Laparoscopic right hepatectomy using the caudal approach is superior to open right hepatectomy with anterior approach and liver hanging maneuver: a comparison of short-term outcomes

Evolution of minimally invasive liver surgery in France over the last decade

BACKGROUND

Despite evidence of benefits on postoperative outcomes, minimally invasive liver surgery (MILS) had a very low diffusion up to 2014, and recent evolution is unknown. Our aim was to analyze the recent diffusion and adoption of MILS and compare the trends in indications, extent of resection, and institutional practice with open liver surgery (OLS).

METHODS

We analyzed the French nationwide, exhaustive cohort of all patients undergoing a liver resection in France between January 1, 2013 and December 31, 2022. Average annual percentage changes (AAPC) in the incidence of MILS and OLS were compared using mixed-effects log-linear regression models. Time trends were analyzed in terms of extent of resection, indication, and institutional practice.

RESULTS

MILS represented 25.2% of 74,671 liver resections and year incidence doubled from 16.5% in 2013 to 35.4% in 2022. The highest AAPC were observed among major liver resections [+ 22.2% (19.5; 24.9) per year], primary [+ 10.2% (8.5; 12.0) per year], and secondary malignant tumors [+ 9.9% (8.2; 11.6) per year]. The highest increase in MILS was observed in university hospitals [+ 14.7% (7.7; 22.2) per year] performing 48.8% of MILS and in very high-volume (> 150 procedures/year) hospitals [+ 12.1% (9.0; 15.3) per year] performing 19.7% of MILS. OLS AAPC decreased for all indications and institutions and accelerated over time from - 1.8% (- 3.9; - 0.3) per year in 2013-2018 to - 5.9% (- 7.9; - 3.9) per year in 2018-2022 (p = 0.013).

CONCLUSIONS

This is the first reported trend reversal between MILS and OLS. MILS has considerably increased at a national scale, crossing the 20% tipping point of adoption rate as defined by the IDEAL framework.

A novel Laennec's capsule tunnel approach for pure laparoscopic left hemihepatectomy: a propensity score matching study

Background

With the development of laparoscopic hepatectomy, there are different surgical approaches and pedicle anatomical methods for laparoscopic left hepatectomy. Combined with our practical experience, we proposed a method of transhepatic Laennec membrane tunnel for laparoscopic left hemihepatectomy (LT-LLH) and investigated the feasibility by comparison with the extrahepatic Glissonian approach for laparoscopic left hemihepatectomy (GA-LLH).

Patients and methods

The data of patients who underwent laparoscopic left hepatectomy in the Department of Hepatobiliary Pancreatic surgery of Fujian Provincial Hospital from December 2019 to March 2022 were analyzed retrospectively. Among them, 45 cases underwent laparoscopic left hemihepatectomy with an extrahepatic Glissonian approach, and 38 cases underwent laparoscopic left hemihepatectomy via transhepatic Laennec membrane tunnel approach. A 1:1 propensity score matching (PSM) method was performed to compare the perioperative indexes and long-term tumor prognosis between the two groups.

Results

After 1:1 PSM, 33 patients in each group were selected for further analysis. Compared with the GA-LLH group, the operation time of the LT-LLH group was shorter. There was no significant difference in the incidence of total complications between the two groups. Moreover, no statistical differences were found in disease-free survival and overall survival between the two groups.

Conclusion

It is safe, faster, and convenient for selective appropriate cases to carry out laparoscopic left hemihepatectomy through the hepatic Laennec membrane tunnel, which is suitable for clinical promotion.

Trocar layouts in laparoscopic liver surgery

BACKGROUND

Since the first laparoscopic wedge resection reported by Reich, laparoscopic liver resection (LLR) has been progressively developed, acquiring safety and feasibility. The time has witnessed a milestone leap for laparoscopic hepatectomy from pure laparoscopic partial hepatectomy to anatomical hepatectomy and from minor liver resection to major liver resection. The numerous previous studies have paid more attention to the short-time and long-time surgical outcomes caused by surgical techniques corresponding to various segments and approaches. However, focus on trocar layouts remains poorly described, but it plays an indispensable role in surgical process.

METHODS

We have searched PubMed for English language articles with the key words "trocar," "laparoscopic liver resection," and "liver resection approaches."

RESULTS

This review highlighted each type of trocar layouts corresponding to specific circumstances, including targeted resection segments with various approaches. Notably, surgeon preferences and patients body habitus affect the trocar layouts to some extent as well.

CONCLUSIONS

Although there were fewer researches focus on trocar layouts, they determine the operation field and manipulation space and be likely to have an impact on outcomes of surgery. Therefore, further studies are warranted to firm the role of trocar layouts in LLR.

