Non-cirrhotic liver tolerance to intermittent inflow occlusion during laparoscopic liver resection

International consensus statement on robotic hepatectomy surgery in 2018

The robotic surgical system has been applied in liver surgery. However, controversies concerns exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness of robotic surgery. To promote the development of robotic hepatectomy, this study aimed to evaluate the current status of robotic hepatectomy and provide sixty experts’ consensus and recommendations to promote its development. Based on the World Health Organization Handbook for Guideline Development, a Consensus Steering Group and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 22 topics were prepared analyzed and widely discussed during the 4 meetings. Based on the published articles and expert panel opinion, 7 recommendations were generated by the GRADE method using an evidence-based method, which focused on the safety, feasibility, indication, techniques and cost-effectiveness of hepatectomy. Given that the current evidences were low to very low as evaluated by the GRADE method, further randomized-controlled trials are needed in the future to validate these recommendations.

Robot-assisted versus open liver resection in the right posterior section

BACKGROUND

Open liver resection is the current standard of care for lesions in the right posterior liver section. The objective of this study was to determine the safety of robot-assisted liver resection for lesions located in segments 6 and 7 in comparison with open surgery.

METHODS

Demographics, comorbidities, clinicopathologic characteristics, surgical treatments, and outcomes from patients who underwent open and robot-assisted liver resection at 2 centers for lesions in the right posterior section between January 2007 and June 2012 were reviewed. A 1:3 matched analysis was performed by individually matching patients in the robotic cohort to patients in the open cohort on the basis of demographics, comorbidities, performance status, tumor stage, and location.

RESULTS

Matched patients undergoing robotic and open liver resections displayed no significant differences in postoperative outcomes as measured by blood loss, transfusion rate, hospital stay, overall complication rate (15.8% vs 13%), R0 negative margin rate, and mortality. Patients undergoing robotic liver surgery had significantly longer operative time (mean, 303 vs 233 minutes) and inflow occlusion time (mean, 75 vs 29 minutes) compared with their open counterparts.

CONCLUSIONS

Robotic and open liver resections in the right posterior section display similar safety and feasibility.

The impact of intraoperative vascular occlusion during liver surgery on postoperative peak ALT levels: A systematic review and meta-analysis

BACKGROUND AND AIMS

Intraoperative vascular occlusion techniques during liver surgeries have been performed and refined for decades. However, the impact of these techniques on postoperative peak ALT levels remains uncertain. Thus, we performed a literature review and meta-analysis to determine the impact of intraoperative vascular occlusion during liver surgery on postoperative peak ALT levels.

METHODS

A systematic literature search of the PubMed database was conducted to discover relevant controlled clinical trials. Studies that reported postoperative peak ALT values for both an observation group and a control group were included. The Q statistic and the I(2) index statistic were used to assess heterogeneity. Publication bias was evaluated using Egger's test and Orwin's fail-safe N test.

RESULTS

Of the 281 retrieved articles, 10 articles fulfilled the inclusion criteria. These 10 articles involved 12 randomized controlled trials with a total of 1443 records. The pooled estimation results indicated that intraoperative vascular occlusion significantly elevated postoperative peak ALT levels (test for SMD: Z = 4.09, P < 0.001; 95% CI: 0.59-1.68), with high heterogeneity (I(2) = 93.8%). Subgroup analysis revealed that intermittent inflow occlusion and Pringle's maneuver vascular occlusions may be the potential crucial factors. No obvious publication bias was detected by Egger's test (P = 0.541) or Orwin's fail-safe N test (Nfs0.05 = 2059.19).

CONCLUSIONS

Intraoperative vascular occlusion, especially intermittent inflow occlusion and Pringle's maneuver vascular occlusions, may be a potential risk factor that could lead higher postoperative peak ALT values than non-occlusion procedures for liver surgeries.

Bleeding control during laparoscopic liver resection: a review of literature

Despite the established advantages of laparoscopy, bleeding control during laparoscopic liver resection (LLR) is a liver-specific improvement. The 2nd International Consensus Conference on Laparoscopic Liver Resection was held in October 2014 at Morioka, Japan. One of the most capital questions was: What is essential in bleeding control during LLR? In order to correctly address this question, we conducted a comprehensive review of the literature. Essential points based on personal experience of the expert panel are also discussed. A total of 54 publications were identified. Based on this analysis, the working group built these recommendations: (1) a pneumoperitoneum of 10-14 mmHg should be used as it allows a good control of the bleeding without significant modifications of hemodynamics; (2) a low central venous pressure (<5 mmHg) should be used; (3) laparoscopy facilitates inflow and outflow control; and (4) surgeons should be experienced with the use of all surgical devices for liver transection and should master laparoscopic suture before starting LLR. Precoagulation with radiofrequency can be useful, particularly in cases of atypical resection. These recommendations are mostly based on experts' opinions and on B or C quality of evidence grade studies. More prospective data are required to confirm these results.

Robot assistance in liver surgery: a real advantage over a fully laparoscopic approach? Results of a comparative bi-institutional analysis

BACKGROUND

Laparoscopic liver resection (LAPR) is safe and feasible with a better postoperative course as compared to open resections. Robot-assisted liver surgery (ROBR) is a potential alternative to LAPR. In this study we compare outcomes between ROBR and LAPR.

METHODS

Forty patients underwent ROBR and 223 LAPR for various indications. The surgical outcomes of two institutions, each with a specific advanced experience in laparoscopic and robotic surgery, were reviewed.

RESULTS

The major hepatectomy rate was significantly higher in LAPR (16.6% vs 0%, p = 0.011) while a parenchyma-preserving approach was favoured in ROBR (55% vs 34.1%, p = 0.019). More nodules were resected in the ROBR group (1.97 ± 1.4 vs 1.57 ± 1.1, p = 0.04). Overall conversion rate was 8/40 (20%) in the ROBR and 17/223 (7.6%) in the LAPR group (p = 0.034). Mean blood loss was 330 ± 303 ml and 174 ± 133 ml for the ROBR and LAPR groups, respectively (p = 0.001) CONCLUSIONS: Despite higher conversion rates and blood loss, robot-assisted surgery may allow the resection of more liver lesions, especially those located in the postero-superior segments, facilitating parenchyma-saving surgery with a comparable complication rate with respect to LAPR.