Laparoscopic resection of benign hepatic cysts: a new standard

ACG Clinical Guideline: Focal Liver Lesions

Focal liver lesions (FLLs) have become an increasingly common finding on abdominal imaging, especially asymptomatic and incidental liver lesions. Gastroenterologists and hepatologists often see these patients in consultation and make recommendations for management of multiple types of liver lesions, including hepatocellular adenoma, focal nodular hyperplasia, hemangioma, and hepatic cystic lesions including polycystic liver disease. Malignancy is important to consider in the differential diagnosis of FLLs, and healthcare providers must be familiar with the diagnosis and management of FLLs. This American College of Gastroenterology practice guideline uses the best evidence available to make diagnosis and management recommendations for the most common FLLs.

Imaging features and management of focal liver lesions

Notably, the number of incidentally detected focal liver lesions (FLLs) has increased dramatically in recent years due to the increased use of radiological imaging. The diagnosis of FLLs can be made through a well-documented medical history, physical examination, laboratory tests, and appropriate imaging methods. Although benign FLLs are more common than malignant ones in adults, even in patients with primary malignancy, accurate diagnosis of incidental FLLs is of utmost clinical significance. In clinical practice, FLLs are frequently evaluated non-invasively using ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). Although US is a cost-effective and widely used imaging method, its diagnostic specificity and sensitivity for FLL characterization are limited. FLLs are primarily characterized by obtaining enhancement patterns through dynamic contrast-enhanced CT and MRI. MRI is a problem-solving method with high specificity and sensitivity, commonly used for the evaluation of FLLs that cannot be characterized by US or CT. Recent technical advancements in MRI, along with the use of hepatobiliary-specific MRI contrast agents, have significantly improved the success of FLL characterization and reduced unnecessary biopsies. The American College of Radiology (ACR) appropriateness criteria are evidence-based recommendations intended to assist clinicians in selecting the optimal imaging or treatment option for their patients. ACR Appropriateness Criteria Liver Lesion-Initial Characterization guideline provides recommendations for the imaging methods that should be used for the characterization of incidentally detected FLLs in various clinical scenarios. The American College of Gastroenterology (ACG) Clinical Guideline offers evidence-based recommendations for both the diagnosis and management of FLL. American Association for the Study of Liver Diseases (AASLD) Practice Guidance provides an approach to the diagnosis and management of patients with hepatocellular carcinoma. In this article, FLLs are reviewed with a comprehensive analysis of ACR Appropriateness Criteria, ACG Clinical Guideline, AASLD Practice Guidance, and current medical literature from peer-reviewed journals. The article includes a discussion of imaging methods used for the assessment of FLL, current recommended imaging techniques, innovations in liver imaging, contrast agents, imaging features of common nonmetastatic benign and malignant FLL, as well as current management recommendations.

Laparoscopic Excision of Solitary Dysontogenetic Liver Cysts in Young Children: Technical Aspects and Outcome

Background: Solitary dysontogenetic liver cysts are rare in young children. However, large cysts can cause symptoms and require therapy. Cyst excision is the therapeutic method least associated with cyst recurrence. Only limited data are available on cyst excision performed laparoscopically in this age group. We present our experience using this surgical approach. Methods: Since 2005, 7 children including 5 newborns and infants with solitary dysontogenetic liver cysts have undergone minimally invasive excision of the cyst at our institution. Patient data were analyzed retrospectively. Results: Median age of the patients at surgery was 8 months (3 days to 6 years); 5 of them were younger than 1 year. The cysts had varying locations in the segments IV-VIII, and median size was 5.4 cm (3.8-7.9). Complete excision was realized in all cases. Median duration of surgery was 120 minutes (60-171). All procedures could be completed laparoscopically. One intraoperative complication occurred (injury of a bile duct that could be sutured laparoscopically). Median follow-up was 29 months (14-173). Cyst recurrence was not observed in any of the cases. Conclusion: Laparoscopic excision of solitary dysontogenetic liver cysts is an effective treatment in young children. Resection is not limited to cysts in anterior and lateral liver segments.

