Laparoscopic versus open hepatic resections for benign and malignant neoplasms--a meta-analysis

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

BACKGROUND

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

METHODS

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

RESULTS

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

DISCUSSION

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

Total laparoscopic liver resection for hepatocellular carcinoma located in all segments of the liver

BACKGROUND

Laparoscopic liver resection (LLR) is still not a well-established treatment modality for hepatocellular carcinoma (HCC). Moreover, most reported cases have been limited to tumors in the anterolateral (AL) segments (segments 2, 3, 4b, 5, and 6). We evaluated clinical and oncologic outcomes after LLR for HCC located in all segments, including lesions located in the posterosuperior (PS) segments (segments 1, 4a, 7, and 8).

METHODS

This retrospective study included 69 patients who had undergone LLR for HCC between September 2003 and November 2008. The patients were divided into two groups (group AL and group PS) according to tumor location. The clinical data of the two groups were retrospectively analyzed.

RESULT

There was no postoperative mortality. Fifteen patients (21.7%) experienced 19 postoperative complications. During a median follow-up period of 21.3 months, recurrence was detected in 21 (30.4%) patients. The 3-year overall survival rate and disease-free survival rate were 90.4 and 60.4%, respectively. There was no difference in clinicopathologic characteristics between the two groups except for a male predominance in group PS (p = 0.021) and that there were more patients with thrombocytopenia in group AL (p = 0.001). Although group PS patients had longer operative time (p = 0.001) and longer postoperative hospital stay (p = 0.039), along with a tendency toward a higher rate of open conversion (p = 0.054) and greater blood loss (p = 0.068), there was no significant difference in rates of postoperative complications (p = 0.375), recurrence (p = 0.740), 3-year overall survival (p = 0.237) or disease-free survival (p = 0.411) between the two groups.

CONCLUSIONS

Our experience shows that LLR can be safely performed in selected patients with HCC located in all segments of the liver, including the posterosuperior segments, with acceptable postoperative morbidity and oncologic results.

World review of laparoscopic liver resection-2,804 patients

OBJECTIVE

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

SUMMARY BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

The learning curve in laparoscopic liver resection: improved feasibility and reproducibility

OBJECTIVE

To evaluate the "learning curve" effect on feasibility and reproducibility of laparoscopic liver resection (LLR).

SUMMARY BACKGROUND DATA

LLR is currently limited to few centers and to few procedures. Its reproducibility is still debated.

METHODS

: Patients undergoing LLR between 1996 and 2008 were included. Indications and type of hepatectomies were compared with those of open resections performed in the same period, considering 3 periods (1996-1999, 2000-2003, and 2004-2008). LLRs were divided into 3 equal groups of 58 cases and technical data and outcomes were compared. Risk-adjusted Cumulative Sum model was used for determining the learning curve based on the need for conversion.

RESULTS

Of 782, 174 (22.3%) patients underwent LLR. Proportion of LLR progressively increased (17.5%, 22.4%, and 24.2%), such as hepatocellular carcinoma (17.6%, 25.6%, and 39.4%, P < 0.05), colorectal metastases (0%, 6.5%, and 13.1%, P < 0.05), major hepatectomies (1.1%, 9.1%, 8.5%, P < 0.05), and right hepatectomies (0%, 13.2%, and 13.1%, P < 0.05). Comparing groups, results of LLR significantly improved in terms of conversion rate (15.5%, 10.3%, and 3.4%, P < 0.05), operative time (210, 180, and 150 minutes, P < 0.05), blood loss (300, 200, and 200 mL, P < 0.05), and morbidity (17.2%, 22.4%, and 3.4%, P < 0.05). Pedicle clamping was less used over time (77.6%, 62.1%, and 17.2%, P < 0.05) and for shorter durations (45, 30, and 20 minutes, P < 0.05). Having adjusted for case-mix, the Cumulative Sum analysis demonstrated a learning curve for laparoscopic hepatectomies of 60 cases.

CONCLUSION

A slow but constant evolution of LLR occurred: indications and magnitude of procedures increased and technical outcomes improved. The learning curve demonstrated in this study suggests that LLR is reproducible in liver units but specific training to advanced laparoscopy is required.

Laparoscopic liver surgery

Great advances have occurred in the field of laparoscopic hepatic surgery. It is now clear that in experienced hands, the laparoscopic method of liver resection is as safe as an open procedure. The key phrase in this last sentence is "in experienced hands". The new devices that are available might make an inexperienced hepatic surgeon, well-trained in laparoscopic surgery, embark on hepatic resection without thorough knowledge of hepatic anatomy. The converse may also be true. As no criteria for credentialing of laparoscopic hepatic surgeons exist, the decision as to who is sufficiently trained to perform these procedures is left to individual hospital credentialing boards. While a certification procedure defined by leaders in this field and supported by surgical societies would be welcomed, the ability to achieve and enforce these guidelines appear to be more of a challenge. In addition, while most comparison studies in this area conclude by suggesting that a randomized, clinical trial would be needed to definitively arrive at an answer regarding the benefits of minimally invasive liver surgery compared with open surgery, it would likely be extremely difficult to accrue patients, given the data presented in articles regarding the success of laparoscopic hepatic resections. The authors conclude that an internationalregistry of all laparoscopic cases should b e established to insure patient safety and a mechanism for self-monitoring.

Laparoscopic versus open liver resection: a matched-pair case control study

BACKGROUND

Laparoscopic liver resection (LLR) has become an increasingly popular operation; however, its theoretical benefits remain unproven. The aim of this study was to conduct a comparative outcome study between LLR and matched-pair open liver resections (OLR).

METHODS

Sixty five patients underwent attempted LLR from 1998 through 2008; 52 of which were completed laparoscopically. Patients who underwent OLR prior to 1998 were matched to laparoscopic cases for demographics, comorbidities, diagnosis, tumor characteristics, procedure, and background liver. Perioperative and oncologic outcomes were compared between the two groups. Analyses were performed excluding and including conversion cases.

