Italian experience in minimally invasive liver surgery: a national survey

Minimally invasive tools are necessary for the modern practice of liver surgery

INTRODUCTION

Minimally invasive liver resection (MILR) is performed for other gastrointestinal applications. At our centre, all liver resections are systematically performed using a minimally invasive approach. This study aimed to describe our experience in minimising open surgery and emphasised the importance of minimally invasive surgery.

PATIENTS AND METHODS

We retrospectively reviewed 260 patients who underwent liver surgery and compared the surgical outcomes between the open and MILR groups.

RESULTS

A total of 154 patients (68%) underwent MILR. The proportion of patients who underwent prior abdominal surgery and resection was higher in the open surgery group. However, the proportion of patients with liver cirrhosis was similar between the two groups. The MILR group was superior in terms of operative time, blood loss, Pringle manoeuvre rate and mean hospital stay. In addition, major complication and bile leak rates were lower in the MILR group. No significant differences in the tumour size, number of lesions or underlying liver pathology were observed between the two groups.

CONCLUSION

Acceptable outcomes can be achieved even when the minimally invasive approach is considered the primary option for all patients who require liver resection. Minimally invasive tools are necessary for the modern practice of liver surgery; therefore, laparoscopic or robotic surgery should be included in the armamentarium of liver surgeons.

Early adoption of laparoscopic liver surgery in Poland: a national retrospective cohort study

BACKGROUND

The need for safe and efficient dissemination of minimally invasive approach in liver surgery is among the current challenges for hepatobiliary surgeons. After the stage of innovators and pioneers, the following countries should adopt a laparoscopic approach. The aim of this study was to assess the national experience and trend in implementing laparoscopic liver resection (LLR) in Poland.

MATERIALS AND METHODS

A national registry of LLR performed in Poland was established in June 2020. All LLR cases performed before were included retrospectively, followed by prospectively collected new cases. Baseline characteristics, preoperative and intraoperative data, short-term results and long-term follow-up were recorded.

RESULTS

Since 2010 up to the end of 2022 there were 718 LLRs performed in Poland. The national rate of laparoscopic approach has gradually increased since 2017 ( P <0.001), reaching the rate of 11.7% in 2022. There were 443 (61.7%), 107 (14.9%), and 168 (23.4%) LLRs performed in accordance to increasing grades of difficulty. The move towards more demanding cases had an increasing trend over the years ( P <0.001). Total intraoperative adverse event and postoperative severe complications rates were estimated for 13.5% ( n =97) and 6.7% ( n =48), respectively. 30-day reoperation, readmission and postoperative mortality rates were 3.6% ( n =26), 2.8% ( n =20), and 0.8% ( n =6), respectively. While the R0 resection margin was assessed in 643 (89.6%) cases, the total textbook outcomes (TO) were achieved in 525 (74.5%) cases. Overcoming the learning curve of 60 LLRs, resulted in an increasing TO rate from 72.3 to 80.6% ( P =0.024).

CONCLUSIONS

It is the first national analysis of a laparoscopic approach in liver surgery in Poland. An increasing trend of minimizing invasiveness in liver resection has been observed. Responsible selection of cases in accordance with difficulty may provide results within global benchmark values and textbook outcomes already during the learning curve.

Ten years of Italian mini-invasiveness: the I Go MILS registry as a tool of dissemination, characterization and networking

Purposes of this study are to evaluate the main changes that have occurred in the Italian MILS activity in the last decade in terms of indications, approaches and outcomes as reported in the national registry and to provide specific details on the main areas of development of MILS. Data from patients undergoing minimally invasive liver resections at centers included in the I Go MILS Registry from its start-up (November 2014) to March 2023 were analyzed for the purposes of this study. The registry is intention-to-treat and prospective. Global recruitment trends stratified by indication to surgery and type of approach were analysed. 7413 MILS procedures were performed across all centers (median number of procedures per center: 63). Years (2020-2023) displayed a significantly higher proportion of treated patients diagnosed with hepatocellular carcinoma (HCC) (38.2% vs. 28.9% and 33.9%, p < 0.001) and cholangiocarcinoma (6.7% vs. 6.5% and 4.2%, p < 0.001) compared to the preceding triennial periods. Additionally, technical complexity demonstrated an increased prominence in Years (2019-2023) with a significantly higher percentage of grade III cases compared to the earlier periods (39.3% vs. 21.7% and 25.6%, p < 0.001). Annual case trends focusing on laparoscopic and robotic techniques demonstrated a steadily increase in the use of these techniques for complex case mix of indications. Overall, attitude and attention to MILS approach has evolved, so that currently indications to hepatic mini-invasiveness have expanded and surgical technique has been refined: Areas mainly involved in increasing growth trends are hepatocellular carcinoma, possible applications of MILS in transplant setting, intrahepatic cholangiocarcinoma and robotic approach.

Conversion of Minimally Invasive Liver Resection for HCC in Advanced Cirrhosis: Clinical Impact and Role of Difficulty Scoring Systems

BACKGROUND

Minimally invasive liver resections (MILRs) in cirrhosis are at risk of conversion since cirrhosis and complexity, which can be estimated by scoring systems, are both independent factors for. We aimed to investigate the consequence of conversion of MILR for hepatocellular carcinoma in advanced cirrhosis.

METHODS

After retrospective review, MILRs for HCC were divided into preserved liver function (Cohort-A) and advanced cirrhosis cohorts (Cohort-B). Completed and converted MILRs were compared (Compl-A vs. Conv-A and Compl-B vs. Conv-B); then, converted patients were compared (Conv-A vs. Conv-B) as whole cohorts and after stratification for MILR difficulty using Iwate criteria.

RESULTS

637 MILRs were studied (474 Cohort-A, 163 Cohort-B). Conv-A MILRs had worse outcomes than Compl-A: more blood loss; higher incidence of transfusions, morbidity, grade 2 complications, ascites, liver failure and longer hospitalization. Conv-B MILRs exhibited the same worse perioperative outcomes than Compl-B and also higher incidence of grade 1 complications. Conv-A and Conv-B outcomes of low difficulty MILRs resulted in similar perioperative outcomes, whereas the comparison of more difficult converted MILRs (intermediate/advanced/expert) resulted in several worse perioperative outcomes for patients with advanced cirrhosis. However, Conv-A and Conv-B outcomes were not significantly different in the whole cohort where "advanced/expert" MILRs were 33.1% and 5.5% in Cohort A and B.

