Laparoscopic right posterior sectionectomy (LRPS): surgical techniques and clinical outcomes

Indocyanine Green Fluorescence Imaging-Guided Laparoscopic Right Posterior Sectionectomy with Glissonean Approach and Modified Hanging Maneuver

BACKGROUND

In the era of innovating minimal invasive surgery, laparoscopic right posterior sectionectomy (RLPS) is considered a technically challenging procedure for its deeply anatomic location.1,2 Performed by experienced surgeons, it has been shown to be a safe and feasible procedure.3-6 The purpose of this video was to show the technique of a RLPS.

METHODS

This is the case of a 70-year-old man who was treated for a mid-rectum adenocarcinoma with two synchronous liver metastases located in the posterior sector of the right liver. Tumor board decision was chemoradiotherapy followed by a simultaneous rectal and hepatic surgery.

RESULTS

An extrahepatic Glissonian approach of the right posterior pedicle was performed. After selective clamping of the right posterior pedicle and injection of indocyanine green, the right portal fissure between the two sectors of the right liver appeared. The parenchymal transection performed in a caudal approach, along a perfectly marked plane. One metastasis was in contact with the right hepatic vein. Because R1 vascular surgery has demonstrated similar oncological outcomes to R0 resection, we detached the metastasis from the vein to preserve a good venous drainage of the remaining right liver.7 The procedure was completed with a laparoscopic anterior resection of the rectum. The duration of the liver resection was 200 min, and blood loss was 300 ml. Postoperative course was uneventful, and the patient was discharged on postoperative Day 10.

CONCLUSIONS

Laparoscopic right posterior sectionectomy is a safe and feasible procedure.3-6 However, it is technically challenging and requires advanced experience in liver and laparoscopic surgery.5,6.

Application of the Left Lateral Decubitus Position in Laparoscopic Right Posterior Lobectomy

OBJECTIVE

To investigate the value of the left lateral decubitus position in laparoscopic right posterior lobe tumor resection.

PATIENTS AND METHODS

The clinical data of patients who underwent laparoscopic right posterior lobectomy from January 2020 to March 2023 were retrospectively collected and divided into group A (left lateral decubitus position group, n=30) and group B (conventional position group, n=35) according to different body positions. Intraoperative and postoperative data were collected and compared between the 2 groups.

RESULTS

The operation time (210.43±57.56 vs. 281.97±65.89, t =5.887, P <0.05), hilar occlusion time (23.97±14.25 vs. 35.79±12.62, t =4.791, P <0.05), intraoperative blood loss (162.14±72.61 vs. 239.65±113.56, t =5.713, P <0.05), postoperative feeding time (1.13±0.36 vs. 1.57±0.67, t =3.681, P <0.05), postoperative visual analog scale score (5.16±0.89 vs. 7.42±1.31, t =3.721, P <0.05), postoperative abdominal drainage tube indwelling time (4.58±1.34 vs. 5.42±1.52, t =4.553, P <0.05), incidence rate of complications (43.33% vs. 82.86%, χ 2 =11.075, P <0.05) in group A were lower than those in group B ( P <0.05). Symptoms/side effects (32.42±3.42 vs. 27.44±3.31, t =4.331, P <0.05), and there were significant differences in social function (33.55±2.56 vs. 29.31±3.32, t =4.863, P <0.05).

CONCLUSION

For right posterior lobe tumors of the liver, the left lateral decubitus position has many advantages in laparoscopic right posterior lobectomy, such as a wide field of view, simple steps, a short operation time, less bleeding, and a high postoperative quality of life. It is an effective treatment for right posterior lobe tumors of the liver and is worthy of being widely popularized.

