Pure laparoscopic right hepatectomy for giant hemangioma using anterior approach

Safety and effectiveness of laparoscopic intratumoral resection facilitated by coagulation of giant hepatic hemangioma: a matched case-control study and literature review

BACKGROUND

To report the safety and effectiveness of laparoscopic intratumoral resection facilitated by coagulation (LIRC) compared with laparoscopic hepatectomy (LH) in treating giant hepatic hemangioma.

METHODS

From 2017 to 2020, 19 consecutive patients with giant hepatic hemangioma (≥ 10 cm) received LIRC in one center. We selected a subgroup of 103 patients treated by LH in other four centers who well matched the 19 consecutive patients treated with LIRC, in a 1:1 fashion based on the tumor location, tumor size, and body mass index. Furthermore, the differences in technical success, operative time, operative blood loss, change of laboratory indexes, hospital stays, complication and clinical responds are compared between the two groups.

RESULTS

Technical success was achieved in all 38 patients. Patients in the LIRC group had a relative shorter operative time (P < 0.001) and less operative blood loss (P = 0.003). The serum levels of C-reactive protein (CRP), total bilirubin (TBil), alanine aminotransferase (ALT), and aspartate transaminase (AST) were elevated significantly (P < 0.05) 1 day after the resection and returned to normal within 7 days in both groups; however, relatively lower serum levels of those indexes were observed in the LIRC group (P < 0.05). The total complication rate was relatively lower in the LIRC group compared with the LH group (P = 0.029). Patients in the LIRC group had shorter hospital stays than those in the LH group (P = 0.010). The clinical response was similar in the two groups.

CONCLUSIONS

LIRC is safe and effective for treating giant hepatic hemangioma.

Laparoscopic left hemihepatectomy in small dogs: an easy and effective new technique

The present report describes a novel approach to and presents the surgical results for laparoscopic hepatectomy of the left lobes in small dogs. A purely laparoscopic four-port approach was used in seven beagles. The left triangular ligament was cut first, then the base of the left medial lobe (LMB) was ligated with silk thread using a needle, and the liver parenchyma of the LMB approximately 0.5 cm above the ligation site was removed with LigaSure. The left lateral lobe (LLB) was removed in the same manner. Blood was collected on postoperative days 1, 3, 7, and 14 for laboratory testing. Left hepatic lobe resection was successfully completed in all dogs, with an average operation time of 102.53 ± 9.07 min and an average blood loss of 32.10 ± 6.43 ml. Serious postoperative complications were not observed. The white blood cell (WBC) count and alkaline phosphatase (ALP) level were significantly increased in experimental dogs 1 day after surgery (P< 0.05); aspartate transferase (AST) and alanine transaminase (ALT) were significantly different before and after surgery (P< 0.01); and all the indicators were basically normal seven days after the operation. Exploratory laparoscopy at 28 days revealed adhesion of the surface of the liver section to the omentum or the gastric wall, but there were no other abnormal findings. The combined application of liver pedicle ligation and LigaSure for liver lobectomy provides a simple and effective method for generating liver lobectomy models for research on liver disease and regeneration and a feasible laparoscopic liver lobectomy operation scheme for small dogs (10–15 kg).

Anterior approach for pure laparoscopic donor right hepatectomy

BACKGROUND

Pure laparoscopic donor hepatectomy (PLDH) is being increasingly performed at centers with experienced surgeons [1-6]. This procedure is still developing and is associated with several challenges owing to its technical difficulty [7-9]. Conversely, the anterior approach is sometimes applied to both laparoscopic and open right hepatectomy for management of tumors in the liver [10, 11]. However, there are no reports regarding the use of the anterior approach for PLDH. We found this method to be useful; therefore, we aimed to introduce the novel procedure using a video clip.

METHODS

The donor was placed in the supine position. First, the right side of the inferior vena cava was dissected instead of performing the liver hanging maneuver. The right Glissonean pedicle was encircled and controlled, and the liver parenchyma was completely transected. Thereafter, the ligaments around the liver were dissected, and the graft was mobilized. The hilar vessels were respectively separated. Finally, the right hepatic duct, right hepatic artery, right portal vein, and right hepatic vein were divided, and the graft liver was retrieved. This study was approved by institutional ethics board (MH2019-119), and informed consent was taken from the patient.

