major resections are still regarded as innovative procedures in the exploration phase. On this basis, our study aims to explore the efficacy and safety of laparoscopic vs. open major liver resection and therefore increase the existing evidence on major laparoscopic liver surgery. Methods: All consecutive patients who underwent major liver resection, open and laparoscopic from January 2016 to May 2018 were identified from our prospectively maintained database. Propensity score matching analysis was performed using R statistical tool in SPSS to isolate matched open and laparoscopic cases which were compared for intraoperative and postoperative short-term outcomes. Lotus ultrasonic energy device was used for parenchymal transection in laparoscopic cases vs. CUSA in open procedures. Results: Propensity score matching analysis was performed on 82 consecutive patients (61 open and 21 laparoscopic major hepatectomies) resulting in 40 matched patients, 20 in each group. The mean total duration of surgery and duration of parenchymal transection were slightly longer in the laparoscopic group (p = 0.419, p = 0.348). There was no difference in the intraoperative and postoperative transfusion rates. Patients after laparoscopic surgery were discharged 2 days earlier on average (p = 0.310). No difference was observed in complication rates and mortality. Conclusion: Our data did not reveal inferiority of the laparoscopic major hepatectomy vs. the open approach in any parameter compared. The use of the Lotus ultrasonic energy device appeared to be efficient and safe for parenchymal transection in the laparoscopic procedures.
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Affiliation(s)
- Minas Baltatzis
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Ahmed Mirza
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Panos Stathakis
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Ahmed Tyurkylmaz
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Saurabh Jamdar
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, United Kingdom
| | - Ajith K Siriwardena
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, United Kingdom.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Aali J Sheen
- Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, United Kingdom.,Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom.,Department of Biomedical Research Manchester Metropolitan University, Manchester, United Kingdom
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98
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Aldrighetti L, Cipriani F, Fiorentini G, Catena M, Paganelli M, Ratti F. A stepwise learning curve to define the standard for technical improvement in laparoscopic liver resections: complexity-based analysis in 1032 procedures. Updates Surg 2019; 71:273-283. [PMID: 31119579 DOI: 10.1007/s13304-019-00658-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 04/29/2019] [Indexed: 02/07/2023]
Abstract
The objective of this study is to define the learning curve in a series of procedures grouped according to their complexity calculated by difficulty index to define a standard for technical improvement. 1032 laparoscopic liver resections performed in a single tertiary referral center were stratified by difficulty scores: low difficulty (LD, n = 362); intermediate difficulty (ID, n = 332), and high difficulty (HD, n = 338). The learning curve effect was analyzed using the cumulative sum (CUSUM) method taking into consideration the expected risk of conversion. The ratio of laparoscopic/total liver resections increased from 5.8% (2005) to 71.1% (2018). The CUSUM analysis per group showed that the average value of the conversion rate was reached at the 60th case in the LD Group and at the 15th in the ID and HD groups. The evolution from LD to ID and HD procedures occurred only when learning curve in LD resections was concluded. Reflecting different degree of complexity, procedures showed significantly different blood loss, morbidity, and conversions among groups. A standard educational model-stepwise and progressive-is mandatory to allow surgeons to define the technical and technological backgrounds to deal with a specific degree of difficulty, providing a help in the definition of indications to laparoscopic approach in each phase of training.
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Affiliation(s)
- Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy.
| | - Federica Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Guido Fiorentini
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Marco Catena
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Michele Paganelli
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
| | - Francesca Ratti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132, Milan, Italy
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99
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Tanaka S, Kawaguchi Y, Kubo S, Kanazawa A, Takeda Y, Hirokawa F, Nitta H, Nakajima T, Kaizu T, Kaibori M, Kojima T, Otsuka Y, Fuks D, Hasegawa K, Kokudo N, Kaneko H, Gayet B, Wakabayashi G. Validation of index-based IWATE criteria as an improved difficulty scoring system for laparoscopic liver resection. Surgery 2019; 165:731-740. [DOI: 10.1016/j.surg.2018.10.012] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/05/2018] [Accepted: 10/13/2018] [Indexed: 12/16/2022]
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100
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Fahrner R, Rauchfuß F, Bauschke A, Kissler H, Settmacher U, Zanow J. Robotic hepatic surgery in malignancy: review of the current literature. J Robot Surg 2019; 13:533-538. [PMID: 30895519 DOI: 10.1007/s11701-019-00939-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 02/25/2019] [Indexed: 12/18/2022]
Abstract
The use of minimally invasive liver surgery, such as laparoscopic and robotic surgery, is increasing worldwide. Robot-assisted laparoscopy is a new surgical technique that improves surgical handling. The advantage of this technique is improved dexterity, which leads to increased surgical precision and no tremor or fatigue. Comparable oncological results were documented for laparoscopic and open surgery. Currently, "conventional" laparoscopic liver surgery has limitations with respect to the treatment of lesions in the posterior-superior segments, and there are limited technical features for the reconstruction steps. These limitations might be overcome with the use of robotic surgery. The use of robotic surgery for hepatic procedures originated because of the technical potential to overcome several of the major technical limitations known from conventional laparoscopy and the possibility of performing more extended liver resections. Additionally, there is increasing evidence indicating that robotic hepatic surgery is feasible and safe in resections of the posterior segments. Studies showed that using the robotic technique is associated with a decreased or at least equal amount of intraoperative blood loss compared to that of the conventional laparoscopic or open technique. There is increasing evidence that robotic liver surgery might be as safe as conventional laparoscopic procedures in cancer cases in terms of resection margins, disease-free and overall survival. Furthermore, robotic surgery might be more favorable with respect to postoperative patient recovery. Despite promising results, still large, multicenter, randomized and prospective studies are needed to analyze the exact value of robotic liver surgery in patients with malignant liver tumors.
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Affiliation(s)
- René Fahrner
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07740, Jena, Germany.
| | - Falk Rauchfuß
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07740, Jena, Germany
| | - Astrid Bauschke
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07740, Jena, Germany
| | - Hermann Kissler
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07740, Jena, Germany
| | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07740, Jena, Germany
| | - Jürgen Zanow
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, Am Klinikum 1, 07740, Jena, Germany
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