3D vision and maintenance of stable pneumoperitoneum: a new step in the development of laparoscopic right hepatectomy

Operating room time savings in Germany- and UK-based hospitals with 3D- VS. 2D-imaging technology in laparoscopic surgery: Meta analysis and budget impact model - Health economic evaluation

AIMS

Opportunity cost (OC) analysis is key when evaluating surgical techniques. Operating room (OR) time is one potential source of OC in laparoscopic surgery. This study quantifies differences in OR time between 3D- and 2D-imaging technology in laparoscopic surgery, translates these into OC and models the economic impact in real-world hospitals.

METHODS

First a systematically performed literature review and meta-analysis were conducted. Then, methods to translate OR time savings into OC were theorised and a budget impact model was created. After that, the potential time savings of real-world hospital case mixes were extrapolated. Finally, the opportunity costs of not using 3D-imaging in laparoscopic surgery were evaluated.

RESULTS

Average OR time saving per laparoscopic procedure was -19.4 min (-24.3; -14.5) (-14%) in favour of 3D. The Budget Impact Model demonstrated an economic impact of using 3D-laparoscopy instead of 2D laparoscopy, ranging from £183,045-£866,316 in the British and 73,049€-437,829€ in German hospitals, modelling a mixture of cost savings and performing additional procedures (earning additional revenue).

CONCLUSION

The OC analysis revealed significant economic benefits of introducing 3D-imaging technology in laparoscopic surgery, on the basis that average procedure time is reduced. Utilising the saved OR time to perform additional procedures was the biggest driver of OC. Hospital case mix and procedure volume indicated the magnitude of the OC.

Standardized Technique of Selective Left Liver Vascular Exclusion During Laparoscopic Liver Resection for Benign and Malignant Tumors

BACKGROUND

Tumors located close to major hepatic veins pose a technical challenge to standard laparoscopic liver resection. Hepatic outflow occlusion may reduce the risks of bleeding from hepatic vein and gas embolism. The aim of this study was to detail our standardized laparoscopic approach for a safe extrahepatic control of the common trunk of middle and left hepatic veins during laparoscopic liver resection and to assess its feasibility in patients with tumors located in both right and left lobes of the liver.

METHODS

Data of 25 consecutive patients who underwent laparoscopic liver resection with extrahepatic control of the common trunk of middle and left hepatic veins were reviewed.

RESULTS

All patients underwent primary hepatectomy. The vast majority (84%) of patients had malignant tumors. The control of the common trunk of middle and left hepatic veins was achieved in 96% of patients. There were 14 (56%) major hepatectomies and 11 (44%) minor hepatectomies. Some form of vascular clamping was performed in 23 (62%) patients: Pringle maneuver in 17 (median time = 45 min; range, 10-109) and selective vascular exclusion of the liver in 6 patients (median time = 30 min; range, 15-94). The median duration of operation was 254 min (range, 70-441). There was one case (4%) of gas embolism but without any complications during the postoperative course. Conversion to open surgery was performed in 2 (7.7%) patients: 1 for oncologic reason and 1 for non-progression during the transection plane. Perioperative blood transfusion rate was nil. The overall morbidity rate was 24%.

CONCLUSIONS

The laparoscopic approach for an extrahepatic control of the common trunk of middle and left hepatic veins is reproducible, safe, and effective, and can be applied during laparoscopic liver resection for tumors close to major hepatic veins.

Short-term outcomes of laparoscopic versus open hepatectomy in the elderly patient: systematic review and meta-analysis

BACKGROUND AND AIM

Favorable outcomes of laparoscopic hepatectomy (LH) over open hepatectomy (OH) have been demonstrated. LH offers less postoperative morbidity, less blood loss, and shorter hospital stay, while maintaining oncological safety. Only limited evidence about outcomes of LH in elderly is currently available. Therefore, this study aimed to compare short term outcomes of LH to OH for patients >65 years.

METHODS

A systematic review and meta-analysis were performed according to Cochrane guidelines. Embase, PubMed, Cochrane Library, and Google Scholar were searched to identify eligible studies. Studies were included if they compared LH to OH, and focused on an elderly population, or had a majority of patients >65 years. Perioperative and postoperative outcomes were analyzed.

RESULTS

Thirteen studies with 1174 patients (LH:532, OH:642) were included for analysis. When compared to OH, elderly undergoing LH had significantly less postoperative complications (risk ratio [RR]0.52; 95% confidence interval (CI):0.43-0.63), less blood loss (mean difference [MD]-198.58; 95% CI:-299.88 to -97.28), and shorter length of stay (MD-4.83; 95%CI:-7.91 to -1.84), while oncological safety was non-inferior (RR1.04; 95%CI:1.00-1.08).

