Laparoscopic liver resection: experience of 53 procedures at a single center

Laparoscopic left lateral sectionectomy: surgical technique and our results from Leeds

BACKGROUND

Although laparoscopic left lateral sectionectomy is increasingly becoming the accepted approach for resection of tumors in hepatic segments II and III, the variations in surgical technique exist.

METHODS

Our technique relies on mobilization of the left lateral sector followed by extracorporeal control of the portal pedicle allowing intermittent occlusion when needed. The parenchyma is thinned, exposing the inflow and outflow allowing application of endoscopic staplers under direct vision for parenchymal transection.

RESULTS

Eleven patients underwent left lateral sectionectomy between 2000 and November 2007 and had a median postoperative stay of 3 days. Two patients had to be converted early on.

CONCLUSION

Left lateral sectionectomy using this approach appears to be safe and reproducible, and this technique should be considered for patients with tumors in hepatic segments II and III.

Laparoscopic left hemihepatectomy: a safety and feasibility study of 19 cases

BACKGROUND

Laparoscopic liver resection was performed at some institutes. The procedure mainly included local resection, segmentectomy, and left lateral segmentectomy. With experience accumulation and technique innovation, laparoscopic left hemihepatectomy was performed in selected patients. This study was designed to introduce and evaluate the safety and feasibility of this procedure.

METHODS

Nineteen successive patients underwent laparoscopic left hemihepatectomy from 2005 to 2007. They were compared by the matched-pair method with 19 other patients who underwent conventional open left hemihepatectomy. Surgical feature, postoperative course, and the learning curve of laparoscopic left hemihepatectomy were studied.

RESULTS

Laparoscopic hemihepatectomy was successfully performed in 17 cases. Two conversions were required. Compared with the open group, the blood loss was significantly less in the laparoscopic group (462 +/- 372 vs. 895 +/- 704, p = 0.03). Postoperative hospital stay of the laparoscopic group was shorter but not significant compared with the open group (9 +/- 5 vs. 13 +/- 7, p = 0.086). Postoperative albumin level in the laparoscopic group was significantly higher than the open group (33 +/- 4.8 vs. 27.6 +/- 3.2, p = 0.001). There was no perioperative mortality in either group. Two complications occurred in the laparoscopic group (11%) and four in the open group (21%). A tendency of gradually decreased transecting time was noticed in the early cases (R(2) = 0.676; p = 0.012).

CONCLUSIONS

Laparoscopic left hemihepatectomy is a safe and feasible procedure for select patients.

Laparoscopic liver resection for cancer

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

Laparoscopic liver resection: when to use the laparoscopic stapler device

Minimally invasive hepatic resection was first described by Gagner et al. in the early 1990s and since then has become increasingly adopted by hepatobiliary and liver transplant surgeons. Several techniques exist to transect the hepatic parenchyma laparoscopically and include transection with stapler and/or energy devices, such as ultrasonic shears, radiofrequency ablation and bipolar devices. We believe that coagulative techniques allow for superior anatomic resections and ultimately permit for the performance of more complex hepatic resections. In the stapling technique, Glisson's capsule is usually incised with an energy device until the parenchyma is thinned out and multiple firings of the staplers are then used to transect the remaining parenchyma and larger bridging segmental vessels and ducts. Besides the economic constraints of using multiple stapler firings, the remaining staples have the disadvantage of hindering and even preventing additional hemostasis of the raw liver surface with monopolar and bipolar electrocautery. The laparoscopic stapler device is, however, useful for transection of the main portal branches and hepatic veins during minimally invasive major hepatic resections. Techniques to safely perform major hepatic resection with the above techniques will be described with an emphasis on when and how laparoscopic vascular staplers should be used.

A new approach to hand-assisted laparoscopic liver surgery

BACKGROUND

The best type of laparoscopic approach in solid liver tumours (SLTs), whether total laparoscopic surgery or hand-assisted laparoscopic surgery (HALS), has not yet been established. Our objective is to present our experience with laparoscopic liver resections in SLTs performed by HALS using a new approach.