Clinical response after laparoscopic fenestration of symptomatic hepatic cysts: a systematic review and meta-analysis

BACKGROUND

Laparoscopic fenestration is one of the treatment options for symptomatic hepatic cysts, either solitary or in context of polycystic liver disease (PLD), but indications, efficacy and surgical techniques are under debate.

METHODS

A systematic literature search (1950-2017) of PubMed, Embase, Web of Science and the Cochrane Library was performed (CRD42017071305). Studies assessing symptomatic relief or symptomatic recurrence after laparoscopic fenestration in patients with symptomatic, non-parasitic, hepatic cysts were included. Complications were scored according to Clavien-Dindo. Methodological quality was assessed by Newcastle-Ottawa scale (NOS) for cohort studies. Pooled estimates were calculated using a random effects model for meta-analysis.

RESULTS

Out of 5277 citations, 62 studies with a total of 1314 patients were included. Median NOS-score was 6 out of 9. Median follow-up duration was 30 months. Symptomatic relief after laparoscopic fenestration was 90.2% (95% CI 84.3-94.9). Symptomatic recurrence was 9.6% (95% CI 6.9-12.8) and reintervention rate was 7.1% (95% CI 5.0-9.4). Post-operative complications occurred in 10.8% (95% CI 8.1-13.9) and major complications in 3.3% (95% CI 2.1-4.7) of patients. Procedure-related mortality was 1.0% (95% CI 0.5-1.6). In a subgroup analysis of PLD patients (n = 146), symptomatic recurrence and reintervention rates were significantly higher with respective rates of 33.7% (95% CI 18.7-50.4) and 26.4% (95% CI 12.6-43.0). Complications were more frequent in PLD patients, with a rate of 29.3% (95% CI 16.0-44.5).

CONCLUSIONS

Laparoscopic fenestration is an effective procedure for treatment of symptomatic hepatic cysts with a low symptomatic recurrence rate. The symptomatic recurrence rate and risk of complications are significantly higher in PLD patients.

Predictors and implications of unplanned conversion during minimally invasive hepatectomy: an analysis of the ACS-NSQIP database

BACKGROUND

Minimally-invasive hepatectomy (MIH) is increasingly utilized; however, predictors and outcomes for patients requiring conversion to an open procedure have not been adequately studied.

METHODS

The 2014-15 ACS-NSQIP database was analyzed. Unplanned conversion was compared to successful MIH and elective open hepatectomy.

RESULTS

Among 6918 hepatectomies, 1062 (15.4%) underwent attempted MIH: 989 laparoscopic, 73 robotic. Conversion occurred in 203 (19.1%). Compared to successful MIH, patients requiring unplanned conversion experienced higher rates of complications (34.5% vs 14.6%, p<0.001), including bile leaks (7.4% vs 2.8%, p=0.002), organ space infection (6.4% vs 2.9%, p=0.016), UTI (4.9% vs 1.2%, p=0.002), perioperative bleeding (21.2% vs 6.1%, p<0.001), DVT (3.0% vs 0.8%, p=0.024), and sepsis (5.9% vs 1.9%, p=0.001). Conversion led to greater LOS (5 days vs 3 days, p<0.001) and 30-day mortality (3.0% vs 0.5%, p=0.005). Compared to elective open hepatectomy, conversion was associated with greater perioperative bleeding (21.2% vs 15.3%, p = 0.037). On multivariate analysis, major hepatectomy (OR 2.21, p<0.001), concurrent ablation (OR 1.79, p=0.020), and laparoscopic approach (vs. robotic) (OR 3.22, p=0.014) were associated with conversion.

CONCLUSION

Analysis of this national database revealed unplanned conversion during MIH is associated with greater morbidity and mortality. MIH should be approached cautiously in patients requiring major hepatectomy.

Long-term outcomes and quality of life after surgical or conservative treatment of benign simple liver cysts

BACKGROUND

Benign liver cysts are common and are often detected incidentally. Most patients do not require intervention. Occasionally, large dominant or multifocal small cysts cause symptoms as a result of rapid growth, secondary infection, intra-cystic bleeding or compression of adjacent organs.

