The learning curve in laparoscopic liver resection: improved feasibility and reproducibility. Ann Surg. 2009;250:772-782. [PMID: 19801926 DOI: 10.1097/sla.0b013e3181bd93b2]

Developments and perspectives of laparoscopic liver resection in the treatment of hepatocellular carcinoma

Laparoscopic liver resection (LLR) was introduced in the early 1990s, initially for partial resection of the anterolateral segments, from where it has expanded in a stepwise fashion. Movement restriction makes bleeding control demanding. Managing pneumoperitoneum pressure with inflow control can inhibit venous bleeding and create a dry surgical field for easier hemostasis. Since the lack of overview leads to disorientation, simulation and navigation with imaging studies have become important. Improved direct access to the liver inside the rib cage can be obtained in LLR, reducing destruction of the associated structures and decreasing the risk of refractory ascites and liver failure, especially in patients with a cirrhotic liver. Although LLR can be performed as bridging therapy to transplantation for severe cirrhosis, its impact on expanding the indications of liver resection (LR) and the consequent survival benefits must be evaluated. For repeat LR, LLR is advantageous by producing fewer adhesions and reducing the need for adhesiolysis. The laparoscopic approach facilitates better access in a small operative field between adhesions. Further evaluations are needed for repeat anatomical resection, since alterations of the anatomy and surrounding scars and adhesions of major vessels have a larger impact.

[Early outcomes of robot-assisted liver resection]

AIM

To assess an experience of robot-assisted liver resection using CUSUM-test.

MATERIAL AND METHODS

The results of 46 robot-assisted liver resections were retrospectively analyzed by using of CUSUM-test.

RESULTS

There were 3 periods in development of the technology. The 1^st period - procedures with the lowest index of difficulty (n=16), the 2^nd period - expansion of the indications for difficult resections (n=18) and the 3^rd period - stabilization of the results (n=12). The dynamics of difficulty index, intraoperative blood loss, duration of procedure and morbidity (Clavien-Dindo Grade II-V) were evaluated. Five liver resections were needed to decrease blood loss and duration of the procedure. Expansion of indications was feasible after 16 procedures. Stable results were obtained after 34 liver resections.

Laparoscopic vs. open left lateral sectionectomy: An update meta-analysis of randomized and non-randomized controlled trials

BACKGROUND

Left lateral sectionectomy (LLS) is thought to be the anatomical liver resection most suitable for the laparoscopic approach. Despite increasing popularity, comparative analysis of laparoscopic and open LLS are mostly limited to retrospective, underpowered studies with small sample size. Recent population-based studies and prospective trials have generated new data; however, this new body of knowledge has not been submitted systematic reviews or meta-analyses and high quality evidence regarding the actual benefits of minimally invasive LLS is lacking.

METHODS

Systematic review of studies published until December 31st, 2017 and indexed in Medline, EMBASE, Cochrane Library Central and Scielo/LILACS databases. Randomized controlled trials and observational studies comparing perioperative results of laparoscopic and open LLS were included. Studies with patients submitted to LLS for living donation were excluded. Treatment outcomes, including conversion rates, estimated blood loss, transfusion rates, operative time, length of in-hospital stay, morbidity and mortality rates, were evaluated.

RESULTS

The primary search yielded 2838 articles, 23 of which (21 observational studies and 2 randomized controlled trials; 3415 patients) were included in the meta-analysis. Overall conversion rate was 7.4%. Patients submitted to laparoscopic LLS had less blood loss (mean difference, MD = -119.81 ml, 95% CI = -127.90, -111.72, P < .00001, I² = 32%, N = 618), lower transfusion rates (4.1% vs. 10.1%; risk difference, RD = - 0.06, 95% CI = - 0.08, - 0.05, P < .00001, I² = 13%, N = 2968) and shorter length of in-hospital stay (MD = - 2.02 days, 95% CI = - 2.15, - 1.89, P < .00001, I² = 77%, N = 3160) compared to those undergoing open surgery. Marginally decreased overall complication (21.4% vs. 27.5%; RD = - 0.03, 95% CI = - 0.06, 0.00, P = .05, I² = 0%, N = 3268) and perioperative mortality (0.3% vs. 1.5%; RD = - 0.01, 95% CI = - 0.02, - 0.00, P = .01, I² = 0%; N = 3332) rates were also observed. Operative time and biliary, cardiac or pulmonary complication rates did not differ significantly between groups.

CONCLUSION

Current evidence supports the safety and feasibility of laparoscopic LLS. The laparoscopic approach is associated with reduced blood loss, lower transfusion rates and shorter length of in-hospital stay and should be considered the gold-standard for LLS.

Laparoscopic Versus Open Approach for Formal Right and Left Hepatectomy: A Propensity Score Matching Analysis

BACKGROUND

Laparoscopic liver surgery is expanding worldwide, but further evidence is needed to assess safety and efficacy of laparoscopic major hepatectomy. The study analyzes perioperative outcomes of pure laparoscopic versus open major hepatectomies matched by the propensity score method.

METHODS

From 2005 to 2017, 268 major hepatectomies were performed of which 73 were laparoscopic. After a 1:1 propensity score matching, 59 laparoscopic right and left hepatectomies were compared to 59 open. The matching was based on age, gender, year of procedure, BMI, ASA score, underlying liver disease, previous abdominal surgery, type of hepatectomy, preoperative chemotherapy, number, dimension and nature of lesions. An intention-to-treat analysis and a per-protocol analysis were carried out.

RESULTS

Mean surgical time was 315 min in the laparoscopic group and 292.5 min in the open group (p = 0.039); conversion rate in laparoscopy was 20.3%; blood loss was 480 ml (50-3000) versus 550 ml (50-2600), respectively, for laparoscopic and open (p = 0.577). Lengths of postoperative analgesia and hospital stay were shorter in the laparoscopic group (p = 0.0001 and 0.024, respectively). Postoperative complications occurred in 11.9% of laparoscopic cases and in 25.4% of open cases (p = 0.098). Median Comprehensive Complication Index was 26.2 (8.7-54.2) in the open group versus 20.9 (8.7-66.2) in open (p = 0.368). Per-protocol analysis showed a better trend in favor of laparoscopy concerning surgical time.

CONCLUSIONS

Laparoscopic major hepatectomies are safe and feasible procedures allowing a similar complication rate with a shorter hospital stay and diminished postoperative pain with respect to the standard approach.

Intraoperative ultrasonography of robot-assisted laparoscopic hepatectomy: initial experiences from 110 consecutive cases

BACKGROUND

To evaluate the safety and efficacy of IOUS in robotic liver surgery and propose a standard protocol of IOUS for safe robot-assisted hepatectomy.

