Laparoscopic liver resection: experience of 53 procedures at a single center

Minimally Invasive Hepatopancreatobiliary Surgery at a Large Regional Health System: Assessing the Safety of Program Expansion

BACKGROUND

Complex, minimally invasive hepatopancreatobiliary surgery (MIS HPB) is safe at high-volume centers, yet outcomes during early implementation are unknown. We describe our experience during period of rapid growth in an MIS HPB program at a large regional health system.

METHODS

During an increase in MIS HPB (60% greater from preceding year), hospital records of patients who underwent HPB surgery between 1/1/2019 and 12/31/2020 were reviewed. Operative time, estimated blood loss (EBL), conversion rates, length of stay (LOS), and perioperative outcomes were assessed.

RESULTS

267 patients' cases were reviewed. The population was 62 ± 13 years, 50% female, 90% white. MIS was more frequently performed for hepatic than pancreatic resections (59% vs 21%, P < .001). Open cases were more frequently performed for invasive malignancy in both pancreatic (70% vs 40%, P < .018) and hepatic (87% vs 70%, P = .046) resections. There was no difference in operative time between MIS and open surgery (293[218-355]min vs 296[199-399]min, P = .893). When compared to open, there was a shorter LOS (4[2-6]d vs 7[6-10]d, P < .001) and lower readmission rate (21% vs 37%, P = .005) following MIS. Estimated blood loss was lower in MIS liver resections, particularly when performed for benign disease (200[63-500]mL vs 600[200-1200]mL, P = .041). Overall 30-day mortality was similar between MIS and open surgery (1.0% vs 1.8%, P = 1.000).

DISCUSSION

During a surgical expansion phase within our regional health system, MIS HPB offered improved perioperative outcomes when compared to open surgery. These data support the safety of implementation even during intervals of rapid programmatic growth.

Generic surgical process model for minimally invasive liver treatment methods

Surgical process modelling is an innovative approach that aims to simplify the challenges involved in improving surgeries through quantitative analysis of a well-established model of surgical activities. In this paper, surgical process model strategies are applied for the analysis of different Minimally Invasive Liver Treatments (MILTs), including ablation and surgical resection of the liver lesions. Moreover, a generic surgical process model for these differences in MILTs is introduced. The generic surgical process model was established at three different granularity levels. The generic process model, encompassing thirteen phases, was verified against videos of MILT procedures and interviews with surgeons. The established model covers all the surgical and interventional activities and the connections between them and provides a foundation for extensive quantitative analysis and simulations of MILT procedures for improving computer-assisted surgery systems, surgeon training and evaluation, surgeon guidance and planning systems and evaluation of new technologies.

Long-term oncological outcomes after laparoscopic parenchyma-sparing redo liver resections for patients with metastatic colorectal cancer: a European multi-center study

Background

Laparoscopic redo resections for colorectal metastases are poorly investigated. This study aims to explore long-term results after second, third, and fourth resections.

Material and methods

Prospectively updated databases of primary and redo laparoscopic liver resections in six European HPB centers were analyzed. Procedure-related overall survival after first, second, third, and fourth resections were evaluated. Furthermore, patients without liver recurrence after first liver resection were compared to those with one redo, two or three redo, and patients with palliative treatment for liver recurrence after first laparoscopic liver surgery. Survival was calculated both from the date of the first liver resection and from the date of the actual liver resection. In total, 837 laparoscopic primary and redo liver resections performed in 762 patients were included (630 primary, 172 first redo, 29 second redo, and 6 third redo). Patients were bunched into four groups: Group 1—without hepatic recurrence after primary liver resection (n = 441); Group 2—with liver recurrence who underwent only one laparoscopic redo resection (n = 154); Group 3—with liver recurrence who underwent two laparoscopic redo resections (n = 29); Group 4—with liver recurrence who have not been found suitable for redo resections (n = 138).

Results

No significant difference has been found between the groups in terms of baseline characteristics and surgical outcomes. Rate of positive resection margin was higher in the group with palliative recurrence (group 4). Five-year survival calculated from the first liver resection was 67%, 62%, 84%, and 7% for group 1, 2, 3, and 4, respectively. Procedure-specific 5-year overall survival was 50% after primary laparoscopic liver resection, 52% after the 1st reoperation, 52% after the 2nd, and 40% after the 3rd reoperation made laparoscopic.

Conclusions

Multiple redo recurrences can be performed laparoscopically with good long-term results. Liver recurrence does not aggravate prognosis as long as the patient is suitable for reoperation.

Evolution of laparoscopic liver surgery: 20-year experience of a Norwegian high-volume referral center

BACKGROUND

Laparoscopic liver surgery has evolved to become a standard surgical approach in many specialized centers worldwide. In this study we present the evolution of laparoscopic liver surgery at a single high-volume referral center since its introduction in 1998.

METHODS

Patients who underwent laparoscopic liver resection (LLR) between August 1998 and December 2018 at the Oslo University Hospital were analyzed. Perioperative outcomes were compared between three time periods: early (1998 to 2004), middle (2005 to 2012) and recent (2013-2018).

RESULTS

Up to December 2020, 1533 LLRs have been performed. A total of 1232 procedures were examined (early period, n = 62; middle period, n = 367 and recent period, n = 803). Colorectal liver metastasis was the main indication for surgery (68%). The rates of conversion to laparotomy and hand-assisted laparoscopy were 3.2% and 1.4%. The median operative time and blood loss were 130 min [interquartile range (IQR), 85-190] and 220 ml (IQR, 50-600), respectively. The total postoperative complications rate was 20.3% and the 30-day mortality was 0.3%. The median postoperative stay was two (IQR, 2-4) days. When comparing perioperative outcomes between the three time periods, shorter operation time (median, from 182 to 120 min, p < 0.001), less blood loss (median, from 550 to 200 ml, p = 0.023), decreased rate of conversions to laparotomy (from 8 to 3%) and shorter postoperative hospital stay (median, from 3 to 2 days, p < 0.001) was observed in the later periods, while the number of more complex liver resections had increased.

CONCLUSION

During the last two decades, the indications, the number of patients and the complexity of laparoscopic liver procedures have expanded significantly. Initially being an experimental approach, laparoscopic liver surgery is now safely implemented across our unit and has become the method of choice for surgical treatment of most liver tumors.

Hand-assisted Laparoscopic Repeat Hepatectomy for Secondary Liver Neoplasm

BACKGROUND

Hand-assisted laparoscopic surgery is a widely accepted alternative to an open approach. The use of this technique in repeat liver resection is limited due to technical difficulties caused by postsurgical adhesions. We aimed to assess the feasibility and safety of hand-assisted laparoscopic repeat hepatectomy (HALRH).

MATERIALS AND METHODS

This was a retrospective study of the medical files of patients who had undergone HALRH between 2010 and 2017 in 2 university-affiliated medical centers.

RESULTS

Sixteen patients with repeat hepatectomy were included with a median age of 67.5 years. The first liver resection was a traditional laparotomy for 9 patients and hand-assisted laparoscopic surgery for 7 patients. The conversion rate to open surgery was 6%. The median operative time, blood loss during surgery, and postoperative hospital stay were 166 minutes, 400 mL, and 7 days, respectively. R0 resections were achieved in 88% of patients. The median number of tumors and tumor size were 1 and of 25 mm, respectively. There were no mortalities or major complications postoperatively. For patients with colorectal liver metastases, the median follow-up and overall survival were 21 and 43 months, respectively.

CONCLUSION

The findings suggest HALRH to be safe and feasible. Future ERAS guidelines should evaluate this approach for liver surgery.

Hand-assisted Laparoscopic Surgery for Colorectal Liver Metastasis: Analysis of Short-term and Long-term Results

BACKGROUND

There is scant data regarding the outcomes of hand-assisted laparoscopic surgery (HALS) for colorectal liver metastasis (CRLM). The aim of this study is to report our experience and analyze the short-term and long-term results.

MATERIALS AND METHODS

Retrospective study of patients undergoing HALS for CRLM in 2 university affiliated medical centers.

RESULTS

Two hundred and thirty-eight liver procedures were performed on 145 patients including 205 parenchymal sparing resections and 33 anatomic resections. The median number of metastases was 1 (range: 1 to 8), 38 patients (26.2%) had 3 or more metastases, and 41 patients (28.3 had a bi-lobar disease. The tumor size was 20 (2 to 90) mm, and 52 patients (36.6%) had a tumor larger than 30 mm. Nighty-nine patients (67.8%) received neoadjuvant chemotherapy. In 8 patients (5.5%) the laparoscopic liver resection was combined with ablation, and 16 patients (11%) underwent a synchronous resection of colorectal cancer. The median operative time, blood loss during surgery, and postoperative hospital stay were 163 minutes, 300 mL, and 4 days, respectively. The median modified Iwate complexity score was 4 (0 to 10) and the conversion rate to open surgery was 5.5%. The overall and major complication rates were 23.8% and 3.6%, respectively. The mortality rate was 0.7%. R0 resections were achieved in 91% of patients. Median overall survival for all the cohort (intend to treat) was 59 months, and the 8- and 10-year overall survival rates were 47.3% and 24.9%, respectively.

