Perioperative and oncological outcomes of laparoscopic anatomical hepatectomy for hepatocellular carcinoma introduced gradually in a single center

Standardization of laparoscopic anatomic liver resection of segment 2 by the Glissonean approach

BACKGROUND

Anatomic liver resection (ALR) has been established to eliminate the tumor-bearing hepatic region with preservation of the remnant liver volume for liver malignancies. Recently, laparoscopic ALR has been widely applied; however, there are few reports on laparoscopic segmentectomy 2. This study aimed to present the standardization of laparoscopic segmentectomy 2 with surgical outcomes.

METHODS

This study included seven patients who underwent pure laparoscopic segmentectomy 2 by the Glissonean approach from January 2020 to December 2021. Four of them had hepatocellular carcinoma, two had colorectal liver metastasis, and one had hepatic angiomyolipoma, which was preoperatively diagnosed with hepatocellular carcinoma. In all patients, preoperative three-dimensional (3D) simulation images from dynamic CT were reconstructed using a 3D workstation. The layer between the hepatic parenchyma and the Glissonean pedicle of segment 2 (G2) was dissected to encircle the root of G2. After clamping or ligation of the G2, 2.5 mg of indocyanine green was injected intravenously to identify the boundaries between segments 2 and 3 with a negative staining method under near-infrared light. Parenchymal transection was performed from the caudal side to the cranial side according to the demarcation on the liver surface, and the left hepatic vein was exposed on the cut surface if possible.

RESULTS

The mean operative time for all patients was 281 min. The mean blood loss was 37 mL, and no transfusion was necessary. Estimated liver resection volumes significantly correlated with actual liver resection volumes (r = 0.61, P = 0.035). After the operation, one patient presented with asymptomatic deep venous and pulmonary thrombosis, which was treated with anticoagulant therapy. The mean length of hospital stay was 8.9 days.

CONCLUSION

Laparoscopic segmentectomy 2 by the Glissonean approach is a feasible and safe procedure with the preservation of the nontumor-bearing segment 3 for liver tumors in segment 2.

Counterclockwise modular laparoscopic anatomical mesohepatectomy using combined glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches

Background

Although laparoscopic anatomical hepatectomy (LAH) is widely adopted today, laparoscopic anatomic mesohepatectomy (LAMH) for patients with hepatocellular carcinoma (HCC) remains technically challenging.

Methods

In this study, 6 patients suffering from solitary liver tumors located in the middle lobe of the liver underwent counterclockwise modular LAMH using combined Glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches. In this process, the Glissonean pedicle approach (Takasaki approach) was first used to transect the liver pedicles of segment right anterior (G58) and segment 4 (G4). Second, the hepatic vein-guided approach was performed along the umbilical fissure vein (UFV) to sever the liver parenchyma from the caudal to cranial direction, and the middle hepatic vein (MHV) and anterior fissure vein (AFV) were then disconnected at the root. Last, the hepatic vein-guided approach was once more performed along the ventral side of the right hepatic vein (RHV) to transect the liver parenchyma from the cranial to anterior direction, and the middle lobe of the liver, including the tumor, was removed completely. The entire process was applied in a counterclockwise fashion, and the exposure or transection sequence was G58, and G4, followed by UFV, MHV, AFV, and finally, the liver parenchyma along the ventral side of RHV.

Results

The counterclockwise modular LAMH using combined Glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches was feasible in all 6 cases. The median duration of the operation was 275 ± 35.07 min, and the mean estimated blood loss was 283.33 ml. All of the 6 patients recovered smoothly. The Clavien-Dindo Grade I-II complications rate was up to 33.33%, mainly characterized by postoperative pain and a small amount of ascites. No Clavien-Dindo Grade III-V complications occurred, and the mean postoperative hospital stay was 6.83 ± 1.47 days. Follow-up results showed that the average disease-free survival (DFS) was 12.17 months, and the 21-months OS rate, DFS rate and tumor recurrent rate were 100%, 83.33% and 16.67% respectively.

Conclusions

Counterclockwise modular LAMH using combined Glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches takes the advantages of the two approaches, is a novel protocol for LAMH. It is thought to be technically feasible for patients with a centrally located solitary HCC. The oncologic feasibility of this technique needs to be investigated based on long-term follow-up. A multicenter, large-scale, more careful study is necessary.