METHODS

We performed 35 laparoscopic resections in SLTs, of which 26 were carried out using HALS (in 25 patients) and 21 patients had liver metastases of a colorectal origin (LMCRC) (1 patient had 2 resections), 1 metastasis from a neuroendocrine tumour of the pancreas, 1 hepatocarcinoma on a healthy liver, 1 primary hepatic leiomyosarcoma and 1 giant haemangioma. Mean follow-up was 22 months. OPERATION: One right hemihepatectomy, one left hemihepatectomy, five bisegmentectomies II-III, three bisegmentectomies VI-VII and 16 segmentectomies (five of S. VI, three of S. VIII; three of S. V; two of S. IVb; one of S. II; one of S. IV; and in the remaining case resection of S. III and VI plus resection of a metastasis in S. VIII).

MAIN OUTCOME MEASURES

Morbidity and mortality, conversion to open procedure, intraoperative blood loss, intra- and postoperative transfusion, length of stay and survival.

RESULTS

There were no intra- or postoperative deaths, nor were there any conversions. One patient presented with morbidity (3.8%) (liver abscess). Mean blood loss was 200 ml (range 0-600 ml). One patient required transfusion (3.8%). Mean operative time was 180 min (range 120-360 min). Mean length of hospital stay was 4 days (range 2-5 days). The actuarial survival rate of the patients at 36 months with liver metastases from colorectal carcinoma (LMCRC) was 80%.

CONCLUSIONS

Liver resection with HALS reproduces the low morbidity and mortality rates and effectiveness (3-year survival) of open surgery in SLTs when indicated selectively.

Laparoscopic hepatectomy, a systematic review

This systematic review was undertaken to assess the published evidence for the safety, feasibility and reproducibility of laparoscopic liver resection. A computerized search of the Medline and Embase databases identified 28 non-duplicated studies including 703 patients in whom laparoscopic hepatectomy was attempted. Pooled data were examined for information on the patients, lesions, complications and outcome. The most common procedures were wedge resection (35.1%), segmentectomy (21.7%) and left lateral segmentectomy (20.9%). Formal right hepatectomy constituted less than 4% of the reported resections. The conversion and complication rates were 8.1% and 17.6%, respectively. The mortality rate over all these studies was 0.8% and the median (range) hospital stay 7.8 days (2-15.3 days). Eight case-control studies were analysed and although some identified significant reductions in-hospital stay, time to first ambulation after surgery and blood loss, none showed a reduction in complication or mortality rate for laparoscopically carried out resections. It is clear that certain types of laparoscopic resection are feasible and safe when carried out by appropriately skilled surgeons. Further work is needed to determine whether these conclusions can be generalized to include formal right hepatectomy.

Laparoscopic liver surgery for everyone: the hybrid method

Minimally invasive techniques have been described recently for liver resections. We have developed a surgical approach to liver resection that combines the benefits of minimally invasive surgery with the safety of open liver resection. We have applied this hybrid approach to selected cases, and we feel that it can be adopted by most hepatobiliary surgeons, even those with minimal or no laparoscopic experience. Briefly, this technique consists of laparoscopic mobilization of the target liver lobe, followed by standard open liver resection through the extraction site. The required incisions parallel those needed for hand-assisted laparoscopic liver resections. We have compared these hybrid procedures with contemporaneous laparoscopic, hand-assisted, and open liver resections at our institution and have found that they compare favorably with minimally invasive procedures. A wider utilization of this approach by both general and hepatobiliary surgeons will result in a more generalized acceptance of minimally invasive liver resection that ultimately will advance the field and benefit patients in need of liver surgery.

The role of minimal access surgery for metastasectomy and cytoreduction

This article summarizes findings about the applicability of minimal-access techniques for thoracic and upper gastrointestinal cancers, including those affecting the lung, liver, stomach, and adrenal gland. If metastasectomy and cytoreductive surgery are rapidly evolving, minimal-access surgery in this setting is in its introductory stages. Nevertheless, minimal-access metastasectomy and cytoreductive surgery harbor great potential for selected patients, but further clinical studies are needed.

