Laparoscopic-assisted limited liver resection: technique, indications and results

Laparoscopy-assisted versus open and pure laparoscopic approach for liver resection and living donor hepatectomy: a systematic review and meta-analysis

BACKGROUND

Laparoscopy-assisted (hybrid) liver surgery is considered a minimally invasive technique, however there are doubts regarding loss of the benefits of laparoscopy due to the use of an auxiliary incision. The aim of this study was to compare perioperative results of hybrid vs. open and hybrid vs. pure laparoscopic approach to liver resection for focal lesions and living donation.

METHODS

A systematic review was performed in Medline, EMBASE, Cochrane Library Central and LILACS databases. Perioperative outcomes were analyzed.

RESULTS

21 studies were included. Hybrid vs. open: operative time was lower in open group (mean difference [MD] = 34 min; 95%CI: 22-47; P < 0.001; N = 669). Hybrid technique was associated with a reduction in operative blood loss [MD = -43 ml; 95%CI: -74-(-13); P = 0.005, N = 1738]; shorter hospital stay [MD = -1.9 days; 95%CI: -3.2-(-0.5); P = 0.008; N = 833] and lower morbidity [risk difference (RD) = -0.05; 95%CI: -0.10-(-0.01); P = 0.010; N = 1359]. Hybrid vs. pure laparoscopic: There was no difference regarding blood loss, transfusion rate, hospital stay and morbimortality.

DISCUSSION

Hybrid technique had perioperative outcomes that were more in keeping with pure laparoscopic outcomes than open surgery. Hybrid liver surgery should be considered a minimally invasive approach.

Comparative Short-term Benefits of Laparoscopic Liver Resection: 9000 Cases and Climbing

OBJECTIVE

To perform a systematic review of worldwide literature on laparoscopic liver resections (LLR) and compare short-term outcomes against open liver resections (OLR) by meta-analyses.

SUMMARY BACKGROUND DATA

There are no updated pooled data since 2009 about the current status and short-term outcomes of LLR worldwide.

PATIENTS AND METHODS

All English language publications on LLR were screened. Descriptive worldwide data and short-term outcomes were obtained. Separate analyses were performed for minor-only and major-only resection series, and series in which minor/major resections were not differentiated. Apparent case duplications were excluded.

RESULTS

A set of 463 published manuscripts were reviewed. One hundred seventy-nine single-center series were identified that accounted for 9527 LLR cases worldwide. Minor-only, major-only, and combined major-minor series were 61, 18, and 100, respectively, including 32, 8, and 43 comparative series, respectively. Of the total 9527 LLR cases reported, 6190 (65%) were for malignancy and 3337 (35%) were for benign indications. There were 37 deaths reported (mortality rate = 0.4%). From the meta-analysis comparing case-matched LLR to OLR (N = 2900 cases), there was no increased mortality and significantly less complications, transfusions, blood loss, and hospital stay observed in LLR vs OLR.

CONCLUSIONS

This is the largest review of LLR available to date with over 9000 cases published. It confirms growing safety when performed in selected patients and by trained surgeons, and suggests that LLR may offer improved patient short-term outcomes compared with OLR. Improved levels of evidence, standardized reporting of outcomes, and assuring proper training are the next challenges of laparoscopic liver surgery.

Harness Traction Technique (HARNESS): Novel Method for Controlling the Transection Plane During Laparoscopic Hepatectomy

We present our experience using a novel method for controlling the transection plane, which we termed as the Harness Traction Technique (HARNESS) and evaluate its usefulness. From May 2009 to March 2012, laparoscopic hepatectomies using HARNESS were performed on 35 patients. After the superficial hepatic parenchyma on the line was transected at 1 to 2 cm depth, 5 mm tape was placed along the groove of the line and tied to prevent it from slipping off. Tape was tied and pulled using a forceps toward the best direction for minimizing the bleeding, moving the transection point to the appropriate position and creating good tension for parenchymal transection at the transection point. There were no conversions to laparotomy or intraoperative complications. HARNESS is useful for controlling the dissection line during laparoscopic hepatectomy, leading to precise and safe laparoscopic liver parenchymal dissection.