CONCLUSIONS

Conversion in the setting of advanced cirrhosis can be associated with non-inferior outcomes compared to compensated cirrhosis, provided careful patient selection is applied (patients elected to low difficulty MILRs). Difficulty scoring systems may help in identifying the most appropriate candidates.

Textbook outcomes and benchmarks of minimally invasive left lateral sectionectomy across North America

BACKGROUND

Minimally invasive approach represents the gold standard for the resection of the left lateral section of the liver. Recently, the American Minimally Invasive Liver Resection (AMILES) registry has become available to track outcomes of laparoscopic and robotic liver resection in the Americas. The aim of the present study is to determine the benchmark performance of MILLS throughout the AMILES database.

METHODS

The AMILES registry was interrogated for cases of minimally invasive left lateral sectionectomies (MILLS). Centers with best practices according to the achievement of textbook outcomes (TOs) were identified and were used to define benchmark performances.

RESULTS

Seven institutions from US and Canada entered 1665 minimally invasive liver resections, encompassing 203 MILLS. Overall, 49% of cases of MILLS satisfied contemporarily all textbook outcomes. While all centers obtained TOs with different rates of success, the outcomes of the top-ranking centers were used for benchmarking. Benchmark performance metrics of MILLS across North America are: conversion rate ≤ 3.7%, blood loss ≤ 200 ml, OR time ≤ 199 min, transfusion rate ≤ 4.5%, complication rate ≤ 7.9%, LOS ≤ 4 days.

CONCLUSION

Benchmark performances of MILLS have been defined on a large multi-institutional database in North America. As more institutions join the collaboration and more prospective cases accrue, benchmark for additional procedures and approaches will be defined.

Robot-Assisted Liver Resection and Cholecystectomy Using Indocyanine-Green for Intrahepatic Cholangiocarcinoma, in a Very Rare Anatomical Anomaly of ‘Bipartite Liver’

Robotic hepatobiliary surgery has significantly developed worldwide with substantial clinical results. Hepatobiliary anatomical anomalies increase the complexity of hepatobiliary resection with a relevant risk of iatrogenic lesions. Among congenital liver anomalies, the ‘bipartite liver’ is an extremely rare condition which might be associated with complex surgical dissection of the hepatic hilum. We herein report a rare case of congenital ‘bipartite liver’ associated with a cholangiocarcinoma of segment VI and calculous cholecystitis. The patient underwent robot-assisted segmentectomy and cholecystectomy with the use of indocyanine-green cholangiography and intraoperative ultrasound. A challenging hilar dissection was performed using this approach. To the best of our knowledge, this is the first case reported that describes a robot-assisted liver resection and cholecystectomy in a patient having a cholangiocarcinoma associated with this rare liver anomaly. The robotic approach was safe and effective and the 3D preoperative imaging, as well as the intraoperative green-indocyanine cholangiography was extremely useful, especially during hilar dissection and cholecystectomy.

Pan-European survey on the implementation of robotic and laparoscopic minimally invasive liver surgery

BACKGROUND

Laparoscopic and robotic minimally invasive liver surgery (MILS) is gaining popularity. Recent data and views on the implementation of laparoscopic and robotic MILS throughout Europe are lacking.

METHODS

An anonymous survey consisting of 46 questions was sent to all members of the European-African Hepato-Pancreato-Biliary Association.

RESULTS

The survey was completed by 120 surgeons from 103 centers in 24 countries. Median annual center volume of liver resection was 100 [IQR 50-140]. The median annual volume of MILS per center was 30 [IQR 16-40]. For minor resections, laparoscopic MILS was used by 80 (67%) surgeons and robotic MILS by 35 (29%) surgeons. For major resections, laparoscopic MILS was used by 74 (62%) surgeons and robotic MILS by 33 (28%) surgeons. The majority of the surgeons stated that minimum annual volume of MILS per center should be around 21-30 procedures/year. Of the surgeons performing robotic surgery, 28 (70%) felt they missed specific equipment, such as a robotic-CUSA. Seventy (66%) surgeons provided a formal MILS training to residents and fellows. In 5 years' time, 106 (88%) surgeons felt that MILS would have superior value as compared to open liver surgery.

CONCLUSION

In the participating European liver centers, MILS comprised about one third of all liver resections and is expected to increase further. Laparoscopic MILS is still twice as common as robotic MILS. Development of specific instruments for robotic liver parenchymal transection might further increase its adoption.

Minimally Invasive Liver Surgery: A Snapshot from a Major Dutch HPB and Transplant Center

BACKGROUND

Minimally invasive liver surgery (MILS) has been progressively adopted on a nationwide scale. The aim of this study is to investigate MILS implementation in a high-volume Dutch hepato-pancreato-biliary and transplant center, which is considered a moderate to low-volume center from a European standpoint.

METHODS

All patients who underwent MILS at Erasmus Medical Center between April 2010 and December 2021 were retrospectively reviewed. Patients' surgical outcomes were compared after stratification according to resections' difficulty and liver cirrhosis.

RESULTS

A total of 212 cases were included. Major liver resections were performed in 24 patients (11%), while minor resections were performed in 188 patients (89%). Among those, 177 (94%) resections were classified as technically minor and 11 (6%) as technically major. Major morbidity was reported in 14/177 patients (8%) after technically minor resections and in 3/24 patients (13%) after major resections. Anatomically and technically major resections had higher intraoperative blood losses (425 (0-2100) vs. 240 (50-110) vs. 100 (0-2400) mL; p-value < 0.001) and longer hospital stay (6 (3-25) vs. 5 (2-9) vs. 3 (1-44); p-value < 0.001) when compared with the technically minor counterpart. Perioperative outcomes were similar when comparing cirrhotic MILS with the non-cirrhotic cohort.

CONCLUSION

MILS program implementation can lead to encouraging surgical outcomes even in low- to moderate-volume centers. Although low procedural volume might be predictive of impaired outcomes, long-standing experience in the HPB and liver transplant field could mitigate low-case volume effects on surgical outcomes.

Two decades of liver resection with a multidisciplinary approach in a single institution: What has changed? Analysis of 1409 cases

OBJECTIVES

To evaluate results of patients undergoing liver resection in a single center over the past two decades with a particular look at Colorectal Liver Metastasis (CRLM) and Hepatocellular Carcinoma (HCC).

METHOD

Patients were divided into two eras, from 2000 to 2010 (Era 1) and 2011 to 2020 (Era 2). The most frequent diagnosis was CRLM and HCC, with 738 (52.4%) and 227 (16.1%) cases respectively. An evaluation of all liver resection cases and a subgroup analysis of both CRLM and HCC were performed. Preoperative and per operative variables and long-term outcomes were evaluated.