Laparoscopic hepatectomy for hepatolithiasis: a feasibility and safety study in 29 patients

BACKGROUND

Hepatolithiasis is a prevalent disease in Southeast Asia. Hepatectomy was considered the best treatment for majority of cases. Laparoscopic hepatectomy is a new procedure for liver lesions that uses a minimal invasive approach. The aim of this study was to evaluate the feasibility and safety of laparoscopic hepatectomy for hepatolithiasis by comparing it with open hepatectomy.

METHODS

From November 2002 to March 2006 a total of 30 consecutive patients underwent laparoscopic hepatectomy for hepatolithiasis in Sir Run Run Shaw Hospital. Twenty-nine were included in this study (a converted case was excluded) and called the laparoscopic hepatectomy group (LH). During the same period 22 patients with hepatolithiasis who met the inclusion criteria for laparoscopic hepatectomy were selected for open hepatectomy and called the open group (OH). All operations were performed by the authors. There was no significant difference in preoperative data between the two groups. Data were statistically compared.

RESULTS

Compared with open hepatectomy, those who underwent laparoscopic hepatectomy had a shorter postoperative hospital stay and fasting time, a lower postoperative serum aminotransferase level, and a higher postoperative serum albumin level. Stone clearance rate (intermediate rate, 89.7% vs. 86.4%; final rate, 100% vs. 96.5%), stone recurrence rate (0% vs. 4.5%), operating time, and intraoperative blood loss were similar for the two groups. Six complications occurred, two (6.8%) in LH and four (18.2%) in OH. There was no perioperative mortality in either group.

CONCLUSION

Laparoscopic hepatectomy for hepatolithiasis is feasible and safe in selected patients.

Laparoscopic spray application of fibrin sealant effects on hemodynamics and spray efficiency at various application pressures and distances

BACKGROUND

Laparoscopic resections of parenchymal organs are increasingly performed. However, little is known about the effects of laparoscopic fibrin sealant spray applications on intraabdominal pressure (IAP) and hemodynamics.

METHODS

Cardiac and pulmonary monitoring was performed via two central venous pressure lines in the thoracic and abdominal vena cava, a pulmonary artery catheter, and a peripheral artery line. Air was sprayed into the abdomen at pressures of 2, 3, and 4 bar for 30 s. According to the group, a valve on a trocar was open or closed. To optimize fibrin sealant application, the sealant was sprayed at three different application pressures (2, 2.5, and 3 bar) and distances (2, 3.5, and 5 cm).

RESULTS

All spray simulations caused a significant increase in the IAP. During the first 10 s of spraying, the IAP increase was 5 mmHg or less, but rose rapidly during the last 20 s of spraying. The IAP increase resulted in decreased pulmonary compliance. Pulmonary resistance and the central venous pressures of both the thoracic and abdominal vena cava increased. At application pressures of 3 and 4 bar, the IAP increase was greater than 2 bar of pressure, reaching IAP values exceeding 35 mmHg. Spray mist formation was primarily dependent on application pressure, whereas clot formation and surface coverage depended on both application pressure and distance. The best results were achieved with an application pressure of 2.5 bar and a distance of 5 cm from the surface.

CONCLUSIONS

This study shows that fibrin sealants can be used safely in laparoscopic procedures. Keeping the spray periods short and allowing air to escape from the abdomen can minimize the IAP increase. According to our results, a laparoscopic spray application of fibrin sealant should start with an insufflation pressure of 10 mmHg, an application pressure of 2.5 bar, and an application distance of 5 cm with a valve on the trocar left open.