AIM

To compare presenting symptoms and outcomes of a consecutive series of patients with benign liver cysts treated either conservatively or by surgical intervention. Long-term quality of life (QoL) was also assessed.

METHODS

Retrospective analysis of prospectively collected data was conducted. Long-term general and disease-specific quality of life was also documented.

RESULTS

Ninety-five patients were included in the study (46 treated operatively, 49 treated conservatively). 80% were female, and the mean age of the cohort was 58 years. Those who had surgical intervention were older (62 vs 55 years, p = 0.004), were more likely to have shortness of breath at presentation (11 vs 5%, p = 0.018) and had larger cysts (12 vs 4 cm, p < 0.001) compared with those offered conservative treatment. Laparoscopic stapled excision was the most common operative procedure (70%) and the overall complication rate was 20%. At a median follow-up of 64 months, 17% (8/46) of the surgically treated patients had radiological evidence of cyst recurrence but only 9% (4/46) were symptomatic. At median follow-up of 71 months, 37% (14/38) of conservatively treated patients had unchanged or new symptoms compared to the first presentation. Furthermore, 10% (4/38) of this group had additional radiological or surgical intervention for persistent symptoms during the follow-up period. Overall, there was no difference in long-term QoL between the two groups.

CONCLUSION

Surgical intervention for selected patients with symptomatic benign liver cysts results in low long-term recurrence rates and excellent patient-reported outcomes and quality of life. Laparoscopic-stapled excision can be done safely and reliably in carefully selected patients.

Biliary Cystadenoma Causing Esophageal Varices

Biliary cystadenomas are benign but potentially malignant cystic neoplasm. The preferred treatment is radical resection because it is difficult to differentiate a benign from a malignant biliary cystadenoma. A 40 year-old woman presented with moderate abdominal discomfort. Esophageal varix was found up to mid-esophagus on endoscopy. She has no prior history of liver disease or chronic alcohol ingestion. About 15cm sized biliary cystadenoma was diagnosed by ultrasonography, computed tomography and magnetic resonance imaging. Serum level of bilirubin, alanine aminotransferase, alkaline phosphatase, gamma-glutamyl transpeptidase and tumor marker were elevated. The patient underwent US-guided aspiration. Tumor markers from the aspirated fluid are increased. Left hepatectomy was performed to completely remove the cyst. Histology of the resected specimen confirmed a biliary cystadenoma of the liver with ovary-like stroma. Without prior history of liver disease or chronic alcoholic ingestion, incidental finding of esophageal varix could show an important clue for diagnosis of biliary cystadenoma.

Evaluation of the utility value of percutaneous drainage of symptomatic hepatic cysts combined with an obliteration attempt

Aim

The goal of the paper was to evaluate the procedure of percutaneous drainage of symptomatic hepatic cysts under the transabdominal ultrasound control combined with obliteration.

Material and method

Within the period from 2005 to 2015, 70 patients diagnosed with a simple hepatic cyst of symptomatic nature were subject to hospitalization and treated at the 2^nd General, Gastroenterological and Cancer Surgery of the Alimentary System Center and Clinics of the Medical University of Lublin. All the patients subject to evaluation were qualified to percutaneous drainage under an ultrasound control. The drainage utilized typical sets of drains with the diameter of at least 9 F, most often of pigtail type. The fluid aspirated form the cyst was dispatched for complex laboratory testing. Further, a 10% sodium chloride solution was administered to the cyst through the drain, in the volume depending on the previous size of the cyst and the patient's reaction.

Results

Patients reported for a re-visit within the period from 3 to 9 months following the procedure. Complete obliteration of the cyst was confirmed only in 8 patients (11%). Cyst recurrence was reported in cases when during the ultrasound evaluation, the diameter of the cyst following aspiration and obliteration enlarged to over 75% of the initial dimension. In this group, in 10 out of 12 examined (83%) there was a relapse of the previously observed ailments. Among patients, who has a cyst imaged within the period of observation, which had the diameter from 50% to 75% of the previous size, only in 6 cases (37.5%) the initial symptoms relapsed.