CONCLUSIONS

This study shows that HALS is a safe and efficacious treatment for selected patients with CRLM.

Laparoscopic Liver Resection: A 7-Year Experience of 123 Resections in a Single Institution

There has been a significant increase in the use of laparoscopic liver resection (LLR) over the past 2 decades. This study aimed to analyze the outcomes associated with LLR at a single tertiary care hospital. Patients with benign or malignant tumors who underwent LLR by a single surgeon from January 2012 to November 2019 were identified. There were 123 patients who underwent LLR in the study period; 52% were men, and the median age was 61 (24-90) years. Five patients (4.1%) had unplanned conversion to open resection. Ninety-five patients (77.2%) had a wedge resection or single segmentectomy, and 28 (22.8%) underwent resection of 2+ liver segments. Seventy-one cases (57.7%) were for hepatocellular carcinoma (HCC), 24 (19.5%) for colorectal metastasis, and 28 (22.8%) were for other benign and malignant tumors. Median operative time was 239 (range 89-526) minutes. Mean estimated blood loss was 192 (range 0-1800) mL. The median length of stay (LOS) overall was 2 (range 0-9) days. From 2017 to 2019, the mean LOS was 1.2 days, compared to a mean LOS of 3.3 days from 2012 to 2016. More cases were performed as same-day surgery from 2017 onward; 19 patients (33.9%) had same-day surgery from 2017 to 2019, in comparison to only 1 patient (1.5%) in the period of 2012-2016 (P < .0001). Overall, 28 patients (22.8%) experienced postoperative morbidity; major postoperative morbidity occurred in 4 patients (3.3%). The 90-day mortality was .8%, and the 30-day readmission rate was 5.7%. In conclusion, LLR can be performed safely to treat liver tumors, and LOS decreased over time. Although overall morbidity is moderate, serious morbidity is low, as was the readmission rate. Laparoscopic wedge resection may be a feasible option as an outpatient procedure in select patients.

Laparoscopic liver resection for non-colorectal non-neuroendocrine metastases: perioperative and oncologic outcomes

BACKGROUND

Liver resection is a treatment of choice for colorectal and neuroendocrine liver metastases, and laparoscopy is an accepted approach for surgical treatment of these patients. The role of liver resection for patients with non-colorectal non-neuroendocrine liver metastases (NCNNLM), however, is still disputable. Outcomes of laparoscopic liver resection for this group of patients have not been analyzed.

MATERIAL AND METHODS

In this retrospective study, patients who underwent laparoscopic liver resection for NCNNLM at Oslo University Hospital between April 2000 and January 2018 were analyzed. Perioperative and oncologic data of these patients were examined. Postoperative morbidity was classified using the Accordion classification. Kaplan-Meier method was used for survival analysis. Median follow-up was 26 (IQR, 12-41) months.

RESULTS

Fifty-one patients were identified from a prospectively collected database. The histology of primary tumors was classified as adenocarcinoma (n = 16), sarcoma (n = 4), squamous cell carcinoma (n = 4), melanoma (n = 16), gastrointestinal stromal tumor (n = 9), and adrenocortical carcinoma (n = 2). The median operative time was 147 (IQR, 95-225) min, while the median blood loss was 200 (IQR, 50-500) ml. Nine (18%) patients experienced postoperative complications. There was no 90-day mortality in this study. Thirty-five (68%) patients developed disease recurrence or progression. Seven (14%) patients underwent repeat surgical procedure for recurrent liver metastases. One-, three-, and five-year overall survival rates were 85%, 52%, and 38%, respectively. The median overall survival was 37 (95%CI, 25 to 49) months.

CONCLUSION

Laparoscopic liver resection for NCNNLM results in good outcomes and should be considered in patients selected for surgical treatment.

Laparoscopic Hepatectomy Versus Open Hepatectomy for the Management of Hepatocellular Carcinoma: A Comparative Study Using a Propensity Score Matching

OBJECTIVES

The aim of this study was to compare the results between laparoscopic hepatectomy and open hepatectomy in two French university hospitals, for the management of hepatocellular carcinoma (HCC) using a propensity score matching.

MATERIALS AND METHODS

A patient in the laparoscopic surgery group (LA) was randomly matched with another patient in the open approach group (OA) using a 1:1 allocated ratio with the nearest estimated propensity score. Matching criteria included age, presence of comorbidities, American Society of Anesthesiologists score, and resection type (major or minor). Patients of the LA group without matches were excluded. Intraoperative and postoperative data were compared in both groups. Survival was compared in both groups using the following matching criteria: number and size of lesions, alpha-fetoprotein rate, and cell differentiation.

RESULTS

From January 2012 to January 2017, a total of 447 hepatectomies were consecutively performed, 99 hepatectomies of which were performed for the management of hepatocellular carcinomas. Forty-nine resections were performed among the open approach (OA) group (49%), and 50 resections were performed among the laparoscopic surgery (LA) group (51%). Mortality rate was 2% in the LA group and 4.1% in the OA group. After propensity score matching, there was a statistical difference favorable to the LA group regarding medical complications (54.55% versus 27.27%, p = 0.04), and operating times were shorter (p = 0.03). Resection rate R0 was similar between both groups: 90.91% (n = 30) in the LA group and 84.85% (n =) in the OA group. There was no difference regarding overall survival (p = 0.98) and recurrence-free survival (p = 0.42).

CONCLUSIONS

Laparoscopic liver resection for the management of HCC seems to provide the same short-term and long-term results as compared to the open approach. Laparoscopic liver resections could be considered as an alternative and become the gold standard in well-selected patients.

Laparoscopic Parenchyma-sparing Liver Resection for Colorectal Metastases

Background

Laparoscopic liver resection (LLR) of colorectal liver metastases (CLM) is increasingly performed in specialized centers. While there is a trend towards a parenchyma-sparing strategy in multimodal treatment for CLM, its role is yet unclear. In this study we present short- and long-term outcomes of laparoscopic parenchyma-sparing liver resection (LPSLR) at a single center.

Patients and methods

LLR were performed in 951 procedures between August 1998 and March 2017 at Oslo University Hospital, Oslo, Norway. Patients who primarily underwent LPSLR for CLM were included in the study. LPSLR was defined as non-anatomic hence the patients who underwent hemihepatectomy and sectionectomy were excluded. Perioperative and oncologic outcomes were analyzed. The Accordion classification was used to grade postoperative complications. The median follow-up was 40 months.

Results

296 patients underwent primary LPSLR for CLM. A single specimen was resected in 204 cases, multiple resections were performed in 92 cases. 5 laparoscopic operations were converted to open. The median operative time was 134 minutes, blood loss was 200 ml and hospital stay was 3 days. There was no 90-day mortality in this study. The postoperative complication rate was 14.5%. 189 patients developed disease recurrence. Recurrence in the liver occurred in 146 patients (49%), of whom 85 patients underwent repeated surgical treatment (liver resection [n = 69], ablation [n = 14] and liver transplantation [n = 2]). Five-year overall survival was 48%, median overall survival was 56 months.

Conclusions

LPSLR of CLM can be performed safely with the good surgical and oncological results. The technique facilitates repeated surgical treatment, which may improve survival for patients with CLM.

Laparoscopic liver resection for metastatic melanoma

BACKGROUND

Stage IV metastatic melanoma carries a poor prognosis. In the case of melanoma liver metastasis (MLM), surgical resection may improve survival and represents a therapeutic option, with varying levels of success. Laparoscopic liver resection (LLR) for metastatic melanoma is poorly studied. The aim of this study was to analyze the outcomes of LLR in patients with MLM.

MATERIALS AND METHODS

Between April 2000 and August 2013, 11 (1 cutaneous, 9 ocular and 1 unknown primary) patients underwent LLR for MLM at Oslo University Hospital-Rikshospitalet and 13 procedures in total were carried out. Perioperative and oncologic outcomes were analyzed. Postoperative morbidity was classified using the Accordion classification. Kaplan-Meier method was used for survival analysis.

RESULTS

A total of 23 liver specimens were resected. The median operative time was 137 (65-470) min, while the median blood loss was less than 50 (<50-900) ml. No intraoperative unfavorable incidents and 30-day mortality occurred. Median follow-up was 33 (9-92) months. Ten patients (91%) developed recurrence within a median of 5 months (2-18 months) and two patients underwent repeat LLR for recurrent liver metastases. One-, three-, and five-year overall survival rates were 82, 45 and 9%, respectively. The median overall survival was 30 (9-92) months.

