Gas embolism in laparoscopic hepatectomy: what is the optimal pneumoperitoneal pressure for laparoscopic major hepatectomy?

Early outcomes of robotic vs open living donor right hepatectomy in a US Center

BACKGROUND

Robotic living donor hepatectomy offers potential advantages but has been limited to high-volume centers, primarily in Asia and the Middle East. We report our experience establishing a robotic living donor right hepatectomy program in a U.S. center with low LDLT volume and no prior laparoscopic donor hepatectomy experience and analyze early outcomes.

METHODS

This retrospective cohort study analyzed 37 living donor right hepatectomies (13 robotic [including one open conversion], 24 open) performed between June 2022 and February 2024.

RESULTS

The robotic group had longer operative times (median [range], 451 [374-568] minutes vs 368 [276-421] minutes; P < 0.001) but less blood loss (median [range], 200 [50-700] mL vs 900 [300-2500] mL; P < 0.001). One case required unplanned open conversion due to gas embolism. Two hematomas/bleeding (Clavien-Dindo grade IIIB) occurred in the robotic group, but no biliary complications. Comprehensive Complication Index, liver function tests, and hospital stays were similar between the two groups, with no 90-day graft failure/mortality.

CONCLUSION

With extensive surgical experience in both open donor hepatectomy and robotic surgery, along with meticulous preparation as a team, U.S. centers with lower LDLT volume and no laparoscopic experience can safely implement robotic living donor right hepatectomy, achieving comparable short-term outcomes to the open approach. Further research on long-term outcomes and donor quality of life is necessary.

Anesthetic Considerations for Robotic Liver Transplantation

Liver transplantation has traditionally been performed through a large, bilateral subcostal incision. Recently, liver transplant programs across the world, including our own, have reported successful liver transplants via total robotic approaches on recipients with low Model for End-stage Liver Disease scores and preexisting abdominal wall laxity. This review discusses the unique anesthetic considerations of robotic liver transplantation based on our group's initial experience with this novel surgical approach. Robotic liver transplantation presents a unique set of considerations and challenges for the anesthesiologist, and a thorough understanding of liver disease, liver transplant surgery, venovenous bypass, and the various implications of robotic surgery is essential to ensure optimal patient outcomes. Specific management topics discussed here include appropriate patient selection, preoperative assessment, and intraoperative management. We also discuss certain theoretical and actual challenges that our group has experienced.

Combining occlusion of the right hepatic vein with the Pringle maneuver in laparoscopic anatomic right posterior liver resection

BACKGROUND

Laparoscopic right posterior anatomic resection (LRPAR) presents challenges due to uncontrollable hemorrhage from the inferior vena cava and the risk of carbon dioxide (CO2) gas embolism. However, there is a lack of research specifically addressing the safe exposure of right hepatic vein (RHV). Herein, we introduced a novel technique of combining occlusion of the RHV with the Pringle maneuver and presented the outcomes of our initial series.

PATIENT AND METHOD

All consecutive patients who underwent LRPAR using this novel technique were enrolled in this study from March 2021 to January 2024. The demographic characteristics, perioperative outcomes and follow-up data were collected and analyzed.

RESULTS

A total of 12 patients underwent LRPAR using the technique of double occlusion during study period. All the procedures were performed laparoscopically, with no conversions to open surgery. The median operative time was 203 min (range of 172-279 min) and the median blood loss was 200 ml (range of 50-280 ml). No patient received a blood transfusion during the perioperative period. Of note, the main trunk of the RHV was fully exposed on the cutting surface in all cases, and no evidence of CO2 gas embolism was observed following double occlusion. None of the patients suffered from Clavien-Dindo grade II or higher postoperative complications, and the perioperative mortality was nil. The median postoperative stay was 5 days (range of 5-7 days). The median hospitalization cost was 43,048.5 RMB (40,240.35-57,921.53 RMB). At a median follow-up period of 24 months (range of 4-35 months), all patients were alive with normal daily living and no disease recurrence was observed.

CONCLUSIONS

Combining occlusion of the right hepatic vein with the Pringle maneuver appears to be a feasible and expected technique for securing the exposure of RHV in LRPAR. Further follow-up and well-designed prospective comparative studies are needed to validate the feasibility and efficacy of this technique.

A portent of catastrophic carbon dioxide embolism in laparoscopic hepatectomy: A case report

INTRODUCTION

Laparoscopic hepatectomy (LH) poses a high risk of carbon dioxide embolism due to extensive hepatic transection, long surgery duration, and dissection of the large hepatic veins or vena cava.

PATIENT CONCERNS

A 65-year-old man was scheduled to undergo LH. Following intraperitoneal carbon dioxide (CO2) insufflation and hepatic portal occlusion, the patient developed severe hemodynamic collapse accompanied by a decrease in the pulse oxygen saturation (SpO2).

DIAGNOSIS

Although a decrease in end-tidal carbon dioxide (ETCO2) was not observed, CO2 embolism was still suspected because of the symptoms.

INTERVENTIONS AND OUTCOMES

The patient was successfully resuscitated after the immediate discontinuation of CO2 insufflation and inotrope administration. CO2 embolism must always be suspected during laparoscopic surgery whenever sudden hemodynamic collapse associated with decreased pulse oxygen saturation occurs, regardless of whether ETCO2 changes. Instant arterial blood gas analysis is imperative, and a significant difference between PaCO2 and ETCO2 is indicative of carbon dioxide embolism.

CONCLUSION

Instant arterial blood gas analysis is imperative, and a significant difference between PaCO2 and ETCO2 is indicative of carbon dioxide embolism.

Carbon dioxide embolism during laparoscopic hepatectomy in a patient with an iatrogenic atrial septal defect:a case report

BACKGROUND

Laparoscopic hepatectomy has advantages including shorter hospital stay, lesser blood loss, and lower complication rates. Carbon dioxide gas embolism is a life-threatening complication associated with laparoscopic hepatectomy. During catheter ablation, the standard treatment for atrial fibrillation, an iatrogenic atrial septal defect (ASD) is developed when performing a septal puncture from the right to the left atrium.

CASE PRESENTATION

Carbon dioxide embolism occurred during laparoscopic liver resection in a 70-year-old male patient with a history of catheter ablation for atrial fibrillation. Transesophageal echocardiography detected iatrogenic ASD. The surgery was converted into an open procedure after consulting with the surgeon. Postoperatively, the patient exhibited no evidence of poor arousal nor obvious neurological abnormalities.

CONCLUSION

In patients with a history of catheter ablation, particular attention should be paid to the bubble inflow into the left ventricular system in the event of gas embolism during laparoscopic hepatectomy. J. Med. Invest. 71 : 320-322, August, 2024.

Utilization of deep neuromuscular blockade combined with reduced abdominal pressure in laparoscopic radical gastrectomy for gastric cancer: An academic perspective

BACKGROUND

Few studies have examined the specific efficacy of deep neuromuscular blockade (NMB) combined with pneumoperitoneal pressure reduction in laparoscopic radical gastrectomy (LRG) in the elderly.