Conclusions

The utilization of a drainage and obliteration enables one to achieve the acceptable result of the therapy as well as significant decrease in the number of previously reported ailments and symptoms described.

Robot-assisted Laparoscopic Fenestration of Giant Hepatic Cysts

BACKGROUND

Traditionally, nonparasitic hepatic cysts are marsupialized using laparotomy. In the last 2 decades, laparoscopic fenestration has become the preferred treatment for hepatic cysts. However, this technique is limited by 2-dimensional view and the limited mobility of straight laparoscopic instruments. These limitations may be overcome by the use of a robotic system. We describe laparoscopic fenestration of giant hepatic cysts using the da Vinci Si robotic system with the use of the Endowrist One Vessel Sealer.

METHODS

Our first patient is a 32-year-old female with a solitary hepatic cyst. The second patient is a 51-year-old female with polycystic liver disease.

RESULTS

We performed robot-assisted laparoscopic cyst fenestration with good clinical outcome. No intraoperative complications occurred and patients recovered rapidly.

CONCLUSION

These data show that the da Vinci Si robotic system is eminently suited for the laparoscopic fenestration of large hepatic cysts and that this procedure is associated with rapid recovery.

Laparoscopic surgery and polycystic liver disease: Clinicopathological features and new trends in management

BACKGROUND:

Polycystic liver disease (PLD) has a low frequency overall in the worldwide population. As the patient's symptoms are produced by the expansion of hepatic volume, the different therapeutic alternatives are focused on reducing it. Surgery is still considered the most effective treatment for symptomatic PLD. The aim of this study was to evaluate the long-term outcomes of laparoscopic surgery for PLD.

MATERIALS AND METHODS:

This study included 14 patients who were diagnosed with symptomatic PLD and underwent surgery by a laparoscopic approach between 2004 and 2012. It involved collecting data on the characteristics of those patients and their liver disease, surgical procedures, intra- and postoperative complications, and the long-term follow-up.

RESULTS:

Twelve laparoscopic multiple-cyst fenestrations and two segmentary liver resections associated with remaining-cyst fenestration were performed. One procedure required conversion to laparotomy and the other was complicated by anhepatic severe bleeding. The rest of the procedures were uneventful. One patient developed persistent self-limited ascites in the immediate postoperative period. Symptoms disappeared after surgical intervention in all patients. During a median follow-up of 62 months (range 14-113 months), there were two clinical recurrences and one asymptomatic radiological recurrence. One patient required further surgery.

CONCLUSION:

Laparoscopic cystic fenestration and laparoscopic liver resection are safe and long-term, effective procedures for the treatment of symptomatic PLD. Severity and morphological characteristics of the hepatic disease will determine the surgical indication and the optimal approach for each patient.

Laparoscopic parenchymal preserving hepatic resections in semiprone position for tumors located in the posterosuperior segments

INTRODUCTION

All patients who underwent laparoscopic liver resections in the posterosuperior segments (LPSS) at our center were positioned in semiprone since August 2011. The aims of this study were to assess differences in perioperative outcomes between laparoscopic left lateral sectionectomies (LLLS) performed in supine position and LPSS in semiprone position.

METHODS

We reviewed our prospectively collected database of all liver resections performed between January 2012 and January 2015. LLLS and LPSS were compared with respect to demographics and perioperative outcomes.

RESULTS

Forty-five patients underwent LLLS (n = 20) or LPSS (n = 25). There were no differences in patient demographics or tumor diameter (p = 0.946). There were no conversions. Pringle maneuver was not used in both groups. There was no difference in peroperative central venous pressure (p = 0.511). The median operative time in the LLLS group was 100 min (60-260) and 160 min (95-270) in the LPSS group (p = 0.002) with median intraoperative blood loss in the LLLS group of 50 ml (0-550) versus a larger 150 ml (50-700) (p = 0.010) for patients receiving LPSS. No patients required transfusion. Intraoperative and postoperative complication rates were similar in both groups. Median hospital stay was 6 days in both groups (p = 0.554).