CONCLUSION

Perioperative morbidity and long-term survival after LLR for MLM seems to be comparable to open liver resection. Thus, LLR may be preferred over open liver resection due to the well-known advantages of laparoscopy, such as reduced pain and improved possibility for repeated resections.

The ALPPS in the Treatment of Hepatitis B-Related Hepatocellular Carcinoma With Cirrhosis: A Single-Center Study and Literature Review

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) has been reported to be a new treatment strategy for patients with predicted small volumes of future liver remnant (FLR). ALPPS is associated with rapid hypertrophy of FLR but it has a high postoperative mortality and morbidity. Up to now, it is controversial to apply ALPPS in hepatocellular carcinoma, especially for patients with liver cirrhosis.

METHODS

Between May 2014 and June 2015, consecutive patients who underwent ALPPS with hepatitis B-related hepatocellular carcinoma with cirrhosis carried out in our center were included into the study. Demographic characteristics, surgical outcomes, and pathological results were evaluated. Subsequently, follow-up was still in progress.

RESULTS

The median operating time of the first (n = 12) and the second procedures (n = 10) were 285.0 and 212.5 minutes, respectively. The median blood loss were 200 and 800 mL for 2 stages of operations. The severe complication (≥IIIB) rates for the first and the second operations were 25.0% versus 40.0%, respectively. Six patients with too small future live remnant died of postoperative hepatic failure. On a median follow-up of 16 months of the 6 patients discharged, 4 patients were still alive and of 2 were disease-free.

CONCLUSION

In terms of the feasibility and safety, this study showed that ALPPS in the treatment of hepatocellular carcinoma with insufficient future liver remnant might be a double-edged sword, and careful patients selected was proposed. Too small of FLR/SLV, less than 30%, is not recommended for ALPPS in liver with cirrhosis.

Is Laparoscopic Hepatectomy a Safe, Feasible Procedure in Patients with a Previous Upper Abdominal Surgery?

Background:

Laparoscopic liver resection has become an accepted treatment for liver tumors or intrahepatic bile duct stones, but its application in patients with previous upper abdominal surgery is controversial. The aim of this study was to evaluate the feasibility and safety of laparoscopic hepatectomy in these patients.

Methods:

Three hundred and thirty-six patients who underwent laparoscopic hepatectomy at our hospital from March 2012 to June 2015 were enrolled in the retrospective study. They were divided into two groups: Those with previous upper abdominal surgery (PS group, n = 42) and a control group with no previous upper abdominal surgery (NS group, n = 294). Short-term outcomes including operating time, blood loss, hospital stay, morbidity, and mortality were compared among the groups.

Results:

There was no significant difference in median operative duration between the PS group and the NS group (180 min vs. 160 min, P = 0.869). Median intraoperative blood loss was same between the PS group and the control group (200 ml vs. 200 ml, P = 0.907). The overall complication rate was significantly lower in the NS group than in the PS group (17.0% vs. 31.0%, P = 0.030). Mortality and other short-term outcomes did not differ significantly between groups.

Conclusions:

Our study showed no significant difference between the PS group and NS group in term of short-term outcomes. Laparoscopic hepatectomy is a feasible and safe procedure for patients with previous upper abdominal surgery.

Laparoscopic hepatectomy versus open hepatectomy for colorectal cancer liver metastases: comparative study with propensity score matching

BACKGROUND

The objective of this study was to compare the results of laparoscopic hepatectomy with those of open hepatectomy for colorectal cancer liver metastases (CCLM) using a propensity score matching (PSM) in two university hospital settings.

METHODS

A patient in the laparoscopic approach (LA) surgery group was randomly matched with another patient in the open approach (OA) group using a 1:1 allocated ratio with the nearest estimated propensity score. No patients of the LA group were excluded for the matching. Matching criteria included age, gender, body mass index (BMI), American society anesthesiologists score, potential co-morbidities, hepatopathies, synchronous or metachronous lesions, size and number of CCLM, preoperative chemotherapy, minor or major liver resections. Intraoperative, postoperative data, and survival were compared in both groups.

RESULTS

From January 2012 to January 2015, a total of 242 hepatectomies were consecutively performed, of which 119 for CCLM, namely 101 in the OA group (84.9%) and 18 in the LA group (15.1%). The conversion rate was 5.6% (n=1). The mortality rate was 1% in the OA group and 0% in the LA group. Prior to PSM, there was a statistically significant difference favorable to the LA group regarding operative time, blood loss, length of hospital stay and the rate of medical complications. After PSM, there was no difference regarding operative time or length of hospital stay. However, there was a trend towards less blood loss (P=0.066) and fewer medical complications (44.4% vs.16.7%, P=0.07). The R0 resection rate was 94.4% (n=17) in the two groups. In addition, there was no difference regarding overall survival (P=0.358) and recurrence-free survival [HR =0.99 (0.1-12.7); P=0.99].

CONCLUSIONS

Laparoscopic liver resections for CCLM seem to yield short- and long-term results, which are similar to open hepatectomies, and could well be considered an alternative to open surgery and become the gold standard in carefully selected patients.

Colorectal cancer liver metastases: laparoscopic and open radiofrequency-assisted surgery

INTRODUCTION

The liver is the most common site of colorectal metastases (colorectal liver metastases - CLM). Surgical treatment in combination with oncological therapy is the only potentially curative method. Unfortunately, only 10-25% of patients are suitable for surgery. Traditionally, open liver resection (OLR) is usually performed. However, laparoscopic liver resection (LLR) has become popular worldwide in the last two decades.

AIM

To evaluate the effectiveness and benefits of radiofrequency minor LLR of CLM in comparison with OLR.

MATERIAL AND METHODS

The indication for surgery was CLM and the possibility to perform minor laparoscopic or OLR not exceeding two hepatic segments according to Couinaud's classification.

RESULTS

Sixty-six minor liver resections for CLM were performed. Twenty-five (37.9%) patients underwent a laparoscopic approach and 41 (62.1%) patients underwent OLR. The mean operative time was 166.4 min for LLR and 166.8 min for OLR. Average blood loss was 132.3 ±218.0 ml during LLR and 149.5 ±277.5 ml during OLR. Length of hospital stay was 8.4 ±2.0 days for LLR and 10.5 ±5.8 days for OLR. All resections were R0. There was no case of mortality. Postoperative complications were recognized in 9 (13.6%) patients: 8 in the group of OLR patients and 1 in the LLR group. The median survival time for LLR was 70.5 months and for OLR 61.9 months. The 5-year overall survival rate was higher for LLR vs. OLR - 82.1% vs. 69.8%. The average length of disease-free interval after LLR was greater (52.2 months) in comparison with OLR (49.4%). The 5-year disease-free interval was 63.2% for LLR and 58% for OLR.

CONCLUSIONS

Outcomes and oncological radicality of minor laparoscopic liver resections of CLM are comparable to outcomes of OLR.

The role of adult living donor liver transplantation and recent advances

Twenty years since the first cases were described, adult living donor liver transplantation (ALDLT) is now considered a valid option to expand the donor pool in view of the ongoing shortage of organs and the high waiting list mortality rate. Despite the rapid evolution and acceptance of this complex process of donation and transplantation in clinical practice, the indications, outcome, ethical considerations and quality and safety aspects continue to evolve based on new data from large cohort studies. This article reviews the surgical and clinical advances in the field of liver transplantation, focusing on technical refinements and discussing the issues that may lead to a further expansion of this complex surgical procedure and the role of ALDLT.

Outcomes of repeat laparoscopic liver resection compared to the primary resection

BACKGROUND

Repeat laparoscopic liver resection (R-LLR) can be technically challenging. Data on this topic are scarce and many investigators would question its feasibility and outcomes. The aim of the present study was to evaluate the safety, feasibility, oncological efficiency and outcomes of R-LLR.

METHODS

We reviewed a prospectively collected database of 403 patients undergoing 422 laparoscopic liver resections (LLRs) from August 2003 to August 2013. Data of 19 patients undergoing R-LLR were analyzed and compared to the primary resection (P-LLR) in these patients. Demographic and clinical data were studied. A subgroup analysis was done for minor resections.

RESULTS

Twenty R-LLRs were performed in 19 patients (female 58 %; mean age: 57.5 years; age range: 23-79 years). Colorectal liver metastases (CRLM) were the commonest indication for R-LLR (60 %), followed by neuroendocrine tumor liver metastases (NETLM) (20 %) and hepatocellular carcinoma (HCC) (10 %). The majority (90 %) of resections were for malignant disease (18/20). There were three conversions (15 %), and two patients developed complications (10 %). The operative time (p = 0.005) and blood loss (p = 0.03) were both significantly greater in R-LLR compared to P-LLR, whereas length of stay (median 4 days; p = 0.30) and complications (p = 0.58) did not differ between the groups. R0 resection rates for P-LLR and R-LLR were 95 and 90 %, respectively (p = 0.73).