METHODS

Between February 2015 and December 2016, liver resection was performed in 110 patients with robotic approach in Tongji Hospital. In these patients, IOUS was routinely performed. All data about demographic, surgical procedure, postoperative course were collected prospectively and analyzed.

RESULTS

A four steps IOUS protocol in robotic liver surgery was proposed, including exploration, verification, guidance, and confirmation. A total of 11 additional lesions in 11 patients were detected and 7 patients accepted strategic surgical modification. No patient suffered from any single or multiple organ dysfunctions, and there were no mortalities observed.

CONCLUSION

IOUS is indispensable to understand lesions and vessels in robotic liver surgery. A four-step standard protocol of IOUS is essential for safe robot-assisted hepatectomy.

Laparoscopic left hemihepatectomy is suitable as a first step in pure laparoscopic major hepatectomy

AIM

As a procedure, major laparoscopic liver resection (LLR) remains in the exploration phase. Previous studies have assessed major LLR en bloc, including hepatectomies of varying complexities; however, the number of segments alone does not convey the complexity of a resection. This study aimed to assess operative outcomes of LLR procedures with more than one sectionectomy, and to identify the best procedure as a first step when learning to carry out major LLR in order to make LLR a safer, more widely used procedure.

METHODS

We carried out a retrospective review of the operative outcomes of 120 consecutive patients who underwent pure LLR with more than one sectionectomy. Operative outcomes were compared according to the complexity classification recently published, and the learning curve for each LLR procedure was assessed and compared.

RESULTS

Operative outcomes, including operative time, blood loss, and the comprehensive complication index, were significantly stratified according to complexity. There were significant differences in operative outcomes among the medium complexity procedures. The operative time for left hemihepatectomy was the shortest, and the amount of blood loss was the lowest among the medium complexity LLR. Operative times for left hemihepatectomy shortened significantly with time and experience (r = -0.639), and the slope of the learning curve was steeper than for right hemihepatectomy and right posterior sectionectomy.

CONCLUSION

Left hemihepatectomy is suitable as a first step in pure laparoscopic major hepatectomy and, given its safety and rapid learning curve for surgeons, it could become the gold standard procedure.

Laparoscopy-assisted versus open and pure laparoscopic approach for liver resection and living donor hepatectomy: a systematic review and meta-analysis

BACKGROUND

Laparoscopy-assisted (hybrid) liver surgery is considered a minimally invasive technique, however there are doubts regarding loss of the benefits of laparoscopy due to the use of an auxiliary incision. The aim of this study was to compare perioperative results of hybrid vs. open and hybrid vs. pure laparoscopic approach to liver resection for focal lesions and living donation.

METHODS

A systematic review was performed in Medline, EMBASE, Cochrane Library Central and LILACS databases. Perioperative outcomes were analyzed.

RESULTS

21 studies were included. Hybrid vs. open: operative time was lower in open group (mean difference [MD] = 34 min; 95%CI: 22-47; P < 0.001; N = 669). Hybrid technique was associated with a reduction in operative blood loss [MD = -43 ml; 95%CI: -74-(-13); P = 0.005, N = 1738]; shorter hospital stay [MD = -1.9 days; 95%CI: -3.2-(-0.5); P = 0.008; N = 833] and lower morbidity [risk difference (RD) = -0.05; 95%CI: -0.10-(-0.01); P = 0.010; N = 1359]. Hybrid vs. pure laparoscopic: There was no difference regarding blood loss, transfusion rate, hospital stay and morbimortality.

DISCUSSION

Hybrid technique had perioperative outcomes that were more in keeping with pure laparoscopic outcomes than open surgery. Hybrid liver surgery should be considered a minimally invasive approach.

A learning curve for laparoscopic liver resection: an effective training system and standardization of technique

The incidence of laparoscopic liver resection (LHx) has been increased in the past decade. There have been some reports about some advantages of LHx, in both short and long-term outcomes after operation. The use of a minor LHx was regarded as a standard surgical practice, and some peri-operative complications hindered worldwide increase of LHx in the Second International Consensus Conference on LHx at Morioka. However, no suggestions were described in terms with how to provide the best teaching and training necessary to shorten the learning curve for inexperienced surgeons using a new surgical technique while continuing to maintain a low rate of morbidity from the very beginning. This study includes a literature review of published research which looked at a learning curve for LHx. As well, it proposes a new step-wise training method for inexperienced surgeons and standardization of a technique for LHx focusing especially on laparoscopic left hepatectomy (LLHx).

Minimally invasive donor hepatectomy, are we ready for prime time?

Minimally invasive surgery potentially reduces operative morbidities. However, pure laparoscopic approaches to donor hepatectomy have been limited by technical complexity and concerns over donor safety. Reduced-wound donor hepatectomy, either in the form of a laparoscopic-assisted technique or by utilizing a mini-laparotomy wound, i.e., hybrid approach, has been developed to bridge the transition to pure laparoscopic donor hepatectomy, offering some advantages of minimally invasive surgery. To date, pure laparoscopic donor left lateral sectionectomy has been validated for its safety and advantages and has become the standard in experienced centres. Pure laparoscopic approaches to major left and right liver donation have been reported for their technical feasibility in expert hands. Robotic-assisted donor hepatectomy also appears to be a valuable alternative to pure laparoscopic donor hepatectomy, providing additional ergonomic advantages to the surgeon. Existing reports derive from centres with tremendous experience in both laparoscopic hepatectomy and donor hepatectomy. The complexity of these procedures means an arduous transition from technical feasibility to reproducibility. Donor safety is paramount in living donor liver transplantation. Careful donor selection and adopting standardized techniques allow experienced transplant surgeons to safely accumulate experience and acquire proficiency. An international prospective registry will advance the understanding for the role and safety of pure laparoscopic donor hepatectomy.

Changing trends and outcomes associated with the adoption of minimally invasive hepatectomy: a contemporary single-institution experience with 400 consecutive resections

BACKGROUND

Several studies published mainly from pioneers and early adopters have documented the evolution of minimally invasive hepatectomy (MIH). However, questions remain if these reported experiences are applicable and reproducible today. This study examines the changing trends, safety, and outcomes associated with the adoption of MIH based on a contemporary single-institution experience.

METHODS

This is a retrospective review of 400 consecutive patients who underwent MIH between 2006 and 2017 of which 360 cases (90%) were performed since 2012. To determine the evolution of MIH, the study population was stratified into four equal groups of 100 patients. Analyses were also performed of predictive factors and outcomes of open conversion.