RESULTS

1409 liver resections were performed. In Era 2 the authors observed higher BMI, more: minimally invasive surgeries, Pringle maneuvers, and minor liver resections; and less transfusion, less ICU necessity, and shorter length of hospital stay. Severe complications were observed in 14.7% of patients, and 90-day mortality was 4.2%. Morbidity and mortality between eras were not different. From 738 CRLM resections, in Era 2 there were significantly more patients submitted to neoadjuvant chemotherapy, bilateral metastases, and smaller sizes with significantly less transfusion, the necessity of ICU, and shorter length of hospital stay. More pedicle clamping, minimally invasive surgeries, and minor resections were also observed. From 227 HCC resections, in Era 2 significantly more minimally invasive surgeries, fewer transfusions, less necessity of ICU, and shorter length of hospital stay were observed. OS was not different between eras for CRLM and HCC.

CONCLUSIONS

Surgical resection in a multidisciplinary environment remains the cornerstone for the curative treatment of primary and metastatic liver tumors.

Robotic surgery for colorectal liver metastases resection: A systematic review

BACKGROUND

The role of robotic surgery for colorectal cancer liver metastases (CRCLMs) has never been investigated in large series.

METHODS

A systematic literature review was carried out on PubMed and Cochrane libraries.

RESULTS

We selected nine studies between 2008 and 2021. Two hundred sixty-two patients were included. One hundred thirty-one patients underwent simultaneous resections. The mean blood loss was 309.4 ml (range, 200-450 ml), the mean operative time was 250.5 min (range, 198.5-449.0 min). The mean length of hospital stay was 7.98 days (range, 4.5 to 12 days). The overall postoperative mortality was 0.4%. The overall morbidity rate was 37.0%, Clavien-Dindo grade III-IV complications were 8.4%. The mean 3-year overall survival was 55.25% (range, 44.4-66.1%), the mean 3-year disease free survival was 37% (range, 33.3-41.9%) CONCLUSION: We can conclude that robotic-assisted surgery might be considered as a technical upgrade option for minimally invasive approach to CRCLM resections even for simultaneous operations and challenging cases.

Fluorescence and Ultrasound-guided Laparoscopic Resection of Caudate Lobe for Hepatocellular Carcinoma Located in the Retrocaval Portion

BACKGROUND

Contrast-enhanced intraoperative ultrasonography (CEIOUS) and indocyanine green fluorescence were interesting tool for the visualization of intrahepatic neoplastic nodules. The combinations of the 2 technologies could increase tumor detection and the radicality of resection, allowing the use of a pure laparoscopic approach.

METHODS

The patient was an 81-year-old man with a history of hypertension and treated hepatitis C infection, with a sustained serological response from 2018, previously undergoing laparotomic resection for hepatocellular carcinoma (HCC) in segment 8.During his regular hepatological follow-up, a 25 mm nodule was detected in segment 1, in a retrocaval position. Considering clinical presentation, good liver function (Child A5-MELD 8) and imaging, pure laparoscopic resection of the caudate lobe was performed using fluorescence imaging and CEIOUS navigation guidance.

RESULTS

The operation last for 205 minutes. Blood loss was 100 mL and no blood transfusion was required. She resumed diet on the next day and was discharged 4 days after the operation. Histopathologic examination showed 27 mm HCC with a clear margin. Contrast computed tomography scan performed 3 months after the operation showed no recurrence of the disease.

CONCLUSIONS

A laparoscopic isolated caudate resection for HCC located in the retrocaval portion of the cirrhotic liver seems to be feasible in selected patients and fluorescence imaging and CEIOUS navigation guidance could guarantee a safe and successful surgery.

Systematic review of perioperative and oncologic outcomes of minimally-invasive surgery for hilar cholangiocarcinoma

Most surgeons have traditionally been reluctant toward minimally-invasive surgery for bile duct tumors. This study aimed to perform a systematic literature review on perioperative and oncologic results of pure laparoscopic and robotic curative-intent surgery for hilar cholangiocarcinoma. According to the PRISMA statement, a systematic review was conducted into Pubmed, EMBASE and Cochrane. A critical appraisal of study was performed according to the Joanna Briggs Institute tools. Nineteen studies (12 on pure laparoscopy and 7 on robotics) were included: 7 case reports, 9 case series, 3 case-control (193 patients). The pooled conversion, morbidity, biliary leak and mortality rates were 5.5%, 43%, 16.4% and 4%. The weighted mean of operative time, blood loss and postoperative stay were 388 min, 446 mL and 14 days. For pure laparoscopy, the pooled R0 rate was 86%; overall survival and disease-free survival rates ranged from 85 to 100% and from 80 to 100% (median observation time 6-18 months). For robotic surgeries, the pooled R0 rate was 69% and overall survival rates ranged from 90 to 100% (median observation time 5-15 months). Case reports were overall of high quality, case series of moderate / high-quality, case-control studies ranged from low to high quality. In selected patients, minimally-invasive surgery for Klatskin tumors appears feasible, safe, satisfactory for perioperative outcomes and adequate for oncologic results. However, the results are based on few studies, limited in patient numbers and with allocation criteria more restrictive than open, reporting short follow-up and mainly with non-comparative design: evidence of higher quality is recommended.

Effects of volume on outcome in hepatobiliary surgery: a review with guidelines proposal

The positive relationship between volume and outcome in hepatobiliary surgery has been demonstrated for many years. As for other complex surgical procedures, both improved short- and long-term outcomes have been associated with a higher volume of procedures. However, whether the centralization of complex hepatobiliary procedures makes full sense because it should be associated with higher quality of care, as reported in the literature, precise criteria on what to centralize, where to centralize, and who should be entitled to perform complex procedures are still missing. Indeed, despite the generalized consensus on centralization in hepatobiliary surgery, this topic remains very complex because many determinants are involved in such a centralization process, of which some of them cannot be easily controlled. In the context of different health systems worldwide, such as national health systems and private insurance, there are different stakeholders that demand different needs: politicians, patients, surgeons, institutions and medical associations do not always have the same needs. Starting from a review of the literature on centralization in hepatobiliary surgery, we will propose some guidelines that, while not data-driven due to low evidence in the literature, will be based on good clinical practice.

Surgical Management of Hepatic Benign Disease: Have the Number of Liver Resections Increased in the Era of Minimally Invasive Approach? Analysis from the I Go MILS (Italian Group of Minimally Invasive Liver Surgery) Registry

BACKGROUND

Increased expertise with minimally invasive liver surgery (MILS) could cause an unjustified extension of indications to resect liver benign disease (BD). The aim of this study was to evaluate the operative risk of MILS for BD and if implementation and diffusion of MILS have widened indications for BD resection.