CONCLUSIONS

Repeat LLR is safe, feasible, and can be performed with minimal morbidity. It appears to be technically more challenging than P-LLR, but without any increase in complications or length of hospital stay.

Laparoscopic liver resection for malignancy: A review of the literature

AIM: To review the published literature about laparoscopic liver resection for malignancy.

METHODS: A PubMed search was performed for original published studies until June 2013 and original series containing at least 30 patients were reviewed.

RESULTS: All forms of hepatic resections have been described ranging from simple wedge resections to extended right or left hepatectomies. The usual approach is pure laparoscopic, but hand-assisted, as well as robotic approaches have been described. Most studies showed comparable results to open resection in terms of operative blood loss, postoperative morbidity and mortality. Many of them showed decreased postoperative pain, shorter hospital stays, and even lower costs. Oncological results including resection margin status and long-term survival were not inferior to open resection.

CONCLUSION: In the hands of experienced surgeons, laparoscopic liver resection for malignant lesions is safe and offers some short-term advantages over open resection. Oncologically, similar survival rates have been observed in patients treated with the laparoscopic approach when compared to their open resection counterparts.

Laparoscopic liver resection: Wedge resections to living donor hepatectomy, are we heading in the right direction?

Despite inception over 15 years ago and over 3000 completed procedures, laparoscopic liver resection has remained mainly in the domain of selected centers and enthusiasts. Requirement of extensive open liver resection (OLR) experience, in-depth understanding of anatomy and considerable laparoscopic technical expertise may have delayed wide application. However healthy scepticism of its actual benefits and presence of a potential publication bias; concern about its safety and technical learning curve, are probably equally responsible. Given that a large proportion of our work, at least in transplantation is still OLR, we have attempted to provide an entirely unbiased, mature opinion of its pros and cons in the current invited review. We have divided this review into two sections as we believe they merit separate attention on technical and ethical grounds. The first part deals with laparoscopic liver resection (LLR) in patients who present with benign or malignant liver pathology, wherein we have discussed its overall outcomes; its feasibility based on type of pathology and type of resection and included a small section on application of LLR in special scenarios like cirrhosis. The second part deals with the laparoscopic living donor hepatectomy (LDH) experience to date, including its potential impact on transplantation in general. Donor safety, graft outcomes after LDH and criterion to select ideal donors for LLR are discussed. Within each section we have provided practical points to improve safety in LLR and attempted to reach reasonable recommendations on the utilization of LLR for units that wish to develop such a service.

Margin status after laparoscopic resection of colorectal liver metastases: does a narrow resection margin have an influence on survival and local recurrence?

OBJECTIVES

Recent studies of margin-related recurrence have raised questions on the necessity of ensuring wide resection margins in the resection of colorectal liver metastases. The aim of the current study was to determine whether resection margins of 10 mm provide a survival benefit over narrower resection margins.

METHODS

A total of 425 laparoscopic liver resections were carried out in 351 procedures performed in 317 patients between August 1998 and April 2012. Primary laparoscopic liver resections for colorectal metastases were included in the study. Two-stage resections, procedures accompanied by concomitant liver ablations and one case of perioperative mortality were excluded. A total of 155 eligible patients were classified into four groups according to resection margin width: Group 1, margins of < 1 mm [n = 33, including 17 patients with positive margins (Group 1a)]; Group 2, margins of 1 mm to < 3 mm (n = 31); Group 3, margins of ≥ 3 mm to <10 mm (n = 55), and Group 4, margins of ≥ 10 mm (n = 36). Perioperative and survival data were compared across the groups. Median follow-up was 31 months (range: 2-136 months).

RESULTS

Perioperative outcomes were similar in all groups. Unfavourable intraoperative incidents occurred in 9.7% of procedures (including 3.2% of conversions). Postoperative complications developed in 11.0% of patients. Recurrence in the resection bed developed in three (1.9%) patients, including two (6.1%) patients in Group 1. Rates of actuarial 5-year overall, disease-free and recurrence-free survival were 49%, 41% and 33%, respectively. Median survival was 65 months. Margin status had no significant impact on patient survival. The Basingstoke Predictive Index (BPI) generally underestimated survival. This underestimation was especially marked in Group 1 when postoperative BPI was applied.

CONCLUSIONS

Patients with margins of <1 mm achieved survival comparable with that in patients with margins of ≥ 10 mm. When modern surgical equipment that generates an additional coagulation zone is applied, the association between resection margin and survival may not be apparent. Further studies in this field are required. Postoperative BPI, which includes margin status among the core factors predicting postoperative survival, seems to be less precise than preoperative BPI.

Colorectal hepatic metastasis: Evolving therapies

The approach for colorectal hepatic metastasis has advanced tremendously over the past decade. Multidrug chemotherapy regimens have been successfully introduced with improved outcomes. Concurrently, adjunct multimodal therapies have improved survival rates, and increased the number of patients eligible for curative liver resection. Herein, we described major advancements of surgical and oncologic management of such lesions, thereby discussing modern chemotherapeutic regimens, adjunct therapies and surgical aspects of liver resection.

Laparoscopic liver resections in normal and cirrhotic livers: a retrospective analysis in a tertiary hepato-biliary unit

BACKGROUND

Liver surgery in patients with underlying liver disease results in higher mortality and morbidity rates compared to patients without underlying liver disease. Laparoscopy seems to have good results in patients with normal liver in terms of postoperative outcomes, but is more challenging in cirrhotic patients. Aim of this study was to evaluate the feasibility of laparoscopic liver resection both in normal and cirrhotic livers, and secondary endpoint was to compare the surgical results.

METHODS

We retrospectively evaluated 105 patients who underwent laparoscopic liver resection between November 2001 and January 2012. Candidates for laparoscopic liver resection were divided into two groups according to the presence or absence of an underlying liver disease.

RESULTS

105 patients (52.4% males, median age 56.1 years) were enrolled, and 37.1% had liver cirrhosis. Hepatocellular carcinoma in hepatitis C virus-related cirrhosis (89.7%) and liver metastases (57.6%) were the main indications for surgery in patients with cirrhosis and non-cirrhotic livers, respectively. None of the patients died post-operatively. Cirrhotic patients had greater blood loss (100 vs 50 ml; p<0.012) and longer hospital stays (6 vs 4 days; p<0.031) compared to non-cirrhotics.

CONCLUSIONS

Laparoscopic liver resections are safe and feasible procedures in both patients with cirrhotic and non-cirrhotic livers.

Laparoscopic hepatectomy for hepatic colorectal metastases -- a retrospective comparative cohort analysis and literature review

Background

Laparoscopic hepatectomy (LH) for management of hepatic colorectal metastases (HCRM) is commonly being performed; however, there are limited reports comparing LH outcomes with those of open hepatectomy (OH) procedure. The aim of the present study was to compare perioperative outcomes between the LH and OH procedures performed at a single medical center.

Methods

From Jan 2008 to May 2012, 30 patients with pathologically confirmed HCRM underwent LH, and 140 patients underwent OH at our hospital. Patients' demographics, perioperative outcomes were retrospectively analyzed.

Results

2 patients (6.7%) in the LH group underwent laparotomies for intraoperative hemorrhage. The LH group had an increased surgical duration (235 min vs. 365 min, (P<0.001), shorter hospital stay (7.5 days vs. 11.5 days, P<0.001), and fewer complications (26.2% vs. 55%, P<0.001) than the OH group. However, in a matched cohort comparison of 30 LH cases and 30 OH cases, no significant variations were observed in the following parameters: surgical duration (235 min vs. 255 min, P = 0.23), positive margin rates (6.7% vs. 0.0%, P = 0.27), or postoperative hematological changes. LH patients had less estimated blood loss (215 ml vs. 385 ml, P<0.001), less morbidity (26.2% vs. 50%, P = 0.02), shorter hospital stay (7.5 days vs. 11.5 days, P<0.001), and lower analgesic requests than with those in the OH group.

Conclusions

LH for metastatic colorectal cancer is a safe and feasible treatment, even in patients who underwent prior laparotomy surgeries and provides significantly less morbidity and shorter hospital stay than OH, without compromising curability or increasing morbidity.

Laparoscopic resection of hepatocellular carcinoma

The current treatment of HCC is truly multidisciplinary. Notwithstanding, surgical management remains the gold standard which other therapies are compared to. Operative management is divided into transplantation and resection; the latter is further subdivided among open and laparoscopic approaches. Resection has become safer, remains superior to locoregional treatments, and can be a life-prolonging bridge to transplantation. The decision to pursue laparoscopic resection for HCC is driven by safety and a view toward the long-term management of both the malignancy and the underlying liver disease. For patients with a solitary HCC <5 cm in segments 2, 3, 4b, 5, and 6, no evidence of extrahepatic tumor burden, compensated liver disease, and the absence of significant portal hypertension, laparoscopy has an important role. Under these circumstances, resection can be performed with reduced mortality and morbidity and equivalent oncologic outcomes, disease-free survival, and overall survival when compared with similarly selected cirrhotic patients undergoing open resection. Blood loss and transfusion requirements are low, and laparoscopy itself does not expose the patient to complications and does not increase the risk of cancer recurrence or dissemination. Finally, because HCC recurrence remains high in the cirrhotic liver, treatment following surgical resection mandates routine surveillance and treatment by locoregional therapy, reresection, or transplantation as required-the latter two of which are facilitated by an initial laparoscopic resection.