CONCLUSION

LPSS in semiprone can be performed with similar clinical outcomes as a minor laparoscopic liver resection except for longer operative time and larger intraoperative blood loss without the need for transfusion.

Single-incision laparoscopic management of a giant hepatic cyst

Large symptomatic hepatic cysts may warrant surgical management. Traditional multiport laparoscopic technique is typically preferred over open laparotomy, but the use of the single-incision laparoscopic approach for this diagnosis is not well documented. Here, we describe the case of a 68-year-old woman who underwent complete anterior wall fenestration, excision and cauterization of a simple hepatic cyst via a single-incision laparoscopic technique through an incision at the umbilicus. The objective of this case report is to document single-incision laparoscopy as a safe, feasible and cosmetically appealing approach for the management of a large hepatic cyst.

ACG clinical guideline: the diagnosis and management of focal liver lesions

Focal liver lesions (FLL) have been a common reason for consultation faced by gastroenterologists and hepatologists. The increasing and widespread use of imaging studies has led to an increase in detection of incidental FLL. It is important to consider not only malignant liver lesions, but also benign solid and cystic liver lesions such as hemangioma, focal nodular hyperplasia, hepatocellular adenoma, and hepatic cysts, in the differential diagnosis. In this ACG practice guideline, the authors provide an evidence-based approach to the diagnosis and management of FLL.

Pathophysiology, epidemiology, classification and treatment options for polycystic liver diseases

Polycystic liver diseases (PLD) represent a group of genetic disorders in which cysts occur in the liver (autosomal dominant polycystic liver disease) or in combination with cysts in the kidneys (autosomal dominant polycystic kidney disease). Regardless of the genetic mutations, the natural history of these disorders is alike. The natural history of PLD is characterized by a continuous increase in the volume and the number of cysts. Both genders are affected; however, women have a higher prevalence. Most patients with PLD are asymptomatic and can be managed conservatively. Severe symptoms can affect 20% of patients who develop massive hepatomegaly with compression of the surrounding organs. Rrarely, patients with PLD suffer from acute complications caused by the torsion of hepatic cysts, intraluminal cystic hemorrhage and infections. The most common methods for the diagnosis of PLD are cross sectional imaging studies. Abdominal ultrasound and computerized tomography are the two most frequently used investigations. Magnetic resonance imaging is more sensitive and specific, and it is a valuable test for patients with intravenous contrast allergies or renal dysfunction. Different treatment modalities are available to physicians caring for these patients. Medical treatment has been ineffective. Percutaneous sclerotherapy, trans-arterial embolization, cyst fenestration, hepatic resection and liver transplantation are indicated to specific groups of patients and have to be tailored according to the extent of disease. This review outlines the current knowledge of the pathophysiology, clinical course, diagnosis and treatment strategies of PLD.

Management of giant hepatic cysts in the laparoscopic era

Purpose

We sought to evaluate the feasibility and outcomes of laparoscopic resection of giant hepatic cysts and surgical success, focusing on cyst recurrence.

Methods

From February 2004 to August 2011, 37 consecutive patients with symptomatic hepatic cysts were evaluated and treated at Dong-A University Hospital. Indications were simple cysts (n = 20), multiple cysts (n = 6), polycystic disease (n = 2), and cystadenoma (n = 9).

Results

The median patient age was 64 years, with a mean lesion diameter of 11.4 cm. The coincidence between preoperative imaging and final pathologic diagnosis was 54% and half (n = 19) of the cysts were located in segments VII and VIII. Twenty-two patients had American Society of Anesthesiologists (ASA) classification I and II, and nine had ASA classification III. Surgical treatment of hepatic cysts were open liver resection (n = 3), laparoscopic deroofing (n = 24), laparoscopic cyst excision (n = 4), laparoscopic left lateral sectionectomy (n = 2), hand assisted laparoscopic procedure (n = 2), and single port laparoscopic deroofing (n = 2). The mean fellow-up was 21 months, and six patients (16%) experienced radiographic-apparent recurrence. Reoperation due to recurrence was performed in two patients. Among the factors predicting recurrence, multivariate analysis revealed that interventional radiological procedures and pathologic diagnosis were statistically significant.