METHODS

A prospective study including centers with > 6 MILS for BD, enrolled in the I Go MILS registry from January 2015 to October 2016. Cysts fenestrations were excluded.

RESULTS

Eight hundred eighteen MILS were performed in 15 centers. One hundred seventy-three of these (21.1%) were for BD: conversion rate was 6.9%, postoperative mortality and morbidity rates were 0 and 13.9%. During the same period, 3713 liver resections (open + MILS) were performed and 407 (11.0%) were for BD. A time-trend analysis showed that the total number of MILS and the number of MILS for malignant disease significantly increased, but this increasing trend was not documented for the number of MILS for BD, which remained stable during the study period of time. This trend was confirmed for the overall rate of resected BD (open + MILS) that remained stable.

DISCUSSION

BD represents a valid indication for MILS. For BD, 21.1% of MILS was performed, rate significantly lower than that previously reported in Italy. Although an evident growth of the use of MILS was observed during the time period analysis in Italy, this trend did not correspond to an increased number of MILS for BD, and the overall rate of resected BD was comparable to that reported in previous large open series.

Impact of anthropometric data on technical difficulty of laparoscopic liver of resections of segments 7 and 8: the CHALLENGE index

BACKGROUND

The high technical difficulty of using a laparoscopic approach to reach the posterosuperior liver segments is mainly associated with their poor accessibility. This study was performed to analyze correlations between anthropometric data and intraoperative outcomes.

STUDY DESIGN

All patients who underwent segmentectomy or wedge laparoscopic liver resection (LLR) of segments seven and/or eight from June 2012 to November 2019 were retrospectively analyzed. The exclusion criteria were intrahepatic cholangiocarcinoma, associated resection, multiple concomitant LLR, redo resection, and lack of preoperative imaging. Anthropometric data were correlated with intraoperative outcomes.

RESULTS

Forty-one patients (wedge resection, n = 32; segmentectomy, n = 9) were analyzed. A strong correlation was found between the craniocaudal liver diameter (CCliv) and liver volume (r = 0.655, p < 0.001). The anteroposterior liver diameter was moderately correlated with both the laterolateral abdominal diameter (LLabd) (r = 0.372, p = 0.008) and anteroposterior abdominal diameter (r = 0.371, p = 0.008). The body mass index (BMI) was not correlated with liver diameters. Women had a longer CCliv (p = 0.002) and shorter LLabd (p < 0.001) than men. The liver and abdominal measurements were combined to reduce this sex-related disparity. The CCliv/LLabd ratio (CHALLENGE index) was significantly correlated with the time of transection (r = 0.382, p = 0.037) and blood loss (r = 0.352, p = 0.029). The association between the CHALLENGE index and intraoperative blood loss was even stronger when considering only anatomical resection (r = 0.577, p = 0.048). A CHALLENGE index of > 0.4 (area under the curve, 0.757; p = 0.046) indicated a higher bleeding risk. The BMI predicted no intraoperative outcomes.

CONCLUSION

Anthropometric data rather than the BMI can help anticipate the difficulty of LLR of segments seven and eight.

Pure laparoscopic right hepatectomy: A risk score for conversion for the paradigm of difficult laparoscopic liver resections. A single centre case series

BACKGROUND

Converted laparoscopic hepatectomies are known to lose some advantages of the minimally-invasiveness, and factors are identified to predict patients at risk. Specific evidence for laparoscopic right hepatectomy is expected of usefulness in clinical practice, given its technical peculiarities. The purpose of the study was the identification of risk factors and the development of a risk score for conversion of laparoscopic right hepatectomy.

MATERIALS AND METHODS

Laparoscopic right hepatectomy performed at a single hepatobiliary surgical center were analyzed. The cohort was split in half to obtain a derivation and a validation set. Risk factors for conversion were identified by uni- and multivariable analysis. A "conversion risk score" was built assigning each factor 1 point and comparing the score with the conversion status for each patient. The accuracy was assessed by the area-under-the-receiver-operator-characteristic-curve.

RESULTS

Among 130 operations, 22 were converted (16.9%). Reasons were: 45.5% oncologic inadequacy, 31.8% bleeding, 9.1% adhesions, 9.1% biliostasis, 4.5% anaesthesiological problems. Independent risk factors for conversion were: previous laparoscopic liver surgery (Hazard Ratio 4.9, p 0.011), preoperative chemotherapy ( Hazard Ratio 6.2, p 0.031), malignant diagnosis (Hazard Ratio 3.3, p 0.037), closeness to hepatocaval confluence or inferior vena cava (Hazard Ratio 4.1, p 0.029), tumor volume (Hazard Ratio 2.9, p 0.024). Conversion rates correlated positively with the score, raising from 0 to 100% when the score increased from 0 to 5 (Spearman: p 0.032 in the derivation set, p 0.020 in the validation set). The risk of conversion showed a sharp increase passing from class 3 to 4, reaching a probability estimated between 60 and 71.4%. The score showed good accuracy (area-under-the-receiver-operator-characteristic-curve 0.82).

CONCLUSION

Specific risk factors for conversion are identified for laparoscopic right hepatectomy. This score may help in standardizing the choice of a pure laparoscopic or open approach for such challenging resections.

A falciform ligament flap surface sealing technique for laparoscopic and robotic-assisted liver surgery

Whether sealing the hepatic resection surface after liver surgery decreases morbidity is still unclear. Nevertheless, various methods and materials are currently in use for this procedure. Here, we describe our experience with a simple technique using a mobilized falciform ligament flap in minimally invasive liver surgery (MILS). We retrospectively analyzed the charts from 46 patients who received minor MILS between 2011 and 2019 from the same surgical team in a university hospital setting in Germany. Twenty-four patients underwent laparoscopic liver resection, and 22 patients received robotic-assisted liver resection. Sixteen patients in the laparoscopic group and fourteen in the robotic group received a falciform ligament flap (FLF) to cover the resection surface after liver surgery. Our cohort was thus divided into two groups: laparoscopic and robotic patients with (MILS + FLF) and without an FLF (MILS-FLF). Twenty-eight patients (60.9%) in our cohort were male. The overall mean age was 56.8 years (SD 16.8). The mean operating time was 249 min in the MILS + FLF group vs. 235 min in the MILS-FLF group (p = 0.682). The mean blood loss was 301 ml in the MILS + FLF group vs. 318 ml in the MILS-FLF group (p = 0.859). Overall morbidity was 3.3% in the MILS + FLF group vs. 18.8% in the MILS-FLF group (p = 0.114). One patient in the MILS-FLF group (overall 2.2%), who underwent robotic liver surgery, developed bile leakage, but this did not occur in the MILS + FLF group. Covering the resection surface of the liver after minor minimally invasive liver resection with an FLF is a simple and cost-effective technique that does not prolong surgical time or negatively affect other perioperative parameters. In fact, it is a safe add-on step during MILS that may reduce postoperative morbidity. Further studies with larger cohorts will be needed to substantiate our proof of concept and results.