RESULTS

Characteristics were comparable between both groups. LLR was associated with significant reductions in estimated blood loss, frequency of transfusion, frequency of Pringle maneuver, postoperative morbidity, time to recovery, length of hospital stay, and incidence of incisional hernia. For patients with malignant tumors, there were no positive surgical margins or local recurrence in either group and the overall pattern of recurrence was similar.

CONCLUSION

For well-selected patients, LLR is a feasible operation that does not compromise operative or oncologic outcomes. While LLR was associated with some benefits, these can only be definitively proven in a randomized controlled trial.

Laparoscopy-assisted and open living donor right hepatectomy: a comparative study of outcomes

BACKGROUND

Minimally invasive liver surgery is a rapidly advancing field with demonstrated applicability to living donation. In this paper, we compare the safety and efficacy of laparoscopy-assisted donor right hepatectomy (LADRH) to open donor right hepatectomy (ODRH).

METHODS

We performed a retrospective, comparative analysis of 33 LADRH to the most recent 33 ODRH performed at our institution, evaluating donor complications, costs, and recipient outcomes.

RESULTS

Donor demographics including age, gender, body mass index (BMI), and vascular and biliary anomalies were comparable. Donor complication rates were equivalent for LADRH and ODRH. Donor operative times were shorter for LADRH (LADRH 265 minutes, ODRH 316; P < .001) even after adjusting for BMI. Blood loss and length of stay were comparable. Additionally, total hospitalization costs were equivalent (LADRH $1.11, ODRH $1.00; P = .19). Higher operative supply costs for LADRH were balanced by higher time-based operative costs for ODRH resulting in no significant differences in total operative costs. Finally, there were no differences in graft size, recipient patient or graft survival, or recipient vascular or biliary complications.

CONCLUSION

Our experience suggests that LADRH compares favorably with ODRH with equivalent safety, resource utilization, and effectiveness. We believe that LADRH provides potential physical and psychological benefits without an adverse effect on outcomes.

Open versus laparoscopic resection for liver tumours

BACKGROUND

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

METHODS

Literature review on liver resection and laparoscopy.

RESULTS

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

DISCUSSION

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

Laparoscopic hepatectomy for liver tumors: proposals for standardization

BACKGROUND/PURPOSE

We draw on our experience with laparoscopic hepatectomy (LH) to present recommendations for standardization of LH for the treatment of liver tumors.

METHODS

At our center, 90 LHs were performed from April 1993 to January 2008. These were divided equally into early cases and late cases, and short-term postoperative results were compared. Forty-nine of the LH procedures were total-laparoscopic procedures, 16 were hand-assisted procedures, and 25 were laparoscopy-assisted procedures. The tumors were malignant in 76 cases and benign in 14 cases.

RESULTS

Among late cases, the numbers of malignant tumors and tumors located in the posterosuperior region of the liver (Segments VII, VIII, and IVb) were significantly higher than among early cases; however, operative blood loss and postoperative hospital stay were significantly lower in the late cases (158.9 +/- 213.4 vs. 377.6 +/- 421.2 cc, P = 0.007; and 8.7 +/- 3.6 vs. 15.3 +/- 8.7 days, P = 0.0001, respectively). No operative deaths occurred in either group.

CONCLUSIONS

Although LH does have a steep learning curve, we believe that it can be standardized and provide a less invasive surgical option--with no reduction in disease curability--for the treatment of liver tumors in selected patients.

Laparoscopic versus open left lateral hepatectomy

Laparoscopic liver surgery is becoming more popular, and many high-volume liver centers are now gaining expertise in this area. Laparoscopic left lateral hepatectomy (LLLH) is a standardized and anatomically well-defined resection and may transform into a primarily laparoscopic procedure for cancer surgery or living donor hepatectomy for transplantation. Five case-control series were identified comparing a total of 167 cases (86 cases of LLLH plus 81 cases of open left lateral hepatectomy). Groups were matched by age and sex, with broadly similar indications for surgery and resection techniques. LLLH is associated with shorter hospital stays and less blood loss without compromising the margin status or increasing complication rates. Donors of LLLH grafts did not have higher graft-related morbidity. Prospective studies are required to define the safety in terms of disease-free and overall survival in this new avenue in laparoscopic liver surgery.

The impact of carbon dioxide pneumoperitoneum on liver regeneration after liver resection in a rat model

BACKGROUND

In recent years, laparoscopic hepatic resection is performed by an increasing number of surgeons. Despite many advantages of the laparoscopic procedure, it is unclear whether the pneumoperitoneum affects the postoperative liver regeneration after liver resection. The current study aimed to investigate the influence of a carbon dioxide (CO(2)) pneumoperitoneum on liver regeneration in a rat model.

METHODS

In this study, 60 male Wistar rats were subjected to 70% partial hepatic resection. Of these 60 animals, 30 underwent preoperative pneumoperitoneum at 9 mmHg for 60 min. After hepatic resection, the rats were killed at 12, 24, and 48 h, and on days 4 and 7. The outcome parameters were hepatocellular injury (plasma aminotransferases), oxidative stress (plasma malondialdehyde), interleukin-6 (IL-6), and liver regeneration (mitotic index, KI-67; regenerating liver mass).

RESULTS

The mitotic index was significantly lower in the pneumoperitoneum group than in the group without pneumoperitoneum at all time points (p < 0.05). In the pneumoperitoneum group, KI-67 was significantly lower on day 4 (p < 0.05). The liver regeneration rate was significantly lower for the animals with pneumoperitoneum on days 2 and 4 (p < 0.05). The postoperative hepatocellular injury was significantly greater after pneumoperitoneum at 12, 24, and 48 h (p < 0.05). Plasma malondialdehyde and IL-6 were significantly higher in the pneumoperitoneum group at 24 h and on day 4 (p < 0.05).