Minimally invasive versus open living donors right hepatectomy: A systematic review and meta-analysis

BACKGROUND

Although minimally invasive technology has been widely used in hepatectomy, it remains controversial with regards to liver transplantation, especially in donors right hepatectomy. Herein, we compared the short-term safety and efficacy of minimally invasive donors right hepatectomy (MIDRH) with open donors right hepatectomy (ODRH).

METHODS

A systematic literature search was carried out using PubMed, Embase, Web of Science and the Cochrane Library database in order to identify comparison studies of MIDRH and ODRH. Next, we obtained the relevant data, and carried out the meta-analysis.

RESULTS

This meta-analysis included 12 studies, which included 1755 cases that underwent donors right hepatectomy. Compared to ODRH, patients that underwent MIDRH had less bleeding (SWD = -0.52, p<0.001), shorter hospital stays (SWD = -0.58, p < 0.001) and lower overall postoperative complications of donors (RR = 0.74, p = 0.008). However, MIDRH was found to be associated with prolonged operative times (SWD = 0.74, p < 0.001), as well as a higher rate of biliary complications in donors (RR = 2.26, p = 0.007) and recipients (RR = 1.69, p < 0.001). There were no statistically significant differences between MIDRH and ODRH in postoperative liver function, rate of major complications and vascular complications of both donors and recipients and overall postoperative complications.

DISCUSSION

MIDRH is superior to ODRH with regards to intraoperative bleeding, postoperative hospital stay and overall donor complications. Although biliary-related complications are higher, it is feasible to develop MIDRH in experienced liver transplant centers. However, higher-quality research is still needed for corroboration.

Cranial-Dorsal Approach Along the Middle Hepatic Vein Facilitating Laparoscopic Left Hemihepatectomy

The exposure and protection of middle hepatic vein (MHV) is crucial and difficult for anatomic laparoscopic left hemihepatectomy in the treatment of left hepatic tumor. 1, 2 The traditional caudal approach, which the liver is transected from the branch to the main trunk of MHV, is prone to damage the vessels. 3, 4 The ventral approach is easy to expose the main trunk of MHV; however, the risk of vascular laceration caused by the caudal approach cannot be completely avoided, since the direction of endoscopic view and liver dissection are from the foot to the head side. We herein present a cranial-dorsal approach along the middle hepatic vein during laparoscopic left hemihepatectomy.The key point of the cranial-dorsal approach was the hepatic parenchyma transection from the root of MHV toward its distal branches. Briefly, left hepatic blood inflow was blocked, followed by the dissociation and transection from the left hepatic duct and vein. Along the direction of the main trunk of the MHV, the liver resection plane could be clearly exposed from the cranial and dorsal sides, and then the branches of the MHV were managed separately. Owing to the full exposure along the MHV trunk, the remaining liver parenchyma could be quickly transected to complete the anatomic left hepatectomy finally. This technique was performed in 10 patients who underwent laparoscopic left hemihepatectomy from March 2017 to December 2019. The median operative time was 188 min (range 150-265 min), and the intraoperative blood loss was 191 mL (range 100-300 mL). The median postoperative hospital stay was 6 days (range 4-8 days). No major postoperative complications or mortality was reported (Table 1). Cranial-dorsal approach along the MHV may be a feasible and effective technique during laparoscopic left hemihepatectomy, contributing to the process of anatomic left liver resection by full exposure and protection of hepatic veins.

Major robotic hepatectomies: technical considerations

Robotic approach to the liver may allow to perform difficult resections with a minimally invasive strategy in an easier way as compared to standard laparoscopy. The aim of this study is to review our experience with robotic major hepatectomies, reporting technical considerations, and describing the outcomes of patients that underwent either left (LRH) or right robotic hepatectomy (RRH). Our prospectively maintained database was screened to identify all patients that received a major liver resection for benign or malignant disease. Preoperative data and postoperative short-term and long-term outcomes were reported. 261 robotic procedures were performed in our Center between May 2014 and October 2020. 12 patients underwent robotic left hepatectomy (RLH) and 10 patients were treated by robotic right hepatectomy (RRH). In the RLH group, median operative time (OT) was 383 min, median estimated blood loss (EBL) was 300 ml, and median in-hospital stay was of 3 days. In the RRH group, median OT was 490 min, median EBL 725 ml, and median hospital stay was 5 days. Although one of the advantages of minimally invasive surgery is to obtain radical resections with parenchyma sparing strategies, patients that need a major hepatectomy may benefit of a robotic resection with good postoperative outcomes. Team learning curve and growth instead of personal progression is crucial to expand the limits of novel surgical techniques.

Benchmark performance of laparoscopic left lateral sectionectomy and right hepatectomy in expert centers

BACKGROUND & AIMS

Herein, we aimed to establish benchmark values - based on a composite indicator of healthcare quality - for the performance of laparoscopic left lateral sectionectomy (LLLS) and laparoscopic right hepatectomy (LRH) using data from expert centers.