Long-term survival outcome of laparoscopic liver resection for hepatocellular carcinoma

Long-term survival is the most important outcome measurement of a curative oncological treatment. For hepatocellular carcinoma (HCC), the long-term disease-free and overall survival of laparoscopic liver resection (LLR) is shown to be non-inferior to the current standard of open liver resection (OLR). Some studies have reported a superior long-term oncological outcome in LLR when compared to OLR. It has been argued that improvement of visualization and instrumentation and reduced operative blood loss and perioperative blood transfusion may contribute to reduced risk of postoperative tumor recurrence. On the other hand, since most of the comparative studies of the oncological outcomes of LLR and OLR for HCC are non-randomized, it remained inconclusive as to whether LLR confers additional survival benefit compared to OLR. Despite the paucity of level 1 evidence, the practice of LLR for HCC has gained wide-spread acceptance due to the reproducible improvements in the perioperative outcomes and non-inferior oncological outcomes demonstrated by large-scaled, matched comparative studies. Meta-analyses of the outcomes of these studies by multiple systematic reviews have also returned noncontradictory conclusions. On the basis of a theoretical advantage of LLR over OLR in preventing tumor recurrence, the current review aims to dissect from the current meta-analyses and comparative studies any evidence of such superiority.

Retroperitoneal laparoscopic hepatectomy of recurrent hepatocellular carcinoma: case report and literature review

BACKGROUND

Almost all liver tumours can be removed laparoscopically, but some difficult tumour locations complicate laparoscopic surgery. Recurrent liver tumours often pose great difficulties to laparoscopic surgery due to adhesions caused by previous operations. Referring to laparoscopic adrenalectomy, a retroperitoneal approach is proposed to remove liver tumours near the adrenal gland, which will provide a new method for liver surgery.

CASE PRESENTATION

Our case involves a patient with recurrent hepatocellular carcinoma (HCC) whose last operation was laparoscopic hepatectomy in our department, with a recurrence of HCC 2 years after the first surgery. In this case, based on preoperative CT and MRI, through a retroperitoneal approach, combined with intraoperative ultrasound (IOUS) localization and indocyanine green (ICG) fluorescence navigation, laparoscopic hepatectomy was successfully performed to precisely resect recurrent hepatocellular carcinoma in segment VII. The patient was discharged on the third day after the operation. The AFP decreased to normal levels on the 28th postoperative day.

CONCLUSIONS

Retroperitoneal hepatectomy has the advantages of less trauma, shorter operation times, fewer complications and faster recovery for hepatic tumours near the adrenal gland. Accurate localization of tumours is needed to ensure accurate resection; therefore, IOUS and ICG fluorescence are very important. Liver parenchyma was severed strictly according to fluorescent labelling during hepatectomy, which prevented the deviation of liver parenchyma from the plane and ensured that the margin of hepatectomy was tumour-free. In order to ensure a radical resection of the tumour, it may be necessary to enter the abdominal cavity.

Anatomic Laparoscopic Liver Resection in the Scenario of the Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

Aim: To assess the impact of the laparoscopic anatomic resections (LARs) on hepatocellular carcinoma (HCC) patients, analyzing the pooled short- and long-term outcomes of this technique and comparing it with the standard open approach [open anatomic resections (OAR)]. Material and Methods: A systematic literature search was performed in PubMed, Embase, and Scopus for studies published between 2010 and 2020 concerning LAR for HCC. Results: After screening 311 articles, 10 studies with a total of 398 patients who underwent LAR for HCC were included. The pooled cohort included mostly male (76.6%), Child A (98.2%), with hepatitis B virus (HBV)-related disease (60.5%). The pooled conversion rate was 7.3%. The pooled overall complication rate was 10.2 with a mortality rate of 1.0%. In the pooled analyses of only comparative studies, LAR group included 378 versus 455 in OAR. Operative time was longer in the LAR group (329 minutes versus 248; P = .001). Blood loss (179 versus 331 mL; P = .018) was lower in the LAR group. The pooled mean length of hospital stay was 8.4 days in LARs and 11.3 in OARs (P = .002). The pooled rate of postoperative complications was higher in the OAR group (25.3 versus 13.8; P = .009), while mortality rates were similar. The LAR group had a pooled 3- and 5-year overall survival of 90.1 and 81.9 versus 83.5 and 80.7 of the OARs (P > .05), respectively. Conclusions: In conclusion, the LAR for HCC is safe and associated with decreased blood loss and length of hospital stay. Survival rates are comparable with those of the conventional open approach.