Lessons learned from the first 100 laparoscopic liver resections: not delaying conversion may allow reduced blood loss and operative time

BACKGROUND

The laparoscopic approach to liver resective surgery is slowly spreading to specialized centers. Little is known about factors influencing the immediate postoperative outcome.

STUDY DESIGN

The purpose of the study was to evaluate the immediate outcome of laparoscopic liver resection (LLR), with particular emphasis on intraoperative bleeding and conversion. A retrospective analysis of demographic, clinical, and surgical data, including conversion, morbidity/mortality, and hospital stay, of the first 100 patients at our institution undergoing LLR from February 1997 through March 2007 was performed.

RESULTS

Indication for LLR was benign lesion in 28 patients, malignancy in 33, and living donation in 39. Seventy-five resections involved two or more segments. Mean blood loss was 120 ± 127.6 mL. One patient (1%) required transfusion. Mean operative time was 253 ± 91.6 minutes. No patient died. Postoperative complications occurred in 21 patients. The conversion rate was 17%. Variables related to conversion were American Society of Anesthesiologists Class II, body mass index, cirrhosis, necessity for the Pringle maneuver, and intraoperative blood loss. Conversion did not influence the operative time. Patients with conversion had more complications and a longer hospital stay.

CONCLUSIONS

Liver resection by laparoscopy is feasible and safe, implying low intraoperative blood loss. Not perfect physical conditions, cirrhosis, high body mass index, and, intraoperatively, blood loss and the necessity of a Pringle maneuver should be considered risk factors for conversion. A meticulous dissection by bipolar coagulation, Harmonic(®) (Ethicon) scalpel, and ultrasound dissector, other than the attitude not to delay conversion in difficult cases, may allow for low blood loss without prolongation of operative time, with a possible, slight increase of the conversion rate.

Has laparoscopy increased surgical indications for benign tumors of the liver?

BACKGROUND

We aimed to analyze the risk of an increased surgical indication rate in patients with benign tumors of the liver since the development of laparoscopy. Previous articles have reported increased numbers of laparoscopic procedures in different surgical fields.

METHODS

A literature search of MEDLINE (PubMed), Google Scholar, and The Cochrane Library was carried out. All articles that analyzed benign liver tumors (hemangiomas, focal nodular hyperplasia, and adenoma) were divided in two groups: group I included all manuscripts with open procedures between 1971 at 1990, and group II included all manuscripts with open or laparoscopic procedures between 1991 and 2010. Group II articles were divided into two subgroups. Subgroup IIA patients were treated by open or laparoscopic procedures between 1991 and 2000, and subgroup IIB patients were treated by open or laparoscopic procedures between 2001 and 2010.

RESULTS

Specific analysis of each kind of tumor observed in the two groups showed fewer surgically treated patients for hepatic hemangioma and hepatic adenoma in group II compared with group I and a greater number of patients for focal nodular hyperplasia. Fewer patients were treated with laparoscopic procedures in subgroup IIA than in subgroup IIB. A chi-square test with Yates' correction gave a P value of <0.001.

CONCLUSION

Laparoscopy has increased the rate of hepatic resection for benign tumors with doubtful indications.

Laparoscopy in Liver Transplantation: The Future has Arrived

In the last two decades, laparoscopy has revolutionized the field of surgery. Many procedures previously performed with an open access are now routinely carried out with the laparoscopic approach. Several advantages are associated with laparoscopic surgery compared to open procedures: reduced pain due to smaller incisions and hemorrhaging, shorter hospital length of stay, and a lower incidence of wound infections. Liver transplantation (LT) brought a radical change in life expectancy of patients with hepatic end-stage disease. Today, LT represents the standard of care for more than fifty hepatic pathologies, with excellent results in terms of survival. Surely, with laparoscopy and LT being one of the most continuously evolving challenges in medicine, their recent combination has represented an astonishing scientific progress. The intent of the present paper is to underline the current role of diagnostic and therapeutic laparoscopy in patients waiting for LT, in the living donor LT and in LT recipients.

Surgical management of colorectal liver metastases

Colorectal cancer is the third most commonly diagnosed cancer with approximately half of the patients developing liver metastases during the course of their disease. Modern multimodal therapies have improved the overall survival. Liver resection remains the most important modality in the treatment of colorectal liver metastases. The evolution of the criteria for resectability has resulted in more patients being offered a hepatectomy. This is further augmented with the utilization of adjuncts to liver resection, including portal vein embolization and local ablative techniques. Two-stage hepatectomy is also being used to increase resectability. Overall survival is improved by the deployment of new chemotherapeutic agents and the use of combination chemotherapy. Neoadjuvant chemotherapy is a promising development in the treatment of colorectal liver metastases. Patients with colorectal liver metastases can achieve long-term survival. A multidisciplinary approach is essential in the management of these patients.

Surgical management of colorectal liver metastases

Colorectal cancer is the third most commonly diagnosed cancer with approximately half of the patients developing liver metastases during the course of their disease. Modern multimodal therapies have improved the overall survival. Liver resection remains the most important modality in the treatment of colorectal liver metastases. The evolution of the criteria for resectability has resulted in more patients being offered a hepatectomy. This is further augmented with the utilization of adjuncts to liver resection, including portal vein embolization and local ablative techniques. Two-stage hepatectomy is also being used to increase resectability. Overall survival is improved by the deployment of new chemotherapeutic agents and the use of combination chemotherapy. Neoadjuvant chemotherapy is a promising development in the treatment of colorectal liver metastases. Patients with colorectal liver metastases can achieve long-term survival. A multidisciplinary approach is essential in the management of these patients.

Comparative evaluation of laparoscopic liver resection for posterosuperior and anterolateral segments

Background

Totally laparoscopic liver resection of lesions located in the posterosuperior segments is reported to be technically challenging. This study aimed to define whether these technical difficulties affect the surgical outcome.

Methods

A total of 220 patients underwent laparoscopic liver resection during 244 procedures from August 1998 to December 2010. The patients who underwent primary minor single liver resection for malignant tumors affecting either posterosuperior segments 1, 7, 8, and, 4a (group 1) or anterolateral segments 2, 3, 5, 6, and 4b (group 2) were included in the study. Seventy-five procedures found to be eligible for the study, including 28 patients in group 1 and 47 patients in group 2. Intraoperative unfavorable incidents were graded on the basis of the Satava approach and postoperative complications were graded in agreement with the Accordion classification.

Results

The operative time (median, 127 min) and blood loss (median, 200 ml) were equivalent in the two groups. The rates for blood transfusions and intraoperative accidents did not differ statistically between the groups. A tumor-free margin resection was achieved in 94.7% of the procedures, equivalently in both groups. The postoperative course was similar in the two groups. Postoperative complications developed in 2 cases (7.1%) in group 1 and 2 cases (4.3%) in group 2 (p = 0.626). The median hospital stay was 2 days in both groups.

Conclusions

Laparoscopic liver resection for lesions located in posterosuperior segments represents certain technical challenges. However, appropriate adjustment of surgical techniques and optimal patient positioning enables the laparoscopic technique to provide safe and effective parenchyma-sparing resections for lesions located in both posterosuperior and anterolateral segments.

[Current state of laparoscopic hepatic surgery: results of a survey of DGAV-members]

BACKGROUND

To date laparoscopic hepatic surgery is only common in a few centres for a specific selected patient group. The intention of this survey was to estimate the current state of affairs for laparoscopic hepatic surgery in Germany at 2008.

MATERIALS AND METHODS

A questionnaire was prepared and sent out by e-mail in May 2009 to the members of the DGAV (German Society of General and Visceral Surgery). The feedback was evaluated anonymously.

RESULTS

A total of 181 answers were received by 31st July 2009 (return rate of 15.9%). The return rate of basic and standard care hospitals was 9.2%, specialized hospitals 23.6%, hospitals with maximum care 50% and university hospitals had a return rate of 71.9%. The question whether laparoscopic hepatic surgery had been performed in 2008 was answered with YES by 125 (69.1%) and NO by 54 (29.8%) members. The number of laparoscopic hepatic surgery interventions (laparoscopic ultrasound, laparoscopic radiofrequency ablation and resection) in 2008 was given as more than 50 by 4 (2.2%) hospitals, between 20 and 50 by 11 (6.1%) hospitals, between 10 and 20 by 23 (12.7%) hospitals, between 5 and 10 by 45 (24.9%) hospitals and between 0 and 5 by 54 (29.8%) hospitals. In 2008 the frequency of laparoscopic ultrasound during intraoperative staging to confirm the diagnosis ranged from 2 to 250, whereby 96.4% of the hospitals had less than 50 and only 2 hospitals (2.7%) had 211 and 250 examinations, respectively. 50 hospitals carried out laparoscopic radiofrequency ablation (RFA). 69 (38.1%) of the interviewed hospitals reported hepatic laparoscopic resections (n=551).