RESULTS

The overall surgical time was 400 min, the volume of blood loss was 31 mL, the warm ischemic time was 7 min, and no complications were seen.

CONCLUSION

The advantages of the anterior approach for right-sided PLDH might be attribute to reduction of compression injury and incidence of subcapsular hematoma, as liver mobilization is easily performed because of increased liver mobility. However, PLDH is a highly-skilled procedure, and indications for PLDH should be extended in a step-wise manner. Further, the procedure should be performed only by highly proficient surgeons having extensive experience in both laparoscopic liver resection and living donor liver transplantation.

Short-term Outcomes of "Difficult" Laparoscopic Liver Resection at Specialized Centers: Report From INSTALL (International Survey on Technical Aspects of Laparoscopic Liver Resection)-2 on 4478 Patients

OBJECTIVE

To define the current status of "difficult" LLR, a global database was created and investigated.

BACKGROUND

In the Second International Consensus Conference in 2014, minor LLR was considered as a standard practice and major LLR remained an innovative procedure. Since then, no updates on worldwide trends have been available.

METHODS

A questionnaire on all consecutive patients who underwent difficult LLR (major hepatectomy, posterosuperior segmentectomy, sectionectomy, living donor hepatectomy, tumor size ≥10 cm, Child-Pugh grade ≥B, combined with biliary reconstruction, and Iwate criteria difficulty score ≥7) in 2014-2018 was distributed via email to 65 high-volume LLR centers worldwide. Individual data on patient and tumor demographics, surgical information, and short-term outcomes were obtained to create a large-scale international registry for analyses.

RESULTS

Overall, 58 centers in 19 countries performed 4478 difficult LLR (median, 58.5; range, 5-418) during the study period. Hepatocellular carcinoma accounted for ≥40% of all indications. Half of the patients underwent major hepatectomy, followed by sectionectomy, posterosuperior segmentectomy, and living donor hepatectomy. In the vast majority of procedures, Clavien-Dindo grade ≥IIIa complication rates of ≈10% and 90-day mortality rates of ≈1% were achieved. Left or right trisectionectomy had the worst Clavien-Dindo grade ≥IIIa complication rate of ≥10% and 90-day mortality rate of 5%-10%. No significant correlation was observed between center volume and short-term outcomes.

CONCLUSIONS

Total 4478 patients underwent difficult LLR worldwide in 2014-2018. Most procedures are safe and feasible when conducted in specialized centers.

A novel exposure maneuver in laparoscopic right hepatectomy

BACKGROUND AND OBJECTIVES

Laparoscopic access to the posterosuperior and lateral parts of the right liver is difficult for blocked and deep surgical situations. We invented a novel water bag device (WBD) to improve the exposure of the right liver.

METHODS

Eighteen consecutive patients with lesions isolated to the posterosuperior or lateral right liver were included in our research. They underwent laparoscopic right hepatectomy with the help of the device and were compared with previous similar laparoscopic cases of our operating surgeon.

RESULTS

The device was successfully employed without related complications and provided enhanced and stable surgical exposure. All patients were operated on without the need for blood transfusions or laparotomy conversion. The median operation time and estimated blood loss were 227 minutes (range, 114-568) and 88 mL (range, 25-250), respectively. In all cases, tumor-free surgical margins were confirmed and no major complications were observed. The results were better than those in previous similar laparoscopic cases.

CONCLUSIONS

The WBD is safe and effective for laparoscopic exposure when lesions are located in the posterosuperior and lateral parts of the right liver. With the help of the device, laparoscopic right liver resection is easier to perform instead of undergoing open hepatectomy.

Outcomes of Laparoscopic Liver Resection for Patients with Multiple Hepatocellular Carcinomas Meeting the Milan Criteria: A Propensity Score-Matched Analysis

Background: Until now, there is little knowledge about the value of laparoscopic liver resection (LLR) for patients with multiple hepatocellular carcinomas (HCC). This study was performed to assess the efficacy and outcomes of LLR versus open liver resection (OLR) for patients with multiple HCC meeting the Milan criteria.