Conclusion

Laparoscopic resection of giant hepatic cysts is a simple and effective method to relieve symptoms with minimal surgical trauma. Moreover, the recurrence is dependent on the type of pathology involved, and the sclerotherapy undertaken.

Complications arising in simple and polycystic liver cysts

Liver cysts are common, affecting 5%-10% of the population. Most are asymptomatic, however 5% of patients develop symptoms, sometimes due to complications and will require intervention. There is no consensus on their management because complications are so uncommon. The aim of this study was to perform a collected review of how a series of complications were managed at our institutions. Six different patients presenting with rare complications of liver cysts were obtained from Hepatobiliary Units in the United Kingdom and The Netherlands. History and radiological imaging were obtained from case notes and computerised radiology. As a result, 1 patient admitted with inferior vena cava obstruction was managed by cyst aspiration and lanreotide; 1 patient with common bile duct obstruction was first managed by endoscopic retrograde cholangiopancreatography and stenting, followed by open fenestration; 1 patient with ruptured cysts and significant medical co-morbidities was managed by percutaneous drainage; 1 patient with portal vein occlusion and varices was managed by open liver resection; 1 patient with infected cysts was treated with intravenous antibiotics and is awaiting liver transplantation. The final patient with a simple liver cyst mimicking a hydatid was managed by open liver resection. In conclusion, complications of cystic liver disease are rare, and we have demonstrated in this series that both operative and non-operative strategies have defined roles in management. The mainstays of treatment are either aspiration/sclerotherapy or, alternatively laparoscopic fenestration. Medical management with somatostatin analogues is a potentially new and exciting treatment option but requires further study.

Laparoscopic liver resection: Current role and limitations

Laparoscopic liver resection (LLR) for the treatment of benign and malignant liver lesions is often performed at specialized centers. Technological advances, such as laparoscopic ultrasonography and electrosurgical tools, have afforded surgeons simultaneous improvements in surgical technique. The utilization of minimally invasive techniques for liver resection has been reported to reduce operative time, decrease blood loss, and shorten length of hospital stay with equivalent postoperative mortality and morbidity rates compared to open liver resection (OLR). Non-anatomic liver resection and left lateral sectionectomy are now routinely performed laparoscopically at many institutions. Furthermore, major hepatic resections are performed by pure laparoscopy, hand-assisted technique, and the hybrid method. In addition, robotic surgery and single port surgery are revealing early promising results. The consensus recommendation for the treatment of benign liver disease and malignant lesions remains unchanged when considering a laparoscopic approach, except when comorbidities and anatomic limitations of the liver lesion preclude this technique. Disease free and survival rates after LLR for hepatocellular carcinoma and metastatic colon cancer correspond to OLR. Patient selection is a significant factor for these favorable outcomes. The limitations include LLR of superior and posterior liver lesions; however, adjustments in technique may now consider a laparoscopic approach as a viable option. As growing data continue to reveal the feasibility and efficacy of laparoscopic liver surgery, this skill is increasingly being adopted by hepatobiliary surgeons. Although the full scope of laparoscopic liver surgery remains infrequently used by many general surgeons, this technique will become a standard in the treatment of liver diseases as studies continue to show favorable outcomes.

Surgical management of cystic lesions in the liver

BACKGROUND

Liver cysts are common, occurring in up to 5% of the population. For many types of cysts, a variety of different treatment options exist and the preferred management is unclear.

METHODS

A Pubmed and Medline literature review using key words non-parasitic hepatic cysts, polycystic liver disease, echinococcus, hydatid cysts parasitic cysts, Caroli's disease, cystadenoma; liver abscess, surgery, aspiration and treatment was undertaken and papers pertaining to the diagnosis and management of cystic lesions within the liver were retrieved.