CONCLUSION

This study showed that pneumoperitoneum before extended liver resection impaired postoperative liver regeneration. Oxidative stress reaction and hepatocellular damage was markedly higher after pneumoperitoneum. Further investigations, especially with patients that have impaired liver function, are necessary for clinical consequences to be drawn from these results.

Laparoscopic liver resection: a systematic review

BACKGROUND

Outcomes of laparoscopic liver resection (LLR) are not clarified. The objective of this article is to depict the state of the art of LLR by means of a systematic review of the literature.

METHODS

Studies about LLR published before September 2008 were identified and their results summarized.

RESULTS

Indications for laparoscopic hepatectomy do not differ from those for open surgery. Technical feasibility is the only limiting factor. Bleeding is the major intraoperative concern, but, if managed by an expert surgeon, do not worsen outcomes. Hand assistance can be useful in selected cases to avoid conversion. Patient selection must take both tumor location and size into consideration. Potentially good candidates are patients with peripheral lesions requiring limited hepatectomy or left lateral sectionectomy; their outcomes, including reduced blood loss, morbidity, and hospital stay, are better than those of their laparotomic counterparts. The same advantages have been observed in cirrhotics. Laparoscopic major hepatectomies and resections of postero-superior segments need further evaluation. The results of LLR in cancer patients seem to be similar to those obtained with the laparotomic approach, especially in cases of hepatocellular carcinoma, but further analysis is required.

CONCLUSIONS

Laparoscopic liver resection is safe and feasible. The laparoscopic approach can be recommended for peripheral lesions requiring limited hepatectomy or left lateral sectionectomy. Preliminary oncological results suggest non-inferiority of laparoscopic to laparotomic procedures.

Laparoscopic hepatectomy for hepatocellular carcinoma in cirrhotic patients

INTRODUCTION

We have used laparoscopic hepatectomy as a surgical treatment for HCC in patients with cirrhosis. We describe the indications, evaluate invasiveness and analyze the outcomes of laparoscopic hepatectomy.

METHODS AND RESULTS

With respect to operative method, laparoscopic hepatectomy involving either partial hepatectomy or left lateral sectionectomy is a less invasive procedure in patients with cirrhosis than conventional hepatectomy. Among our laparoscopic hepatectomy cases, operative time was shorter and bleeding was less in recent, as compared to earlier, cases. Furthermore, laparoscopic hepatectomy was less invasive than conventional hepatectomy, as determined by the E-PASS scoring system. Patients also recovered more quickly, which resulted in shorter hospital stays even for patients with cirrhosis. Both the 5-year survival rate and the rate of survival without recurrence of HCC were nearly identical to those of open conventional hepatectomy.

CONCLUSION

These findings indicate that laparoscopic hepatectomy avoids the disadvantages of standard hepatectomy for HCC in properly selected patients with cirrhosis and that its minimal invasiveness improves patients' quality of life.

Status of endoscopic liver surgery in Japan: a questionnaire survey conducted by the Japanese Endoscopic Liver Surgery Study Group

BACKGROUND/PURPOSE

In 2007, the First Annual Meeting of the Japanese Endoscopic Liver Surgery Study Group was convened. We report the results of a questionnaire survey conducted by this study group that attempted to assess the current status and safety of endoscopic liver surgery.

METHODS

A questionnaire survey was conducted at 26 hospitals to determine the operative procedures, rates of conversion to open surgery, and morbidity rates in patients who had undergone laparoscopic hepatectomy and endoscopic ablation therapy.

RESULTS

Laparoscopic hepatectomy was performed in 471 patients by means of nonanatomical partial resection (57.7%), left lateral sectionectomy (24.6%), hemihepatectomy (12.5%), sectionectomy other than lateral sectionectomy (2.5%), and segmentectomy (2.5%). Hepatectomy was performed by a totally laparoscopic procedure in 47% of the patients and by a hybrid procedure in 53%. The rate of complications was 12.3%; there was no case of serious liver failure or operative mortality. Endoscopic ablation therapy was performed in 169 patients through a thoracoscopic (25.4%) or laparoscopic approach (74.6%), using radiowaves (55.6%), microwaves (40.2%), cryotherapy (1.8%), or ethanol (0.6%). The incidence of complications was 6.6%.

CONCLUSIONS

In properly selected patients, laparoscopic hepatectomy and endoscopic ablation therapy are safe treatments for liver tumors.

Standardization of basic skills for laparoscopic liver surgery towards laparoscopic donor hepatectomy

INTRODUCTION

We have accumulated over 170 patients since 1995 who underwent laparoscopic partial liver resection, laparoscopic left lateral sectionectomy, and laparoscopy-assisted hepatectomy. Bleeding control, which is a basic element of liver resection, needs to be better managed by methods suitable for safer laparoscopic liver resection. The aim of this study was to standardize the basic skills and to establish safer techniques for laparoscopic liver surgery in order to perform safe laparoscopic donor hepatectomy.

MATERIALS AND METHODS

We analyzed initial results from the viewpoint of operative techniques of laparoscopic liver resection in our series. Laparoscopic liver resections have been successfully performed by the application of automatic suturing devices and the radiofrequency method.

RESULTS

We have performed 105 laparoscopic partial liver resections, 26 laparoscopic left lateral sectionectomies, and 45 laparoscopy-assisted major hepatectomies. A total of 176 patients underwent minimally invasive liver resections.

CONCLUSION

For safer laparoscopic liver resection, efficient bleeding control techniques, such as radiofrequency pre-coagulation and the liver hanging maneuver, are needed during parenchymal transection of the liver. Laparoscopy-assisted donor hepatectomy can be safely performed without increasing operative risks with mini-laparotomy.