AIM

To investigate the application effect of deep neuromuscular blockade (NMB) combined with reduced pneumoperitoneum pressure in LRG for gastric cancer (GC) in elderly patients and its influence on inflammation.

METHODS

Totally 103 elderly patients with GC treated in our hospital between January 2020 and January 2022 were retrospectively analyzed. Among them, 45 patients treated with surgery based on deep NMB and conventional pneumoperitoneum pressure were assigned to the control group, while the rest of the 58 patients who underwent surgery based on deep NMB and reduced pneumoperitoneum pressure were assigned to the observation group. The two groups were compared in the changes of the Leiden-surgical rating scale score, serum tumor necrosis fact-α (TNF-α) and interleukin 6 (IL-6) before and after therapy. The visual analogue scale (VAS) was adopted for evaluating the shoulder pain of patients at 8 h, 24 h and 48 h after the operation. The driving pressure of the two groups at different time points was also compared. Additionally, the operation time, pneumoperitoneum time, infusion volume, blood loss, extubation time after surgery, residence time in the resuscitation room, TOF% = 90% time and post-anesthetic recovery room (PACU) stay time were all recorded, and adverse PACU-associated respiratory events were also recorded. The postoperative hospitalization time and postoperative expenses of the two groups were counted and compared.

RESULTS

No significant difference was found between the two groups at the time of skin incision, 60 minutes since the operation and abdominal closure after surgery (P > 0.05). The observation group exhibited significantly lower VAS scores than the control group at 24 and 48h after surgery (P < 0.05). Additionally, the observation group had significantly lower driving pressure than the control group at 5 min and 60 min after the establishment of pneumoperitoneum (P < 0.05). Additionally, the two groups were similar in terms of the operation time, pneumoperitoneum time, infusion volume, blood loss, extubation time after surgery, residence time in the resuscitation room and TOF% = 90% time (P > 0.05), and the observation group showed significantly lower TNF-α and IL-6 Levels than the control group at 24 h after therapy (P < 0.05). Moreover, the incidence of adverse events was not significantly different between the two groups (P > 0.05), and the observation group experienced significantly less hospitalization time and postoperative expenses than the control group (P < 0.05).

CONCLUSION

Deep NMB combined with reduced pneumoperitoneum pressure can decrease the VAS score of shoulder pain and inflammatory reaction, without hindering the surgical vision and increasing adverse PACU-associated respiratory events, and can thus shorten the hospitalization time and treatment cost for patient.

Anesthesia Management in Laparoscopic Donor Hepatectomy: The First Report from Turkey

BACKGROUND

We aimed to report a single-center experience in laparoscopic donor left-side and right-side hepatectomy cases regarding preoperative evaluation, perioperative and anesthetic management protocols, and postoperative follow-up.

METHODS

Laparoscopic donor left-side and right-side hepatectomy cases were included in the study because of their excessive transection area and bleeding potential. Medical records of living donors were reviewed in terms of age, sex, body mass index (BMI), presence of consanguinity with the recipient, perioperative and early postoperative biochemical parameters, hemodynamic changes during surgery, duration of surgery, the ratio of liver volume to total liver volume, perioperative complications, and length of hospital stay.

RESULTS

Eighty-one laparoscopic living-donor hepatectomy procedures were performed in our unit between 2018 and 2022. Six laparoscopic donor right-side cases and two left-side cases were retrospectively reviewed. Donors' mean age and BMI were 29.6 ± 8.6 years and 23.1 ± 4.3, respectively. The average weights of the right and left lobe liver grafts were 727 g and 279 g, respectively, constituting 65.8% and 22.7% of the total liver volume, respectively. The mean operation time was 593 ± 94 minutes, and the mean volume of blood loss was 437 ± 294 mL. A major complication, namely portal vein stenosis, developed in 1 donor (1/8), and portal vein patency was achieved postoperatively.

CONCLUSIONS

Anesthesia management and teamwork between surgeons and anesthesiologists are the most important building blocks for donor safety, which is of the utmost priority. Effective communication and cooperation in the operating room may prevent potential donor complications and improve postoperative recovery time.

Delimiting Low Level of Difficulty Scoring System Based on the Extent of Resection Difficulty Scoring System for Laparoscopic Liver Resection

Background: The difficulty scoring system based on the extent of resection (DSS-ER) is a common tool for assessing the difficulty and risk of laparoscopic liver resection (LLR), but DSS-ER fails to comprehensively and accurately assess low level for beginners. Methods: The 93 cases of LLRs for primary liver cancer in the general surgery department of the Second Affiliated Hospital of Guangxi Medical University from 2017 to 2021 were retrospectively analyzed. The low level of DSS-ER difficulty scoring system was reclassified into three grades. The intraoperative and postoperative complications were compared among different groups. Results: There were significant differences in the operative time, blood loss, intraoperative allogeneic blood transfusion, conversion to laparotomy, and allogeneic blood transfusion among the different groups. Meanwhile, the postoperative complications were mainly pleural effusion and pneumonia, and the incidence of grade III was higher compared with other two grades. No significant difference existed in the postoperative biliary leakage and liver failure among three grades. Conclusions: This reclassified low level of DSS-ER difficulty scoring system has certain clinical value for LLR beginners to complete the corresponding learning curve.

Cerebral infarction by paradoxical gas embolism detected after laparoscopic partial hepatectomy with an insufflation management system: a case report

BACKGROUND

Laparoscopic surgery has reduced surgical morbidity and postoperative duration of hospital stay. Gas embolism is commonly known as a risk factor for all laparoscopic procedures. We report a case of severe cerebral infarction presumably caused by paradoxical CO₂ embolism in laparoscopic partial hepatectomy with an insufflation management system.

CASE PRESENTATION

A male in his 60 s was diagnosed with recurrence of liver metastasis in the right hepatic lobe after laparoscopic lower anterior resection for rectal cancer. We performed laparoscopic partial hepatectomy with an AirSeal® under 10 mmHg of intra-abdominal pressure. During the surgery, the patient's end-tidal CO₂ and percutaneous oxygen saturation dropped from approximately 40-20 mmHg and 100-90%, respectively, while the heart rate increased from 60 to 120 beats/min; his blood pressure remained stable. Postoperatively, the patient developed right hemiplegia and aphasia. Brain magnetic resonance imaging showed cerebral infarction in the broad area of the left cerebral cortex. Thereafter, transesophageal echocardiography revealed a patent foramen ovale, suggesting cerebral infarction due to paradoxical gas embolism.

CONCLUSIONS

A patent foramen ovale is found in approximately 15-20% of healthy individuals. While gas embolism is a rare complication of laparoscopic surgery, cerebral infarction must be considered a possible complication even if the intra-abdominal pressure is constant under 10 mmHg with an insufflation management system.

