Modified liver hanging maneuver in laparoscopic major hepatectomy: the learning curve and evolution of indications

Technical aspects and learning curve of complex laparoscopic hepatectomy: how we do it

INTRODUCTION

Laparoscopic liver surgery has advanced significantly, offering benefits, such as reduced intraoperative complications and quicker recovery. However, complex laparoscopic hepatectomy (CLH) is technically demanding, requiring skilled surgeons. This study aims to share technical aspects, insightful tips, and outcomes of CLH at our center, focusing on the safety and learning curve.

METHODS

We reviewed all patients undergoing liver resection at our center from July 2017 to December 2023, focusing on those who underwent CLH. Of 135 laparoscopic liver resections, 63 (46.7%) were CLH. The learning curve of CLH was also assessed through linear and piecewise regression analyses considering the operation time and intraoperative blood loss.

RESULTS

Postoperative complications occurred only in 4.8% of patients, with a 90-day mortality rate of 3.2%. The mean operation time and blood loss significantly decreased after the first 20 operations, marking the learning curve's optimal cut-off. Significant improvements in R0 resection (p = 0.024) and 90-day mortality (p = 0.035) were noted beyond the learning curve threshold.

CONCLUSION

CLH is a safe and effective approach, with a relatively short learning curve of 20 operations. Future large-scale studies should further investigate the impact of surgical experience on CLH outcomes to establish guidelines for training programs.

Impact of sarcopenia on the surgical outcomes in patients with hepatolithiasis: A multicenter 10-year experience

BACKGROUND

The impact of sarcopenia on the surgical outcomes of hepatectomy for hepatolithiasis has not been investigated. The present study elucidated the effect of sarcopenia on short-term outcomes after hemihepatectomy for hepatolithiasis and investigated the benefit of different surgical approaches to hepatectomy in patients with sarcopenia.

METHODS

Patients who underwent hemihepatectomy for hepatolithiasis at Fujian Provincial Hospital and 5 other medical centers from 2010 to 2020 were enrolled. The sarcopenic obesity subgroup had sarcopenia coexisting with obesity, and the sarcopenic nonobesity subgroup had sarcopenia without obesity. We analyzed the postoperative outcomes of the sarcopenia group, sarcopenic obesity subgroup and sarcopenic nonobesity subgroup and the corresponding benefits of different surgical approaches.

RESULTS

Patients with sarcopenia (n = 481) had worse surgical outcomes than nonsarcopenia, such as longer postoperative hospital duration of stay, longer time to oral intake, longer time to bowel movement, and longer time to off-bed activities. In postoperative short-term outcomes, we also found that sarcopenia had higher rates of major complications, bile leakage, and intensive care unit occupancy than the nonsarcopenic group. Subgroup analysis showed that sarcopenic obesity subgroup (n = 182) had the worst results in intraoperative outcomes and postoperative short-term outcomes. Multivariate analysis identified sarcopenic obesity as a significant risk factor for postoperative hospital duration of stay (hazard ratio = 2.994, P < .001). Furthermore, the sarcopenic obesity and sarcopenic nonobesity (n = 299) subgroups benefited from laparoscopic surgery compared with open surgery, including postoperative recovery and major complications (all P < .05). However, sarcopenic nonobesity subgroup had more significant benefits of laparoscopy than the sarcopenic obesity subgroup. The learning curve for laparoscopic hemihepatectomy for the sarcopenic obesity subgroup had a plateau, and the surgical outcomes of the sarcopenic obesity subgroup were closer to the sarcopenic nonobesity subgroup after the plateau.

CONCLUSION

Sarcopenia is associated with more adverse events after hepatectomy and patients with sarcopenic obesity have a higher incidence of adverse events. Patients with sarcopenia could benefit from laparoscopy. Compared with the sarcopenic obesity patients, the sarcopenic nonobesity patients benefited more from laparoscopy. Although the sarcopenic obesity patients had more complications and slower postoperative recovery than the sarcopenic nonobesity patients, laparoscopic also could improve their short-term outcomes, but a longer learning curve was required.

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.

Pure Laparoscopic Hepatectomy for Tumors Close to the Major Hepatic Veins: Intraparenchymal Identification of the Major Hepatic Veins using the Ventral Approach

BACKGROUND

Laparoscopic hepatectomy for tumors close to the major hepatic veins (HVs) is a technically demanding procedure that is relatively contraindicated. We investigated this surgical technique and the outcomes of intraparenchymal identification of the major HVs using the ventral approach in pure laparoscopic hepatectomy for tumors close to the major HVs.

METHODS

In the present study, tumors < 10 mm from the major HVs were defined as lesions in proximity to the major HVs. The cranio-ventral part of the liver parenchyma along the targeted major hepatic veins was opened to facilitate an open cutting plane. After a wide exposure of the surgical plane, the targeted major HVs were identified.

RESULTS

Thirteen patients with tumors close to the major HVs underwent laparoscopic hepatectomy. The median operative time was 260 min (range, 160-410 min), while the intraoperative blood loss was 100 mL (range, 30-310 mL). The median Pringle maneuver time was 45 min (range, 40-75 min). The median tumor size was 50 mm (range, 17-140 mm), and the median tumor margin was 4 mm (range, 0-10 mm). Three patients (23.1%) experienced minor postoperative complications. The median postoperative hospital stay was 7 days (range, 4-25 days).

CONCLUSIONS

Pure laparoscopic hepatectomy for tumors close to the major HVs is technically feasible in selected patients. Intraparenchymal identification of the major HVs using the ventral approach achieves transection plane accuracy and avoids inadvertent injury to the major HVs.

Up-to-down open and laparoscopic liver hanging maneuver: an overview

BACKGROUND

The liver hanging maneuver (LHM) was described by Belghiti et al. to facilitate liver resection and is done classically by creating a space between the caudate lobe and the inferior vena cava starting on the edge of caudate lobe and extending cranially, in a para-caval fashion, towards the space between the right and middle hepatic veins. LHM facilitates liver transection, guides anatomical resections, decreases blood loss, facilitates harvesting of the liver graft in live donors, and also has oncological advantages.

STUDY DESIGN

We describe a new approach named "up-to-down" to perform LHM in open and laparoscopic liver resections. This approach was mainly used in obese patients, in laparoscopic liver resections and in cases of failure of the classic approach. The advantages/disadvantages, complications, and different modalities of LHM are also summarized.

RESULTS

The peritoneal layer between the liver capsule and the infrahepatic vena cava is opened, and a short blind dissection is initiated on the right anterolateral aspect of the inferior vena cava to the left of the hepatic vein of segment VI. The suprahepatic vena cava is exposed, and the space between the right and middle hepatic veins and the vena cava is created by gentle dissection. A 16-Fr nasogastric tube is positioned in the space between the right and middle hepatic vein, pointing inferiorly, and pushed downwards, in a para-caval manner caudally until it is seen inferiorly. The results of this approach are given.

CONCLUSION

LHM facilitates liver resection, and many variations have been described worldwide in open and laparoscopic liver surgery. The up-to-down approach should be part of the surgical armamentarium in order to offer a safer way to achieve LHM in some patients.