Prevalence and clinical significance of the Sg6/Sg7 intersegmental veins based on re-evaluation of the Couinaud classification for the right posterior portal vein

Although Segment 6(Sg6) and Segment 7(Sg7) are two independent units, there are currently no clear anatomical boundary markers between Sg6 and Sg7. This study aimed to identify intersegmental veins (ISV) in the intersegmental plane of Sg6 and Sg7, and evaluate the prevalence of ISV, and its clinical significance in anatomical hepatectomy. We analyzed data from 180 patients undergoing abdominal computed tomography (CT) examination, and simultaneously performed 3D reconstruction models of the liver for each patient. The right posterior portal vein was analyzed and re-typed. Furthermore, the existence of ISV was defined, and prevalence and confluence patterns of ISV were analyzed. The author attempted to apply ISV to laparoscopic S6/S7 segmentectomy. We sorted data from the right posterior portal vein and divided it into six types. The ISV could be identified in 82.2% (148/180) of the patients, which were derived from the right hepatic vein (RHV) (91.9%) and right posterior inferior vein (IRHV) (8.1%). Ten ISV-guided laparoscopic Sg6/Sg7 segmentectomy were successfully carried out, seven patients underwent Sg6 segmentectomy, and three patients underwent Sg7 segmentectomy. There was no perioperative mortality. The median operative time was 223 min (range 181-260 min). The median blood loss was 200 ml (range 150-310 ml). The R0 resection rate was 100%. The ISV may be a candidate vessel to distinguish the boundary of the right posterior sector; it is expected to be a landmark in the liver parenchyma of anatomical hepatectomy.

Surgical treatment for recurrent hepatocellular carcinoma: Current status and challenges

Primary liver cancer is the sixth most commonly diagnosed cancer and was the third leading cause of cancer deaths worldwide in 2020. It includes hepatocellular carcinoma (HCC) (representing 75%-85% of cases), intrahepatic cholangiocarcinoma (representing 10%-15% of cases), and other rare types. The survival rate of patients with HCC has risen with improved surgical technology and perioperative management in recent years; however, high tumor recurrence rates continue to limit long-term survival, even after radical surgical resection (exceeding 50% recurrence). For resectable recurrent liver cancer, surgical removal [either salvage liver transplantation (SLT) or repeat hepatic resection] remains the most effective therapy that is potentially curative for recurrent HCC. Thus, here, we introduce surgical treatment for recurrent HCC. Areas Covered: A literature search was performed for recurrent HCC using Medline and PubMed up to August 2022. Expert commentary: In general, long-term survival after the re-resection of recurrent liver cancer is usually beneficial. SLT has equivalent outcomes to primary liver transplantation for unresectable recurrent illness in a selected group of patients; however, SLT is constrained by the supply of liver grafts. SLT seems to be inferior to repeat liver resection when considering operative and postoperative results but has the major advantage of disease-free survival. When considering the similar overall survival rate and the current situation of donor shortages, repeat liver resection remains an important option for recurrent HCC.

Caudodorsal approach combined with in situ split for laparoscopic right posterior sectionectomy

BACKGROUND

Laparoscopic right posterior sectionectomy (LRPS) was technically challenging and lack of standardization. There were some approaches for LRPS, such as caudal approach and dorsal approach. During our practice, we initiated pure LRPS using the caudodorsal approach with in situ split and present several advantages of this method.

METHODS

From April 2018 to December 2021, consecutive patients who underwent pure LRPS using the caudodorsal approach with in situ split at our institution entered into this retrospective study. The key point of the caudodorsal approach was that the right hepatic vein was exposed from peripheral branches toward the root and the parenchyma was transected from the dorsal side to ventral side. Specially, the right perihepatic ligaments were not divided to keep the right liver in situ before parenchymal dissection for each case.

RESULTS

11 patients underwent pure LRPS using the caudodorsal approach with in situ split. There were 9 hepatocellular carcinoma, 1 sarcomatoid hepatocellular carcinoma, and 1 hepatic hemangioma. Five patients had mild cirrhosis and 1 had moderate cirrhosis. All the procedures were successfully completed laparoscopically. The median operative time was 375 min (range of 290-505 min) and the median blood loss was 300 ml (range of 100-1000 ml). Five patients received perioperative blood transfusion, of which 1 patient received autologous blood transfusion and 2 patients received blood transfusion due to preoperative moderate anemia. No procedure was converted to open surgery. Two patients who suffered from postoperative complications, improved after conservative treatments. The median postoperative stay was 11 days (range of 7-25 days). No postoperative bleeding, hepatic failure, and mortality occurred.