Treatment of hepatic venous system hemorrhage and carbon dioxide gas embolization during laparoscopic hepatectomy via hepatic vein approach

With the improvement of laparoscopic surgery, the feasibility and safety of laparoscopic hepatectomy have been affirmed, but intraoperative hepatic venous system hemorrhage and carbon dioxide gas embolism are the difficulties in laparoscopic hepatectomy. The incidence of preoperative hemorrhage and carbon dioxide gas embolism could be reduced through preoperative imaging evaluation, reasonable liver blood flow blocking method, appropriate liver-breaking device, controlled low-center venous pressure technology, and fine-precision precision operation. In the case of blood vessel rupture bleeding in the liver vein system, after controlling and reducing bleeding, confirm the type and severity of vascular damage in the liver and venous system, take appropriate measures to stop the bleeding quickly and effectively, and, if necessary, transfer the abdominal treatment in time. In addition, to strengthen the understanding, prevention and emergency treatment of severe CO2 gas embolism in laparoscopic hepatectomy is also the key to the success of surgery. This study aims to investigate the methods to deal with hepatic venous system hemorrhage and carbon dioxide gas embolization based on author's institutional experience and relevant literature. We retrospectively analyzed the data of 60 patients who received laparoscopic anatomical hepatectomy of hepatic vein approach for HCC. For patients with intraoperative complications, corresponding treatments were given to cope with different complications. After the operation, combined with clinical experience and literature, we summarized and discussed the good treatment methods in the face of such situations so that minimize the harm to patients as much as possible.

Detection of paradoxical carbon dioxide gas embolism with opening of patent foramen ovale by perioperative transesophageal echocardiography during laparoscopic hepatectomy - A case report -

Background: Due to its various advantages, laparoscopic surgery is preferred over laparotomy in patients who require hepatic resection. Carbon dioxide embolism —which occurs approximately ten times more often in laparoscopic hepatectomy than in general laparoscopic surgery—presents with insignificant symptoms and may be overlooked.Case: A 70-year-old male with hepatic cell carcinoma underwent laparoscopic hepatectomy. Though his vital signs were stable during the initiation of surgery, they became unstable during the procedure. The surgeon detected portal vein rupture, and transesophageal echocardiography was subsequently performed. A large amount of gas in the heart chamber and paradoxical embolism through a patent foramen ovale due to a right-to-left shunt were observed. We treated the symptoms, and the surgery was completed without any further issues.Conclusions: Active use of transesophageal echocardiography to identify and monitor heart functions during a suspected carbon dioxide embolism can significantly reduce morbidity and mortality associated with that embolism.

Impact of AirSeal® insufflation system on respiratory and circulatory dynamics during laparoscopic abdominal surgery

The effect of the AirSeal^® insufflation system on hemodynamic parameters, especially end-tidal carbon dioxide (EtCO₂), during laparoscopic abdominal surgery remains unclear. This retrospective single-center study included 333 consecutive patients who underwent laparoscopic hepatectomy (n = 43), gastrectomy (n = 69), colectomy (n = 137), or proctectomy (n = 84) using the AirSeal^®. Patient demographics and intraoperative hemodynamic parameters, such as EtCO₂, peripheral capillary oxygen saturation (SpO₂), and arterial systolic blood pressure (ABP), were collected and analyzed. EtCO₂ was evaluated during the entire operative period (whole period) as well as the pneumoperitoneum period until specimen removal (pneumoperitoneum period). We defined “positive respiratory and circulatory responses” (positive responses) as a decrease in EtCO₂ ≥ 3 mmHg in addition to decreases in SpO₂ ≥ 3% and ABP ≥ 10 mmHg simultaneously, which suggest possible carbon dioxide (CO₂) embolism. The median EtCO₂ values of hepatectomy, gastrectomy, colectomy, and proctectomy in the whole period/pneumoperitoneum period were 37.3/37.4, 37.1/37.3, 37.4/37.9, and 38.2/38.4 mmHg, respectively. The EtCO₂ of proctectomy was significantly higher than that of gastrectomy during the whole and pneumoperitoneum periods (P < 0.05). In contrast, the EtCO₂ of hepatectomy was comparable to that of the other three surgeries in the whole and pneumoperitoneum periods. Meanwhile, nine (2.7%; eight hepatectomies and one proctectomy) patients showed positive responses, and one who underwent a partial hepatectomy developed a clinically manifested CO₂ embolism. Positive responses occurred during venous exposure or bleeding in all nine cases. Although the EtCO₂ of hepatectomy was comparable to that of the other surgeries using the AirSeal^®, laparoscopic hepatectomy showed a tendency of CO₂ embolism. Thus, a secure and careful surgical approach is mandatory for laparoscopic hepatectomy using the AirSeal^® insufflation system.

Carbon dioxide embolism during transanal total mesorectal excision: A hint of prevention from a case report

Transanal total mesorectal excision is a relatively new approach for treating lower rectal cancer. Carbon dioxide embolism is a critical complication of this procedure. We report the case of a 69-year-old man with lower rectal cancer who underwent transanal total mesorectal excision followed by laparoscopic low anterior resection. He had a sudden intraoperative carbon dioxide embolism during the transanal mesorectal excision. During the ventral dissection of the rectum, end-tidal carbon dioxide and blood oxygen saturation suddenly decreased. We stopped the insufflation of carbon dioxide and suspended the procedure. There was no circulatory collapse, and the vital signs gradually recovered; therefore, we resumed the surgery approximately 30 minutes later and completed it without additional complications. Upon reviewing the video, we found a small injured vein that would aspirate carbon dioxide. These findings suggested that careful hemostasis is essential to prevent carbon dioxide embolus during transanal total mesorectal excision.

Leaping the Boundaries in Laparoscopic Liver Surgery for Hepatocellular Carcinoma

The minimally invasive approach for hepatocellular carcinoma (HCC) had a slower diffusion compared to other surgical fields, mainly due to inherent peculiarities regarding the risks of uncontrollable bleeding, oncological inadequacy, and the need for both laparoscopic and liver major skills. Recently, laparoscopic liver resection (LLR) has been associated with an improved postoperative course, including reduced postoperative decompensation, intraoperative blood losses, length of hospitalization, and unaltered oncological outcomes, leading to its adoption within international guidelines. However, LLR for HCC still faces several limitations, mainly linked to the impaired function of underlying parenchyma, tumor size and numbers, and difficult tumor position. The aim of this review is to highlight the state of the art and future perspectives of LLR for HCC, focusing on key points for overcoming currents limitations and pushing the boundaries in minimally invasive liver surgery (MILS).

Paradoxical carbon dioxide embolism during laparoscopic hepatectomy without intracardiac shunt: A case report

BACKGROUND

Laparoscopic hepatectomy has recently become popular because it results in less bleeding than open hepatectomy. However, CO₂ embolism occurs more frequently. Most CO₂ embolisms during laparoscopic surgery are self-resolving and non-symptomatic; however, severe CO₂ embolism may cause hypotension, cyanosis, arrhythmia, and cardiovascular collapse. In particular, paradoxical CO₂ embolisms are highly likely to cause neurological deficits. We report a case of paradoxical CO₂ embolism found on transesophageal echocardiography (TEE) during laparoscopic hepatectomy, although the patient had no intracardiac shunt.