Appropriate treatment modality for solitary small hepatocellular carcinoma: Radiofrequency ablation vs. resection vs. transplantation?

There has been controversy regarding the first-line treatment modality for the patients who have small solitary hepatocellular carcinoma (HCC); radiofrequency ablation (RFA) or percutaneous ethanol injection (PEI), surgical hepatic resection (HR) and liver transplantation (LT). For selection of treatment modality of HCC, it should be considered of hepatic reservoir function as well as the tumor stage. If the liver function is good enough, HR may be the first choice regardless of the tumor size. However, recent studies comparing RFA with resection showed comparable outcome and similar survival rates. RFA, HR and LT provide good outcome for patients who have small HCCs. RFA would be desired in patients who have below 3.0 cm in size and low alpha-fetoprotein (<200 ng/mL). However, in small HCC with high tumor marker, HR should be considered. Better patient selection for the ‘resection first’ approach and early detection of recurrence can achieve better outcomes of the salvage LT strategy. Another benefit of resection first strategy is that it make possible to do enlist of LT for patients before recurrence at high risk of HCC recurrence after resection on the basis of pathologic aggressiveness, microvascular invasion and/or satellites nodule. They should be applied appropriately according to the tumor size, location, tumor markers and underlying liver parenchymal disease.

Comparison of Clinical Efficacy and Complications Between Laparoscopic Partial and Open Partial Hepatectomy for Liver Carcinoma: A Meta-Analysis

OBJECTIVE

To contrast the clinical effects and complications for the treatment of liver carcinoma in laparoscopic partial hepatectomy (LPH) and open partial hepatectomy (OPH).

METHODS

The multiple databases were adopted to search relevant studies, and the articles eventually satisfying the inclusion criteria were included. All the meta-analyses were conducted with the Review Manager 5.3, and to estimate the quality of each article risk of bias table was performed.

RESULTS

In the end, 17 studies including 3897 patients were involved, which eventually satisfied the eligibility criteria. The number of samples in LPH group and OPH group were 1723 and 2174, respectively. The results of heterogeneity test suggested that recurrence rate (odds ratio [OR] = -20.11, 95% confidence interval, CI [-35.93 to -4.29], P = .01; P for heterogeneity <.00001, I² = 100%), hospital days (mean difference (MD) = -2.21, 95% CI [-2.53 to -1.88], P < .000001; P for heterogeneity = .41, I² = 58%), and blood loss (MD = -68.09, 95% CI [-85.07 to -51.11], P < .00001; P for heterogeneity = .13, I² = 37%) were significantly different, whereas operating time (MD = 4.00, 95% CI [-17.50 to 25.49], P = .72; P for heterogeneity <.00001, I² = 99%) and complication events (OR = 0.68, 95% CI [0.46 to 1.01], P = .05; P for heterogeneity = .34, I² = 11%) between LPH and OPH were insignificantly different.

CONCLUSION

This study demonstrated that clinical efficacy of OPH was better than that of LPH to some extent, but LPH was a quicker recovery and less harmful therapy.

Laparoscopic Right Hepatectomy for Hepatocellular Carcinoma: A Propensity Score Matching Analysis of Outcomes Compared with Conventional Open Surgery

BACKGROUND

The application of laparoscopic hepatectomy is gaining momentum. However, the safety and efficacy of laparoscopic right hepatectomy (LRH) on hepatocellular carcinoma (HCC) are yet to be adequately evaluated. We aimed to assess the surgical and oncological outcomes of LRH for HCC by comparing it with open right hepatectomy (ORH).

MATERIALS AND METHODS

Data of patients who underwent hepatectomy for HCC from May 2007 to January 2018 in our hospital were obtained. Baseline characteristics, postoperative recovery, and survival outcomes were compared. One-to-one propensity score matching (PSM) was used to minimize selection biases by balancing factors, including age, sex, preoperative therapy, tumor size, and pattern.

RESULTS

The original cohort included 109 patients (LRH, 41 patients; ORH, 68 patients). Of the 41 patients who underwent LRH, 8 patients (19.5%) required conversion to laparotomy. The overall morbidity was 19.5%, and no mortality in LRH was noted. After PSM, LRH was associated with a tendency of prolonged operative time (255.5 ± 93.4 minutes versus 225.9 ± 39.8 minutes, P = .08) and less intraoperative blood loss [300 (100-1200) versus 500 (200-2000) mL, P < .01]. LRH showed up a trend of less overall morbidity without statistical significance (18.4% versus 26.3%, P = .41). Moreover, the 3-year overall and disease-free survival did not differ significantly between the groups during a median follow-up of 19 (3-58) months for the LRH group and 23 (3-97) months for the ORH group.