Methods: One hundred fifteen patients with multiple HCC meeting the Milan criteria who underwent liver resection from April 2015 to March 2018 were enrolled into this study. According to the different surgical procedures, patients were divided into LLR group and OLR group. Perioperative and oncological outcomes were compared between the two groups after propensity score matching (PSM) with 1:1 match.

Results: Thirty three patients were included into each group after PSM with well-balanced basic level. The intraoperative blood loss in LLR group was less than OLR group before PSM (median, 200 vs. 300 mL, P = .004), but the difference was not statistically significant after PSM (median, 200 vs. 300 mL, P = .064). LLR group showed shorter postoperative hospital stay when compared with OLR group (median, 7 vs. 8 days, respectively, P = .014). The perioperative complications and early mortality were comparable in both groups. There were no significant differences in the term of overall survival (OS. P = .502) or recurrence-free survival (RFS. P = .887) between the two groups after PSM.

Conclusions: LLR could be safely and feasibly performed for patients with multiple HCC meeting the Milan criteria in selected patients. It does not increase the risks of postoperative complications and has a similar oncological outcomes compared to OLR.

Robot-assisted enucleation of gigantic liver hemangiomas: Case series of 3 patients

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The key aspect of this technique is to selectively control the arterial inflow.

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Mass enucleation represents the most challenging part of the procedure.

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ICG allows identifying the surgical plane between the mass and normal parenchyma.

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The robotic platform allows to replicate the enucleation performed in open surgery.

Introduction

Liver hemangiomas are benign liver lesions that require surgical excision when large and symptomatic. Often, these tumors are removed through large anatomical resections which sacrifice more liver parenchyma than needed. Tumor enucleation, which takes advantage of a digitoclasia-like technique along the plane between the tumor pseudo-capsule and liver parenchyma, poses challenges when performed laparoscopically. We propose a parenchymal sparing, minimally invasive, robotic-assisted technique to remove liver hemangiomas.

Presentation of cases

Three male patients with symptomatic hemangiomas were treated in our center between 2015 and 2018. The lesions were located in segment II, III and segment IV-V respectively. Robotic-assisted hemangioma enucleation was accomplished successfully in all three patients. The procedures were performed with a parenchyma-sparing intent and a formal segmentectomy was not required. There were no conversions to open surgery.

Discussion

The robotic platform provides a powerful tool in the enucleation of liver hemangiomas. The enhanced vision and the superior suturing ability allow to develop safely the plane between the tumor pseudo-capsule and the liver parenchyma, with outstanding selective control of all the vascular supply and drainage encountered during the dissection. Furthermore, precision of the hilar dissection allows selective lobar or sectorial arterial control which helps minimize intraoperative bleeding.

Conclusion

In our experience, robot-assisted enucleation of liver hemangiomas offers low morbidity, fast recovery, excellent cosmetic results, and it could become a therapeutic option when the location of the hemangioma allows this approach.

Is laparoscopic hepatectomy suitable for giant hepatic hemangioma larger than 10 cm in diameter?

BACKGROUND

Surgical treatment of giant hepatic hemangioma larger than 10 cm in diameter often requires major laparoscopic liver resection (LLR), which is very difficult and has a high risk of bleeding. There is no consensus as to whether giant hepatic hemangioma is an indication or a contraindication for laparoscopic surgery.

METHODS

From 2011/09 to 2018/05, 58 patients with giant hepatic hemangioma larger than 10 cm underwent laparoscopic surgery. They were divided into high-difficulty (HD) group and low-difficulty (LD) group according to the operation difficulty score. The perioperative data of the two groups were analyzed and compared.