Laparoscopic Versus Open Left Lateral Segmentectomy for Large Hepatocellular Carcinoma: A Propensity Score-Matched Analysis

BACKGROUND

With the advancement of endoscopic technology, laparoscopic liver resection has become the standard procedure for left lateral segmentectomy. The aim of this study was to compare perioperative and oncological outcomes between laparoscopic and open left lateral segmentectomy for hepatocellular carcinoma (HCC) >5 cm.

PATIENTS AND METHODS

A total of 66 patients underwent left lateral segmentectomy for HCC (>5 cm) during the period spanning between 2013 and 2015. To overcome selection bias, 1:3 match using propensity score-matched analysis was performed between laparoscopic and open liver resection.

RESULTS

Relatively smaller tumor size (6.0 vs. 7.0 cm; P=0.030) and more frequent incidence of complete tumor capsule (93.3% vs. 58.8%; P=0.013) were observed in the laparoscopic group compared with the open group before matching. Although the longer operation time (195 vs. 150 min; P=0.022) was consumed in the laparoscopic procedure after matching, the laparoscopic group had shorter postoperative hospital stay (6 vs. 7 d; P=0.002) and less blood loss volume (50 vs. 100 mL; P=0.022). The Pringle maneuver for hepatic inflow occlusion was more likely to be applied in patients who underwent open surgery. The incidence of postoperative complication seemed to be lower in the laparoscopic group (6.7%) compared with that in the open group (11.8%) before matching. On the basis of propensity score-matched analysis, the complication rates were comparable between the 2 groups (7.1% vs. 6.7%, P=0.953). No difference in the 1-year and 3-year overall and recurrence-free survival rates was found between the laparoscopic and open groups.

CONCLUSION

Laparoscopic left lateral segmentectomy for large HCC patients showed better perioperative outcomes and equivalent oncologic outcomes as the open procedure, providing evidence for considering as a standard laparoscopic practice through careful selection.

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.

The role of minimally invasive hepatectomy for hilar and intrahepatic cholangiocarcinoma: A systematic review of the literature

Despite the fact laparoscopic liver resections (LLR) for cholangiocarcinoma is still limited, this systematic review addressed surgical and oncological outcomes of LLR to treat both perihilar cholangiocarcinoma (pCCA) and intrahepatic cholangiocarcinoma (iCCA). Five comparative and 20 noncomparative studies were found. Regarding iCCA, LLR had lower blood loss and less need for Pringle maneuver. However, open liver resections (OLR) were performed more for major hepatectomies, with better lymphadenectomy rates and higher number of harvested lymph nodes. High heterogeneity and selection bias were suggested for iCCA studies.

Multicentre evaluation of case volume in minimally invasive hepatectomy

Background

Surgical outcomes may be associated with hospital volume and the influence of volume on minimally invasive liver surgery (MILS) is not known.

Methods

Patients entered into the prospective registry of the Italian Group of MILS from 2014 to 2018 were considered. Only centres with an accrual period of at least 12 months and stable MILS activity during the enrolment period were included. Case volume was defined by the mean number of minimally invasive liver resections performed per month (MILS/month).

Results

A total of 2225 MILS operations were undertaken by 46 centres; nine centres performed more than two MILS/month (1376 patients) and 37 centres carried out two or fewer MILS/month (849 patients). The proportion of resections of anterolateral segments decreased with case volume, whereas that of major hepatectomies increased. Left lateral sectionectomies and resections of anterolateral segments had similar outcome in the two groups. Resections of posterosuperior segments and major hepatectomies had higher overall and severe morbidity rates in centres performing two or fewer MILS/month than in those undertaking a larger number (posterosuperior segments resections: overall morbidity 30·4 versus 18·7 per cent respectively, and severe morbidity 9·9 versus 4·0 per cent; left hepatectomy: 46 versus 22 per cent, and 19 versus 5 per cent; right hepatectomy: 42 versus 34 per cent, and 25 versus 15 per cent).

Conclusion

A volume–outcome association existed for minimally invasive hepatectomy. Complex and major resections may be best managed in high-volume centres.

Implementation and outcome of minor and major minimally invasive liver surgery in the Netherlands

BACKGROUND

While most of the evidence on minimally invasive liver surgery (MILS) is derived from expert centers, nationwide outcomes remain underreported. This study aimed to evaluate the implementation and outcome of MILS on a nationwide scale.

METHODS

Electronic patient files were reviewed in all Dutch liver surgery centers and all patients undergoing MILS between 2011 and 2016 were selected. Operative outcomes were stratified based on extent of the resection and annual MILS volume.

RESULTS

Overall, 6951 liver resections were included, with a median annual volume of 50 resections per center. The overall use of MILS was 13% (n = 916), which varied from 3% to 36% (P < 0.001) between centers. The nationwide use of MILS increased from 6% in 2011 to 23% in 2016 (P < 0.001). Outcomes of minor MILS were comparable with international studies (conversion 0-13%, mortality <1%). In centers which performed ≥20 MILS annually, major MILS was associated with less conversions (14 (11%) versus 41 (30%), P < 0.001), shorter operating time (184 (117-239) versus 200 (139-308) minutes, P = 0.010), and less overall complications (37 (30%) versus 58 (42%), P = 0.040).

CONCLUSION

The nationwide use of MILS is increasing, although large variation remains between centers. Outcomes of major MILS are better in centers with higher volumes.

Robotic liver resection for hepatocellular carcinoma: A systematic review

BACKGROUND

Hepatocellular carcinoma (HCC) represents a leading cause of death in patients with cirrhosis. This review attempts to clarify the role of robotic surgery for HCC in terms of oncologic outcomes.

MATERIALS AND METHODS

A systematic literature search was performed according to the PRISMA statement including papers comparing open, robotic, and laparoscopic approach for liver surgery. If more than one study was reported by the same institute, only the most recent or the highest quality study was included.

RESULTS

The literature search yielded 302 articles; titles and abstracts were reviewed for inclusion. Ten papers were finally included in this review for a total of 307 patients who underwent robotic resection for HCC.