RESULTS

Four hundred patients underwent MIH of which 379 (94.8%) were totally laparoscopic/robotic. Eighty-eight (22.0%) patients underwent major hepatectomy and 160 (40.0%) had resection of tumors located in the posterosuperior segments. There were 38 (9.5%) open conversions. Comparison across the four groups demonstrated that patients were older, had higher ASA score, and had increased frequency of previous abdominal surgery and repeat liver resections. There was also an increase in the proportion of patients who underwent totally laparoscopic/robotic surgery, major liver resection, resection of ≥ 3 segments, and multiple resections. Comparison of outcomes demonstrated that there was a significant decrease in open conversion rate, longer operation time, and increased use of Pringles maneuver. The presence of cirrhosis and institution experience (1st 100 cases) were independent predictors of open conversion. Patients who required open conversion had significantly increased operation time, blood loss, blood transfusion rate, morbidity, and mortality.

CONCLUSION

The case volume of MIH performed increased rapidly at our institution over time. Although the indications of MIH expanded to include higher risk patients and more complex hepatectomies, there was a decrease in open conversion rate and no change in other perioperative outcomes.

The Southampton Consensus Guidelines for Laparoscopic Liver Surgery: From Indication to Implementation

OBJECTIVE

The European Guidelines Meeting on Laparoscopic Liver Surgery was held in Southampton on February 10 and 11, 2017 with the aim of presenting and validating clinical practice guidelines for laparoscopic liver surgery.

BACKGROUND

The exponential growth of laparoscopic liver surgery in recent years mandates the development of clinical practice guidelines to direct the speciality's continued safe progression and dissemination.

METHODS

A unique approach to the development of clinical guidelines was adopted. Three well-validated methods were integrated: the Scottish Intercollegiate Guidelines Network methodology for the assessment of evidence and development of guideline statements; the Delphi method of establishing expert consensus, and the AGREE II-GRS Instrument for the assessment of the methodological quality and external validation of the final statements.

RESULTS

Along with the committee chairman, 22 European experts; 7 junior experts and an independent validation committee of 11 international surgeons produced 67 guideline statements for the safe progression and dissemination of laparoscopic liver surgery. Each of the statements reached at least a 95% consensus among the experts and were endorsed by the independent validation committee.

CONCLUSION

The European Guidelines Meeting for Laparoscopic Liver Surgery has produced a set of clinical practice guidelines that have been independently validated for the safe development and progression of laparoscopic liver surgery. The Southampton Guidelines have amalgamated the available evidence and a wealth of experts' knowledge taking in consideration the relevant stakeholders' opinions and complying with the international methodology standards.

The clinical and biological impacts of the implementation of fast-track perioperative programs in complex liver resections: A propensity score-based analysis between the open and laparoscopic approaches

BACKGROUND

The aim of this study was to evaluate the impact of the fast-track approach in patients undergoing complex liver procedures and to analyse factors that influence morbidity and functional recovery.

METHODS

Hepatic resections (2014-2016) were stratified according to difficulty score, obtaining a group of 215 complex resections (102 laparoscopic, 163 open). The laparoscopic group was matched by propensity score with open patients to obtain the minimally invasive liver surgery group (n = 102) and the open group (n = 102).

RESULTS

Groups were similar in terms of patient and disease characteristics. The postoperative morbidity was 31.4% in the minimally invasive liver surgery and 38.2% in the open group (P = .05), and functional recovery was shorter in the minimally invasive liver surgery (respectively 4 versus 6 days, P = .041). The adherence to fast-track was high in both groups, with several items with higher penetrance in the minimally invasive liver surgery group. Among factors associated with morbidity and functional recovery, a laparoscopic approach and strict adherence to a fast-track protocol resulted in protective factors.

CONCLUSION

The combination of minimally invasive approaches and fast-track protocols allows a reduced rate of postoperative morbidity and satisfactory functional recovery even in the setting of complex liver resections. When the laparoscopic approach is not feasible, strict adherence to a fast-track program is associated with the achievement of adequate results and should be implemented.

Minimally Invasive Approaches for Surgical Management of Primary Liver Cancers

The benefits of minimally invasive approaches in oncologic surgery are increasingly recognized, and laparoscopic liver surgery has become increasingly widespread. In light of the complexity and technical challenges of hepatobiliary procedures, robotic approaches are also employed. The utility, safety, and oncologic integrity of these methods in the management of primary liver cancers are reported. PubMed was used to search the medical literature for studies and articles pertaining to laparoscopic and robotic liver surgery. Studies that particularly addressed hepatocellular carcinoma and cholangiocarcinoma were identified and reviewed. Laparoscopic liver surgery, including for major resections, has been shown to be safe in experienced hands without any compromise of oncologic outcomes for either hepatocellular carcinoma or intrahepatic cholangiocarcinoma. Some studies show improved clinical outcomes including shorter hospital stays and lower complication rates when compared to open surgery, particularly for patients with cirrhosis. Robotic liver surgeries seem to have equally acceptable clinical outcomes; however, there is limited data regarding oncologic integrity and considerable additional expense. Laparoscopic and robotic liver resections are both feasible and safe for the management of primary liver tumors. Future studies should aim to clarify specific indications and optimize applications of these approaches.

Development and validation of a difficulty score to predict intraoperative complications during laparoscopic liver resection

Background

Previous studies have demonstrated that patient, surgical, tumour and operative variables affect the complexity of laparoscopic liver resections. However, current difficulty scoring systems address only tumour factors. The aim of this study was to develop and validate a predictive model for the risk of intraoperative complications during laparoscopic liver resections.

Methods

The prospectively maintained databases of seven European tertiary referral liver centres were compiled. Data from two-thirds of the patients were used for development and one-third for validation of the model. Intraoperative complications were based on a modified Satava classification. Using the methodology of the Framingham Heart Study, developed to identify risk factors that contribute to the development of cardiovascular disease, factors found to predict intraoperative complications independently were assigned points, and grouped into low-, moderate-, high- and extremely high-risk groups based on the likelihood of intraoperative complications.

Results

A total of 2856 patients were included. Neoadjuvant chemotherapy, lesion type and size, classification of resection and previous open liver resection were found to be independent predictors of intraoperative complications. Patients with intraoperative complications had a longer duration of hospital stay (5 versus 4 days; P &lt; 0·001), higher complication rates (32·5 versus 15·5 per cent; P &lt; 0·001), and higher 30-day (3·0 versus 0·3 per cent; P &lt; 0·001) and 90-day (3·8 versus 0·8 per cent; P &lt; 0·001) mortality rates than those who did not. The model was able to predict intraoperative complications (area under the receiver operating characteristic (ROC) curve (AUC) 0·677, 95 per cent c.i. 0·647 to 0·706) as well as postoperative 90-day mortality (AUC 0·769, 0·681 to 0·858).

Conclusion

This comprehensive scoring system, based on patient, surgical and tumour factors, and developed and validated using a large multicentre European database, helped estimate the risk of intraoperative complications.