RESULTS

There were 30 patients in the LD group and 28 in the HD group. No differences were showed in sex, age, ASA grade, tumor size, operation time, conversion rate, intraoperative and post-operative blood transfusion rate, and post-operative complications between the two groups. The amount of bleeding in the HD group was significantly higher than that in the LD group (285.7 ± 224.0 vs 189.6 ± 157.6 ml, p = 0.007). The time of hepatic hilar occlusion in the HD group was longer than that in the LD group (25.4 ± 8.8 vs 20.6 ± 7.3 min, p = 0.001), and the rate of hepatic hilar occlusion in the HD group was also higher than that in the LD group (71.4% vs 33.3%, p = 0.004). The incidence of hospitalization days and discharge time in the LD group were shorter than those in the HD group (6.3 ± 1.6 vs 8.2 ± 1.4 days, p = 0.000; 16.4 ± 5.5 vs 21.9 ± 4.6 h, p = 0.019). There was no significant difference in enzymatic parameters between the two groups after operation.

CONCLUSIONS

Although there are great difficulties and risks objectively, laparoscopic treatment of giant hepatic hemangioma is safe and feasible.

Laparoscopic liver resection: a review of current indications and surgical techniques

Laparoscopic liver resection (LLR) has been the most impressive development in the field of liver surgery in recent two decades. Technical innovations and experience accumulation have made LLR a safe and effective procedure with faster postoperative recovery. Despite the fast spreading of the procedure, details regarding the indications, oncological outcomes and technical essentials were still disputable. To address these issues, two international consensus conferences were hold to update the knowledge in this field. The statements of the both conferences were not conclusive and more high-quality researches are required. In this article, we reviewed the development and the current state of LLR. Indications, outcomes, surgical techniques and devices used in LLR were also discussed.

Long-term results of laparoscopic liver resection for the primary treatment of hepatocellular carcinoma: role of the surgeon in anatomical resection

BACKGROUND

Liver resection is a potentially curative therapy for hepatocellular carcinoma (HCC). LLR is a newly developed and safe technique associated with shorter hospital stay, less pain, better cosmetic outcomes, and similar complication rates as open surgery; however, data on its long-term outcomes remain scarce.

METHODS

We retrospectively examined the clinical and follow-up data of 234 patients who underwent LLR (performed by a single surgeon in all cases) for the primary treatment of HCC between July 2007 and December 2015 at Asan Medical Center.

RESULTS

The mean patient age was 55.63 (range 31-76) years; 167 were men. The median follow-up duration was 38 (range 6-116) months. A total of 227 patients (97.0%) had Child-Turcotte-Pugh grade A disease. Of them, 167 (71.4%) underwent anatomical resections and 63 (28.6%) underwent non-anatomical partial hepatectomies. Overall survival rates were 98.3, 91.7, and 87.1%, and recurrence-free survival rates were 82.1, 67.5, and 55.3% at 1, 3, and 5 years, respectively. In Cox regression analysis, anatomical resection was a risk factor for recurrence (univariate analysis: hazard ratio [HR] 0.49; 95% confidence interval [CI] 0.31-0.75; p = 0.001; multivariate analysis: HR 0.59; 95% CI 0.38-0.94; p = 0.025).

CONCLUSIONS

LLR is an acceptable primary treatment for patients with HCC with good hepatic function and with an appropriate anatomical structure, and is associated with improved prognosis. LLR can achieve lower recurrence rates through anatomical resection.

Highlights of the Third Expert Forum of Asia-Pacific Laparoscopic Hepatectomy; Endoscopic and Laparoscopic Surgeons of Asia (ELSA) Visionary Summit 2017

The application of laparoscopy for liver surgery is rapidly increasing and the past few years have demonstrated a shift in paradigm with a trend towards more extended and complex resections. The development of instruments and technical refinements with the effective use of magnified caudal laparoscopic views have contributed to the ability to overcome the limitation of laparoscopic liver resection. The Endoscopic and Laparoscopic Surgeons of Asia (ELSA) Visionary Summit 2017 and the 3^rd Expert Forum of Asia-Pacific Laparoscopic Hepatectomy organized hepatobiliary pancreatic sessions in order to exchange surgical tips and tricks and discuss the current status and future perspectives of laparoscopic hepatectomy. This report summarizes the oral presentations given at the 3^rd Expert Forum of Asia-Pacific Laparoscopic Hepatectomy.