CONCLUSIONS

Within the elderly population LH seems to be superior to OH, concerning short-term outcomes. However, for broader applicability more trials are needed including more difficult and major resections.

Efficiency, Accuracy and Clinical Applicability of a New Image-Guided Surgery System in 3D Laparoscopic Liver Surgery

BACKGROUND

To investigate efficiency, accuracy and clinical benefit of a new augmented reality system for 3D laparoscopic liver surgery.

METHODS

All patients who received laparoscopic liver resection by a new image-guided surgery system with augmented 3D-imaging in a university hospital were included for analysis. Digitally processed preoperative cross-sectional imaging was merged with the laparoscopic image. Intraoperative efficiency of the procedure was measured as time needed to achieve sufficient registration accuracy. Technical accuracy was reported as fiducial registration error (FRE). Clinical benefit was assessed trough a questionnaire, reporting measures in a 5-point Likert scale format ranging from 1 (high) to 5 (low).

RESULTS

From January to March 2018, ten laparoscopic liver resections of a total of 18 lesions were performed using the novel augmented reality system. Median time for registration was 8:50 min (range 1:31-23:56). The mean FRE was reduced from 14.0 mm (SD 5.0) in the first registration attempt to 9.2 mm (SD 2.8) in the last attempt. The questionnaire revealed the ease of use of the system (1.2, SD 0.4) and the benefit for resection of vanishing lesions (1.0, SD 0.0) as convincing positive aspects, whereas image registration accuracy for resection guidance was consistently judged as too inaccurate.

CONCLUSIONS

Augmented reality in 3D laparoscopic liver surgery with landmark-based registration technique is feasible with only little impact on the intraoperative workflow. The benefit for detecting particularly vanishing lesions is high. For an additional benefit during the resection process, registration accuracy has to be improved and non-rigid registration algorithms will be required to address intraoperative anatomical deformation.

Surgical Glove Technique for Laparoscopic Liver Resection

BACKGROUND

Liver tumors located in segments 7 and 8 pose a technical challenge to standard laparoscopic liver resection. Intraoperative placement of a surgical glove behind the right liver after the right triangular ligament and coronary ligament are divided facilitates liver exposure during parenchymal transection and control of the bleeding at the deeper part of the parenchymal plane. The aim of this study was to describe our standardized technique in detail and to assess the feasibility of this technique in patients with different clinical backgrounds and clarify the limits of this technique.

METHODS

Medical records of 20 consecutive patients considered for laparoscopic liver resection using the surgical glove technique were reviewed.

RESULTS

All patients had malignant disease and the vast majority of patients had colorectal metastatic tumors. Overall, 65% of patients had tumors located in segment 8. Placing the surgical water glove could be achieved without complication in all 20 patients. One surgical glove was used in this series (usually size 6.5 to 7.5 is an adequate size). Time for preparing the surgical green water glove was estimated to be less than 1 min. The mean duration of operation ranged from 136 to 332 min (median, 240 min). Intermittent Pringle's maneuver was applied in all patients with a median time of 33 min. No additional intercostal trocars were required. There was no intraoperative blood transfusion or conversion to open surgery. The median maximum size of the tumor was 23 mm. There was no operative mortality. Overall morbidity was 30%. Surgical margins were negative in 80% of patients.

CONCLUSIONS

The surgical glove technique is easy, reproducible, effective, and safe and can be applied to both laparoscopic and robotic liver resection.

Techniques for laparoscopic liver parenchymal transection

Laparoscopic liver surgery has gained wide acceptance resulting in a paradigm shift of liver surgery. Technical innovations and accumulation of surgeon's experience have allowed laparoscopic liver resection (LLR) to become an effective procedure with favorable peri- and post-operative outcomes. Through the overall process of LLR, liver parenchymal transection remains the most critical step with the aim of minimizing blood loss and secures the appropriate cutting line, i.e., securing major vessels and obtaining adequate surgical margin clearance for malignancies. Multiple preoperative imaging modalities and intraoperative ultrasonography findings may contribute to the best determination of the appropriate cutting line during the LLR; however, technical expertise in minimizing and controlling bleeding during liver parenchymal transection is still a challenge for safe LLR, and therefore represents a major concern for hepatobiliary surgeons. Along with the historical fact that the technique of liver parenchymal transection itself is chosen according to surgeon's preference and "savoir-faire", the best technical modality in laparoscopic liver parenchymal transection remains to be determined. However, better understanding the technical issue may serve a contribution to the standardization of LLR. This review article therefore focuses on the technical aspects of the laparoscopic liver parenchymal transection.