Fully laparoscopic left hepatectomy - a technical reference proposed for standard practice compared to the open approach: a retrospective propensity score model

BACKGROUND

Laparoscopic left hemihepatectomy (LLH) may be an alternative to open (OLH). There are several original variations in the technical aspects of LLH, and no accepted standard. The aim of this study is to assess the safety and effectiveness of the technique developed at Henri Mondor Hospital since 1996.

METHODS

The technique of LLH was conceived for safety and training of two mature generations of lead surgeons. The technique includes full laparoscopy, ventral approach to the common trunk, extrahepatic pedicle dissection, CUSA^® parenchymal transection, division of the left hilar plate laterally to the Arantius ligament, and ventral transection of the left hepatic vein. The outcomes of LLH and OLH were compared. Perioperative analysis included intra- and postoperative, and histology variables. Propensity Score Matching was undertaken of background covariates including age, ASA, BMI, fibrosis, steatosis, tumour size, and specimen weight.

RESULTS

17 LLH and 51 OLH were performed from 1996 to 2014 with perioperative mortality rates of 0% and 6%, respectively. In the LLH group, two patients underwent conversion to open surgery. Propensity matching selected 10 LLH/OLH pairs. The LLH group had a higher proportion of procedures for benign disease. LLH was associated with longer operating time and less blood loss. Perioperative complications occurred in 30% (LLH) and 10% (OLH) (p = 1). Mortality and ITU stay were similar.

CONCLUSION

This technique is recommended as a possible technical reference for standard LLH.

The Effectiveness of a Clinical Pathway in Liver Surgery: a Case-Control Study

BACKGROUND

In the field of liver surgery, evidence on the effectiveness of clinical pathways based on ERAS principles is limited.

METHODS

This is a single-center observational study from a prospectively maintained database. Two cohorts were formed of all patients undergoing liver surgery during a defined period before (traditional management) and after introduction of a clinical pathway. Additionally, a case-match analysis-based on approach, tumor location, and Brisbane classification of resection-was performed. A cost analysis and patient satisfaction questionnaire were carried out.

RESULTS

In both the overall analysis (n = 229) as well as the case-match analysis (n = 100), hospital stay was significantly reduced from 8 to 4 days and from 6.5 to 4 days, respectively (p < 0.05). Postoperative morbidity (traditional management 11/50 vs clinical pathway 5/50; p = 1.00) and readmission rate did not increase. Cost analysis showed a significant decrease in postoperative costs in favor of the clinical pathway (traditional management €3666.7 vs clinical pathway €1912.2; p < 0.001). Overall, 92.3% of the survey questions were answered with satisfied (86.0%) or very satisfied (6.3%).

DISCUSSION

Implementation of clinical pathway for liver surgery is feasible and safe. A clinical pathway significantly reduces hospital stay without increasing postoperative morbidity and readmission rates. Postoperative costs are significantly reduced. Patient satisfaction is high.

Initial experience with robotic hepatectomy in Singapore: analysis of 48 resections in 43 consecutive patients

BACKGROUND

Presently, the adoption of laparoscopic hepatectomy is rapidly increasingly worldwide. However, the application of robotic hepatectomy (RH) remains limited and its role remains undefined today.

METHODS

A retrospective review of 43 consecutive patients who underwent RH at two institutions in the Singapore Health Services Group.

RESULTS

Forty-three consecutive patients underwent 48 resections during the study period. Seven (16.3%) patients underwent major resections and seven (16.3%) underwent right posterior sectionectomies. Nineteen (44.2%) patients had tumours located in the difficult posterosuperior segments, five had multiple resections and three underwent repeat resections for recurrent tumours. RH was performed for malignant tumours in 32 (74%) patients and 16 (37.2%) had cirrhosis. Seven RH was performed with other concomitant procedures including three colectomies, three hilar lymphadenectomies and one portal vein ligation. The median operation time was 360 min (range 75-825) and the median blood loss was 300 mL (range 25-4500). There was one (2.3%) open conversion for bleeding. The median post-operative stay was 4 days (range 2-33) and there was one (2.3%) readmission. There was one (2.3%) major (>grade 2 morbidity) in a patient with concomitant anterior resection who underwent reoperation for anastomotic leak. There was no 90 day/in-hospital mortality. Comparison between RH for tumours in the anterolateral segments versus posterosuperior segments demonstrated no significant difference in perioperative outcomes.

CONCLUSION

Our initial experience demonstrated that RH is safe, feasible and associated with excellent post-operative outcomes. It can be performed successfully with low morbidity even for complex resections such as major hepatectomies, posterior sectionectomies, tumours in difficult posterosuperior segments and repeat liver resections.

Are the current difficulty scores for laparoscopic liver surgery telling the whole story? An international survey and recommendations for the future

BACKGROUND

Recent studies have suggested that the difficulty of laparoscopic liver resections are related to both patient and tumour factors, however the available difficulty scoring systems only incorporate tumour factors. The aim of this study was to assess the opinion of laparoscopic liver surgeons regarding the factors that affect the perceived difficulty of laparoscopic liver resections.

METHOD

Using a Visual Analogue Scale an international survey of laparoscopic liver surgeons was undertaken to assess the perceived difficulty of 26 factors previously demonstrated to affect the difficulty of a laparoscopic liver resection.

RESULTS

80 surgeons with a combined experience of over 7000 laparoscopic liver resections responded to the survey. The difficulty of laparoscopic liver surgery was suggested to be increased by a BMI > 35 by 89% of respondents; neo-adjuvant chemotherapy by 79%; repeated liver resection by 99% and concurrent procedures by 59% however these factors have not been included in the previous difficulty scoring systems.

CONCLUSION

The results suggests that the difficulty of laparoscopic liver surgery is not fully assessed by the available difficulty scoring systems and prompts the development of a new difficulty score that incorporates all factors believed to increase difficulty.

Totally intra-corporeal Pringle maneuver during laparoscopic liver resection

INTRODUCTION

Laparoscopic resection has gained a significant place in liver surgery. As in open liver resection, bleeding control during hepatic transection remains a major issue and it represents the main reason for conversion to laparotomy. Pringle maneuver (PM) remains the standard inflow occlusion technique and a specific step-by-step description of totally intracorporeal laparoscopic PM is described.

METHODS

The technique includes placement of a tape around the hepatoduodenal which is then passed through a plastic drain. This creates a tourniquet that is locked with a heavy duty clip to allow intermittent use.

RESULTS

This technique has been used in over 400 cases over the past 15 years and has proved safe and efficient with no specific complications encountered. It has been used in in 97 of 170 cases (57%) in the past 4 years and its feasibility has been 97%. Its intracorporeal position does not require an additional trocar and does not interfere with the surgeons' view and operating technique. Cycles of clamping and unclamping can be performed in few seconds including in the emergency setting.