Laparoscopic-assisted combined colon and liver resection for primary colorectal cancer with synchronous liver metastases: initial experience

BACKGROUND

Laparoscopic approaches have become increasingly used in selected patients with either colorectal or liver cancer. However, the feasibility of laparoscopic-assisted combined colon and liver resection in primary colorectal cancer with synchronous liver metastases remains unknown. The aim of the present study was to determine the feasibility of laparoscopic-assisted combined colon and liver resection for primary colorectal cancer with synchronous liver metastases.

METHODS

Laparoscopic surgery involving intestinal anastomosis was performed for primary colorectal cancer. The liver was then mobilized with the assistance of a hand inserted through the upper midline incision. For minor resections, the parenchymal transection was performed laparoscopically. For major resection involving a hilar dissection, transection was performed according to the standard open techniques under direct vision through the incision. Resected specimens were retrieved directly through the midline incision.

RESULTS

Ten patients with primary colorectal cancer and synchronous liver metastases underwent the above procedure between September 2006 and April 2007. Surgical procedures for colorectal cancer included 5 low anterior resections, 3 anterior resections, 1 right hemicolectomy, and 1 subtotal colectomy. Combined hepatic surgery included 6 major hepatectomies, 3 segmentectomies, and 1 tumorectomy. All procedures were successful, with no conversions to open surgery required. The median operation time was 439 min (range: 210-690 min), and the median estimated blood loss was 350 ml (range: 300-1,200 ml). There was no surgical mortality or major morbidity, except in one patient in whom postoperative bleeding at the site of para-aortic node dissection was promptly controlled.

CONCLUSIONS

Laparoscopic-assisted combined colon and liver resection is a feasible and safe procedure for the treatment of primary colorectal cancer with synchronous liver metastases.

The role of minimally invasive treatments in surgical oncology

This article reviews the use of minimally invasive surgical and endoscopic techniques in the field of surgical oncology. It reviews the indications and techniques of the use of minimally invasive surgery for several oncologic indications in general surgery. In particular, it reviews the currently published literature discussing the oncologic outcomes of these techniques.

Laparoscopic and robot-assisted one-stage resection of colorectal cancer with synchronous liver metastases: a pilot study

BACKGROUND/PURPOSE

One-stage resection of primary colon cancer and synchronous liver metastases is considered an effective strategy of cure. A laparoscopic approach may represent a safe and advantageous choice for selected patients with the aim of improving the early outcome.

METHODS

Between January 2008 and October 2008, 7 patients underwent one-stage laparoscopic resection for primary colorectal cancer combined with laparoscopic or robot-assisted liver resection.

RESULTS

A total of five laparoscopic left-colon, one right-colon, and one rectal resections were performed. Three patients underwent preoperative left-colon stenting and two received neoadjuvant chemotherapy. The patient with rectal cancer underwent neoadjuvant radiotherapy. Liver procedures included one bisegmentectomy (segments 2, 3), 3 segmentectomies, 6 metastasectomies, and four laparoscopic ultrasound-guided radiofrequency ablations (LUG-RFAs). One patient with multiple liver metastases was managed by a two-stage hepatectomy partially conducted by a totally laparoscopic approach. The overall postoperative morbidity was null. The median hospital stay was 10 days (range 7-10 days).

CONCLUSIONS

This pilot study suggests that laparoscopic one-stage colon and liver resection is feasible and safe. Robot assistance may facilitate liver resection, increasing the number of patients who may benefit from a minimally invasive operation.

Ten-year experience of totally laparoscopic liver resection in a single institution

BACKGROUND

Recent developments in liver surgery include the introduction of laparoscopic liver resection. The aim of the present study was to review a single institution's 10-year experience of totally laparoscopic liver resection (TLLR).

METHODS

Between May 1997 and April 2008, 82 patients underwent TLLR for hepatocellular carcinoma (HCC) (37 patients), liver metastases (39) and benign liver lesions (six). Operations included 69 laparoscopic wedge resections, 11 laparoscopic left lateral sectionectomies and two thoracoscopic wedge resections. Nine patients underwent simultaneous laparoscopic resection of colorectal primary cancer and synchronous liver metastases.

RESULTS

Median operating time was 177 (range 70-430) min and blood loss 64 (range 1-917) ml. Median tumour size and surgical margin were 25 (range 15-85) and 6 (range 0-40) mm respectively. One procedure was converted to a laparoscopically assisted hepatectomy. Three patients developed complications. Median postoperative stay was 9 (range 3-37) days. The overall 5-year survival rate after surgery for HCC and colorectal metastases was 53 and 64 per cent respectively.

CONCLUSION

TLLR can be performed safely for a variety of primary and secondary liver tumours, and seems to offer at least short-term benefits in selected patients.

Laparoscopic versus open right hepatectomy: a comparative study

BACKGROUND

The safety of laparoscopic major liver resections is still uncertain. The aim of this study was to compare our results for laparoscopic right hepatectomy (LRH) with those for open right hepatectomy (ORH).

METHODS

Patients undergoing LRH were compared with retrospectively selected patients from our ORH database. The 2 groups were well matched for sex, age, American Society of Anesthesiologists score, body mass index, liver disease, and tumor size. Surgical and postsurgical outcomes were compared.

RESULTS

Seventy-two patients were analyzed: 22 in the LRH group and 50 in the ORH group. Operating time was similar. Blood loss was significantly less in laparoscopic resections (P = .038). Specific morbidity rates were not different, general morbidity was lower after laparoscopy (P = .04), and the severity of postsurgical complications was not different. Mean hospital stay was significantly shorter after laparoscopy (P = .009).

COMMENTS

Laparoscopy improved surgical and postsurgical outcomes for ORH in selected patients. This is the first comparative study to demonstrate an advantage of laparoscopy for a major liver resection. Prospective randomized studies with a greater number of cases are needed to confirm the role of laparoscopy in major liver resections.