CONCLUSION

The preliminary clinical effect of the caudodorsal approach with in situ split for LRPS was satisfactory. Our method was feasible and expected to provide ideas for the standardization of LRPS. Further researches are required due to some limitations of this study.

The safety and feasibility of laparoscopic right posterior sectionectomy vs. open approach: A systematic review and meta-analysis

Background

Laparoscopic right posterior sectionectomy (LRPS) is one of the most technically challenging and potentially hazardous procedures in laparoscopic liver resection. Although some available literature works demonstrated the safety and feasibility of LRPS, these data are limited to reports from a single institution and a small sample size without support from evidence-based medicine. So, we performed a meta-analysis to assess further the safety and feasibility of LRPS by comparing it with open right posterior sectionectomy (ORPS).

Methods

MEDLINE, Embase, and Cochrane Library were systematically searched for eligible studies comparing LRPS and open approaches. Random and fixed-effects models were used to calculate outcome measures.

Results

Four studies involving a total of 541 patients were identified for inclusion: 250 in the LRPS group and 291 in the ORPS group. The postoperative complication and margin were not statistically different between the two groups (OR: 0.49, 95% CI: 0.18 to 1.35, P = 0.17) (MD: 0.05, 95% CI: −0.47 to 0.57, P = 0.86), respectively. LRPS had a significantly longer operative time and shorter hospital stay (MD: 140.32, 95% CI: 16.73 to 263.91, P = 0.03) (MD: −1.64, 95% CI: −2.56 to −0.72, P = 0.0005) respectively.

Conclusion

Data from currently available literature suggest that LRPS performed by an experienced surgeon is a safe and feasible procedure in selected patients and is associated with a reduction in the hospital stay.

Safely Modified Laparoscopic Liver Resection for Segment VI and/or VII Hepatic Lesions Using the Left Lateral Decubitus Position

Purpose

To explore the feasibility and safety of using the left lateral decubitus position (LLDP) to perform laparoscopic liver resection (LLR) for the treatment of hepatic lesions in segment VI and/or VII.

Patients and Methods

Clinical data concerning 50 patients underwent LLR including 25 patients in the LLDP and the other 25 patients in the routine operative position (ROP) at Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College (Hangzhou, China) and Shulan (Quzhou) Hospital between March 2019 and May 2022 were retrospectively analyzed. All of the patients underwent LLR while in the LLDP or the ROP for the treatment of hepatic lesions located in segment VI and/or VII.

Results

The preoperative clinical and laboratory parameters were comparable between the two groups (P > 0.05). All patients completed the surgery successfully. There were two patients required conversion to open resection in the ROP comparing with zero in the LLDP. The mean operative time was 256.9 ± 132.7 minutes in LLDP and 255.7 ± 92.1 minutes in ROP, while the median perioperative blood loss was 100 mL (range: 50–300 mL) in LLDP and 200 mL (range: 50–425 mL), respectively. The postoperative pathological examination showed that margin-negative resection was achieved all of the cases. The important postoperative parameters all returned to normal within five days after the LLR. The mean postoperative hospital stay (15.6 vs 19.3 days; p < 0.05) and the extraction of the drainage tube time (7.8 vs 10.4 days; p < 0.05) were shorter for patients in LLDP.

Conclusion

The LLDP represents a safe and feasible position for performing LLR in selected patients with lesions in segment VI and/or VII. LLR in the LLDP is helpful in terms of the exposure of the surgical field and the recovery of the patient.

Different Surgical Approaches for Early-Stage Ovarian Cancer Staging. A Large Monocentric Experience

Introduction

Ovarian cancer is the third most frequent gynecological cancer. In early stage ovarian cancer (ESOC) comprehensive surgical staging is recommended. Surgical staging is traditionally approached by laparotomy, although minimally invasive surgery can be a valid alternative in selected patients. This study aims to analyze the surgical and oncological outcomes of three different surgical approaches in a large series of patients.