CONCLUSION

Laparoscopic liver surgery has been done in Germany in patients with benign or malignant liver lesions. Pure laparoscopy is the most common access. Atypical resections are the primarily indication followed by left lateral resections. All further types of resection have been done in a very small number. Laparoscopic liver surgery has been performed in all types of hospitals.

High intra-abdominal pressure during experimental laparoscopic liver resection reduces bleeding but increases the risk of gas embolism

BACKGROUND

Various recommendations exist regarding intra-abdominal pressure (IAP) during laparoscopic liver resection. A high IAP may reduce bleeding but at the same time increase the risk of gas embolism. This study investigated the effects of two different IAPs during laparoscopic left liver lobe resection in piglets.

METHODS

Sixteen piglets underwent laparoscopic left liver lobe resection using carbon dioxide pneumoperitoneum of either 8 or 16 mmHg (8 per group). A combination of CUSA System 200™ and LigaSure™ instruments was used for parenchymal division. During resection, a standard injury to the left liver vein was also created to increase the risk of bleeding and/or gas embolism during the operation. Heart rate, cardiac output, and arterial, pulmonary arterial, pulmonary capillary wedge and central venous pressures were measured. Arterial blood gases were monitored continuously. Transoesophageal echocardiography was video recorded to detect and quantify gas embolism within the right cardiac ventricle. The duration of operation and bleeding were noted.

RESULTS

High IAP resulted in reduced bleeding (P = 0·016), but gas embolism occurred more frequently (P = 0·001) than with low IAP. Gas embolism disturbed gas exchange, with an increase in arterial pressure of carbon dioxide, and a decrease in arterial partial pressure of oxygen and pH. These effects were sustained for at least 30 min after surgery.

CONCLUSION

High IAP reduces the amount of bleeding but increases the risk of gas embolism. Monitoring for gas embolism is therefore indicated if a high IAP is used during laparoscopic liver resection.

Is laparoscopic repeat hepatectomy feasible? A tri-institutional analysis

BACKGROUND

A laparoscopic approach has not been advocated for repeat hepatectomy on a large scale. This report analyzes the experience of 3 institutions pioneering laparoscopic repeat liver resection (LRLR). The aim of this study was to evaluate the feasibility, safety, oncologic integrity, and outcomes of LRLR.

STUDY DESIGN

All patients undergoing LRLR were identified. Since 1997, 76 LRLRs have been attempted. Operative indications were metastasis (n = 63), hepatocellular carcinoma (n = 3), and benign tumors (n = 10). All patients had 1 or more earlier liver resections (28 open, 44 laparoscopic), including 16 major resections (en bloc removal of 3 or more Couinaud segments).

RESULTS

Eight conversions (11%) to open resections (n = 7) or radiofrequency ablation (n = 1) were required due to technical difficulties or hemorrhage. LRLRs included 49 wedge or segmental resections and 19 major hepatectomies. Median blood loss and operative time were 300 mL and 180 minutes. Patients with previous open liver resection (group B) experienced more intraoperative blood loss and transfusion requirements than those with earlier laparoscopic resections (group A) (p = 0.02; p = 0.01, respectively). R0 resection was achieved in 58 of 64 (91%) patients with malignant tumor. The incidence of postoperative complications and duration of hospital stay were not statistically different between the 2 groups. Bile leakages developed in 5 (6.6%) patients, including 1 requiring reoperation. There was no perioperative death. Median tumor size was 25 mm (range 5 to 125 mm) and the median number of tumors was 2 (range 1 to 7). Median follow-up was 23.5 months (range 0 to 86 months). There was no port-site metastasis. The 3- and 5-year actuarial survivals for patients with colorectal metastases were 83% and 55%, respectively.

CONCLUSIONS

Laparoscopic repeat hepatic resections can be performed safely and with good results, particularly in patients with earlier laparoscopic resections.

A comparative study of the long-term outcomes after laparoscopy-assisted and open left lateral hepatectomy for hepatocellular carcinoma

BACKGROUND

Laparoscopic hepatectomy was initially reported in 1992. However, the reported experiences are scarce, and this operation has not been a standard procedure until now. The aims of this study were to assess our results of laparoscopy-assisted left lateral hepatectomy for hepatocellular carcinoma (HCC) and to compare them with those of open conventional procedures.

METHODS

From 1984 to 2002, left lateral hepatectomy for HCC less than 5 cm in diameter was carried out in 21 patients. Ten patients received a laparoscopy-assisted procedure, and remaining 11 patients received an open procedure.

RESULTS

There were no significant differences in the operation time, blood loss, resected liver weight, and resection margin between the 2 groups. The total time that analgesics were given, body temperature on postoperative day 1, weight loss on postoperative day 7, and postoperative hospital stay in the laparoscopic group were significantly better than in the conventional group. With regard to the long-term prognosis, there were no differences in patient survival or disease-free survival rates between the 2 groups.

CONCLUSIONS

Laparoscopy-assisted left lateral hepatectomy for HCC is superior to the conventional open surgery in terms of its short-term results and does not cause the long-term survival to deteriorate. Therefore, laparoscopic hepatectomy may be an alternative choice for treatment of HCC.

Laparoscopic resection for liver tumors: initial experience in a single center

BACKGROUND

Laparoscopic liver resections are 1 of the most complex procedures in hepatobiliary surgery. During the last 20 years, laparoscopic liver surgery has had an important development in specialized centers.

OBJECTIVE

To describe the initial experience in laparoscopic liver resection for benign and malignant tumors, to assess its indications and outcomes, and to describe technical aspects of these resections.

METHODS

Review of the records of 28 patients who underwent laparoscopic liver resection between November 2000 and November 2007. Analysis of the data regarding preoperative management and postoperative outcomes.

RESULTS

Twenty-six liver resections were performed laparoscopically (20 purely laparoscopic, 3 hand assisted, and 3 hybrid technique) and 2 were converted to open surgery. The laparoscopic approach was attempted in 6% (28 out of 459) of the liver resections carried out in the analyzed period. Indications for resection were: benign tumors in 22 patients (78%) and malignant tumors in 6 patients (22%). Resections were minor in 27 patients (96%) and major in 1 patient (4%). Pringle maneuver was performed in 14 patients (50%). Margins were negative in all the cases. Mean operative time was 170 minutes (range 70 to 350), and the mean length of stay was 3 days (range 1 to 6). Mortality rate was 0%. Only 2 patients (7%) had postoperative minor complications (self-limited bile leaks).

CONCLUSIONS

In selected patients with benign and malignant liver tumors, laparoscopic liver resections can be safely performed. This procedure must be carried out by the surgeons trained in both the hepatobiliary and laparoscopic surgery.

Laparoscopic resection of colorectal liver metastases: surgical and long-term oncologic outcome

OBJECTIVE

To analyze the immediate and long-term outcome after laparoscopic resection of colorectal liver metastases and difference between observed and predicted [Fong's and Basingstoke Predictive Index (BPI) scores] survivals.

BACKGROUND

: Laparoscopic liver resection has been reported safe and feasible and improves postoperative course. The oncologic outcomes after resection of colorectal metastases are poorly reported.

METHODS

Between August 1998 and January 2010, 122 patients underwent laparoscopic resection for colorectal liver metastases during 135 procedures at Rikshospitalet. Patients undergoing surgery between August 1998 and June 2009 were included in research analysis. The patients had median Fong's and BPI's scores of 2 (0-5) and 7 (0-23), respectively. Mainstream analysis of hospital data was done on intent-to-treat basis. Intraoperative incidents and postoperative complications were analyzed according to the Satava and Clavien-Dindo classifications. Median follow-up was 24 (0-100) months.

RESULTS

One hundred fifty-one liver resections were performed in 107 patients during 118 procedures: 117 nonanatomic and 34 anatomic liver resections. There were 5 conversions to laparotomy (4.2%). The resection margin was free of tumor tissue in 141 (93.4%) of 151 specimens, and the distance between the resection margin and tumor tissue was median 6 (0-40) mm. Intraoperative incidents occurred in 14 cases (11.9%), including 5 (4.2%), 8 (6.8%), and 1 (0.8%) cases of grades I, II, and III, respectively. Postoperative complications were observed in 16 cases (14.3%), including 2, 3, 7, 3, 0, and 1 cases of grades I, II, IIIa, IIIb, IV, and V, respectively. During follow-up, 21 patients received repeat liver resection of recurrences (11 by laparoscopy and 10 by laparotomy). The 5-year overall survival rates were 51% as laparoscopically completed cases and 47% as intent-to-treat. The observed actuarial survival values exceeded the values expected by Fong's and BPI's score, with 10.2% and 6.7% as laparoscopically completed cases and with 3.8% and 2.4% as intent-to-treat, respectively.