Perioperative analysis of laparoscopic versus open liver resection

BACKGROUND

Over the past decade there has been an increasing trend toward minimally invasive liver surgery. Initially limited by technical challenges, advances in laparoscopic techniques have rendered this approach safe and feasible. However, as health care costs approach 50% of some provincial budgets, surgical innovation must be justifiable in costs and patient outcomes. With introduction of standardized postoperative liver resection guidelines to optimize patient hospital length of stay, the advantages of laparoscopic liver resection (LLR) compared with open liver resection (OLR) measured by perioperative outcomes and resource utilization are not well defined. It remains to be established whether LLR is superior to OLR by these measurements.

METHODS

Eighteen LLRs performed at the Vancouver General Hospital from 2005 to 2007 were prospectively analyzed. These data were compared with an equivalent group of 12 consecutive OLRs undertaken immediately prior to the introduction of LLR. Outcomes were evaluated for differences in perioperative morbidity, hospital length of stay, and operative costs.

RESULTS

There were no differences between LLRs and OLRs in demographics, pathology, cirrhosis, tumour location or extent of resection. There were no deaths. LLRs had significantly decreased intraoperative blood loss (287 ml versus 473 ml, p = 0.03), postoperative complications (6% versus 42%, p = 0.03), and length of stay (4.3 versus 5.8 days, p = 0.01) compared with OLRs. There were no differences in operating time for LLRs compared to OLRs (135 min versus 138 min, respectively), total time in the operating theatre (214 min versus 224 min), or costs related to stapler/trocar devices (CA $1267 versus CA $1007).

CONCLUSIONS

LLR is associated with decreased morbidity and decreased resource utilization compared with OLR. Perioperative patient outcomes and cost-effectiveness justify LLR despite introduction of standardized postoperative liver resection guidelines and decreased length of stay for OLR.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

The effect of a multimodal fast-track programme on outcomes in laparoscopic liver surgery: a multicentre pilot study

OBJECTIVES

This study was conducted to evaluate the added value of an enhanced recovery after surgery (ERAS) programme in laparoscopic liver resections for solid tumours.

METHODS

Patients undergoing laparoscopic liver resection between July 2005 and July 2008 were included. Indications for resections included presumed benign and malignant liver lesions. Primary outcome was total length of hospital stay (LOS). Secondary outcomes were functional recovery, complications, conversions, blood loss and duration of operation.

RESULTS

Thirteen patients were treated by laparoscopic liver resections in the ERAS programme in one centre (group 1). Their outcomes were compared with outcomes of 13 laparoscopic procedures performed either before the introduction of the ERAS programme during 2003-2005 in the same centre or during the same period in other centres using traditional care (group 2). Median total LOS was 5.0 days (range 3-10 days) in group 1 and 7.0 days (3-12 days) in group 2. This difference was not statistically significant. Functional recovery occurred 2 days earlier in group 1 (median 3.0 days [range 1-7 days] vs. median 5.0 days [range 2-8 days]; P < 0.044). There were no significant differences in complications, conversions or duration of operation. Blood loss was significantly less in the ERAS group (median 50 ml [range 50-200 ml] vs. median 250 ml [range 50-800 ml]; P < 0.002).

CONCLUSIONS

This exploratory, multicentre, fast-track laparoscopic liver resection study is the first such study conducted. Although small, the study suggests that a multimodal enhanced recovery programme in laparoscopic liver surgery is feasible, safe and may lead to accelerated functional recovery and reductions in LOS.

Comparison of laparoscopic versus open liver tumor resection: a case-controlled study

BACKGROUND

Although there are data in the literature about the safety and efficacy of laparoscopic liver resections, there are not many studies comparing laparoscopic versus open approaches in a case-matched design. The purpose of this study is to compare the perioperative outcome of laparoscopic versus open liver resections from a single institution.

METHODS

Thirty-one patients underwent laparoscopic liver resection between April 1997 and August 2007, with a prospective laparoscopic program started in April 2006 (n=25). This group of patients was compared with 43 consecutive patients undergoing open resection who were matched by size of the lesion (5 cm or less for malignant and 8 cm or less for benign), anatomical location (segments 2, 3, 4b, 5, 6), and type of resection (wedge resection, segmentectomy, partial liver resection). Data were obtained from medical records as well as from a prospective database. Statistical analysis was performed using t-test and chi-square. All data are expressed as mean +/- standard error on the mean (SEM).

RESULTS

Mean age in the laparoscopic group was 57.6+/-2.7 years versus 61.9+/-2.3 years in the open group (p=0.2). There were more women in the laparoscopic group [74% females (n=23) and 26% males (n=8)] versus in the open group [40% females (n=17) and 60% males (n=26)] (p=0.003). There were more patients with malignant lesions in the open group (73%) versus in the laparoscopic group (45%) (p=0.01). Eight patients underwent partial and 23 patients segmental/wedge liver resection in the laparoscopic group versus 15 patients who underwent partial and 28 patients segmental/wedge liver resection in the open group (p=0.7). Mean tumor size was 3.9+/-0.4 cm in the laparoscopic group versus 4.2+/-0.3 cm in the open group (p=0.5). Ten (32%) out of 31 cases in the laparoscopic group were hand-assisted. Inflow occlusion was used in 1 case (3%) in the laparoscopic group versus 16 (37.2%) in the open group. Mean operating time was 201+/-15 min for the laparoscopic group and 172+/-12 min for the open group (p=0.1). Mean estimated blood loss during the procedure was 122.5+/-45.4 cc for the laparoscopic group and 299.6+/-33.6 cc for the open group (p=0.002). Surgical margin was similar for malignant cases in both groups. Mean hospital stay was 3.2+/-1.0 days for the laparoscopic group and 6.8+/-0.7 days for the open group (p=0.004). The incidence of postoperative complications was 13% (n=4) in the laparoscopic and 16% (n=7) in the open group (p=0.7).