METHODS

Data from a nationwide multicenter survey including all patients undergoing LLLS and LRH between 2000 and 2017 were analyzed. Textbook outcome (TO) completion was considered in patients fulfilling all 6 of the following characteristics: negative margins, no transfusion, no complication, no prolonged hospital stay, no readmission and no mortality. For each procedure, a cut-off laparoscopic liver resection (LLR) volume by center was associated with TO on multivariable analysis. These cut-offs defined the expert centers. The benchmark values were set at the 75th percentile of median outcomes among these expert centers.

RESULTS

Among 4,400 LLRs performed in 29 centers, 855 patients who underwent LLLS and 488 who underwent LRH were identified. The overall incidences of TO after LLLS and LRH were 43.7% and 23.8%, respectively. LLR volume cut-offs of 25 LLR/year (odds ratio [OR] 2.45; bootstrap 95% CI 1.65-3.69; p = 0.001) and 35 LLR/year (OR 2.55; bootstrap 95% CI 1.34-5.63; p = 0.003) were independently associated with completion of TO after LLLS and LRH, respectively. Eight centers for LLLS and 6 centers for LRH, including 516 and 346 patients undergoing LLLS/LRH respectively, reached these cut-offs and were identified as expert centers. After LLLS, benchmark values of severe complication, mortality and TO completion were defined as ≤5.3%, ≤1.2% and ≥46.6%, respectively. After LRH, benchmark values of severe complication, mortality and TO completion were ≤20.4%, ≤2.8% and ≥24.2%, respectively.

CONCLUSIONS

This study provides an up-to-date reference on the benchmark performance of LLLS and LRH in expert centers.

LAY SUMMARY

In a nationwide French survey of laparoscopic liver resection, expert centers were defined according to the completion of a textbook outcome, which is a composite indicator of healthcare quality. Benchmark values regarding intra-operative details and outcomes were established using data from 516 patients with laparoscopic left lateral sectionectiomy and 346 patients with laparoscopic right hepatectomy from expert centers. These values should be used as a reference point to improve the quality of laparoscopic resections.

Pure laparoscopic right hepatectomy: A risk score for conversion for the paradigm of difficult laparoscopic liver resections. A single centre case series

BACKGROUND

Converted laparoscopic hepatectomies are known to lose some advantages of the minimally-invasiveness, and factors are identified to predict patients at risk. Specific evidence for laparoscopic right hepatectomy is expected of usefulness in clinical practice, given its technical peculiarities. The purpose of the study was the identification of risk factors and the development of a risk score for conversion of laparoscopic right hepatectomy.

MATERIALS AND METHODS

Laparoscopic right hepatectomy performed at a single hepatobiliary surgical center were analyzed. The cohort was split in half to obtain a derivation and a validation set. Risk factors for conversion were identified by uni- and multivariable analysis. A "conversion risk score" was built assigning each factor 1 point and comparing the score with the conversion status for each patient. The accuracy was assessed by the area-under-the-receiver-operator-characteristic-curve.

RESULTS

Among 130 operations, 22 were converted (16.9%). Reasons were: 45.5% oncologic inadequacy, 31.8% bleeding, 9.1% adhesions, 9.1% biliostasis, 4.5% anaesthesiological problems. Independent risk factors for conversion were: previous laparoscopic liver surgery (Hazard Ratio 4.9, p 0.011), preoperative chemotherapy ( Hazard Ratio 6.2, p 0.031), malignant diagnosis (Hazard Ratio 3.3, p 0.037), closeness to hepatocaval confluence or inferior vena cava (Hazard Ratio 4.1, p 0.029), tumor volume (Hazard Ratio 2.9, p 0.024). Conversion rates correlated positively with the score, raising from 0 to 100% when the score increased from 0 to 5 (Spearman: p 0.032 in the derivation set, p 0.020 in the validation set). The risk of conversion showed a sharp increase passing from class 3 to 4, reaching a probability estimated between 60 and 71.4%. The score showed good accuracy (area-under-the-receiver-operator-characteristic-curve 0.82).

CONCLUSION

Specific risk factors for conversion are identified for laparoscopic right hepatectomy. This score may help in standardizing the choice of a pure laparoscopic or open approach for such challenging resections.

Laparoscopic liver resection: indications, limitations, and economic aspects

Background

Minimally invasive techniques have increasingly found their way into liver surgery in recent years. A multitude of mostly retrospective analyses suggests several advantages of laparoscopic over open liver surgery. Due to the speed and variety of simultaneous technical and strategic developments, it is difficult to maintain an overview of the current status and perspectives in laparoscopic liver surgery.