Methods

We retrospectively included all histologically proven ESOC cases treated between January 2014 and December 2017. ESOC was defined as stage IA to IIB according to the 2018 FIGO staging system. Subjects were divided into groups 1, 2, and 3, based on the surgical approach (open abdominal, laparoscopic, or robotic, respectively).

Results

Within patients enrolled during the study period, 455 met the inclusion criteria. No difference in intraoperative complications was recorded in the three groups (p = 0.709). Conversely, a significant difference occurred in postoperative complications (16.2 vs. 3.8 vs. 11.1%, in groups 1, 2, and 3 respectively, p = 0.004). No difference was found in overall survival (OS) (32 vs. 31 vs. 25 months, p = 0.481) and disease-free survival (DFS) (26 vs. 29 vs. 24 months, p = 0.178) in groups 1, 2, and 3, respectively. At univariate analysis FIGO stage I (p = 0.004) showed a lower recurrence rate compared to FIGO stage II.

Conclusion

No significant difference was found in OS and DFS among the three groups (open, laparoscopic, and robotic). The minimally invasive approach showed lower rate of complications than the laparotomic approach.

International multicentre propensity score-matched analysis comparing robotic versus laparoscopic right posterior sectionectomy

BACKGROUND

Minimally invasive right posterior sectionectomy (RPS) is a technically challenging procedure. This study was designed to determine outcomes following robotic RPS (R-RPS) and laparoscopic RPS (L-RPS).

METHODS

An international multicentre retrospective analysis of patients undergoing R-RPS versus those who had purely L-RPS at 21 centres from 2010 to 2019 was performed. Patient demographics, perioperative parameters, and postoperative outcomes were analysed retrospectively from a central database. Propensity score matching (PSM) was performed, with analysis of 1 : 2 and 1 : 1 matched cohorts.

RESULTS

Three-hundred and forty patients, including 96 who underwent R-RPS and 244 who had L-RPS, met the study criteria and were included. The median operating time was 295 minutes and there were 25 (7.4 per cent) open conversions. Ninety-seven (28.5 per cent) patients had cirrhosis and 56 (16.5 per cent) patients required blood transfusion. Overall postoperative morbidity rate was 22.1 per cent and major morbidity rate was 6.8 per cent. The median postoperative stay was 6 days. After 1 : 1 matching of 88 R-RPS and L-RPS patients, median (i.q.r.) blood loss (200 (100-400) versus 450 (200-900) ml, respectively; P < 0.001), major blood loss (> 500 ml; P = 0.001), need for intraoperative blood transfusion (10.2 versus 23.9 per cent, respectively; P = 0.014), and open conversion rate (2.3 versus 11.4 per cent, respectively; P = 0.016) were lower in the R-RPS group. Similar results were found in the 1 : 2 matched groups (66 R-RPS versus 132 L-RPS patients).

CONCLUSION

R-RPS and L-RPS can be performed in expert centres with good outcomes in well selected patients. R-RPS was associated with reduced blood loss and lower open conversion rates than L-RPS.

Laparoscopic hepatectomy versus open hepatectomy for tumors located in right posterior segment: A single institution study

OBJECT

With the gradual advancement of laparoscopic technology, surgeries can be successfully performed with the help of laparoscopy increasingly. This study initially explored the difference between laparoscopic right posterior sectionectomy (LRPS) and open right posterior sectionectomy (ORPS)of liver in our center, discussed the effectiveness, benefits and safety of LRPS and introduce some surgical techniques in our center.

MATERIALS AND METHODS

We retrospectively analyze 96 cases of liver tumor located in the right posterior lobe of liver in our institution from January 2015 to January 2018. There were 46 cases performed the LRPS surgery and 50 cases performed the ORPS surgery. Through analysis of the perioperative outcomes of these two groups by a case control study, we compare the differences between these two groups.