CASE SUMMARY

A 71-year-old man was admitted for laparoscopic left hemihepatectomy. During left hepatic vein ligation, the inferior vena cava was accidentally torn. We observed a sudden drop in oxygen saturation to 85%, decrease in systolic blood pressure (SBP) below 90 mmHg, and reduction in end-tidal CO₂ to 24 mmHg. A “mill-wheel” murmur was auscultated over the precordium. The fraction of inspired oxygen was increased to 100% with 5 cmH₂O of positive end-expiratory pressure (PEEP) and hyperventilation was maintained. Norepinephrine infusion was increased to maintain SBP above 90 mmHg. A TEE probe was inserted, revealing gas bubbles in the right side of the heart, left atrium, left ventricle, and ascending aorta. The surgeon reduced the pneumoperitoneum pressure from 17 to 14 mmHg and repaired the damaged vessel laparoscopically. Thereafter, the patient’s hemodynamic status stabilized. The patient was transferred to the intensive care unit, recovering well without complications.

CONCLUSION

TEE monitoring is important to quickly determine the presence and extent of embolism in patients undergoing laparoscopic hepatectomy.

Short-term outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma in older patients: a propensity score matching analysis

Background

The incidence of hepatocellular carcinoma (HCC) requiring surgical treatment in older patients has been continuously increasing. This study aimed to examine the safety and feasibility of performing laparoscopic liver resection (LLR) versus open liver resection (OLR) for HCC in older patients at a Japanese institution.

Methods

Between January 2010 and June 2021, 133 and 145 older patients (aged ≥ 70 years) who were diagnosed with HCC underwent LLR and OLR, respectively. Propensity score matching (PSM) analysis with covariates of baseline characteristics was performed. The intraoperative and postoperative data were evaluated in both groups.

Results

After PSM, 75 patients each for LLR and OLR were selected and the data compared. No significant differences in demographic characteristics, clinical data, and operative times were observed between the groups, although less than 10% of cases in each group underwent a major resection. Blood loss (OLR: 370 mL, LLR: 50 mL; P < 0.001) was lower, and the length of postoperative hospital stay (OLR: 12 days, LLR: 7 days; P < 0.001) and time to start of oral intake (OLR: 2 days, LLR: 1 day; P < 0.001) were shorter in the LLR group than in the OLR group. The incidence of complications ≥ Clavien–Dindo class IIIa was similar between the two groups.

Conclusions

LLR, especially minor resections, is safely performed and feasible for selected older patients with HCC.

New 5-mm laparoscopic pneumodissector device to improve laparoscopic dissection: an experimental study of its safety in a swine model

BACKGROUND

To improve the laparoscopic surgical dissection, the aim of the study was to assess the safety of burst of high-pressure CO₂ using a 5-mm laparoscopic pneumodissector (PD) operating at different flow rates and for different operating times regarding the risk of gas embolism (GE) in a swine model.

METHODS

The first step was to define the settings use of the PD device ensuring no GE. Successive procedures were conducted by laparotomy: cholecystectomy, the PD was placed 10 mm deep in the liver and the PD was directly introduced into the lumen of the inferior vena cava. Different PD flow rates of 5, 10, and 15 mL/s were used. The second step was to assess the safety of the device (PD group) during a laparoscopic dissection task (cystic and hepatic pedicles dissection, cholecystectomy and right nephrectomy) in comparison with the use of a standard laparoscopic hook device (control group). PD flow rate was 10 mL/s and consecutive burst of high-pressure CO₂ was delivered for 3-5 s.

RESULTS

In the first step (n = 17 swine), no GE occurred during cholecystectomy regardless of the PD flow rate used. When the PD was placed in the liver or into the inferior vena cava, no severe or fatal GE occurred when a burst of high-pressure CO₂ was applied for 3 or 5 s with PD flow rates of 5 and 10 mL/s. In the second step (PD group, n = 10; control group, n = 10), no GE occurred in the PD group. The use of the PD did not increase operative time or blood loss. The quality of the dissection was significantly improved compared to the control group.

CONCLUSIONS

The 5-mm laparoscopic PD appears to be free from CO₂ GE risk when consecutive bursts of high-pressure CO₂ are delivered for 3-5 s with a flow rate of 10 mL/s.

Gas embolism under standard versus low pneumoperitoneum pressure during laparoscopic liver resection (GASES): study protocol for a randomized controlled trial

Background

Gas embolism induced by CO₂ pneumoperitoneum is commonly identified as a risk factor for morbidity, especially cardiopulmonary morbidity, after laparoscopic liver resection (LLR) in adults. Increasing pneumoperitoneum pressure (PP) contributes to gas accumulation following laparoscopy. However, few studies have examined the effects of PP in the context of LLR. In LLR, the PP-central venous pressure (CVP) gradient is increased due to hepatic vein rupture, hepatic sinusoid exposure, and low CVP management, which together increase the risk of CO₂ embolization. The aim of this study is to primarily determine the role of low PP (10 mmHg) on the incidence of severe gas embolism.

Methods

Adult participants (n = 140) undergoing elective LLR will be allocated to either a standard (15 mmHg) or low (10 mmHg) PP group. Anesthesia management, postoperative care, and other processes will be performed similarly in both groups. The occurrence of severe gas embolism, which is defined as gas embolism ≥ grade 3 according to the Schmandra microbubble method, will be detected by transesophageal echocardiography (TEE) and recorded as the primary outcome. The subjects will be followed up until discharge and followed up by telephone 1 and 3 months after surgery. Postoperative outcomes, such as the Post-Operative Quality of Recovery Scale, pain severity, and adverse events, will be assessed. Serum cardiac markers and inflammatory factors will also be assessed during the study period. The correlation between intraoperative inferior vena cava-collapsibility index (IVC-CI) under TEE and central venous pressure (CVP) will also be explored.

Discussion

This study is the first prospective randomized clinical trial to determine the effect of low versus standard PP on gas embolism using TEE during elective LLR. These findings will provide scientific and clinical evidence of the role of PP.

Trial status

Protocol version: version 1 of 21-08-2020

Trial registration

ChiCTR2000036396 (http://www.chictr.org.cn). Registered on 22 August 2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05678-8.

Maturation of robotic liver resection during the last decade: A systematic review and meta-analysis

BACKGROUND

Minimally invasive hepatectomy techniques have developed rapidly since 2000. Pure laparoscopic liver resection (LLR) has become the primary approach for managing liver tumors and procuring donor organs for liver transplantation. Robotic liver resection (RLR) has emerged during the last decade. The technical status of RLR seems to be improving.

AIM

To conduct a systematic review and meta-analysis comparing the short-term clinical outcomes of LLR and RLR over two 5-year periods.