CONCLUSIONS

Robotic liver resection for HCC is effective in terms of oncological results as compared with open and laparoscopic approach when performed in experienced centers and is accurate in terms of R0 rates and disease-free surgical margin.

A stepwise learning curve to define the standard for technical improvement in laparoscopic liver resections: complexity-based analysis in 1032 procedures

The objective of this study is to define the learning curve in a series of procedures grouped according to their complexity calculated by difficulty index to define a standard for technical improvement. 1032 laparoscopic liver resections performed in a single tertiary referral center were stratified by difficulty scores: low difficulty (LD, n = 362); intermediate difficulty (ID, n = 332), and high difficulty (HD, n = 338). The learning curve effect was analyzed using the cumulative sum (CUSUM) method taking into consideration the expected risk of conversion. The ratio of laparoscopic/total liver resections increased from 5.8% (2005) to 71.1% (2018). The CUSUM analysis per group showed that the average value of the conversion rate was reached at the 60th case in the LD Group and at the 15th in the ID and HD groups. The evolution from LD to ID and HD procedures occurred only when learning curve in LD resections was concluded. Reflecting different degree of complexity, procedures showed significantly different blood loss, morbidity, and conversions among groups. A standard educational model-stepwise and progressive-is mandatory to allow surgeons to define the technical and technological backgrounds to deal with a specific degree of difficulty, providing a help in the definition of indications to laparoscopic approach in each phase of training.

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.

Liver resection for extra-pancreatic biliary cancer: what is the role of laparoscopic approach?

BACKGROUND

Laparoscopic liver resection (LLR) has evolved over time, yet its role in extra-pancreatic biliary cancer has been limited due to several factors. We aimed to evaluate the short-term outcome of LLR in extra-pancreatic biliary tract cancer.

METHODS

From January 2002 to 2016, all patients who underwent LLR for extra-pancreatic biliary tract cancer including gallbladder cancer (GBC), intra-hepatic cholangiocarcinoma (ICC), and peri-hilar cholangiocarcinoma (PHC) with curative intent (R0 or R1) at Institute Mutualiste Montsouris were identified from prospectively collected databases. Patient characteristics, and perioperative outcomes, were analyzed in all three groups.

RESULTS

A total of 35 patients were included: 10 with GBC, 14 with ICC, and 11 with PHC. There were 19 (54%) women and median age was 71 years. Median operative time was 240 min, and estimated blood loss was 200 ml. Conversion to an open procedure was more common in patients with PHC (45% vs. 7% for ICC and 0% for GBC, p = 0.010). R0 resection was achieved in 10 (100%), 12 (86%), and 8 (73%) patients in GBC, ICC, and PHC groups, respectively (p = 0.204). Postoperative morbidity was reported in 19 (54%) patients of whom 12 (34%) had minor complications. Postoperative mortality was reported in 4 (11%) patients; one (7%) in GBC group, one (7%) in ICC group, and two (18%) in PHC, p = 0.681. Median hospital stay was 11 days.

CONCLUSIONS

The present series suggests that LLR is feasible in GBC, challenging but achievable in ICC but unsuitable for the moment in PHC.

Challenges and Technical Innovations for an Effective Laparoscopic Lymphadenectomy in Liver Malignancies

BACKGROUND

Intrahepatic cholangiocarcinoma (ICC) and gallbladder cancer (GC) are relatively uncommon indications for minimal invasiveness, mainly due to the technical complexity required for a laparoscopic loco-regional lymphadenectomy. The aim of this presentation is to provide a step-by-step overview for the technical approach to laparoscopic lymphadenectomy of the hepatic pedicle and parenchymal transection.

MATERIALS AND METHODS

Two cases of an ICC and a GC are shown. Patients were placed supine in the modified French position. One optic port was inserted through open access and four more operative trocars were placed under direct vision in a standardized fashion. Lymphadenectomy of the common hepatic artery (station 8) and of the hepato-duodenal ligament for proper hepatic artery, common bile duct, and portal vein (stations 12A, 12B, and 12P, respectively) is shown. Parenchymal transection is depicted using alternation of an energy device with an ultrasonic aspirator, while intrahepatic vascular structures are sealed with bypolar forceps, clips, or stapled according to dimension.

RESULTS

In the first case operative time was 210 minutes, lymphadenectomy time (LT) 40 minutes, and estimated blood loss (EBL) 200 mL. Final pathology was consistent with ICC pT2N1(1/7)M0. In the second case, operative time was 180 minutes, LT 35 minutes, and EBL 150 mL. Final pathology reported gallbladder adenocarcinoma pT2N0(0/7)M0. Postoperative courses were uneventful; drains were removed on postoperative day (POD) 2. Patients were discharged on POD 3.

CONCLUSIONS

Overcoming the technical limitation embodied by the need of performing an appropriate lymphadenectomy represents the milestone for having patients affected by primary biliary tumors of the liver enrolled to laparoscopy; therefore, this subgroup of patients can benefit from the advantages offered by minimal invasiveness. The leading assumption, however, remains the requirement of performing an oncologically adequate lymph nodal dissection.

The Southampton Consensus Guidelines for Laparoscopic Liver Surgery: From Indication to Implementation

OBJECTIVE

The European Guidelines Meeting on Laparoscopic Liver Surgery was held in Southampton on February 10 and 11, 2017 with the aim of presenting and validating clinical practice guidelines for laparoscopic liver surgery.

BACKGROUND

The exponential growth of laparoscopic liver surgery in recent years mandates the development of clinical practice guidelines to direct the speciality's continued safe progression and dissemination.

METHODS

A unique approach to the development of clinical guidelines was adopted. Three well-validated methods were integrated: the Scottish Intercollegiate Guidelines Network methodology for the assessment of evidence and development of guideline statements; the Delphi method of establishing expert consensus, and the AGREE II-GRS Instrument for the assessment of the methodological quality and external validation of the final statements.

RESULTS

Along with the committee chairman, 22 European experts; 7 junior experts and an independent validation committee of 11 international surgeons produced 67 guideline statements for the safe progression and dissemination of laparoscopic liver surgery. Each of the statements reached at least a 95% consensus among the experts and were endorsed by the independent validation committee.

CONCLUSION

The European Guidelines Meeting for Laparoscopic Liver Surgery has produced a set of clinical practice guidelines that have been independently validated for the safe development and progression of laparoscopic liver surgery. The Southampton Guidelines have amalgamated the available evidence and a wealth of experts' knowledge taking in consideration the relevant stakeholders' opinions and complying with the international methodology standards.