CONCLUSIONS

LRH can be performed as safe and effective as ORH for HCC in regard to both surgical and oncological outcomes. LRH holds the benefit in less intraoperative blood loss and appears to achieve less postoperative morbidity, which could serve as a promising alternative to ORH in selected individuals.

Outcomes of pure laparoscopic Glissonian pedicle approach hepatectomy for hepatocellular carcinoma: a propensity score matching analysis

BACKGROUND

Few studies had been performed to concern the outcomes of pure laparoscopic Glissonian pedicle approach hepatectomy (LGAH) for hepatocellular carcinoma (HCC). The aim of this study was to compare the outcomes of LGAH versus open Glissonian pedicle approach hepatectomy (OGAH) for HCC, especially in patients with cirrhosis.

METHODS

Hepatocellular carcinoma patients who underwent pure LGAH and OGAH between January 2015 and July 2017 in our institution were retrospectively enrolled in this study. Propensity score matching (PSM) of patients in a ratio of 1:1 was conducted to adjust the known confounders. The perioperative and oncological outcomes were compared between the two groups after PSM.

RESULTS

Some 80 patients underwent pure LGAH and 134 had OGAH. After PSM, 67 patients in each group were well matched for analysis. Both the postoperative overall complication rates (13.4% vs. 29.9%, P = 0.021) and mean comprehensive complication index (2.63 vs. 7.40, P = 0.035) were significantly lower in the LGAH group than those in OGAH group. Although the operative time was longer in the LRH group (P < 0.001), the length of postoperative hospital stay was shorter in the LRH group (P = 0.024). Furthermore, both the 3-year overall survival rate (73.3% for LGAH vs. 77.8% for OGAH, P = 0.338) and 3-year disease-free survival rate (56.4% for LGAH vs. 62.5% for OGAH, P = 0.455) were not significantly different between the groups.

CONCLUSION

Pure laparoscopic Glissonian approach may be a better alternative to open Glissonian approach in selected HCC patients, which provided fewer complications, shorter postoperative hospital stay and comparable oncological outcomes.

Meta-analysis of laparoscopic versus open liver resection for hepatocellular carcinoma

AIM

The aim of this study was to evaluate the surgical safety and effectiveness of laparoscopic hepatectomy (LH) in short- and long-term outcomes compared to open hepatectomy (OH) in patients treated for hepatocellular carcinoma (HCC).

METHODS

An electronic search of reports published before August 2017 was carried out to identify comparative studies evaluating LH versus OH for HCC.

RESULTS

A total of 5889 patients (2421 underwent LH; 3468 underwent OH) were included in our meta-analysis from 47 studies. Laparoscopic hepatectomies were associated with favorable outcomes in terms of operative blood loss (mean difference [MD], -147.27; 95% confidence interval [CI], -217.00, -77.55), blood transfusion requirement (odds ratio [OR], 0.51; 95% CI, 0.40, 0.65), pathologic resection margins (MD, 0.07; 95% CI, 0.02, 0.12; P = 0.01), R0 resection rate (OR, 1.34; 95% CI, 0.98, 1.84; P = 0.07), and length of hospital stay (MD, -5.13; 95% confidence interval, -6.23, -4.03). There were no differences between the groups in overall survival (OS) at 1 year (OR, 1.41; 95% CI, 1.00, 1.98), 3 years (OR, 1.12; 95% CI, 0.93, 1.36), or 5 years (OR, 1.18; 95% CI, 0.94, 1.46), in disease-free survival (DFS) at 1 (OR, 1.19; 95% CI, 0.94, 1.51), 3 years (OR, 1.07; 95% CI, 0.86, 1.33), or 5 years (OR, 1.13; 95% CI, 0.92, 1.40), or in recurrence (OR, 0.90; 95% CI, 0.74, 1.08).

CONCLUSION

Compared to OH, LH is superior in terms of lower intraoperative blood loss and the requirement for blood transfusion, larger pathologic resection margins, increased R0 resection rates, and shorter length of hospital stay. Laparoscopic hepatectomy and OH have similar OS, DFS, and recurrence.