Laparoscopic liver surgery: Shifting the management of liver tumors

Laparoscopic liver surgery has evolved rapidly over the past 5 years in a select number of centers. The growing experience with these procedures has resulted in a shift in the diagnostic and therapeutic approach to common liver tumors. The fact that resection of benign and malignant hepatic masses can now be accomplished laparoscopically with relatively low morbidity has influenced the decision-making process for physicians involved in the diagnosis and management of these lesions. For example, should a gastroenterologist or hepatologist seeing a 32-year-old woman with an asymptomatic 4 cm hepatic lesion that is radiologically indeterminate for adenoma or focal nodular hyperplasia (FNH): (1) continue to observe with annual computed tomography/magnetic resonance imaging (CT/MRI) scans, (2) subject the patient to a liver biopsy, or (3) refer for laparoscopic resection? For a solitary malignant liver tumor in the left lateral segment, should laparoscopic resection be considered the new standard of care, assuming the surgeon can perform the operation safely? We present current data and representative case studies on the use of laparoscopic liver resection at 2 major medical centers in the United States. We propose that surgical engagement defined by the managing physician's decision to proceed with a surgical intervention is increasingly affected by the availability of, and experience with, laparoscopic liver resection.

Hepatobiliary Surgery: Lessons Learned from Live Donor Hepatectomy

The liver is unique in the rapid tissue regeneration occurs after resection or injury, and affords the surgeon the opportunity to safely remove up to 60% to 70% of the liver volume for treatment of cancer or for use as a live donor graft for transplantation. The complex development of the liver and biliary system in utero results in multiple and complicated anatomic variations. The hepatobiliary surgeon of today must be able to integrate a broadening array of radiologic and liver resection techniques that may improve patient safety and surgical outcome. Equally important is the ability to quickly recognize postoperative complications so that prompt intervention can be instituted. Successful outcome requires a balance between sound judgement, technical acumen, and attention to detail. Herein, we provide lessons learned from live donor liver transplantation that are directly applicable to any patient undergoing major hepatic resection.

Laparoscopic hepatectomy by curettage and aspiration. Experiences of 62 cases

BACKGROUND

This article introduces a new technique for hepatectomy. Its purpose is to describe the details of laparoscopic hepatectomy by curettage and aspiration (LHCA) and develop a new instrument for this technique.

METHODS

We have performed laparoscopic hepatectomy by curettage and aspiration (LHCA) in 62 patients in our institute between 1998 and 2005: 34 men and 28 women, mean age 47.8 years (range: 26-71 years). Their diagnoses included 18 primary hepatic carcinoma, 2 metastatic carcinoma, 19 intrahepatic duct calculus, and 23 benign entities.

RESULTS

The LHCA operation was completed in 60 patients. In two, the procedure had to be converted to open operation. The mean operative time was 146 min and the mean operative blood loss was 458 ml. Complications occurred in two patients, one with bile leakage and the other with pneumothorax. All the patients were ambulatory within 24 hours of operation. The average length of hospital stay was 1 week.

CONCLUSIONS

Our experience leads us to believe that laparoscopic hepatectomy by curettage and aspiration (LHCA) is a safe and effective technique for resection of liver lesions.

Role and limitations of laparoscopic liver resection of colorectal metastases

BACKGROUND

The current experience of laparoscopic liver resection is reviewed focusing on the role and limitations of resection of colorectal metastases. Surgical technique, outcome, and the main controversies regarding the procedures are described.

METHODS

Current literature on laparoscopic liver resection is reviewed based on reports identified following a specified PubMed search.

RESULTS

Available evidence indicates that laparoscopic liver resection can be made safely in selected patients with comparable duration of surgery, blood loss, tumour clearance, and mortality to that of open resection. Tumours localised peripherally in the left lateral segments of the liver or in segments IV-VI seem to be best suited for laparoscopic resection. The laparoscopic approach may be beneficial to the patients as compared to conventional resection but randomised trials are pending. Laparoscopic resection of colorectal liver metastases is described in a small number of patients only. The long-term outcome following such resections is not adequately documented.

CONCLUSIONS

Laparoscopic liver resection is a promising technique with a comparable short-term outcome to that of open procedures but with the potential advantages of minimal invasive treatment. The technique should be further evaluated in properly designed trials. Laparoscopic resection of colorectal liver metastases should not be performed on a regular basis until long-term results are defined.