RESULTS

There was no significant difference between the LRPS and ORPS group in demographic and baseline characteristics before surgery. Patients in the LRPS group were significantly superior to ORPS in terms of postoperative liver function recovery, postoperative inflammatory factor level, pain sensation (3.03 ± 0.79 vs 4.58 ± 1.25), abdominal incision length (6.25 ± 2.34 vs 32.15 ± 3.21), carrying abdominal drainage tube time (3.26 ± 0.77 vs 4.83 ± 0.76), recovery of bowel function time (1.6 ± 0.61 VS 3.05 ± 0.85)and postoperative hospital stay (5.73 ± 0.99 vs 7.16 ± 0.95) (P < 0.05).

CONCLUSION

Compared with the traditional ORPS, LRPS has the advantages of minor injury, faster recovery and mild inflammatory reaction. The LRPS is safe and feasible, and it should be gradually promoted in clinical practice.

Indocyanine green fluorescence imaging-guided laparoscopic right posterior hepatectomy

BACKGROUND

Laparoscopic right posterior hepatectomy is considered difficult on the basis of the surgery difficulty scoring system. In this study, we evaluated the safety and effectiveness of the technical application of indocyanine green (ICG) fluorescence imaging-guided laparoscopic right posterior hepatectomy.

METHODS

Twenty-six patients who underwent ICG fluorescence imaging-guided laparoscopic right posterior hepatectomy at Hepatobiliary and Pancreatic Surgery Department of Zhongnan Hospital, Wuhan University, from June 2018 to December 2019, were included. The influence of patient position, trocar placement, hepatic inflow occlusion, central venous pressure (CVP), and the ICG fluorescence imaging-guided method were analyzed.

RESULTS

In 17 patients, the left lateral position was maintained when the main tumor was in the S7, and in the remaining nine patients, the supine position was maintained with the right side of the body raised when the main tumor was in the S6. Ten patients who underwent preoperative injection of ICG were successfully developed for nonanatomical hepatectomy. Sixteen patients received intraoperative ICG injection for anatomical hepatectomy (2 cases had positive imaging findings, 14 cases had negative imaging findings, and 2 cases had failed imaging findings). All patients underwent the Pringle maneuver during the procedure. Four patients were preset with subhepatic vena cava blocking and one patient with suprahepatic inferior vena cava blocking. CVP was controlled at 3.00 ± 0.63 (mean ± SD) cmH₂O. The operative time was 216.14 ± 52.05 min, and the bleeding volume was 128.57 ± 75.55 ml. Four patients had Clavien-Dindo level I complications, and one had level III complications. Postoperative hospitalization duration was 6.19 ± 1.40 days. There were 14 patients with hepatocellular carcinoma, 9 with metastatic liver malignancies, 2 with hepatic hemangioma, 1 with focal nodular hyperplasia of the liver, and 10 with hepatitis B liver cirrhosis.

CONCLUSIONS

ICG fluorescence imaging guidance could be helpful for the safe implementation of laparoscopic right posterior hepatectomy.

The Safety and Feasibility of Laparoscopic Technology in Right Posterior Sectionectomy

BACKGROUND

Laparoscopic hepatectomy has been accepted widely due to its advantages as a minimally invasive surgery, but laparoscopic right posterior sectionectomy (LRPS) has rarely been reported. We aimed to explore the safety and feasibility of LRPS by comparing it with open surgical approaches.

MATERIALS AND METHODS

Between January 2014 and July 2019, 51 patients who underwent right posterior sectionectomy were enrolled in this study. The patients' characteristics, intraoperative details, and postoperative outcomes were compared between 2 groups.

RESULTS

There were no statistically significant differences in the preoperative data. LRPS showed significantly less blood loss (P=0.001) and shorter hospital stay (P=0.002) than open right posterior sectionectomy, but hospital expenses (P=0.382), operative time (P=0.196), surgical margin (P=0.311), the rate of other complications, and the postoperative white blood cell count, alanine aminotransferase, aspartate aminotransferase, and total bilirubin showed no statistically significant differences between the 2 groups (P>0.05). For hepatocellular carcinoma, the results showed there were no differences in both disease-free survival (P=0.220) and overall survival (P=0.417) between the 2 groups.