CONCLUSIONS

Laparoscopic resection is a favorable alternative to open liver resection for patients with colorectal liver metastases. The observed actuarial survival values after laparoscopic resection surpass the values expected by major scoring systems.

Resection margin in laparoscopic hepatectomy: a comparative study between wedge resection and anatomic left lateral sectionectomy

BACKGROUND

Experience from open hepatectomy shows that anatomic liver resection achieves a better resection margin than wedge resection. In recent years, laparoscopic hepatectomy has increasingly been performed in patients with liver pathology including malignant lesions. Wedge resection (WR) and left lateral sectionectomy (LLS), which also represent non-anatomic and anatomic resection respectively, are the two most common types of laparoscopic hepatectomy performed. The aim of the present study was to compare the two types of laparoscopic hepatectomy with emphasis on resection margin.

METHODS

Between November 2003 and July 2009, 44 consecutive patients who underwent laparoscopic hepatectomy were identified and retrospectively reviewed. The WR and LLS group of patients were compared in terms of operative outcomes, pathological findings, recurrence patterns and survival.

RESULTS

Out of the 44 patients, 21 underwent LLS and 23 a WR. The two groups of patients were comparable in demographics. The two groups did not differ in conversion rate, blood loss, blood transfusion, mortality, morbidity and post-operative length of stay. The LLS group patients had significantly larger liver lesions, wider resection margin and less sub-centimetre margins. In patients with malignant liver lesions, there was no difference between the two groups in incidence of intra-hepatic recurrence and 3-year overall and disease-free survival.

CONCLUSION

Operative outcomes are similar between laparoscopic WR and LLS. However, WR is less reliable than LLS in achieving a resection margin of more than 1 cm. Larger studies involving more patients with longer follow-up are warranted to determine the impact of the resection margin on intra-hepatic recurrence and survival.

Gas embolism during laparoscopic liver resection in a pig model: frequency and severity

BACKGROUND

Laparoscopic liver surgery is evolving rapidly. Carbon dioxide embolism is a potential complication. The aim of this work was to study the frequency and severity of gas embolism (GE) during laparoscopic liver lobe resection in a pig model and the resulting cardiovascular and respiratory changes.

METHODS

Fifteen anaesthetized piglets underwent laparoscopic left liver lobe resection. Haemodynamic and respiratory variables were monitored, including systemic and pulmonary arterial pressures, end-tidal CO2, and pulmonary dead space. Online blood gas monitoring and a transoesophageal echocardiography (TOE) were used. GE was graded semi-quantitatively as grade 0 (none), grade 1 (minor), or grade 2 (major), depending on the TOE results.

RESULTS

In 10 of 15 piglets, GE occurred. In total, 33 separate episodes of GE were recorded. All 13 episodes of grade 2 and three of grade 1 were serious enough to cause mainly respiratory, but also haemodynamic effects. Mostly, grade 1 GE caused only minor respiratory or haemodynamic changes. Most variables were affected during grade 2 GE; the most important were Pa(o(2)), Pa(co(2)), end-tidal CO2, Vd/Vt, and mean pulmonary arterial pressure.

CONCLUSIONS

GE occurred frequently during laparoscopic liver resection in this experimental study. Approximately half of the embolisms were serious enough to cause respiratory or haemodynamic disturbances or both. Pending further human studies, a combination of several monitoring techniques, with narrow limits for the alarm settings, will ensure correct interpretation of the complex physiological response to GE and reveal it early enough to alert the anaesthetist and the surgeon to the ongoing problem.

Open liver resection for colorectal metastases: better short- and long-term outcomes in patients potentially suitable for laparoscopic liver resection

BACKGROUND

There is no prospective randomized data comparing laparoscopic to open hepatectomy. This study compared short- and long-term outcomes in patients undergoing hepatectomy for colorectal metastases (CRM), who were suitable for either laparoscopic or open surgery.

METHODS

Data were prospectively collected from consecutive patients undergoing hepatic resection of CRM at a single centre (1987-2007). Patients who were suitable for laparoscopic resection (Group 1) were compared with patients whose tumour characteristics would best be considered for open resection (Group 2).

RESULTS

Out of 1152 hepatectomies, 266 (23.1%) were deemed suitable for a laparoscopic approach. The median (IQR) number of metastases was greater in Group 2 [2(1-20) vs. 1(1-10), P < 0.001], as was the mean (SD) tumour size [5.3(3.6) cm vs. 3.3(1.2) cm, P < 0.001]. The median (IQR) operation time [210 (70) min vs. 240 (90) min, P < 0.001] and blood loss [270 (265) ml vs. 355 (320) ml, P < 0.001] were less in Group 1. There was no difference in length of stay, morbidity or mortality. Patients in Group 2 had a higher R1 resection rate (14.9%) compared with Group 1 (4.5%, P < 0.001) and lower 5-year survival (37.8% vs. 44.2%, P= 0.005).

DISCUSSION

Current criteria for laparoscopic hepatectomy selects patients who have more straight-forward surgery, with less risk of an involved resection margin and better long-term survival, compared with patients unsuited to a laparoscopic approach. Clearly defined criteria for laparoscopic hepatectomy are essential to allow meaningful analysis of outcomes and the results of unrandomized series of laparoscopic hepatectomies must be interpreted with caution.

Minimally invasive liver resection for metastatic colorectal cancer: a multi-institutional, international report of safety, feasibility, and early outcomes

OBJECTIVE

To evaluate a multicenter, international series on minimally invasive liver resection for colorectal carcinoma (CRC) metastasis.

SUMMARY BACKGROUND DATA

Multiple single series have been reported on laparoscopic liver resection for CRC metastasis. We report the first collaborative multicenter, international series to evaluate the safety, feasibility, and oncologic integrity of laparoscopic liver resection for CRC metastasis.

METHODS

We retrospectively reviewed all patients who underwent minimally invasive liver resection for CRC metastasis from February 2000 to September 2008 from multiple medical centers from the United States and Europe. The multicenter series of patients were accumulated into a single database. Patient demographics, preoperative, operative, and postoperative characteristics were analyzed. Actuarial overall survival was calculated with Kaplan-Meier analysis.

RESULTS

A total of 109 patients underwent minimally invasive liver resection for CRC metastasis. The median age was 63 years (range, 32-88 years) with 51% females. The most common sites of primary colon cancer were sigmoid/rectum (51%), right colon (25%), and left colon (13%). Synchronous liver lesions were present in 11% of patients. For those with metachronous lesions liver lesions, the median time interval from primary colon cancer surgery to liver metastasectomy was 12 months. Preoperative chemotherapy was administered in 68% of cases prior to liver resection. The majority of patients underwent prior abdominal operations (95%). Minimally invasive approaches included totally laparoscopic (56%) and hand-assisted laparoscopic (41%), the latter of which was employed more frequently in the US medical centers (85%) compared with European centers (13%) (P = 0.001). There were 4 conversions to open surgery (3.7%), all due to bleeding. Extents of resection include wedge/segmentectomy (34%), left lateral sectionectomy (27%), right hepatectomy (28%), left hepatectomy (9%), extended right hepatectomy (0.9%), and caudate lobectomy (0.9%). Major liver resections (> or =3 segments) were performed in 45% of patients. Median OR time was 234 minutes (range, 60-555 minutes) and blood loss was 200 mL (range, 20-2500 mL) with 10% receiving a blood transfusion. There were no reported perioperative deaths and a 12% complication rate. Median length of hospital stay for the entire series was 4 days (range, 1-22 days) with a shorter stay in medical centers in the United States (3 days) versus that seen in Europe (6 days) (P = 0.001). Negative margins were achieved in 94.4% of patients. Actuarial overall survivals at 1-, 3-, and 5-year for the entire series were 88%, 69%, and 50%, respectively. Disease-free survivals at 1-, 3-, and 5-year were 65%, 43%, and 43%, respectively.

CONCLUSIONS

Minimally invasive liver resection for colorectal metastasis is safe, feasible, and oncologically comparable to open liver resection for both minor and major liver resections, even with prior intra-abdominal operations, in selected patients and when performed by experienced surgeons.

The learning curve in laparoscopic liver resection: improved feasibility and reproducibility

OBJECTIVE

To evaluate the "learning curve" effect on feasibility and reproducibility of laparoscopic liver resection (LLR).

SUMMARY BACKGROUND DATA

LLR is currently limited to few centers and to few procedures. Its reproducibility is still debated.