LIVER RESECTION IN BRAZIL: A NATIONAL SURVEY

BACKGROUND

Liver surgery has developed significantly in the past decades. In Brazil, the interest on it has grown significantly, but there is no study regarding its clinical practice. Despite intrinsic limitations, surveys are well suited to descriptive studies and allow understanding the current scenario.

AIM

To provide an overview on the current spread of liver surgery in Brazil, focusing on groups´ profile, operative techniques and availability of resources.

METHOD

From May to November 2016, was conducted a national survey about liver surgery profile in Brazil composed by 28 questions concerning surgical team characteristics, technical preferences, surgical volume, results and available institutional resources. The survey was sent by e-mail to 84 liver surgery team leaders from different centers including all regions of the country.

RESULTS

Forty-three study participants (51.2%), from all Brazilian regions, responded the survey. Most centers have residency/fellowship programs (86%), perform and do laparoscopic procedures (91%); however, laparoscopy is still responsible for a little amount of surgeries (1-9% of laparoscopic procedures over all liver resections in 39.5% of groups). Only seven centers (16.3%) perform more than 50 liver resections/year. Postoperative mortality rate is between 1-3% in 55% of the centers.

CONCLUSION

This is the first depiction of liver surgery in Brazil. It showed a surgical practice aligned with worldwide excellence centers, concentrated on hospitals dedicated to academic practice.

The clinical and biological impacts of the implementation of fast-track perioperative programs in complex liver resections: A propensity score-based analysis between the open and laparoscopic approaches

BACKGROUND

The aim of this study was to evaluate the impact of the fast-track approach in patients undergoing complex liver procedures and to analyse factors that influence morbidity and functional recovery.

METHODS

Hepatic resections (2014-2016) were stratified according to difficulty score, obtaining a group of 215 complex resections (102 laparoscopic, 163 open). The laparoscopic group was matched by propensity score with open patients to obtain the minimally invasive liver surgery group (n = 102) and the open group (n = 102).

RESULTS

Groups were similar in terms of patient and disease characteristics. The postoperative morbidity was 31.4% in the minimally invasive liver surgery and 38.2% in the open group (P = .05), and functional recovery was shorter in the minimally invasive liver surgery (respectively 4 versus 6 days, P = .041). The adherence to fast-track was high in both groups, with several items with higher penetrance in the minimally invasive liver surgery group. Among factors associated with morbidity and functional recovery, a laparoscopic approach and strict adherence to a fast-track protocol resulted in protective factors.

CONCLUSION

The combination of minimally invasive approaches and fast-track protocols allows a reduced rate of postoperative morbidity and satisfactory functional recovery even in the setting of complex liver resections. When the laparoscopic approach is not feasible, strict adherence to a fast-track program is associated with the achievement of adequate results and should be implemented.

Robot-assisted liver surgery in a general surgery unit with a "Referral Centre Hub&Spoke Learning Program". Early outcomes after our first 70 consecutive patients

BACKGROUND

The aim of this study was to evaluate safety, feasibility and short-term outcomes of our first 70 consecutive patients treated by robotic-assisted liver resection after a reversal proctoring between a high HPB volume centre and our well-trained center in minimally invasive General Surgery. Six surgeons were involved in this Hub&Spoke learning program.

METHODS

From September 2012 to December 2016, 70 patients underwent robotic-assisted liver resections (RALR). We treated 18 patients affected by colorectal and gastric cancer with synchronous liver lesions suspected for metastases in a one-stage robotic-assisted procedure. For the first 20 procedures we had a tutor in the operatory room, who was present also in the next most difficult procedures.

RESULTS

The 30- and 90-day mortality rate was zero with an overall morbidity rate of 10.1%. Associated surgical procedures were performed in about 65,7% of patients. The observed conversion rate was 10%. The results of the first 20 cases were similar to the next 50 showing a shortned learning curve.

CONCLUSIONS

Minimally invasive robot-assisted liver resection is a safe technique; it allows overcoming many limits of conventional laparoscopy. This innovative, time-enduring Hub&Spoke may allow patients to undergo a proper standard of care also for complex surgical procedures, without the need of reaching referral centres.

Surgical Resection vs. Ablative Therapies Through a Laparoscopic Approach for Hepatocellular Carcinoma: a Comparative Study

BACKGROUND

When compatible with the liver functional reserve, laparoscopic hepatic resection remains the treatment of choice for hepatocellular carcinoma while laparoscopic ablation therapies appear as a promising less invasive alternative. The aim of the study is to compare two homogeneous groups of patients submitted to either hepatic resection or thermoablation for the treatment of single hepatocellular carcinoma (≤ 3 cm).

METHODS

We enrolled 264 cirrhotic patients out of 905 cases consecutively evaluated for hepatocellular carcinoma. We performed 59 hepatic resections and 205 thermoablations through a laparoscopic approach, and they were then followed for similar follow-up (41.7 ± 31.5 months for laparoscopic hepatic resection vs. 38.7±32.3 for laparoscopic ablation therapy). Outcomes included short- and long-term morbidities, tumoral recurrence, and overall survival.

RESULTS

Short-term morbidity was significantly higher in the resection group (but the two groups had similar rates for severe complications) while, during follow-up, recurrence was more frequent in patients treated with thermoablation, with a clear disadvantage in terms of survival. At multivariate analysis, only the type of surgical treatment was an independent predictor of disease recurrence, while plasmatic alpha-fetoprotein and Hb values, model for end-stage liver disease score, time to recurrence, and the type of surgical treatment were independent predictors of overall survival.

CONCLUSION

Our data ultimately support some therapeutic advantages for hepatic resection in patients with a single nodule and preserved liver function. However, thermoablation is an adequate alternative in patients with nodules that would require complex surgical resections or imply a poor prognosis that might therefore better tolerate a less invasive procedure.