CONCLUSIONS

Our research suggests that LRPS is a safe and feasible surgical procedure that is efficient from an oncological point of view. It may be the preferred choice for lesions in the right posterior hepatic lobe.

Laparoscopic versus open right posterior sectionectomy: an international, multicenter, propensity score-matched evaluation

Background

Although laparoscopic liver resection has become the standard for minor resections, evidence is lacking for more complex resections such as the right posterior sectionectomy (RPS). We aimed to compare surgical outcomes between laparoscopic (LRPS) and open right posterior sectionectomy (ORPS).

Methods

An international multicenter retrospective study comparing patients undergoing LRPS or ORPS (January 2007—December 2018) was performed. Patients were matched based on propensity scores in a 1:1 ratio. Primary endpoint was major complication rate defined as Accordion ≥ 3 grade. Secondary endpoints included blood loss, length of hospital stay (LOS) and resection status. A sensitivity analysis was done excluding the first 10 LRPS patients of each center to correct for the learning curve. Additionally, possible risk factors were explored for operative time, blood loss and LOS.

Results

Overall, 399 patients were included from 9 centers from 6 European countries of which 150 LRPS could be matched to 150 ORPS. LRPS was associated with a shorter operative time [235 (195–285) vs. 247 min (195–315) p = 0.004], less blood loss [260 (188–400) vs. 400 mL (280–550) p = 0.009] and a shorter LOS [5 (4–7) vs. 8 days (6–10), p = 0.002]. Major complication rate [n = 8 (5.3%) vs. n = 9 (6.0%) p = 1.00] and R0 resection rate [144 (96.0%) vs. 141 (94.0%), p = 0.607] did not differ between LRPS and ORPS, respectively. The sensitivity analysis showed similar findings in the previous mentioned outcomes. In multivariable regression analysis blood loss was significantly associated with the open approach, higher ASA classification and malignancy as diagnosis. For LOS this was the open approach and a malignancy.

Conclusion

This international multicenter propensity score-matched study showed an advantage in favor of LRPS in selected patients as compared to ORPS in terms of operative time, blood loss and LOS without differences in major complications and R0 resection rate.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-08109-y) contains supplementary material, which is available to authorized users.

Laparoscopic Liver Resections for Tumors in the Posterosuperior Segments: A Single-center Experience of 174 Consecutive Cases

BACKGROUND

Laparoscopic posterosuperior liver resection is a technically difficult and complex surgery. These patients are seen as poor candidates for laparoscopic surgery. This study aimed to show the safe and effective applicability of the posterosuperior segment resections by experienced surgeons in advanced centers.

MATERIALS AND METHODS

Patients who underwent laparoscopic posterosuperior liver resection between October 2011 and October 2019 at the Groeninge Hospital were evaluated retrospectively. Demographic and perioperative data were obtained from the prospectively maintained database. Resection of at least 3 consecutive Couinaud segments was accepted as a major surgery (trisegmentectomy). Postoperative complications were registered according to the Clavien-Dindo classification.

RESULTS

The median age of the 174 patients was 68 years [interquartile range (IQR): 60 to 75]. The semiprone position was used in the majority of operations (82.2%). Nonanatomic resection was performed in more than half of the operations (55.1%). A total of 5 patients underwent major hepatic resection. The median time of surgery was 150 (IQR: 120 to 190) minutes. Median blood loss was determined to be 150 (IQR: 50 to 300) mL. Malignancy was detected in 95% of the cases. The surgical margin was reported to be R0 in 93.3% of the specimens. The median hospitalization time was 4 (IQR: 3 to 6) days. The major complication rate was 1.7%, and only 1 patient died. Overall survival rates for patients who underwent a resection for colorectal liver metastases in the first and fifth years were 97.5% and 62.2%, and disease-free survival rates were 69.8% and 35.5%, respectively.