CONCLUSIONS

Totally laparoscopic PM is a simple, reproducible and inexpensive method of inflow occlusion during laparoscopic liver resection.

[Robotic approach to hepatobiliary surgery. German version]

Robot-assisted hepatobiliary surgery has been steadily growing in recent years. It represents an alternative to the open and laparoscopic approaches in selected patients. Endowristed instruments and enhanced visualization provide important advantages in terms of selective bleeding control, microsuturing, and dissection. Cholecystectomies and minor hepatectomies are being performed with comparable results to open and laparoscopic surgery. Even complex procedures, such as major and extended hepatectomies, can have excellent outcomes, in expert hands. The addition of indocyanine green fluorescence provides an additional advantage for recognition of the vascular and biliary anatomy. Future innovations will allow for expanding its use and indications. Robotic surgery has become a very important component of modern minimally invasive surgery and the development of new robotic technology will facilitate a broader adoption of this technique.

Dissemination of Minimally Invasive Liver Resection for Primary Malignancy: Reevaluating Effectiveness

BACKGROUND

Experiences at specialized hepatobiliary centers have demonstrated efficacy of minimally invasive liver resection, but concerns exist regarding whether these procedures would remain effective once disseminated to a broad range of clinical practices. We sought to present the first comparison of MILR and open liver resection (OLR) for primary liver malignancy from a nationally representative cancer registry.

METHODS

Cases of liver and intrahepatic bile duct cancer were identified from the National Cancer Data Base Participant Use File. Mixed effects logistic regression and stratified Cox proportional hazards regression were used for analysis. A propensity score matched cohort was used as an alternative form of analysis to evaluate the robustness of results.

RESULTS

A total of 3236 cases were analyzed from 2010 to 2011 with 2581 OLR (80%) and 655 MILR (20%). Of the variation in patient selection for MILR 28.5% was related to treatment at a specific treatment center; however, the proportion of MILR was similar among low-, medium-, and high-volume centers. Overall 90-day mortality was lower at high-volume centers (odds ratio [OR] 0.58; 95% confidence interval [CI] 0.40-0.85) compared with low-volume centers. MILR was similar to OLR in both 90-day mortality and overall survival (OR 0.9; 95% CI 0.62-1.10) and hazard ratio [HR] 0.88 (95% CI 0.72-1.07), regardless of treatment center volume.

CONCLUSIONS

MILR for primary liver malignancy is used across a variety of practice settings, with similar outcomes to OLR. While volume is associated with short-term outcomes of liver resection as a whole, this relationship is not explained by adoption of MILR at low-volume centers.

Outcomes following laparoscopic versus open major hepatectomy for hepatocellular carcinoma in patients with cirrhosis: a propensity score-matched analysis

BACKGROUND

Laparoscopic major hepatectomy (LMH) for hepatocellular carcinoma (HCC) in patients with cirrhosis remains controversial due to limited reports in the literature. This study analyzed the perioperative and oncological outcomes of LMH for HCC with cirrhosis compared with open major hepatectomy (OMH).

METHODS

A retrospective analysis of patients with cirrhosis who underwent major hepatectomy for HCC between January 2015 and January 2017 was performed. Patients were divided into the LMH group and the OMH group. Short-term and oncological outcomes were compared before and after 1:1 propensity score matching (PSM).

RESULTS

A total of 103 HCC patients who received major liver resection were enrolled. There were 36 (35.0%) patients in the LMH group and 67 (65.0%) patients in the OMH group. After 1:1 PSM, well-matched 32 patients in each group were evaluated. Significant differences were observed in operative time (median, 255 vs. 200 min, p < 0.001) and Pringle time (median, 50 vs. 30 min, p < 0.001) between two groups. The blood loss and transfusion requirement were comparable in two groups. The rate of overall postoperative complications did not differ between two groups, while the incidence of ascites in the LMH group was significantly less than OMH group (9.4 vs. 31.3%, p = 0.030). The oncological outcomes between the two groups were comparable with regard to 2-year overall survival (85.7 vs. 86.7%, p = 0.694) and disease-free survival (72.9 vs. 81.5%, p = 0.990), respectively.

CONCLUSIONS

LMH for HCC patients with liver cirrhosis showed comparable results in terms of postoperative morbidity and oncological outcomes compared with traditional open procedure. LMH may serve as a safe and feasible alternative for selected HCC patients with cirrhosis.

Outcomes following laparoscopic versus open major hepatectomy for hepatocellular carcinoma in patients with cirrhosis: a propensity score-matched analysis

BACKGROUND

Laparoscopic major hepatectomy (LMH) for hepatocellular carcinoma (HCC) in patients with cirrhosis remains controversial due to limited reports in the literature. This study analyzed the perioperative and oncological outcomes of LMH for HCC with cirrhosis compared with open major hepatectomy (OMH).

METHODS

A retrospective analysis of patients with cirrhosis who underwent major hepatectomy for HCC between January 2015 and January 2017 was performed. Patients were divided into the LMH group and the OMH group. Short-term and oncological outcomes were compared before and after 1:1 propensity score matching (PSM).

RESULTS

A total of 103 HCC patients who received major liver resection were enrolled. There were 36 (35.0%) patients in the LMH group and 67 (65.0%) patients in the OMH group. After 1:1 PSM, well-matched 32 patients in each group were evaluated. Significant differences were observed in operative time (median, 255 vs. 200 min, p < 0.001) and Pringle time (median, 50 vs. 30 min, p < 0.001) between two groups. The blood loss and transfusion requirement were comparable in two groups. The rate of overall postoperative complications did not differ between two groups, while the incidence of ascites in the LMH group was significantly less than OMH group (9.4 vs. 31.3%, p = 0.030). The oncological outcomes between the two groups were comparable with regard to 2-year overall survival (85.7 vs. 86.7%, p = 0.694) and disease-free survival (72.9 vs. 81.5%, p = 0.990), respectively.

CONCLUSIONS

LMH for HCC patients with liver cirrhosis showed comparable results in terms of postoperative morbidity and oncological outcomes compared with traditional open procedure. LMH may serve as a safe and feasible alternative for selected HCC patients with cirrhosis.

Advances and challenges in laparoscopic surgery in the management of hepatocellular carcinoma

Hepatocellular carcinoma is the fifth most common malignancy and the third most common cause of cancer-related mortality worldwide. From the wide variety of treatment options, surgical resection and liver transplantation are the only therapeutic ones. However, due to shortage of liver grafts, surgical resection is the most common therapeutic modality implemented. Owing to rapid technological development, minimally invasive approaches have been incorporated in liver surgery. Liver laparoscopic resection has been evaluated in comparison to the open technique and has been shown to be superior because of the reported decrease in surgical incision length and trauma, blood loss, operating theatre time, postsurgical pain and complications, R0 resection, length of stay, time to recovery and oral intake. It has been reported that laparoscopic excision is a safe and feasible approach with near zero mortality and oncologic outcomes similar to open resection. Nevertheless, current indications include solid tumors in the periphery < 5 cm, especially in segments II through VI, while according to the consensus laparoscopic major hepatectomy should only be performed by surgeons with high expertise in laparoscopic and hepatobiliary surgery in tertiary centers. It is necessary for a surgeon to surpass the 60-cases learning curve observed in order to accomplish the desirable outcomes and preserve patient safety. In this review, our aim is to thoroughly describe the general principles and current status of laparoscopic liver resection for hepatocellular carcinoma, as well as future prospects.