METHODS

A systematic literature search was performed using PubMed and Medline, including the Cochrane Library. The following inclusion criteria were set for the meta-analysis: (1) Studies comparing LLR vs RLR; and (2) Studies that described clinical outcomes, such as the operative time, intraoperative bleeding, intraoperative conversion rate, and postoperative complications.

RESULTS

A total of 25 articles were included in this meta-analysis after 40 articles had been subjected to full-text evaluations. The studies were divided into early (n = 14) and recent (n = 11) groups. In the recent group, the operative time did not differ significantly between LLR and RLR (P = 0.70), whereas in the early group the operative time of LLR was significantly shorter than that of RLR (P < 0.001).

CONCLUSION

The initial disadvantages of RLR, such as its long operation time, have been overcome during the last 5 years. The other clinical outcomes of RLR are comparable to those of LLR. The cost and quality-of-life outcomes of RLR should be evaluated in future studies to promote its routine clinical use.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Morphologic Change of In Vivo Porcine Liver Under 13 mm Hg Pneumoperitoneum Pressure

BACKGROUND

Clinically, the total and residual liver volume must be accurately calculated before major hepatectomy. However, liver volume might be influenced by pneumoperitoneum during surgery. Changes in liver volume change also affect the accuracy of simulation and augmented reality navigation systems, which are commonly first validated in animal models. In this study, the morphologic changes in porcine livers in vivo under 13 mm Hg pneumoperitoneum pressure were investigated.

MATERIALS AND METHODS

Twenty male pigs were scanned with contrast-enhanced computed tomography without pneumoperitoneum and with 13 mm Hg pneumoperitoneum pressure.

RESULTS

The surface area and volume of the liver and the vascular diameter of the aortic lumen, inferior vena cava lumen, and portal vein lumen were measured. There were statistically significant differences in the surface area and volume of the liver (P=0.000), transverse diameter of the portal vein (P=0.038), longitudinal diameter of the inferior vena cava (P=0.033), longitudinal diameter of the portal vein (P=0.036), vascular cross-sectional area of the inferior vena cava (P=0.028), and portal vein (P=0.038) before and after 13 mm Hg pneumoperitoneum pressure.

CONCLUSIONS

This study indicated that the creation of pneumoperitoneum at 13 mm Hg pressure in a porcine causes liver morphologic alterations affecting the area and volume, as well as the diameter of a blood vessel.

Comparative analysis of vascular bulldog clamps used in laparoscopic liver resection

To compare the clinical effect of Bulldog clamps with traditional Pringle for vascular occlusion during laparoscopic hepatectomy.One hundred ten patients were retrospectively investigated in this research from December 2014 to January 2019 in the second hospital of Anhui Medical University, who underwent laparoscopic liver resection using Bulldog (modified group, n = 54) and cotton tourniquet (traditional group, n = 56) for blocking the liver inflow-blood. Intraoperative blood loss, duration of the operation time, clamping time, postoperative outcomes were analyzed.All the operations were accomplished successfully without conversion to laparotomy, perioperative period clinical date was calculated. Intraoperative operative time, blood loss and resection sections had no statistical significance, but the clamping time (36.2 ± 5.6 vs 277.3 ± 88.4 s, P < .001) was significantly shorter in the bulldog group. Albumin, alanine aminotransferase, aspartate aminotransferase and serum total bilirubin had no statistical differences in postoperative day (POD) 1and 3, but POD 5 alanine aminotransferase (71.0 ± 46.8vs 105.8 ± 61.7IU/L P = .018) and aspartate aminotransferase (72.8 ± 39.7 vs 100.2 ± 16.7 IU/L P = .028). The postoperative hospital stays (7.02 ± 1.56 vs 8.50 ± 2.35 days P = .026) in bulldog group were lower than cotton group and differences had statistical significance. The C-reactive protein levels were significantly higher in the traditional group than in the modified group on POD 3 (46.3 ± 19.2 vs 57.7 ± 23.9 mg/L P = .019), and POD5 (13.3 ± 4.2 vs 17.5 ± 7.3 mg/L P = .001). There were 8 postoperative complications occurred in cotton group, while there was 5 in Bulldog group, all patients with complications were discharged after adequate drainage and symptomatic treatment.Bulldog is an effectively performed approach for vascular occlusion during laparoscopic hepatectomy than traditional Pringle maneuver.

Paradoxical carbon dioxide embolism during laparoscopic surgery without intracardiac right-to-left shunt: two case reports and a brief review of the literature

We herein report two cases of paradoxical carbon dioxide (CO₂) embolism during laparoscopic nephrectomy and hepatic left lateral lobectomy without evidence of a right-to-left shunt or obvious rupture of blood vessels. Transesophageal echocardiography detected paradoxical CO₂ embolism before the end-tidal CO₂ partial pressure (P_ETCO₂) dropped from baseline. The pneumoperitoneum was reduced or stopped immediately after detection of the embolism. One patient developed a postoperative epileptiform seizure. In the other patient, many gas bubbles were drawn out from the central venous line. We speculate that rapid introduction of pneumoperitoneum pushed a large amount of CO₂ into the abdominal blood vessels, exceeding the gas exchange capacity of the lung and causing CO₂ bubble formation in the left-side cardiac system. These two cases indicate that intraoperative transesophageal echocardiography can reduce the influence of CO₂ embolism during laparoscopic tumor surgery by early diagnosis of the embolism and provide helpful information to establish a list of differential diagnoses of postoperative complications.

Does Chemotherapy-Induced Liver Injury Impair Postoperative Outcomes After Laparoscopic Liver Resection for Colorectal Metastases?

BACKGROUND

Chemotherapy-associated liver injuries (CALI) have been associated with poor postoperative outcome after open liver resection. To date, no data concerning any correlation of CALI and laparoscopic liver resection (LLR) are available. In the present study, we evaluated the impact of CALI on short-term outcomes in patients undergoing LLR.

MATERIALS AND METHODS

All patients who underwent in our department LLR for colorectal liver metastases (CRLM) from 2000 to 2016 were retrospectively reviewed. Patients were divided in 4 groups according to their pathological histology. In group 1 patients had normal liver parenchyma. Group 2 included patients with steatosis and steatohepatitis. Patients with sinusoidal obstruction syndrome (SOS) and nodular regenerative hyperplasia (NRH) were allocated to group 3, whereas the remaining with fibrosis and cirrhosis, were assigned to group 4.

RESULTS

A total of 490 LLR for CRLM were included in the study. Perioperative details and morbidity did not differ significantly between the four groups. Subgroup analysis showed that NRH was associated with higher amount of blood loss (p = 0.043), overall (p = 0.021) and liver-specific morbidity (p = 0.039).

CONCLUSION

NRH is a severe form of CALI that may worsen the short-term outcomes of patients undergoing LLR for CRLM. However, the remaining forms of CALI do not have a significant impact on perioperative outcomes after LLR.