CONCLUSION

This study shows that, with a longer operative time, the laparoscopic approach, despite the learning curve, offers advantages regarding operative blood loss, postoperative analgesic requirement, time to regular diet, hospital stay, and overall cost compared with the open approach for minor liver resections.

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 versus open liver segmentectomy: prospective, case-matched, intention-to-treat analysis of clinical outcomes and cost effectiveness

INTRODUCTION

Reduction in hospital stay, blood loss, postoperative pain and complications are common findings after laparoscopic liver resection, suggesting that the laparoscopic approach may be a suitable alternative to open surgery. Some concerns have been raised regarding cost effectiveness of this procedure and potential implications of its large-scale application. Our aim has been to determine cost effectiveness of laparoscopic liver surgery by a case-matched, case-control, intention-to-treat analysis of its costs and short-term clinical outcomes compared with open surgery.

METHODS

Laparoscopic liver segmentectomies and bisegmentectomies performed at Ninewells Hospital and Medical School between 2005 and 2007 were considered. Resections involving more than two Couinaud segments, or involving any synchronous procedure, were excluded. An operation-magnitude-matched control group was identified amongst open liver resections performed between 2004 and 2007. Hospital costs were obtained from the Scottish Health Service Costs Book (ISD Scotland) and average national costs were calculated. Cost of theatre time, disposable surgical devices, hospital stay, and high-dependency unit (HDU) and intensive care unit (ICU) usage were the main endpoints for comparison. Secondary endpoints were morbidity and mortality. Statistical analysis was performed with Student's t-test, chi(2) and Fisher exact test as most appropriate.

RESULTS

Twenty-five laparoscopic liver resections were considered, including atypical resection, segmentectomy and bisegmentectomy, and they were compared to 25 matching open resections. The two groups were homogeneous by age, sex, coexistent morbidity, magnitude of resection, prevalence of liver cirrhosis and indications. Operative time (p < 0.03), blood loss (p < 0.0001), Pringle manoeuvre (p < 0.03), hospital stay (p < 0.003) and postoperative complications (p < 0.002) were significantly reduced in the laparoscopic group. Overall hospital cost was significantly lower in the laparoscopic group by an average of 2,571 pounds sterling (p < 0.04).

CONCLUSIONS

Laparoscopic liver segmentectomy and bisegmentectomy are feasible, safe and cost effective compared to similar open resections. Large-scale application of laparoscopic liver surgery could translate into significant savings to hospitals and health care programmes.

The current role of laparoscopic liver resection for the treatment of liver tumors

Laparoscopic liver resection (LLR) represents a natural extension of minimally invasive surgery. Several case-control studies have demonstrated that LLR is safe and feasible in carefully selected patients. LLR is associated with reduced operative blood loss and earlier recovery when compared with open surgery. In addition, oncologic clearance achieved with LLR is comparable to that achieved with open surgery. Improved cosmesis and postoperative patient comfort also argue in favor of LLR compared with open surgery. When considering whether a patient is suitable for LLR, the size and location of the neoplasm must be taken into account. Operator experience must also be considered as LLR is technically demanding and requires experience in conventional hepatobiliary surgery and advanced laparoscopy. The main indication for LLR is limited resection of superficial or peripherally located tumors. In the case of malignant tumors, LLR should be indicated only if a safe and effective oncologic resection can be performed, and the availability of laparoscopy should not change the indications for benign lesions. Ultimately, the future application of LLR will depend on how easily liver surgeons can master the technique and whether the long-term results of LLR can match those achieved with open resection.

Early experiences of robotic-assisted laparoscopic liver resection

PURPOSE

The surgical robotic system is superior to traditional laparoscopy in regards to 3-dimensional images and better instrumentations. Robotic surgery for hepatic resection has not yet been extensively reported.

PATIENTS AND METHODS

Between March and May 2007, we performed 3 robot-assisted left lateral sectionectomies of the liver. Case 1 had a hepatocellular carcinoma (HCC), case 2 had colon cancer with liver metastasis, and case 3 had intrahepatic duct stones.

RESULTS

All patients had successful operation and recovered without complications. Shorter length of hospital stays, earlier start of oral feeding and less amount of ascites were found. However, case 1 had recurrent HCC at 3 months after operation.

CONCLUSION

Robotic-assisted liver surgery is still a new field in its developing stage. In patients with small malignant tumors and benign liver diseases, robotic-assisted laparoscopic resection is feasible and safe. Through experience, the use of robotics is expected to increase in the treatment of benign diseases and malignant neoplasms. However, careful patient selection is important and long-term outcomes need to be evaluated.

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.

Laparoscopic liver resection using a bipolar vessel-sealing device: LigaSure

Achieving safe outcomes when performing laparoscopic liver surgery requires that the surgical team be expert in the techniques of liver surgery and in the application of appropriate technologies and devices. No other device is capable of effectively providing hemostasis, control of bile duct branches, and dividing parenchyma in every circumstance encountered during major hepatic resections. Therefore, liver surgeons use a variety of surgical technologies and instruments based on their judgment and experience and the individual nature of the operative procedure. Vessel-sealing technology has established itself as useful in liver surgery, for both open and laparoscopic cases. This paper reviews experience with a bipolar, vessel-sealing device (LigaSure, ValleyLab, Inc., Boulder, Colorado) and its application to laparoscopic liver surgery.

The use of water-jet dissection in open and laparoscopic liver resection

BACKGROUND

We intend to give an overview of our experiences with the implementation of a new dissection technique in open and laparoscopic surgery.

METHODS

Our database comprises a total of 950 patients who underwent liver resection. Three hundred and fifty of them were performed exceptionally with the water-jet dissector. Forty-one laparoscopic partial liver resections were accomplished.

RESULTS

Using the water-jet dissection technique it was possible to reduce the blood loss, the Pringle- and resection time in comparison to CUSA and blunt dissection. In the last five years we could reduce the Pringle-rate from 48 to 6% and the last 110 liver resections were performed without any Pringle's manoeuvre. At the same time, the transfusion-rate decreased from 1.86 to 0.46 EC/patient. In oncological resections, the used dissection technique had no influence on long-time survival.