Surgical Treatment of Metastatic Colorectal Cancer

Surgical treatment of metastatic colorectal cancer offers a chance for cure or prolonged survival, particularly for those with more favorable prognostic factors and limited tumor burden. The treatment plan requires multidisciplinary evaluation because multiple therapy options exist. Advanced surgical techniques, adjuncts to resection, and modern chemotherapy all contribute to best outcomes for patients with hepatic metastases. Although cure is less common for patients with metastasis to lung or peritoneum, surgical resection for the former and cytoreduction and intraperitoneal chemotherapy for the latter may help to achieve cancer control in selected patients.

Optimizing associated liver partition and portal vein ligation for staged hepatectomy outcomes: Surgical experience or appropriate patient selection?

BACKGROUND

Early reports of associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) outcomes have been suboptimal. The literature has confirmed that learning curves influence surgical outcomes. We have 54 months of continuous experience performing ALPPS with strict selection criteria. This study aimed to evaluate the impact of the learning curve on ALPPS outcomes.

METHODS

We retrospectively compared patients who underwent ALPPS between April 2012 and March 2016. Patients were grouped into 2 24-month (early and late) periods. All candidates had a high tumour load requiring staged hepatectomy after chemotherapy response, a predicted future liver remnant (FLR) less than 30% and good performance status.

RESULTS

Thirty-three patients underwent ALPPS during the study period: 16 in the early group (median age 65 yr, mean body mass index [BMI] 27) and 17 in the late group (median age 60 yr, mean BMI 25). Bilobar disease was comparable in both groups (94% v. 88%, p > 0.99). Duration of surgery was not statistically different. Intraoperative blood loss and need for transfusion were significantly lower in the late group (200 ± 109 mL v. 100 ± 43 mL, p < 0.05). The late group had a higher proportion of monosegment ALPPS (4:1). There were no deaths within 90 days in either cohort. Rates of postoperative complications were not statistically significant between groups. The R0 resection rate was similar. The entire 1-year disease-free and overall survival were 52% and 84%, respectively.

CONCLUSION

Excellent results can be obtained in innovative complex surgery with careful patient selection and good technical skills. Additionally, the learning curve brought confidence to perform more complex procedures while maintaining good outcomes.

Laparoscopic liver resection in metastatic colorectal cancer treatment: comparison with long-term results using the conventional approach

Background

Laparoscopic liver resections (LLRs) have been shown to be both feasible and safe. However, no randomised control studies have been performed to date comparing results with those of the open surgery approach.

Main aim

To analyse LLR long-term results and compare them with a similar group of open resections in patients with colorectal carcinoma liver metastasis (CRCLM).

Methods

Retrospective study on a prospective database. All patients with anatomopathological diagnosis of CRCLM resected between July 2007 and July 2015.

Results

Twenty-two open resections and 18 laparoscopic resections which presented favourable lesions for laparoscopic approach were analysed. Postoperative grade III morbidity was similar in both groups (p = 0.323). Disease-free survival at 1, 3, and 8 years in the laparoscopy group (n =16) was 81%, 58%, and 58%, respectively, while in the open surgery group (n = 17) it was 64%, 37%, and 19% respectively; no differences were found (p = 0.388). Global survival in the laparoscopy group was 93%, 60%, and 40%, respectively, and 88%, 74.5%, and 58.7%, respectively, in the open surgery group; no differences were found (p = 0.893) with a 37 months average follow-up.

Conclusion

LLR in patients with technically favourable CRCLM had similar morbidity to open resections and resection margins were not compromised because of laparoscopy.

Early experience with robot-assisted laparoscopic hepatobiliary and pancreatic surgery in Singapore: single-institution experience with 20 consecutive patients

INTRODUCTION

Experience with robot-assisted laparoscopic (RAL) hepatobiliary and pancreatic (HPB) surgery remains limited worldwide. In this study, we report our early experience with RAL HPB surgery in Singapore.

METHODS

A retrospective review of the first 20 consecutive patients who underwent RAL HPB surgery at a single institution over a 34-month period from February 2013 to November 2015 was conducted. The 20 cases were performed by three principal surgeons, of which 17 (85.0%) were performed by a single surgeon.

RESULTS

The median age of patients was 56 (range 22-75) years and median tumour size was 4.0 (range 1.2-7.5) cm. The surgeries performed included left-sided pancreatectomies (n = 10), hepatectomies (n = 7), triple bypass with bile duct exploration for obstructing pancreatic head cancer with choledocholithiasis (n = 1), cholecystectomy for Mirizzi's syndrome (n = 1) and gastric resection for gastrointestinal stromal tumour (n = 1). The median operation time was 445 (range 80-825) minutes and median blood loss was 350 (range 0-1,200) mL. There was only 1 (5%) open conversion. There were 2 (10.0%) major morbidities (> Grade II on the Clavien-Dindo classification) and no 30-day/in-hospital mortalities. There was no reoperation for postoperative complications. The median postoperative stay was 5.5 (range 3-22) days.

CONCLUSION

Our initial experience confirms the feasibility and safety of RAL HPB surgery.

Stepwise introduction of laparoscopic liver surgery: validation of guideline recommendations

BACKGROUND

Uncontrolled introduction of laparoscopic liver surgery (LLS) could compromise postoperative outcomes. A stepwise introduction of LLS combined with structured training is advised. This study aimed to evaluate the impact of such a stepwise introduction.

METHODS

A retrospective, single-center case series assessing short term outcomes of all consecutive LLS in the period November 2006-January 2017. The technique was implemented in a stepwise fashion. To evaluate the impact of this stepwise approach combined with structured training, outcomes of LLS before and after a laparoscopic HPB fellowship were compared.

RESULTS

A total of 135 laparoscopic resections were performed. Overall conversion rate was 4% (n = 5), clinically relevant complication rate 13% (n = 18) and mortality 0.7% (n = 1). A significant increase in patients with major LLS, multiple liver resections, previous abdominal surgery, malignancies and lesions located in posterior segments was observed after the fellowship as well as a decrease in the use of hand-assistance. Increasing complexity in the post fellowship period was reflected by an increase in operating times, but without comprising other surgical outcomes.