Current status of radical laparoscopy for treating hepatocellular carcinoma with portal hypertension

The laparoscopic technique is clinically effective in treating hepatocellular carcinoma (HCC) with portal hypertension (PHT). However, existing studies lack systematic arrangement and induction. Here, we review the latest research advancement in laparoscopic technique for treatment of HCC with PHT, based on published literature and our single-institution experience. Our single-center experience reveals no statistical difference in both short- and long-term prognosis of HCC patients after laparoscopic liver resection (LLR), regardless of whether they suffer from PHT, which is consistent with previous studies on the use of LLR for HCC with PHT. Retrieval outcomes indicate existence of short- and long-term prognostic superiority, following laparoscopic treatment, relative to non-laparoscopic treatment. Besides that, LLR offers long-term prognostic advantage compared to laparoscopic radiofrequency ablation. In addition, we review the previous literature and propose corresponding perspectives on the therapy of hypersplenism, the utilization of Pringle maneuver, and the adoption of anatomical hepatectomy during radical laparoscopic treatment. HCC with PHT is not the "forbidden zone" of radical laparoscopic treatment. However, patients’ preoperative liver function should be adequately estimated.

Sonographic findings of hepatic venous gas in association with spontaneous rupture of a Klebsiella pneumoniae liver abscess: a case report

Hepatic venous gas (HVG) is a very rare ultrasonic finding, and it is defined as abnormal accumulation of gas in the hepatic venous system. Various diseases can cause HVG, and femoral venous catheter is the most common cause. We, herein, present the case of a 79-year-old female patient with HVG that was caused by spontaneous rupture of a Klebsiella pneumoniae liver abscess. This was first found by bedside ultrasonography. On the basis of the blood culture results, imipenem-cilastatin and cefoperazone sulbactam were administered and the effect was acceptable. After 41 days of antibacterial and symptomatic treatment in the hospital, the patient had recovered well and was discharged. All of the previous reports on HVG have been summarized by thoroughly reviewing the previous published work. Overall, this is the first patient with HVG in association with spontaneous rupture of a K. pneumoniae liver abscess, and it might provide insights for future studies regarding the treatment of this disease.

Emphysematous pyelonephritis with air bubble in the inferior vena cava

Background

Emphysematous pyelonephritis (EPN) with gas in the inferior vena cava (IVC) is a rare presentation and to our knowledge, this is the first case report in the urologic literature.

Case presentation

A 35-Year-old obese diabetic Hispanic female presented to the emergency room with a clinical picture of septic shock. Prompt computerized tomography scan revealed EPN with gas throughout the right renal parenchyma and extending to the right renal vein, IVC, and pulmonary artery. She died before surgical intervention

Conclusion

This case demonstrates that patients presenting with severe EPN have a high mortality risk and providers should acknowledge that septic shock, endogenous air emboli, or a combination of both could result in cardiovascular collapse and sudden death.

Laparoscopic major liver resections: Current standards

Laparoscopic liver resection was slow to be adopted in the surgical arena at the beginning as there were major barriers including the fear of gas embolism, risk of excessive blood loss from the inability to control bleeding vessels effectively, suboptimal surgical instruments to perform major liver resection and the concerns about oncological safety of the procedure. However, it has come a long way since the early 1990s when the first successful laparoscopic liver resection was performed, spurring liver surgeons worldwide to start exploring the roles of laparoscopy in major liver resections. Till date, more than 9000 cases have been reported in the literature and the numbers continue to soar as the hepatobiliary surgical communities quickly learn and apply this technique in performing major liver resection. Large bodies of evidence are available in the literature showing that laparoscopic major liver resection can confer improved short-term outcomes in terms of lesser operative morbidities, lesser operative blood loss, lesser post-operative pain and faster recovery with shorter length of hospitalization. On the other hand, there is no compromise in the long-term and oncological outcomes in terms of comparable R₀ resection rate and survival rates of this approach. Many innovations in laparoscopic major hepatectomies for complex operations have also been reported. In this article, we highlight the journey of laparoscopic major hepatectomies, summarize the technical advancement and lessons learnt as well as review the current standards of outcomes for this procedure.

Cerebral carbon dioxide embolism after kidney cancer laparoscopic surgery with full neurological recovery: A case report

RATIONALE

Cerebral carbon dioxide embolism (CCDE) is a rare cause of stroke and is a recognized life-threatening complication.CCDE may result from direct intravascular CO2 insufflation during surgery. Due to the lack of typical clinical manifestations, the disease is often missed or mistaken for another condition. The clinical signs and symptoms depend on the speed and volume of embolized gas entering the blood and the patient's condition. In particular, patent foramen ovale has been found to be associated, in rare cases, with the intraoperative entry of gas into the arterial system.

PATIENT CONCERNS

In this report, we present the case of a 35-year-old woman with kidney cancer who underwent laparoscopic right partial nephrectomy.

DIAGNOSIS

After the laparoscopic surgery, the patient was initially diagnosed with acute cerebral infarction.

INTERVENTIONS

The patient was treated according to the standard method for treatment of acute cerebrovascular disease.

OUTCOMES

Three days after the laparoscopic procedure, the patient gained consciousness, and she was discharged without any neurologic sequelae on postoperative day 12.

LESSONS SUBSECTIONS AS PER STYLE

Due to the low incidence and sudden occurrence of CCDE, there is a strong likelihood of missed diagnosis or misdiagnosis, and it is; therefore, important to be aware of the risk. The findings from this report would be highly useful as a reference to clinicians in the future.

Laparoscopic Liver Resection: A South American Experience with 2887 Cases

BACKGROUND

Laparoscopic liver resections (LLR) have been increasingly performed in recent years. Most of the available evidence, however, comes from specialized centers in Asia, Europe and USA. Data from South America are limited and based on single-center experiences. To date, no multicenter studies evaluated the results of LLR in South America. The aim of this study was to evaluate the experience and results with LLR in South American centers.

METHODS

From February to November 2019, a survey about LLR was conducted in 61 hepatobiliary centers in South America, composed by 20 questions concerning demographic characteristics, surgical data, and perioperative results.

RESULTS

Fifty-one (83.6%) centers from seven different countries answered the survey. A total of 2887 LLR were performed, as follows: Argentina (928), Brazil (1326), Chile (322), Colombia (210), Paraguay (9), Peru (75), and Uruguay (8). The first program began in 1997; however, the majority (60.7%) started after 2010. The percentage of LLR over open resections was 28.4% (4.4-84%). Of the total, 76.5% were minor hepatectomies and 23.5% major, including 266 right hepatectomies and 343 left hepatectomies. The conversion rate was 9.7%, overall morbidity 13%, and mortality 0.7%.

CONCLUSIONS

This is the largest study assessing the dissemination and results of LLR in South America. It showed an increasing number of centers performing LLR with the promising perioperative results, aligned with other worldwide excellence centers.

Laparoscopic image of carbon dioxide embolism during laparoscopic hepatectomy: a case report

Background

Carbon dioxide embolism is a life-threatening complication of laparoscopic hepatectomy.