CONCLUSION

Laparoscopic resections in the posterosuperior segments can be performed safely in experienced hands with good short and long term (oncologial) outcomes.

Comparative analysis of the safety and feasibility of laparoscopic versus open caudate lobe resection

PURPOSE

Laparoscopic hepatectomy has been used widely in liver disease due to its advantages as a minimally invasive surgery. However, laparoscopic caudate lobe resection (LCLR) has been reported rarely. We aimed to investigate the safety and feasibility of LCLR by comparing it with open liver surgery.

METHODS

A retrospective study was performed including all patients who underwent LCLR and open caudate lobe resection (OCLR) between January 2015 and August 2019. Twenty-two patients were involved in this study and divided into LCLR (n = 10) and OCLR (n = 12) groups based on preoperative imaging, tumor characteristics, and blood and liver function test. Patient demographic data and intraoperative and postoperative outcomes were compared between the two groups.

RESULTS

There were no significant inter-group differences between gender, age, preoperative liver function, American Society of Anesthesiologists (ASA) grade, and comorbidities (P > 0.05). The LCLR showed significantly less blood loss (50 vs. 300 ml, respectively; P = 0.004), shorter length of hospital stay (15 vs. 16 days, respectively; P = 0.034), and shorter operative time (216.50 vs. 372.78 min, respectively; P = 0.012) than OCLR, but hospital expenses (5.02 vs. 6.50 WanRMB, respectively; P = 0.208) showed no statistical difference between groups. There was no statistical difference in postoperative bile leakage (P = 0.54) and wound infection (P = 0.54) between LCLR and OCLR. Neither LCLR nor OCLR resulted in bleeding or liver failure after operation. There were no deaths.

CONCLUSION

LCLR is a very useful technology, and it is a feasible choice in selected patients with benign and malignant tumors in the caudate lobe.

Laparoscopic or open approaches for posterosuperior and anterolateral liver resections? A propensity score based analysis of the degree of advantage

BACKGROUND

Benefits over the open technique are demonstrated for laparoscopic liver resections. Whether the degree of advantage is different for anterolateral and posterosuperior resections is investigated in this retrospective study.

METHODS

Laparoscopic anterolateral and posterosuperior resections (Lap-AL/Lap-PS) were compared with open (Open-AL/Open-PS) after propensity score matching. Mean/median differences of relevant parameters were calculated after bootstrap sampling. The degree of advantage was compared between anterolateral and posterosuperior resections and expressed as delta of differences (Δ-difference).

RESULTS

239 Lap-AL were compared with 239 matched Open-AL, and 176 Lap-PS with 176 matched Open-PS. Lap-AL showed reduced blood loss, morbidity, time to orally-controlled pain, mobilization and total stay; Lap-PS showed reduced blood loss, transfusions, morbidity, time to orally-controlled pain, mobilization, functional recovery and total stay. The degree of advantage of Lap-PS resulted significantly greater than Lap-AL blood loss (Δ-difference: 101 mL, p 0.017), transfusions (Δ-difference: 6.3%, p 0.008), morbidity (Δ-difference: 7.6%, p 0.034), time to orally-controlled pain (Δ-difference: 1 day, p 0.020) and functional recovery (Δ-difference: 1 day, p 0.042).

CONCLUSIONS

While both resulting in benefit, the advantage of laparoscopy is greater for posterosuperior than anterolateral resections. Despite their technical difficulty, these should be considered among the most worthwhile laparoscopic liver resections.

A Comparison of the Learning Curves of Laparoscopic Liver Surgeons in Differing Stages of the IDEAL Paradigm of Surgical Innovation: Standing on the Shoulders of Pioneers

OBJECTIVE

To compare the learning curves of the self-taught "pioneers" of laparoscopic liver surgery (LLS) with those of the trained "early adopters" in terms of short- and medium-term patient outcomes to establish if the learning curve can be reduced with specific training.