Purpose

This review highlights up-to-date aspects in laparoscopic liver surgery. We discuss established indications with regard to their development over time as well as continuing limitations of applied techniques. We give an assessment based on the current literature and according to our own center experiences, not least with regard to a highly topical cost discussion.

Conclusions

While in the beginning mainly benign tumors were laparoscopically operated on, liver metastasis and hepatocellular carcinoma are now among the most frequent indications. Technical limitations remain and should be evaluated with the overall aim not to endanger quality standards in open surgery. Financial aspects cannot be neglected with the necessity of cost-covering reimbursement.

A comparison between robotic, laparoscopic and open hepatectomy: A systematic review and network meta-analysis

BACKGROUND

The evidence of pairwise meta-analysis of Robotic Hepatectomy (RH) vs Laparoscopic Hepatectomy (LH) and RH vs Open Hepatectomy (OH) is inconclusive. Therefore, the aim of this study, was to compare the outcomes of RH, LH and OH by performing a network meta-analysis.

METHODS

A systematic literature search was performed in the following databases: Pubmed, Google scholar, EMBASE and Cochrane library. Cost-effectiveness and survival benefits were selected as primary outcomes.

RESULTS

The cost was less in OH compared to both minimally invasive procedures, LH demonstrated lower cost compared to RH, but the differences were not statistically significant. Both the RH and LH cohorts demonstrated significantly lower estimated blood loss, reduced major morbidity rate and shorter length of stay compared to OH cohort. The LH and OH cohorts demonstrated significantly shorter operative time and duration of clamping compared to the RH cohort. The LH cohort included significantly smaller tumours compared to the OH cohort.

CONCLUSION

The present network meta-analysis, demonstrated that both RH and LH in malignant and benign conditions were associated with lower morbidity rates, shorter hospital stay and the procedure related costs were statistically nonsignificant between RH, LH and OH.

Minimally Invasive Donor Hepatectomy for Adult Living Donor Liver Transplantation: An International, Multi-Institutional Evaluation of Safety, Efficacy and Early Outcomes

OBJECTIVE

Evaluating the perioperative outcomes of minimally invasive (MIV) donor hepatectomy for adult live donor liver transplants in a large multi-institutional series from both Eastern and Western centers.

BACKGROUND

Laparoscopic liver resection has become standard practice for minor resections in selected patients in whom it provides reduced postoperative morbidity and faster rehabilitation. Laparoscopic approaches in living donor hepatectomy for transplantation, however, remain controversial because of safety concerns. Following the recommendation of the Jury of the Morioka consensus conference to address this, a retrospective study was designed to assess the early postoperative outcomes after laparoscopic donor hepatectomy. The collective experience of 10 mature transplant teams from Eastern and Western countries was reviewed.

METHODS

All centers provided data from prospectively maintained databases. Only left and right hepatectomies performed using a MIV technique were included in this study. Primary outcome was the occurrence of complications using the Clavien-Dindo graded classification and the Comprehensive Complication Index during the first 3 months. Logistic regression analysis was used to identify risk factors for complications.

RESULTS

In all, 412 MIV donor hepatectomies were recorded including 164 left and 248 right hepatectomies. Surgical technique was either pure laparoscopy in 175 cases or hybrid approach in 237. Conversion into standard laparotomy was necessary in 17 donors (4.1%). None of the donors died. Also, 108 experienced 121 complications including 9.4% of severe (Clavien-Dindo 3-4) complications. Median Comprehensive Complication Index was 5.2.

CONCLUSIONS

This study shows favorable early postoperative outcomes in more than 400 MIV donor hepatectomy from 10 experienced centers. These results are comparable to those of benchmarking series of open standard donor hepatectomy.

Oncological Resection for Liver Malignancies: Can the Laparoscopic Approach Provide Benefits?

: Laparoscopic surgery has become an increasingly popular alternative approach to open surgery, resulting in a paradigm shift in liver surgery. Although laparoscopic liver resection (LLR) was initially indicated for small benign and peripheral tumors, at present more than half of LLRs are performed in malignant tumors. Several studies have reported the feasibility of LLR in malignant disease and suggested various short-term benefits compared to open liver resection, including decreased blood loss and postoperative complications and a shorter hospital stay. Although these benefits are important to surgeons, patients, and providers, the main goal of surgery for malignancies is to achieve a maximum oncologic benefit.The relevance of the laparoscopic approach must be assessed in relation to the possibility of respecting basic oncological rules and the expertise of the center. Easy LLRs can be safely performed by most surgeons with minimum expertise in liver surgery and laparoscopy, and can therefore probably provide an oncological benefit. On the other hand, intermediate or difficult LLRs require technical expertise and an oncological benefit can only be achieved in expert centers. Technical standardization is the only way to obtain an oncological benefit with this type of resection, and many problems must still be solved.