The superficial precoagulation, sealing, and transection method: a "bloodless" and "ecofriendly" laparoscopic liver transection technique

Supplemental Digital Content is available in the text.

Background:

Minimizing blood loss is an important aspect of laparoscopic liver resection. Liver transection is the most challenging part of liver resection, but no standard method is available for this step at present. Herein, we have introduced the superficial precoagulation, sealing, and transection (SPST) method, a potentially “bloodless” and “ecofriendly” laparoscopic liver transection technique involving reusable devices: the VIO soft-coagulation system; VIO BiClamp (bipolar electrosurgical coagulation); Olympus SonoSurg (ultrasonic surgical system); and CUSA (ultrasonic aspirator). Furthermore, we have reported the short-term outcomes of laparoscopic liver transection with the SPST method.

Methods:

The study included 14 consecutive patients who underwent laparoscopic partial liver resection with the SPST method at a single institution between August 2008 and June 2010.

Results:

The median operative time was 201 minutes (range, 97 to 332 min) and the median blood loss was 5 mL (range, 5 to 250 mL). There was no requirement for blood transfusion, no intraoperative complications, and no cases of conversion to open laparotomy. There were no liver transection-related complications such as postoperative bile leakage, bleeding, or infection. All surgical margins were negative, with a mean margin of 4.6 mm, and no local recurrence was observed at an average follow-up of 37.6 months.

Conclusions:

The SPST method is a simple, efficient, and cost-effective surgical technique for laparoscopic liver resection. It is associated with low intraoperative blood loss and good short-term outcomes. We recommend that the SPST method should be used as a standard technique for laparoscopic liver transection (Supplemental Digital Content 1, http://links.lww.com/SLE/A103).

Laparoscopic liver mobilization: tricks of the trade to avoid complications

Supplemental Digital Content is available in the text.

Laparoscopic liver resection is gaining popularity because of the availability of new laparoscopic instruments and advanced techniques. Laparoscopic liver mobilization is not only necessary for pure laparoscopic liver resection but also for laparoscopy-assisted hepatectomy. Laparoscopy-assisted hepatectomy significantly reduces the length of the laparotomy incision, and it is a good educational transition to the more advanced laparoscopic liver resection. Laparoscopic liver mobilization is a simple and easy procedure if surgeons know what challenges to expect. Here, the technique of liver mobilization is summarized, along with those challenges.

Video assisted resections. Increasing access to minimally invasive liver surgery?

Objective: To evaluate perioperative outcomes, safety and feasibility of video-assisted resection for primary and secondary liver lesions. Methods : From a prospective database, we analyzed the perioperative results (up to 90 days) of 25 consecutive patients undergoing video-assisted resections in the period between June 2007 and June 2013. Results : The mean age was 53.4 years (23-73) and 16 (64%) patients were female. Of the total, 84% were suffering from malignant diseases. We performed 33 resections (1 to 4 nodules per patient). The procedures performed were non-anatomical resections (n = 26), segmentectomy (n = 1), 2/3 bisegmentectomy (n = 1), 6/7 bisegmentectomy (n = 1), left hepatectomy (n = 2) and right hepatectomy (n = 2). The procedures contemplated postero-superior segments in 66.7%, requiring multiple or larger resections. The average operating time was 226 minutes (80-420), and anesthesia time, 360 minutes (200-630). The average size of resected nodes was 3.2 cm (0.8 to 10) and the surgical margins were free in all the analyzed specimens. Eight percent of patients needed blood transfusion and no case was converted to open surgery. The length of stay was 6.5 days (3-16). Postoperative complications occurred in 20% of patients, with no perioperative mortality. Conclusion : The video-assisted liver resection is feasible and safe and should be part of the liver surgeon armamentarium for resection of primary and secondary liver lesions.