Case presentation

A 59-year-old man was admitted for laparoscopic hepatectomy. Approximately 5 h after commencing the operation, we observed a gradual decline in the SpO₂ from 100 to 94%, reduction in the ETCO₂ from 44 to 19 mmHg, reduction in the systolic blood pressure from 100 to 82 mmHg, and elevation of the heart rate from 82 to 120 beats/min. Intraoperatively, the image displayed on the laparoscopic monitor revealed a small tear in the vein. The inspired O₂ fraction was raised to 1.0, intravenous phenylephrine (0.1 mg bolus) was administered, and the respiratory rate was increased. After the patient was stabilized, the injured vein was cut and sealed. After the embolic event, the entire operation was completed without complications.

Conclusions

Careful observation of the laparoscopic monitor is important, particularly during establishment of pneumoperitoneum in patients undergoing laparoscopic hepatectomy.

Endotracheal administration for intraoperative acute massive pulmonary embolism during laparoscopic hepatectomy: A case report

INTRODUCTION

Acute pulmonary embolism (APE) during an operation is a very urgent occurrence, especially when the patient with hemodynamic instability. Generally, drugs are administered intravenously; however, these drugs have little effects under most circumstances. We present a case of successful resuscitation in a patient with endotracheal administration.

PATIENT CONCERNS

A 67-year-old female presented for laparoscopic hepatectomy. Acute pulmonary gas embolism occurred during the operation with hemodynamic instability. The total amount of carbon dioxide and argon reached 300 mL. We used a novel way of administering drugs instead of intravenous administration for rescuing and the patient condition had improved greatly and was discharged from the hospital without any neurological deficits.

DIAGNOSES

A diagnosis of APE was made because of a lot of gas was extracted out from central venous catheter and sudden observable decrease in end-tidal CO2.

INTERVENTIONS

These measures included endotracheal administration, position adjustment, manual ventilation, and gas extraction.

OUTCOMES

The patient was discharged from the hospital and had no signs of neurological deficits.

CONCLUSION

Intravenous administration may not the best appropriate way of administration when patients occurred APE. Endotracheal administration as a unique method may work wonders and has the value of research and application.

Cerebral infarction detected after laparoscopic partial hepatectomy: case report

Background

Bleeding and carbon dioxide (CO₂) gas embolism have been reported as serious complications associated with laparoscopic surgery. We present a case of cerebral infarction presumably caused by CO₂ gas embolism during laparoscopic hepatectomy.

Case presentation

During liver resection, the end-tidal CO₂ suddenly dropped from 40 to 21 mmHg. Simultaneously, ST elevation in lead II and ST depression in lead V5 of the electrocardiogram were observed. After improvement of these electrocardiographic changes, surgery was continued. Postoperatively, incomplete paralysis was present in the right arm and leg. Magnetic resonance imaging revealed cerebral infarction in the broad area of the left cerebral cortex. These complications might have been caused by paradoxical embolism.

Conclusion

We should always keep in mind the risk of cerebral infarction with neurological deficits in the case of laparoscopic surgery. Careful monitoring and appropriate treatment for gas embolism are necessary during laparoscopic surgery.

Laparoscopic Versus Open Liver Resection for Benign Tumors and Lesions: A Case Matched Study with Propensity Score Matching

Background and Aim: In recent years, minimally invasive surgical approaches have gained an increasingly important role in hepatobiliary surgery. The aim of this study was to investigate the safety and potential benefits of laparoscopic liver resection (LLR) compared with open liver resection (OLR) for benign liver tumors and lesions. Patients and Methods: Between January 2009 and December 2017, 182 patients underwent liver resection for benign liver tumors and lesions at our center. After exclusion of 15 patients, the remaining 167 patients were divided into LLR group (n = 54) and OLR group (n = 113) and were compared with regard to perioperative outcomes. To overcome selection bias, a 1:1 propensity score matching (PSM) was performed. In addition, patients undergoing major hepatectomy were divided into major-LLR and major-OLR groups and perioperative outcomes evaluated. Results: After PSM, 35 patients were included in the OLR group and 35 patients in the LLR group. The LLR group had a significantly shorter median intensive care unit (ICU) stay (LLR: 1 [0-4] days; OLR: 1 [0-3] days; P = .009) and median hospital stay (length of stay [LOS]) (LLR: 7 [4-14] days; OLR: 10 [5-16] days; P < .001). There were no statistically significant differences in postoperative complications graded as Clavien-Dindo ≥III (LLR: 11.4%; OLR: 2.9%; P = .375) in both groups. Postoperative 90-day mortality was 0% in both groups. When comparing major-LLR (n = 8) with major-OLR (n = 59), patients in the major-LLR group had a significantly longer median operation time (major-LLR: 403 [240-501] minutes; major-OLR: 221.5 [111-529] minutes; P < .001), but a significantly shorter median LOS (major-LLR: 7 [5-14] days; major-OLR: 9 [7-129] days; P = .013). The rate of major complications (Dindo Classification ≥III) for major-LLR was 0% and for major-OLR it was 16.9% (P = .207). Conclusion: Our case-matched study demonstrates shorter ICU and hospital stay using laparoscopic techniques while maintaining high-quality perioperative outcomes. Based on our findings, we suggest preferring the LLR over OLR for benign liver tumors and lesions regardless of the resection extent.

An abnormal capnography trace due to air embolism in the lateral position

Venous air embolism occurs when air is entrained into the venous system and travels to the right heart and pulmonary circulation, and commonly occurs as a complication in laparoscopic, neurosurgical and cardiac surgeries. We present a case of abnormal end-tidal carbon dioxide capnography tracing in the lateral position in a laparoscopic major liver procedure and discuss the potential novel use of this as a red flag in aiding the medical practitioner to diagnose air embolism.

Massive Carbon Dioxide Embolism During Laparoscopic Liver Resection: A Case Report

Carbon dioxide embolism during laparoscopic surgery is a serious and life-threatening complication. The overall incidence of embolism during laparoscopic surgery is low (0.15%). Although the potential fatal consequences of this complication are reported in literature, a well-documented report of the effect of massive CO2 embolism during laparoscopic liver resection on cardiovascular, respiratory and encephalographic parameters does not exist. The authors describe a well-documented case of massive carbon dioxide embolism during laparoscopic liver resection suspected by both hemodynamic instability and elevation of EtCO2 and confirmed by arterial blood gas. The surgeon's rapid closure of the vascular breach resulted in an overall improvement of the patient's vital signs without further consequences. Our case report shows the cardiovascular, respiratory and encephalographic effects of a massive carbon dioxide embolism and highlights the importance of a strict cooperation between the surgeon and the anesthesiologist and the importance for a prompt treatment when massive carbon dioxide embolism occurs.