CONCLUSION

A stepwise introduction of LLS combined with structured training reduced the clinical impact of the learning curve, thereby confirming guideline recommendations.

Critical appraisal of the impact of individual surgeon experience on the outcomes of laparoscopic liver resection in the modern era: collective experience of multiple surgeons at a single institution with 324 consecutive cases

BACKGROUND

Most studies analyzing the learning experience of laparoscopic liver resection (LLR) focused on the experience of one or two expert pioneering surgeons. This study aims to critically analyze the impact of individual surgeon experience on the outcomes of LLR based on the contemporary collective experiences of multiple surgeons at single institution.

METHODS

Retrospective review of 324 consecutive LLR from 2006 to 2016. The cases were performed by 10 surgeons over various time periods. Four surgeons had individual experience with <20 cases, four surgeons with 20-30 cases, and two surgeons with >90 cases. The cohort was divided into two groups: comparing a surgeon's experience between the first 20, 30, 40, and 50 cases with patients treated thereafter. Similarly, we performed subset analyses for anterolateral lesions, posterosuperior lesions, and major hepatectomies.

RESULTS

As individual surgeons gained increasing experience, this was significantly associated with older patients being operated, decreased hand-assistance, larger tumor size, increased liver resections, increased major resections, and increased resections of tumors located at the posterosuperior segments. This resulted in significantly longer operation time and increased use of Pringle maneuver but no difference in other outcomes. Analysis of LLR for tumors in the posterosuperior segments demonstrated that there was a significant decrease in conversion rates after a surgeon had experience with 20 LLR. For major hepatectomies, there was a significant decrease in morbidity, mortality, and length of stay after acquiring experience with 20 LLR.

CONCLUSION

LLR can be safely adopted today especially for lesions in the anterolateral segments. LLR for lesions in the difficult posterosuperior segments and major hepatectomies especially in cirrhosis should only be attempted by surgeons who have acquired a minimum experience with 20 LLR.

Evolution of Laparoscopic Liver Surgery from Innovation to Implementation to Mastery: Perioperative and Oncologic Outcomes of 2,238 Patients from 4 European Specialized Centers

BACKGROUND

First seen as an innovation for select patients, laparoscopic liver resection (LLR) has evolved since its introduction, resulting in worldwide use. Despite this, it is still limited mainly to referral centers. The aim of this study was to evaluate a large cohort undergoing LLR from 2000 to 2015, focusing on the technical approaches, perioperative and oncologic outcomes, and evolution of practice over time.

STUDY DESIGN

The demographics and indications, intraoperative, perioperative, and oncologic outcomes of 2,238 patients were evaluated. Trends in practice and outcomes over time were assessed.

RESULTS

The percentage of LLR performed yearly has increased from 5% in 2000 to 43% in 2015. Pure laparoscopy was used in 98.3% of cases. Wedge resections were the most common operation; they were predominant at the beginning of LLR and then decreased and remained steady at approximately 53%. Major hepatectomies were initially uncommon, then increased and reached a stable level at approximately 16%. Overall, 410 patients underwent resection in the posterosuperior segments; these were more frequent with time, and the highest percentage was in 2015 (26%). Blood loss, operative time, and conversion rate improved significantly with time. The 5-year overall survival rates were 73% and 54% for hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM), respectively. The 5-year, recurrence-free survival rates were 50% and 37% for HCC and CRLM, respectively.

CONCLUSIONS

Since laparoscopy was introduced, a long implementation process has been necessary to allow for standardization and improvement in surgical care, mastery of the technique, and the ability to obtain good perioperative results with safe oncologic outcomes.

Hand-assisted Approach as a Model to Teach Complex Laparoscopic Hepatectomies: Preliminary Results

BACKGROUND

Currently, there are limited and scarce models to teach complex liver resections by laparoscopy. The aim of this study is to present a hand-assisted technique to teach complex laparoscopic hepatectomies for fellows in liver surgery.

MATERIALS AND METHODS

Laparoscopic hand-assisted approach for resections of liver lesions located in posterosuperior segments (7, 6/7, 7/8, 8) was performed by the trainees with guidance and intermittent intervention of a senior surgeon. Data as: (1) percentage of time that the senior surgeon takes the surgery as main surgeon, (2) need for the senior surgeon to finish the procedure, (3) necessity of conversion, (4) bleeding with hemodynamic instability, (5) need for transfusion, (6) oncological surgical margins, were evaluated.

RESULTS

In total, 12 cases of complex laparoscopic liver resections were performed by the trainee. All cases included deep lesions situated on liver segments 7 or 8. The senior surgeon intervention occurred in a mean of 20% of the total surgical time (range, 0% to 50%). A senior intervention >20% was necessary in 2 cases. There was no need for conversion or reoperation. Neither major bleeding nor complications resulted from the teaching program. All surgical margins were clear.

CONCLUSIONS

This preliminary report shows that hand-assistance is a safe way to teach complex liver resections without compromising patient safety or oncological results. More cases are still necessary to draw definitive conclusions about this teaching method.

Setting up a robotic hepatectomy program: a Western-European experience and perspective

Currently the majority of liver resections are performed via open resection. Nevertheless, minimally invasive liver surgery is gaining ground and conventional laparoscopy has proven to be beneficial in different fields of liver surgery compared to open resections. Still, conventional laparoscopy has a few downsides, from which straight instruments, 2-dimensional view and awkward ergonomics are the most obvious. The robotic surgical system is developed to overcome these limitations. It offers several advantages over conventional laparoscopy to optimize conditions in minimally invasive surgery: instruments are wristed with a wide range of motion and the view is 3-dimensional and magnified. With instruments with a greater range of motion than in laparoscopic surgery, the use of a robotic system potentially broadens indications for minimally invasive liver resection. Here, we discuss the steps of setting up a robotic hepatectomy program against the background of the initial experience at our institution.

Training robotic hepatectomy: the Hong Kong experience and perspective

The introduction of robotic surgical systems has revolutionized the practice of minimal invasive surgery (MIS). Although little data regarding robotic hepatectomies have been reported, it appears to be similar to conventional laparoscopic approach in terms of blood loss, morbidity rate, mortality rate and hospital stay at least. The application of robotic system in liver surgery was not well evaluated yet, particularly learning curve. Studies were identified by searching MEDLINE and PubMed databases for articles from January 2001 to May 2016 using the keywords "laparoscopic hepatectomy", "robotic hepatectomy", and "learning curve". With the limited data in robotic hepatectomy, the learning curve model of robotic hepatectomy needs to base on the experience of conventional laparoscopic hepatectomy. Based on the learning curve study experience for laparoscopic hepatectomies, the minimal number laparoscopic minor and major hepatectomies to overcome learning curve are 22-64 cases, and 45-75 cases, respectively. Left lateral sectionectomy technique is more standardized, and it is a good start for training of MIS liver surgery. However, the training program required for the robotic liver surgeons still highly depends on the surgeons' experience of previous open and laparoscopic liver surgery, the surgeons' previous experience of other robotic surgeries, the experience of the surgical team including the assistant surgeons and nursing staffs, and the complexity of the diseases. We discourage performance of robotic hepatectomy in the occasional patient by a team that is not well prepared and is not embedded in a specialized center. Knowledge and practical skills are both required in MIS liver surgery and cannot be replaced by newer tools, including the most advanced robotic system.

