The liver hanging maneuver in laparoscopic liver resection: a systematic review. Surg Today. 2018;48:18-24. [PMID: 28365891 DOI: 10.1007/s00595-017-1520-z]

Liver hanging maneuver is suitable in major hepatectomy for liver malignancies over 5 cm

Objectives

Hepatic transection through an anterior approach is required to successfully complete anatomical hepatectomy for large liver malignancies. The liver hanging maneuver (LHM) is an alternative procedure for transection on an adequate cut plane and may reduce intraoperative bleeding and transection times.

Material and Methods

We examined the medical records of 24 patients with large liver malignancies (>5 cm) who had undergone anatomical hepatic resection with LHM (n= 9) or without LHM (n= 15) between 2015 and 2020. Patient demographics, preoperative hepatic function, surgical records, and post-hepatectomy outcomes were retrospectively compared between the LHM and non-LHM groups.

Results

The prevalence of tumors >10 cm was significantly higher in the LHM group than in the non-LHM group (p <0.05). Furthermore, LHM was significantly performed to right and extended right hepatectomies in the background normal liver (p <0.05). Although transection times did not significantly differ between the two groups, the amount of intraoperative blood loss was slightly lower in the LHM group than in the non-LHM group (1.566 mL vs. 2.017 mL), and blood transfusion was not needed for patients in the LHM group. Post-hepatectomy liver failure and bile leakage were not observed in LHM. However, the length of hospitalization was slightly shorter in the LHM group than in the non-LHM group.

Conclusion

LHM is useful for transecting an adequately cut plane in hepatectomy for liver tumors over 5 cm-in-size located on the right side and achieves better outcomes.

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

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Effectiveness of surgical resection for complicated liver cancer and its influencing factors: A retrospective study

BACKGROUND

Surgical resection is the preferred method for patients with complex liver cancer. But the tumor is in a special position, the surgery is highly risky, postoperative complications can easily occur, and the prognosis is not ideal.

AIM

To investigate the effectiveness of surgical resection for complex liver cancer and its influencing factors.

METHODS

Fifty-seven patients who had complicated liver cancer and underwent surgical resection at our hospital from August 2015 to August 2016 were enrolled in this study. All patients were followed for three years, and their postoperative complications, survival, and factors that impacted their survival were analyzed.

RESULTS

The total incidence of postoperative complications was 45.61%, and the incidence of pleural effusion was the highest at 28.07%. There were no correlations between the 2-year and 3-year survival rates and sex, age, and HbsAg of the patients (P > 0.05). In terms of pathological parameters, the 2-year and 3-year survival rates were significantly different according to the presence of a tumor capsule, degree of liver cirrhosis, satellite or focal lesions, hepatic vein thrombosis, portal vein tumor thrombus, and intraoperative blood loss (P < 0.05).

CONCLUSION

The effectiveness of surgical resection for complex hepatocellular carcinoma may be affected by factors such as the presence of a tumor capsule, cirrhosis degree, satellite or focal lesions, hepatic vein embolization, portal vein tumor thrombus, and intraoperative blood loss. Therefore, these factors should be controlled and prevented during surgery to help improve patient survival after surgery.

Short-term Outcomes of Laparoscopic vs. Open Hepatectomy for Primary Hepatocellular Carcinoma: A Prospective Comparative Study

Laparoscopic hepatectomy (LH) is a newly developed technique associated with advantages as open surgery, but the study on outcome of liver function recovery was scarce. This preliminary report was aimed to comparatively assess the short-term outcomes between LH and open hepatectomy (OH) for primary hepatocellular carcinoma (PHC). This study retrospectively analyzed the demographic data and short-term outcomes of 81 patients who underwent LH or OH for the primary treatment of PHC between Oct. 2017 and May 2018 at Union Hospital, Tongji Medical College, Huazhong University of Science and Technology (China). A total of 81 PHC patients who received major liver resection were enrolled. There were 38 (47%) patients in the LH group and 43 (53%) patients in the OH group. The operative time was significantly longer (373.53±173.38 vs. 225.43±55.08, P<0.01), and hospital stay (17.34±5.93 vs. 21.70±6.89, P=0.003), exhaust time (2.32±0.62 vs. 3.07±0.59, P<0.01) and defecation time (2.92±0.78 vs. 3.63±0.58, P<0.01) were significantly shorter in LH group than in OH group. The recovery of liver function was significantly faster in LH group, including higher serum albumin (P=0.002), higher ratio of albumin/globulin (P=0.029) and lower direct bilirubin (P=0.001) than in OH group. It is suggested that LH can serve as a fast recovery and cheap surgical procedure in the treatment of PHC, which is safe and feasible.

Liver hanging maneuver versus conventional approach for open hepatectomy: a meta-analysis

BACKGROUND

This study aimed to compare the safety and efficacy of the liver hanging maneuver (LHM) versus conventional approach for open hepatectomy.

METHODS

A comprehensive medical literature search was performed. Perioperative outcomes and long-term survival outcomes were reported. Subgroup analyses were conducted according to surgical approaches, modification of LHM, geographical region and indications for liver resection.

RESULTS

A total of 16 studies including 1109 patients were enrolled. The LHM was performed on 471 (37%) patients. The pooled outcomes showed hepatectomy with the LHM was associated with less estimated blood loss [standard mean difference (SMD): -0.77, P < 0.001], lower intraoperative transfusion rate [odds ratio (OR): 0.28, P = 0.003], less transection time (SMD: -0.68, P = 0.01), shorter duration of hospitalization (SMD:-0.19, P = 0.004), lower total complication rate (OR: 0.63, P = 0.008) and longer overall survival [hazard ration (HR): 0.70, P = 0.002] compared to conventional open hepatectomy. Subgroup analyses showed similar outcomes to overall analyses.

CONCLUSIONS

The present meta-analysis suggested that the LHM was a safe and feasible alternative to conventional open hepatectomy with better perioperative and long-term outcomes. It was unnecessary to combine the LHM with anterior approach (AA) in consideration of perioperative outcomes.

Useful maneuvers for precise laparoscopic liver resection

Laparoscopic liver resection has evolved over the past decade and nearly replaced open exploration. This procedure not only provides comparable oncological outcomes, but it also has improved recovery after surgery. Many of the challenges presented by limitations of instruments and techniques have been overcome through adaptations and new developments, and it is possible that the remaining obstacles will be overcome within a few years. Moreover, as surgeons continue to gain experience, their technical knowledge has supported further improvement in minimally invasive approaches. This review examines every important procedures in performing a precise laparoscopic liver resection.