CONCLUSIONS

The water-jet dissection technique is fast, feasible, oncologically safe and can be used in open and in laparoscopic liver surgery.

Laparoscopic versus open liver resection of hepatic neoplasms: comparative analysis of short-term results

BACKGROUND

Concerns have been raised regarding outcome after laparoscopic resection of hepatic neoplasms. This prospective study compared morbidity and adequacy of surgical margins in laparoscopic (LLR) versus open liver resection (OLR).

METHODS

Outcome in 359 consecutive patients [male/female ratio 187/172; median age 60 years (range 18-84 years)] who underwent partial hepatectomy was analysed. Cirrhosis was present in 32 patients and preoperative chemotherapy was administered in 141 patients. Comparative analyses were performed using propensity scores for all and for matched patients (n=76 per group).

RESULTS

Complications occurred in 68/250 (27.2%) patients after OLR and in 6/109 (5.5%) after LLR [odds ratio (OR) 0.16; 95% confidence interval (CI) 0.07-0.37; p<0.0001]. Median intraoperative blood loss was 500 ml (range 10-7,000 ml) in OLR and 100 ml (range 5-4,000 ml) in LLR (p<0.0001). Postoperative hospital stay was 8 days (range 0-155 days) after OLR and 6 days (range 0-41 days) after LLR (p<0.0001). In patients treated for liver malignancy, the surgical resection margin was positive on histopathological examination in 5/237 after OLR and in 1/77 after LLR. The magnitude of the resection margin was 7.5 mm (range 0-45 mm) in OLR and 10.0 mm (range 0-30 mm) in LLR (p=0.087).

CONCLUSIONS

LLR for hepatic neoplasms seems to be noninferior to OLR regarding adequacy of surgical margins, and superior to OLR regarding short-term postoperative outcome.

Laparoscopic liver resection without portal clamping: a prospective evaluation

BACKGROUND

Previous comparative studies have demonstrated that laparoscopic liver resection is associated with more frequent use and longer duration of portal camping than open liver resection, a fact that may partially explain the improvement in operative blood loss reported by most series of laparoscopic liver resection. The aim of this prospective study was to evaluate the real need for portal clamping in laparoscopic liver surgery.

STUDY DESIGN

Surgical outcomes of 40 consecutive patients who underwent laparoscopic liver resection for benign and malignant lesions from September 2005 to August 2007 were evaluate. Portal clamping was not systematically used.

RESULTS

No patient required blood transfusion and median blood loss was 160 ml (range 100-340 ml). Mean operating time was 267 min (range 220-370 min) and portal clamping was necessary in only one patient. Surgical complications included two grade I complication, three grade II, and one case of postoperative hemorrhage (grade III).

CONCLUSIONS

Laparoscopic liver surgery without clamping can be performed safely with low blood loss.

Benefit of laparoscopy for rectal resection in patients operated simultaneously for synchronous liver metastases: preliminary experience

BACKGROUND

Resection of the rectal primary neoplasm with synchronous liver metastases (LM) is warranted, because this is the only strategy with curative potential. Combined resection remains controversial because of the risk of morbidity and necessity of a curative abdominal approach to warrant liver resection. Laparoscopic colorectal resection may be beneficial and could facilitate this procedure.

METHODS

Between February 2006 and June 2007, 10 patients underwent 1-step laparoscopic resection for primary rectal cancer combined with open resection of synchronous LM.

RESULTS

All patients underwent a laparoscopic mesorectal excision (n = 10). Liver resections included right hepatectomy (n = 1), bi- or trisegmentectomy (n = 3), and metastasectomy (n = 6). The rectosigmoid specimen was extracted through the right subcostal or a short midline incision used for open liver resection, except in 3 patients who underwent a 1-step totally laparoscopic resection of both the colorectal and hepatic neoplasms. The overall morbidity was 40%. The median hospital stay was 12 days (range, 5-40). Overall morbidity (29% vs 40%) and hospital stay (12 vs 12 days) were similar to those observed in a previous cohort of 27 patients undergoing laparoscopic mesorectal excision only.

CONCLUSION

This pilot study suggests that laparoscopic rectal resection with synchronous resection of LM is feasible with low morbidity and short hospital stay. Moreover, laparoscopy facilitates the operation approach for synchronous major hepatectomy.

Laparoscopic liver resections for hepatocellular carcinoma. Is it a feasible option for patients with liver cirrhosis?

BACKGROUND

Laparoscopic surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver, above all for patients with hepatocellular carcinoma (HCC) and cirrhosis. This approach mainly includes diagnostic procedures and interstitial therapies. However, we believe there is room for laparoscopic liver resections in well-selected cases. The aim of this study is to assess: (a) the risk of intraoperative bleeding and postoperative complications, (b) the safety and the respect of oncological criteria, and (c) the potential benefit of laparoscopic ultrasound in guiding liver resection.

METHODS

A prospective study of laparoscopic liver resections for hepatocellular carcinoma was undertaken in patients with compensated cirrhosis. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6), and the tumor had to be 5 cm or smaller. Tumor location and its transection margins were defined by laparoscopic ultrasound.

RESULTS

From January 1997, 22 out of 250 patients with HCC (9%) underwent laparoscopic liver resections. The mean patient age was 61.4 years (range, 50-79 years). In three patients, conversion to laparotomy was necessary. The laparoscopic resections included five bisegmentectoies (2 and 3), nine segmentectomies, two subsegmentectomies and three nonanatomical resections for extrahepatic growing lesions. The mean operative time, including laparoscopic ultrasonography, was 199 +/- 69 min (median, 220; range, 80-300). Perioperative blood loss was 183 +/- 72 ml (median, 160; range, 80-400 ml). There was no mortality. Postoperative complications occurred in two out of 19 patients: an abdominal wall hematoma occurred in one patient and a bleeding from a trocar access in the other patient requiring a laparoscopic re-exploration. Mean hospital stay of the whole series was 6.5 +/- 4.3 days (median, 5; range, 4-25), while the mean hospital stay of the 19 laparoscopic patients was 5.4 +/- 1 (median, 5; range, 4-8).