SUMMARY OF BACKGROUND DATA

It is expected that a wider adoption of a laparoscopic approach to liver surgery will be seen in the next few years. Current guidelines stress the need for an incremental, stepwise progression through the learning curve in order to minimize harm to patients. Previous studies have examined the learning curve in Stage 2 of the IDEAL paradigm of surgical innovation; however, LLS is now in stage 3 with specific training being provided to surgeons.

METHODS

Using risk-adjusted cumulative sum analysis, the learning curves and short- and medium-term outcomes of 4 "pioneering" surgeons from stage 2 were compared with 4 "early adapting" surgeons from stage 3 who had received specific training for LLS.

RESULTS

After 46 procedures, the short- and medium-term outcomes of the "early adopters" were comparable to those achieved by the "pioneers" following 150 procedures in similar cases.

CONCLUSIONS

With specific training, "early adapting" laparoscopic liver surgeons are able to overcome the learning curve for minor and major liver resections faster than the "pioneers" who were self-taught in LLS. The findings of this study are applicable to all surgical specialties and highlight the importance of specific training in the safe expansion of novel surgical practice.

Pure laparoscopic right posterior sectionectomy using the caudate lobe-first approach

BACKGROUND

In our process of standardizing laparoscopic right-sided anatomical hepatectomy, we found several advantages of the caudate lobe-first approach. We herein describe our standardized procedure of laparoscopic right posterior sectionectomy (Lap-RPS) using this approach.

METHODS

Between January 2011 and January 2018, 31 patients underwent pure Lap-RPS in our hospital. The mean patient age was 68 years (range 47-85 years), and the number of male patients was more than that of female patients (64.5%). Of 31 patients, 20 had metastatic liver tumor, 7 had hepatocellular carcinoma, 3 had intrahepatic cholangiocellular carcinoma, and 1 had hemangioma. All 31 patients had Child-Pugh class A liver function. The surgical technique was recorded on video. Cumulative sum (CUSUM) analyses were applied to assess the learning curve.

RESULTS

The mean operative time was 420 min (range 263-639 min), and the mean amount of blood loss was 304 g (range 10-900 g). No procedure was converted to open surgery. Postoperative bleeding, bile leakage, hepatic failure, and mortality did not occur. CUSUM analyses showed a decrease in the operative time and blood loss after using the caudate lobe-first approach.

CONCLUSION

Our standardized procedure of Lap-RPS using the caudate lobe-first approach is not only feasible but also expected to provide an advantage for laparoscopic anatomical hepatectomy.

Perioperative and long-term outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma with well-preserved liver function and cirrhotic background: a propensity score matching study

BACKGROUND

Although laparoscopic liver resection (LLR) has advanced into a safe and effective alternative to conventional open liver resection (OLR), it has not been widely accepted by surgeons. This article aimed to investigate the perioperative and long-term benefits of LLR versus OLR for hepatocellular carcinoma (HCC) in selected patients with well-preserved liver function and cirrhotic background.

METHODS

A retrospective study was conducted on 1085 patients with HCC who underwent liver resection at Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University from July 2010 to July 2015, and 346 patients with well-preserved liver function and cirrhotic background were selected. A 1:1 propensity score matching (PSM), which is the best option to overcome selection bias, was conducted to compare the surgical outcomes and long-term prognosis between LLR and OLR. After PSM, a logistic regression analysis was used to identify the predictive risk factors of posthepatectomy liver failure (PHLF).

RESULTS

By using PSM, the two groups were well balanced with 86 patients in each group. In the LLR group, only the median operation time was significantly longer than the OLR group, but the hospital stay, overall morbidity, and the incidence of PHLF were significantly decreased compared to OLR. There were no significant differences in the overall survival and disease-free survival rates between the two groups. On multivariate analysis, OLR was identified to be the only independent risk factor for PHLF.

CONCLUSIONS

In selected HCC patients with well-preserved liver function and cirrhotic background, LLR could be a better option compared to OLR.