Current Status of Laparoscopic Hepatectomy

Before the first laparoscopic hepatectomy (LH) was described in 1991, open hepatectomy (OH) was the only choice for surgical treatment of liver tumors. LH indications were initially based solely on tumor location, size, and type. Use of LH has spread rapidly worldwide because it reduces incision size. This review systematically assesses the current status of LH. As compared with OH, LH is significantly less complicated, requires shorter hospital stays, and results in less blood loss. The long-term survival rates of LH and OH are comparable. Development of new techniques and instruments will improve the conversion rate and reduce complications. Furthermore, development of surgical navigation will improve LH safety and efficacy. Laparoscopic major hepatectomy for HCC remains a challenging procedure and should only be performed by experienced surgeons. In the near future, a training system for young surgeons will become mandatory for standardization of LH, and LH will likely become better standardized and have broader applications.

Developments and perspectives of laparoscopic liver resection in the treatment of hepatocellular carcinoma

Laparoscopic liver resection (LLR) was introduced in the early 1990s, initially for partial resection of the anterolateral segments, from where it has expanded in a stepwise fashion. Movement restriction makes bleeding control demanding. Managing pneumoperitoneum pressure with inflow control can inhibit venous bleeding and create a dry surgical field for easier hemostasis. Since the lack of overview leads to disorientation, simulation and navigation with imaging studies have become important. Improved direct access to the liver inside the rib cage can be obtained in LLR, reducing destruction of the associated structures and decreasing the risk of refractory ascites and liver failure, especially in patients with a cirrhotic liver. Although LLR can be performed as bridging therapy to transplantation for severe cirrhosis, its impact on expanding the indications of liver resection (LR) and the consequent survival benefits must be evaluated. For repeat LR, LLR is advantageous by producing fewer adhesions and reducing the need for adhesiolysis. The laparoscopic approach facilitates better access in a small operative field between adhesions. Further evaluations are needed for repeat anatomical resection, since alterations of the anatomy and surrounding scars and adhesions of major vessels have a larger impact.

Laparoscopic liver resection: a review of current indications and surgical techniques

Laparoscopic liver resection (LLR) has been the most impressive development in the field of liver surgery in recent two decades. Technical innovations and experience accumulation have made LLR a safe and effective procedure with faster postoperative recovery. Despite the fast spreading of the procedure, details regarding the indications, oncological outcomes and technical essentials were still disputable. To address these issues, two international consensus conferences were hold to update the knowledge in this field. The statements of the both conferences were not conclusive and more high-quality researches are required. In this article, we reviewed the development and the current state of LLR. Indications, outcomes, surgical techniques and devices used in LLR were also discussed.

Laparoscopic Versus Open Liver Resection for Difficult Lesions: A Meta-Analysis

Background: The value of laparoscopic liver resection (LLR) for difficult lesions (located in segments I, IVa, VII, and VIII) is still controversial nowadays. The aim of this study was to summarize quantitatively the evidence related to this issue. Materials and Methods: Two investigators independently searched the Medline, Embase, Science Citation Index Expanded, and Cochrane Library databases for eligible studies published before December 2017. The RevMan 5.3 software was utilized for statistical meta-analysis. Weighted mean differences (WMDs) and odds ratios (ORs) were calculated for continuous and dichotomous variables, respectively. Results: Five studies with a total number of 638 patients were included in the present meta-analysis, with 274 patients in the LLR group and 364 in the open liver resection (OLR) group. The LLR did not increase the operative time (WMD 12.42 minutes; 95% confidence interval [CI] -8.54 to 33.38 minutes; P = .25) or blood transfusion requirement (OR 0.81; 95% CI 0.40-1.64; P = .57) compared with OLR. Conversely, LLR was associated with significantly lower intraoperative blood loss (WMD -140.57 mL; 95% CI -203.39 to -77.76 mL; P < .001), shorter hospital stay (WMD -2.88 days; 95% CI -4.84 to -0.92 days; P = .004), and lower overall morbidity (OR 0.43; 95% CI 0.28-0.65; P < .001). The oncologic outcomes of R0 resection rate, surgical margin, and tumor recurrence were comparable in the two groups. Conclusion: LLR for difficult lesions in selected patients is safe, technically feasible, and advantageous when performed by experienced surgeons.

Randomized clinical trial comparing the effects of sevoflurane and propofol on carbon dioxide embolism during pneumoperitoneum in laparoscopic hepatectomy

Laparoscopic hepatectomy carries a high risk of gas embolism due to the extensive hepatic transection plane and large hepatic vena cava. Here, we compared the influence of inhaled and intravenous anesthetics on gas embolism during laparoscopic hepatectomy. Fifty patients undergoing laparoscopic hepatectomy were divided into two groups to receive sevoflurane anesthesia (group S, n = 25) or intravenous propofol anesthesia (group p, n = 25). During the operation, gas emboli were detected by transesophageal echocardiography and graded according to their size. Venous CO₂ emboli were detected in all patients, and the embolism grades did not differ between the two groups. However, the mean embolism episode duration was longer in group S than group P (51.24±23.59 vs. 34.00±17.13 sec, p < 0.05). At the point of the most severe gas embolism, the PT_CO2 was higher in group S than group p (44.00±4.47 vs. 41.36±2.77 mmHg, p < 0.05), while the PO₂/FiO₂ (450.52±54.08 vs. 503.80±63.18, p < 0.05) and pH values (7.35±0.05 vs. 7.38±0.02, p < 0.05) were lower in group S than group P. Patients with a history of abdominal surgery or liver cirrhosis had higher gas embolism grades. Thus volatile anesthetics may lengthen the duration of embolism episodes and worsen hemodynamics and pulmonary blood gas exchange during surgery.

Posttraumatic venous gas in the liver - a case report and review of the current literature

Background

There are numerous causes of hepatic gas formation that range from serious pathologies to incidental findings, including mesenteric infarction, liver abscess, inflammatory bowel disease or minimally invasive hepatic interventions.

Case presentation

We report a case of a 50-year-old man who was admitted to the emergency room after a car accident. The clinical examination and further diagnostics revealed a craniocerebral injury with a fracture of the skull, concomitant soft tissue lesions and subarachnoidal bleeding. Furthermore, a blunt thoracic trauma with hemopneumothorax due to rib fractures was treated with a chest tube. No obvious abdominal pathology was seen. While in the operating theatre for the surgical revision of the cranial soft tissue lesions, a femoral venous catheter was inserted without any complications. A routine ultrasound of the abdomen six hours after the trauma revealed unclear hepatic gas formation. A contrast-enhanced computer tomography (CT) scan of the abdomen was performed, and the gas formation was found to be localized within the left hepatic vein. Afterwards, there was no specific treatment of the hepatic venous gas formation, as no alterations of liver function or liver enzymes were seen. The further course of the patient was uneventful regarding the gas formation in the liver, and another ultrasound two days later revealed no further gas in the liver.

Conclusions

The placement of a femoral venous catheter is a risk factor for gas formation in liver veins. No further treatment is needed in cases with stable liver function. To rule out serious pathologies, diagnostic findings (e.g., ultrasound, CT), clinical history and underlying diseases need to be analyzed carefully after the detection of intrahepatic gas formation. With contrast-enhanced CT, the localization of the gas and its potential causes might be detectable.