CONCLUSION

Laparoscopic treatment should be considered in selected patients with HCC and liver cirrhosis in the left lobe or segments 5 and 6 of the liver. It is clear that certain types of laparoscopic resection are feasible and safe when carried out by adequately skilled surgeons with appropriate instruments.

Experiences of laparoscopic liver resection including lesions in the posterosuperior segments of the liver

BACKGROUND

There is a growing interest in laparoscopic liver resection because of its minimal invasiveness, the increased experience with laparoscopic procedures, and the advances of the laparoscopic devices. The authors describe their experience with laparoscopic liver resection, including its use for lesions in the posterosuperior segments of the liver (segments 1, 7, and 8, and the superior part of segment 4).

METHODS

A retrospective analysis was performed for the clinical data of 128 patients who underwent laparoscopic liver resection between January 2004 and December 2007. The patients were classified into two groups according to the location of the lesion: the anterolateral (AL) group (n = 92) and the posterosuperior (PS) group (n = 36).

RESULTS

The study enrolled 76 men and 52 women with a mean age of 57 years. The indications for resection were hepatocellular carcinoma (n = 57), hepatolithiasis (n = 39), liver metastasis from colorectal cancer (n = 21), and benign liver tumor (n = 11). There were no differences between the groups in terms of preoperative patient demographic characteristics or indications for liver resection. Major liver resection was performed more frequently for the PS group than for the AL group (p < 0.001). The mean operative time and the rate of intraoperative transfusion were significantly greater in the PS group than in the AL group (p = 0.009 and 0.015, respectively). However, the mean postoperative hospital stay and the complication rate were similar in the two groups (p = 0.345 and 0.733, respectively). Four patients underwent conversion to open hepatectomy (3.1%), with no difference in the rate of conversion between the two groups (p = 0.323). The complication rate was 18%, and all the patients were managed conservatively without the need for additional surgery.

CONCLUSIONS

Laparoscopic liver resection, including that for lesions in the posterosuperior part of the liver, is technically feasible and safe.

Laparoscopic versus open left lateral hepatic sectionectomy: A comparative study

BACKGROUND

Laparoscopic liver surgery has been difficult to popularize. High volume liver centres have identified left lateral sectionectomy (LLS) as a procedure with potential for transformation into a primarily laparoscopic procedure where surgeons can safely gain proficiency.

METHODS

Forty-four patients underwent either laparoscopic (LLLS) or open (OLLS) left lateral sectionectomy (of segments II/III) for focal lesions at Southampton General Hospital.

RESULTS

OLLS and LLLS groups were matched for age, sex and tumour types resected. Median operative time in the LLLS group was 180 (40-340) min and 155 (110-330) min in the OLLS group (p=0.885) with median intra-operative blood loss in the LLLS group 80 (25-800) ml versus a larger 470 (100-3000) ml; p=0.002 for patients receiving OLLS. Post-operative stay was also shorter in the LLLS group (3.5 (1-6) days) compared to the OLLS group (7 (3-12) days; p<0.001). Resection margin was not different in the two groups (11 (1.5-30) mm (LLLS) versus 12 (4-40) mm (OLLS); p=1) and neither was the complication rate (13% for LLLS versus 25% for OLLS; p=0.541). There were no conversions to open in the LLLS group and no deaths in either group at 90 days. Between the first and second 12 LLLS the median operative time fell from 240 (70-340) min to 120 (40-120) min; p=0.005 as well as median post-operative hospital stay from 4.5 (2-6) days to 2 (1-4) days, p=0.001.

CONCLUSION

LLLS is a viable alternative to OLLS with potential improvements in intra-operative blood loss and shorter hospital stay without adversely affecting successful resection or complication rates. Larger prospective studies are required to explore this new avenue in laparoscopic liver surgery.

Clinical study of laparoscopic versus open hepatectomy for malignant liver tumors

BACKGROUND

The number of reported laparoscopic hepatectomies for liver malignancy is increasing, but comparative data on the survival outcomes between the patients who have undergone laparoscopic hepatectomy versus open surgery are still lacking.

METHODS

We compared 31 laparoscopic liver resections with 31 open liver resections in a pair-matched retrospective analysis with the aim of evaluating the intraoperative hazards, recovery, and survival outcomes of these procedures for liver cancer. The laparoscopic group and the open group were matched for age, sex, the size and location of the tumor, and the presence or absence of cirrhosis.

RESULTS

Thirty cases in the laparoscopic group were performed successfully while one case was converted to open surgery due to intraoperative hemorrhage. The length of hospital stay was 7.5 (5-15) days, which was significantly shorter than those in open group (p < 0.01). The mean operative time and blood loss in the laparoscopic group were 140.1 (60-380) min and 502.9 (50-2000) ml, respectively, which were lower than those in open group but without significant difference. There were no operative complications and no deaths in the laparoscopic group. The mean and median survival times of laparoscopic group were 59.3 and 70 months, compared with 49.4 and 60 months in the open group, respectively. The 1-, 3-, 5-year survival rates in the laparoscopic group were, respectively, 96.55%, 60.47%, and 50.40%, and 96.77%, 68.36%, and 50.64% in the open group. By log-rank test, these two survival curves were not significantly different (p = 0.8535).

CONCLUSION

This study shows that laparoscopic hepatectomy for liver malignancy in selected patients is a safe, effective, and oncologically efficient procedure with better short-term results and similar survival outcomes to open hepatectomy for liver malignancy after midterm follow-up.