Outcomes following laparoscopic versus open major hepatectomy for hepatocellular carcinoma in patients with cirrhosis: a propensity score-matched analysis

BACKGROUND

Laparoscopic major hepatectomy (LMH) for hepatocellular carcinoma (HCC) in patients with cirrhosis remains controversial due to limited reports in the literature. This study analyzed the perioperative and oncological outcomes of LMH for HCC with cirrhosis compared with open major hepatectomy (OMH).

METHODS

A retrospective analysis of patients with cirrhosis who underwent major hepatectomy for HCC between January 2015 and January 2017 was performed. Patients were divided into the LMH group and the OMH group. Short-term and oncological outcomes were compared before and after 1:1 propensity score matching (PSM).

RESULTS

A total of 103 HCC patients who received major liver resection were enrolled. There were 36 (35.0%) patients in the LMH group and 67 (65.0%) patients in the OMH group. After 1:1 PSM, well-matched 32 patients in each group were evaluated. Significant differences were observed in operative time (median, 255 vs. 200 min, p < 0.001) and Pringle time (median, 50 vs. 30 min, p < 0.001) between two groups. The blood loss and transfusion requirement were comparable in two groups. The rate of overall postoperative complications did not differ between two groups, while the incidence of ascites in the LMH group was significantly less than OMH group (9.4 vs. 31.3%, p = 0.030). The oncological outcomes between the two groups were comparable with regard to 2-year overall survival (85.7 vs. 86.7%, p = 0.694) and disease-free survival (72.9 vs. 81.5%, p = 0.990), respectively.

CONCLUSIONS

LMH for HCC patients with liver cirrhosis showed comparable results in terms of postoperative morbidity and oncological outcomes compared with traditional open procedure. LMH may serve as a safe and feasible alternative for selected HCC patients with cirrhosis.

Evolution of laparoscopic surgery in a high volume hepatobiliary unit: 150 consecutive pure laparoscopic hepatectomies

INTRODUCTION

Compared to other surgical areas, laparoscopic liver resection (LLR) has not been widely implemented and currently less than 20% of hepatectomies are performed laparoscopically worldwide. The aim of our study was to evaluate the feasibility, and the ratio of implementation of LLR in our department.

METHODS

We analyzed a prospectively maintained database of 749 liver resections performed during the last 10-year period in a single centre.

RESULTS

A total of 150 (20%) consecutive pure LLR were performed between 2005 and 2015. In 87% of patients the indication was the presence ofprimary or metastatic liver malignancy. We performed 30 major hepatectomies (20%) and (80%) were minor resections, performed in all liver segments. Twelve patients were operated twice and 2 patients underwent a third LLR. The proportion of LLR increased from 12% in 2011 to 62% in the last year. Conversion rate was 9%. Overall morbidity rate was 36% but only one third were classified as severe. The 90-day mortality rate was 1%. Median hospital stay was 4 days and the rate of readmissions was 6%.

CONCLUSIONS

The implementation of LLR has been fast with morbidity and mortality comparable to other published series. In the last 2 years more than half of the hepatectomies are performed laparoscopically in our centre.

First quarter century of laparoscopic liver resection

The beginnings of laparoscopic liver resection (LLR) were at the start of the 1990s, with the initial reports being published in 1991 and 1992. These were followed by reports of left lateral sectionectomy in 1996. In the years following, the procedures of LLR were expanded to hemi-hepatectomy, sectionectomy, segmentectomy and partial resection of posterosuperior segments, as well as the parenchymal preserving limited anatomical resection and modified anatomical (extended and/or combining limited) resection procedures. This expanded range of LLR procedures, mimicking the expansion of open liver resection in the past, was related to advances in both technology (instrumentation) and technical skill with conceptual changes. During this period of remarkable development, two international consensus conferences were held (2008 in Louisville, KY, United States, and 2014 in Morioka, Japan), providing up-to-date summarizations of the status and perspective of LLR. The advantages of LLR have become clear, and include reduced intraoperative bleeding, shorter hospital stay, and - especially for cirrhotic patients-lower incidence of complications (e.g., postoperative ascites and liver failure). In this paper, we review and discuss the developments of LLR in operative procedures (extent and style of liver resections) during the first quarter century since its inception, from the aspect of relationships with technological/technical developments with conceptual changes.

Pure Laparoscopic Hepatectomy Versus Open Hepatectomy for Hepatocellular Carcinoma in 110 Patients With Liver Cirrhosis: A Propensity Analysis at a Single Center

OBJECTIVE

To investigate the long-term outcomes of pure laparoscopic hepatectomy versus open hepatectomy for hepatocellular carcinoma (HCC) with background cirrhosis.

BACKGROUND

Laparoscopic hepatectomy has been gaining popularity, but has not been widely accepted, because published data were gathered from small numbers of patients.

METHODS

Data of patients diagnosed with HCC and cirrhosis treated by hepatectomy were reviewed. The outcomes of pure laparoscopic hepatectomy were compared with those of open hepatectomy. Propensity score matching of patients in a ratio of 1:3 was conducted.

RESULTS

There were 110 patients and 330 patients in the laparoscopic group and the open group, respectively. The laparoscopic group had less blood loss (150 vs 400 mL; P < 0.001), shorter operation time (185 vs 255 minutes; P < 0.001), and shorter hospital stay (4vs 7 days; P < 0.001). The median overall survival was 136 months in the laparoscopic group and 120 months in the open group. The 1, 3, and 5-year overall survival rates were 98.9%, 89.8%, and 83.7%, respectively, in the laparoscopic group, and 94%, 79.3%, and 67.4%, respectively, in the open group (P = 0.033). The median disease-free survival was 66.37 months in the laparoscopic group and 52.4 months in the open group. The 1, 3, and 5-year disease-free survival rates were 87.7%, 65.8%, and 52.2%, respectively, in the laparoscopic group, and 75.2%, 56.3%, and 47.9%, respectively, in the open group (P = 0.141).

CONCLUSIONS

Pure laparoscopic hepatectomy for HCC can be carried out safely with favorable short-term and long-term outcomes even in cirrhotic patients at high-volume liver cancer centers.