A novel ultrasound based approach for lesion segmentation and its applications in gynecological laparoscopic surgery

Laparoscopic ultrasound (LUS) has been widely utilized as a surgical aide in general, urological, and gynecological applications. Our study summarizes the clinical applications of laparoscopic ultrasonography in laparoscopic gynecologic surgery. Retrospective analyses were performed on 42 women subjects using laparoscopic surgery during laparoscopic extirpation and excision of gynecological tumors in our hospital from August 2011 to August 2013. Specifically, the Esaote 7.5 × 10 MHz laparoscopic transducer was used to detect small residual lesions, as well as to assess, locate and guide in removing the lesions during laparoscopic operations. The findings of LUS were compared with those of preoperative trans-vaginal ultrasound, postoperative, and pathohistological examinations. In addition, a novel method for lesion segmentation was proposed in order to facilitate the laparoscopic gynecologic surgery. In our experiment, laparoscopic operation was performed using a higher frequency and more close to pelvic organs via laparoscopic access. LUS facilitates the ability of gynaecologists to find small residual lesions under laparoscopic visualization and their accurate diagnosis. LUS also helps to locate residual lesions precisely and provides guidance for the removal of residual tumor and eliminate its recurrence effectively. Our experiment provides a safer and more valuable assistance for clinical applications in laparoscopic gynecological surgery that are superior to trans-abdominal ultrasound and trans-vaginal ultrasound.

Approaches to laparoscopic liver resection: a meta-analysis of the role of hand-assisted laparoscopic surgery and the hybrid technique

Laparoscopic liver resection has been established as a safe and feasible treatment option. Surgical approaches include pure laparoscopy, hand-assisted laparoscopy (HALS), and the hybrid technique. The role of these three approaches, and their superiority over open laparotomy, is not yet known. A literature review was performed using specific search phrases, relating to hand-assisted or hybrid approaches to laparoscopic liver resection. Surgical results from 18 case series (HALS, nine series; hybrid technique, nine series), each with ≥ 10 patients, were analyzed. Results indicated that HALS was associated with a mean operative time of 82-264.5 min, an estimated blood loss of 82-300 mL, and a complication rate of 3.8-27.1%. Analysis of series involving the hybrid technique indicated a mean operative time of 111-366.5 min, an estimated blood loss of 93-936 mL, and a complication rate of 3.4-23.5%. In conclusion, there is insufficient evidence to conclude that any single approach is superior to the others, although HALS and the hybrid technique are useful when dealing with difficulties associated with pure laparoscopy. Conversely, the need for these two methods, which can function as a bridge to pure laparoscopic liver resection, may be overcome with appropriate training.

Laparoscopic liver resection in the treatment of hepatocellular carcinoma

Laparoscopic liver resection is an emerging technique in liver surgery. Although laparoscopy is well established for several abdominal procedures and is considered by some the preferred approach, laparoscopic hepatic resection has been introduced into clinical practice more widely since 2000. These procedures are performed only in experienced centers and only in a select group of patients. While initially performed only for benign hepatic lesions, the indications for laparoscopic resection have gradually broadened to encompass all kinds of malignant hepatic lesions, including hepatocellular carcinoma in patients with cirrhosis, for whom the advantages of the minimally invasive approach may be most evident.

Laparoscopic repeat resection of recurrent hepatocellular carcinoma

BACKGROUND

The present study was designed to explore the safety and feasibility of laparoscopic re-resection of recurrent liver tumors.

METHODS

Among 120 hepatocellular carcinoma patients who received laparoscopic hepatectomy, six were carefully selected to receive laparoscopic re-resection. Surgical indications were evaluated by specific selection criteria for tumor location, size, metastases, vessel invasion, and liver function. Four patients received laparoscopic partial hepatectomy, and two received laparoscopic anatomical left lateral lobe resection. Results were analyzed retrospectively.

RESULTS

The six surgeries (four laparoscopic partial hepatectomies, two laparoscopic anatomical left lateral lobe resections) were successfully performed with no intraoperative complications. Mean operative time was 140.83 ± 35.69 min, mean blood loss was 283.33 ± 256.25 ml, and mean hospital stay was 5.67 ± 1.63 days.

CONCLUSIONS

Our experience with carefully selected cases meeting specific criteria suggests that laparoscopic hepatic re-resection is a safe, feasible procedure that may offer multiple benefits for treating recurrent hepatocellular carcinoma.