Diffusion, outcomes and implementation of minimally invasive liver surgery: a snapshot from the I Go MILS (Italian Group of Minimally Invasive Liver Surgery) Registry

The Italian Group of MILS (I Go MILS) prospective registry was established in 2014 with the goals to create a hub for data and projects on a national basis and to promote the diffusion and implementation of MILS programs on a national scale. The primary endpoint of the present study is to give a snapshot of the real diffusion and outcomes of MILS in Italy, while analyzing the role of the registry in the implementation of MILS programs nationwide. The I Go MILS Registry is a prospective and intention-to-treat registry opened to any Italian center performing MILS, without restriction criteria based on number of procedures. The Registry is developed through the eClinical, an electronic platform for the management of clinical trials and is based on 34 clinical variables, regarding indication, intra- and postoperative course. Clinical outcomes and data regarding implementation of MILS activity have been analyzed for the aim of the study. Between November 2014 and June 2017, data from 1678 MILS performed in 48 centers have been collected (mean number of procedures per center 35, range 1-302). 22% of procedures were performed for benign and 78% for malignant disease (HCC constituted the 49.1% and CRLM the 31.2% of malignant tumors). Major liver resections (>3 liver segments), including right and left hepatectomies, trisectionectomies and ALPPS procedures were 10% of the series. Mean blood loss was 200 ± 230 mL Morbidity rate was 20.5% and mortality was 0.3%. 10.4% of cases were converted to open approach. Median length of stay was 5 days. MILS/total resections ratio in 13 experienced centers increased from 14 to 30% after Registry establishment. MILS programs are well established in Italy, with progressive increase both in the number of cases and in the numerosity of centers. The I Go MILS Registry is playing a crucial role in monitoring the development of MILS in the real world on a national basis while giving a significant contribution to the implementation of MILS programs.

First quarter century of laparoscopic liver resection

The beginnings of laparoscopic liver resection (LLR) were at the start of the 1990s, with the initial reports being published in 1991 and 1992. These were followed by reports of left lateral sectionectomy in 1996. In the years following, the procedures of LLR were expanded to hemi-hepatectomy, sectionectomy, segmentectomy and partial resection of posterosuperior segments, as well as the parenchymal preserving limited anatomical resection and modified anatomical (extended and/or combining limited) resection procedures. This expanded range of LLR procedures, mimicking the expansion of open liver resection in the past, was related to advances in both technology (instrumentation) and technical skill with conceptual changes. During this period of remarkable development, two international consensus conferences were held (2008 in Louisville, KY, United States, and 2014 in Morioka, Japan), providing up-to-date summarizations of the status and perspective of LLR. The advantages of LLR have become clear, and include reduced intraoperative bleeding, shorter hospital stay, and - especially for cirrhotic patients-lower incidence of complications (e.g., postoperative ascites and liver failure). In this paper, we review and discuss the developments of LLR in operative procedures (extent and style of liver resections) during the first quarter century since its inception, from the aspect of relationships with technological/technical developments with conceptual changes.

Liver surgery in Italy. Criteria to identify the hospital units and the tertiary referral centers entitled to perform it

During the last decades, liver surgery had an extraordinary evolution and diffusion thanks to a drastic reduction of operative mortality and morbidity rates. A debate is ongoing about the need for centralization of liver resections in tertiary referral centers. Robust evidences showed that complex surgical procedures have lower mortality rates when performed in high-volume centers. The present expert group reviewed the literature data and proposed guidelines to identify surgical units that should be entitled to perform liver surgery in Italy. Three separate types of requirements were identified. First, the hospital requirements that include the following criteria: (1) a hospital of 1st level according to the Italian law; (2) the presence of a dedicated hepatobiliary or hepatobiliopancreatic unit or a team dedicated to liver surgery into a general surgery unit; (3) the mandatory presence of oncology, hepatology, radiology, interventional radiology, digestive endoscopy, intensive care, and pathology units; (4) the availability of a liver transplant team into the hospital or into another hospital within an established partnership; (5) a periodic multidisciplinary meeting. Second, the volume requirements: the unit has to perform more than 20 liver resections per year for malignant liver diseases with a 90-day mortality rate < 3 %. Finally, the organization requirements: the presence of specific diagnostic-therapeutic flowcharts for liver diseases.

Impact of totally laparoscopic combined management of colorectal cancer with synchronous hepatic metastases on severity of complications: a propensity-score-based analysis

BACKGROUND

Thanks to widespread diffusion of minimally invasive approach in the setting of both colorectal and hepatic surgeries, the interest in combined resections for colorectal cancer and synchronous liver metastases (SCLM) by totally laparoscopic approach (TLA) has increased. Aim of this study was to compare outcome of combined resections for SCLM performed by TLA or by open approach, in a propensity-score-based study.

STUDY DESIGN

All 25 patients undergoing combined TLA for SCLM at San Raffaele Hospital in Milano were compared in a case-matched analysis with 25 out of 91 patients undergoing totally open approach (TOA group). Groups were matched with 1:2 ratio using propensity scores based on covariates representing disease severity. Main endpoints were postoperative morbidity and long-term outcome. The Modified Accordion Severity Grading System was used to quantify complications.

RESULTS

The groups resulted comparable in terms of patients and disease characteristics. The TLA group, as compared to the TOA group, had lower blood loss (350 vs 600 mL), shorter postoperative stay (9 vs 12 days), lower postoperative morbidity index (0.14 vs 0.20) and severity score for complicated patients (0.60 vs 0.85). Colonic anastomosis leakage had the highest fractional complication burden in both groups. In spite of comparable long-term overall survival, the TLA group had better recurrence-free survival.

CONCLUSION

TLA for combined resections is feasible, and its indications can be widened to encompass a larger population of patients, provided its benefits in terms of reduced overall risk and severity of complications, rapid functional recovery and favorable long-term outcomes.

Intraoperative monitoring of stroke volume variation versus central venous pressure in laparoscopic liver surgery: a randomized prospective comparative trial

BACKGROUND

Central venous pressure (CVP) is used as a marker of cardiac preload to control intraoperative blood loss in open hepatectomies, while its reliability in laparoscopy is less certain. The aim of this randomized prospective trial was to evaluate the outcome of laparoscopic resections performed with stroke volume variation (SVV) or CVP monitoring.

METHODS

All candidates for laparoscopic liver resection were assigned randomly to SVV or to CVP groups. Outcome was evaluated included conversion rate, cause of conversion, intraoperative blood loss, need for transfusions, length of surgery and postoperative results.

RESULTS

Ninety consecutive patients were enrolled: both SVV and CVP groups included 45 patients each and were comparable in terms of patient and disease characteristics. A reduced rate of conversion was recorded in the SVV compared to the CVP group (6.7% and 17.8% respectively, p = 0.02). Blood loss was lower in the SVV group (150 mL), compared to the CVP group (300 mL, p = 0.04). Morbidity, mortality, length of stay and functional recovery were comparable. On multivariate analysis, lesion location, extent of hepatectomy and type of cardiac preload monitoring were associated significantly to risk of conversion.

CONCLUSION

SVV monitoring in laparoscopic liver surgery improves intraoperative outcome, thus enhancing the benefits of the minimally-invasive approach and fast-track protocols.