METHODS

: Patients undergoing LLR between 1996 and 2008 were included. Indications and type of hepatectomies were compared with those of open resections performed in the same period, considering 3 periods (1996-1999, 2000-2003, and 2004-2008). LLRs were divided into 3 equal groups of 58 cases and technical data and outcomes were compared. Risk-adjusted Cumulative Sum model was used for determining the learning curve based on the need for conversion.

RESULTS

Of 782, 174 (22.3%) patients underwent LLR. Proportion of LLR progressively increased (17.5%, 22.4%, and 24.2%), such as hepatocellular carcinoma (17.6%, 25.6%, and 39.4%, P < 0.05), colorectal metastases (0%, 6.5%, and 13.1%, P < 0.05), major hepatectomies (1.1%, 9.1%, 8.5%, P < 0.05), and right hepatectomies (0%, 13.2%, and 13.1%, P < 0.05). Comparing groups, results of LLR significantly improved in terms of conversion rate (15.5%, 10.3%, and 3.4%, P < 0.05), operative time (210, 180, and 150 minutes, P < 0.05), blood loss (300, 200, and 200 mL, P < 0.05), and morbidity (17.2%, 22.4%, and 3.4%, P < 0.05). Pedicle clamping was less used over time (77.6%, 62.1%, and 17.2%, P < 0.05) and for shorter durations (45, 30, and 20 minutes, P < 0.05). Having adjusted for case-mix, the Cumulative Sum analysis demonstrated a learning curve for laparoscopic hepatectomies of 60 cases.

CONCLUSION

A slow but constant evolution of LLR occurred: indications and magnitude of procedures increased and technical outcomes improved. The learning curve demonstrated in this study suggests that LLR is reproducible in liver units but specific training to advanced laparoscopy is required.

Laparoscopic versus open left lateral segmentectomy

BACKGROUND

Laparoscopic liver surgery is becoming increasingly common. This cohort study was designed to directly compare perioperative outcomes of the left lateral segmentectomy via laparoscopic and open approach.

METHODS

Between 2002 and 2006 43 left lateral segmentectomies were performed at King's College Hospital. Those excluded from analysis included previous liver resections, polycystic liver disease, liver cirrhosis and synchronous operations. Of 20 patients analysed, laparoscopic (n = 10) were compared with open left lateral segmentectomy (n = 10). Both groups had similar patient characteristics.

RESULTS

Morbidity rates were similar with no wound or chest infection in either group. The conversion rate was 10% (1/10). There was no difference in operating time between the groups (median time 220 minutes versus 179 minutes, p = 0.315). Surgical margins for all lesions were clear. Less postoperative opiate analgesics were required in the laparoscopic group (median 2 days versus 5 days, p = 0.005). The median postoperative in-hospital stay was less in the laparoscopic group (6 days vs 9 days, p = 0.005). There was no mortality.

CONCLUSION

Laparoscopic left lateral segmentectomy is safe and feasible. Laparoscopic patients may benefit from requiring less postoperative opiate analgesia and a shorter post-operative in-hospital stay.

Laparoscopic liver resection-understanding its role in current practice: the Henri Mondor Hospital experience

OBJECTIVE

To report our complete experience with laparoscopic liver resection (LLR) to understand what role it may play in the broader context of liver surgery.

BACKGROUND

The goal of LLR is to extend the benefits of the laparoscopic approach without compromising the fundamental principles of open liver surgery. LLR, however, presents unique technical challenges and its evaluation is made difficult by the restricted indications for this approach, the few centers world-wide experienced in the technique, and the heterogeneity of procedures and pathologies involved.

METHODS

Retrospective analysis of a prospectively maintained database of liver resections from a unit with a comprehensive liver program, including resection and transplantation.

RESULTS

There were 166 laparoscopic liver resections between May 23, 1996 and December 31, 2007, including 100 (60%) for malignant pathology (64 HCC, 3 cholangiocarcinoma, 33 hepatic metastases) and 66 for benign pathology (adenoma, 23; FNH, 19; cystic, 17; other, 7). Numbers of resections for benign indications remained stable over time whereas those for malignant indications increased. There were 31 major resections, 56 left lateral sectionectomies, 28 segmentectomies, and 51 tumorectomies. There was 0% mortality and 15.1% morbidity. Median blood loss was 200 mL, 9 patients (5.4%) required transfusion, and median operating time was 180 minutes. Left lateral sectionectomies demonstrated reduced bleeding (median, 175 vs. 300 mL, P = 0.0015) and faster operating time (median, 170 vs. 180 minutes, P = 0.0265). In the second half of the experience, there was reduced bleeding (median, 200 vs. 300 mL, P = 0.0022) and a lower conversion rate (2.4% vs. 16.9%, P = 0.0015).

CONCLUSIONS

Good patient selection and refined surgical technique are the keys to successful LLR. The indications for resection of asymptomatic benign lesions should not be increased because the laparoscopic approach is available. Hepatocellular carcinomas (HCCs) are more likely to be suitable to a laparoscopic approach than colorectal liver metastases. Left lateral sectionectomy and limited resection of solitary peripheral lesions are particularly suitable while hemihepatectomies remain challenging procedures. LLR requires an ongoing robust audit to identify any emerging problems.

Laparoscopic major hepato-biliary-pancreatic surgery: formidable challenge to standardization

INTRODUCTION

Although laparoscopic colorectal or gastric surgery has become widely accepted as a superior alternative to conventional open surgery, the surgical management of hepato-biliary-pancreatic disease has traditionally involved open surgery. Recently, many reports have described laparoscopic partial liver resection, lateral segmentectomy, and distal pancreatectomy. However, laparoscopic major hepato-biliary-pancreatic surgery, such as hepatic lobectomy and pancreaticoduodenectomy, has not been widely developed because of technical difficulties.

METHODS

We describe our experience with laparoscopic major hepato-biliary-pancreatic surgery, including right hepatectomy using hilar Glissonean pedicle transaction, and pylorus-preserving pancreaticoduodenectomy.

CONCLUSION

Although our experience is limited, and randomized study is necessary to elucidate the appropriate indications for and effects of the present procedures, we believe that laparoscopic major hepato-biliary-pancreatic surgery can be feasible, safe, and effective in highly selected patients, and that it will be one of the standard therapeutic options for carefully selected patients with hepato-biliary-pancreatic disease.

Laparoscopic liver resection: a systematic review

BACKGROUND

Outcomes of laparoscopic liver resection (LLR) are not clarified. The objective of this article is to depict the state of the art of LLR by means of a systematic review of the literature.

METHODS

Studies about LLR published before September 2008 were identified and their results summarized.

RESULTS

Indications for laparoscopic hepatectomy do not differ from those for open surgery. Technical feasibility is the only limiting factor. Bleeding is the major intraoperative concern, but, if managed by an expert surgeon, do not worsen outcomes. Hand assistance can be useful in selected cases to avoid conversion. Patient selection must take both tumor location and size into consideration. Potentially good candidates are patients with peripheral lesions requiring limited hepatectomy or left lateral sectionectomy; their outcomes, including reduced blood loss, morbidity, and hospital stay, are better than those of their laparotomic counterparts. The same advantages have been observed in cirrhotics. Laparoscopic major hepatectomies and resections of postero-superior segments need further evaluation. The results of LLR in cancer patients seem to be similar to those obtained with the laparotomic approach, especially in cases of hepatocellular carcinoma, but further analysis is required.

CONCLUSIONS

Laparoscopic liver resection is safe and feasible. The laparoscopic approach can be recommended for peripheral lesions requiring limited hepatectomy or left lateral sectionectomy. Preliminary oncological results suggest non-inferiority of laparoscopic to laparotomic procedures.

A series of laparoscopic liver resections with or without HALS in patients with hepatic tumors

BACKGROUND

Differences were compared between laparoscopic surgery with and without hand-assisted laparoscopic technique (HALS) in order to assess whether HALS is a safe and feasible alternative to laparotomy and to determine what factors contributed to successful laparoscopic liver surgery.

METHOD

From a total of 416 liver resections, 45 patients with 46 hepatic tumors were chosen for laparoscopic liver resection with or without a hand-assisted technique. For each patient, her/his surgical duration, intraoperative blood loss, tumor size and location, hospital stay after surgery, mortality, and morbidity were recorded for analysis.

RESULTS

The 45 surgical laparoscopic liver resections included 19 left lateral lobectomies, three hemihepatectomies, three segmentectomies, and 21 partial hepatectomies. A HALS was used more frequently in the right posterior group (14/16) than in the anterior group (6/29). There was no notable difference between these two groups in terms of tumor size, mean surgical time, blood loss during surgical procedure, hospital stay after surgery, and occurrence of complication.

CONCLUSION

Surgical results between HALS and non-HALS usage were similar except for higher blood loss with HALS, higher use of HALS when liver cirrhosis was present, and less likelihood of using HALS when there was a superficial location of the tumor or lesion.