RESULTS

Asymptomatic simple cysts in the liver require no treatment. Therapy for symptomatic cysts may incorporate aspiration with sclerotherapy or de-roofing. At present, insufficient evidence exists to recommend one over the other. Polycystic liver disease presents a unique management problem because of high morbidity and mortality rates from intervention and high rates of recurrence. Careful patient counselling and assessment of symptom index is essential before embarking on any treatment. New medical treatments may ameliorate symptoms. Acquired cystic lesions in the liver require a thorough work-up to fully characterize the abnormality and direct appropriate treatment. Hydatid cysts are best treated by chemotherapy followed by some form of surgical intervention (either aspiration and sclerotherapy or surgery). Liver abscesses can effectively be treated by aspiration or drainage. With improved antimicrobial efficacy, prolonged treatment with antibiotics may also be considered.

CONCLUSION

All patients with cystic lesions in the liver require discussion at multi-disciplinary meetings to confirm and the diagnosis and determine the most appropriate method of treatment.

[Benign non-parasitic hepatic cystic tumours]

Hepatic cystic tumours are a heterogeneous group of diseases with different aetiology and incidence, and with similar clinical signs and symptoms. They are classified as congenital, traumatic, parasitic, or neoplastic cysts. The congenital cystic tumours are the most prevalent, and include the simple cyst and polycystic hepatic disease. Other less common lesions are, hepatic cystadenoma, ciliated embryonic cyst, and a miscellaneous group. We have carried out a review of all benign non-parasitic hepatic cystic tumours, placing special emphasis on therapeutic strategies.

Laparoscopic liver resection

More than 3,000 laparoscopic liver resections (LLR) are performed worldwide for benign disease, malignancy, and living donor hepatectomy. Minimally invasive hepatic resection approaches include pure laparoscopic, hand-assisted laparoscopic, and a laparoscopic-assisted open "hybrid" approach, where the operation is started laparoscopically to mobilize the liver and begin the dissection, followed by a small laparotomy for completion of the parenchymal transection. Surgeons should have an advanced understanding of hepatic anatomy, extensive experience in open liver surgery, and technical skill to control major vascular and biliary structures laparoscopically before embarking on LLR. Although there is no absolute size criterion, smaller, peripheral lesions (<5 cm) that lie far from major vessels and anticipated transection planes are most amenable to LLR. Although the majority of reported LLR are non-anatomic resections or segmentectomies, several surgical groups are now performing laparoscopic major hepatic resections with excellent safety profiles. Patient benefits from LLR include less operative blood loss, less postoperative pain and narcotic requirement, and a shorter length of hospital stay, with comparable postoperative morbidity and mortality to open liver resection. Comparison studies between LLR and open resection have revealed no differences in width of resection margins for malignant lesions or overall survival after resection for hepatocellular cancer or colorectal cancer liver metastases. Advantages of LLR for HCC in particular include avoidance of collateral vessel ligation, decreased postoperative hepatic insufficiency, and fewer postoperative adhesions, all of which are features that enhance subsequent liver transplantation.

Laparoscopic management of a giant hepatic cyst with fibrin glue fixation of the omentum

Approximately 4.5% to 7% of the population will have simple hepatic cysts, but only 5% of these will require treatment. Drainage options include interventional, laparoscopic, and open techniques ranging from simple aspiration to liver resection. We present a case where a giant hepatic cyst was treated laparoscopically and omentum was fixed in the defect using fibrin glue to prevent recurrence. A 69-year-old female patient presented with a recurrent simple hepatic cyst after percutaneous aspiration had failed. Her symptoms were related to the size of the cyst. Laparoscopic drainage was performed with cyst wall excision. Omentum was fixed in the defect using fibrin glue. She was discharged after 24 hours without complication. There are many ways to treat nonparasitic liver cysts. The laparoscopic approach limits morbidity with excellent results. The use of fibrin glue to secure omentum in the defect is a simple technique to limit recurrence.

Biliary obstruction due to a huge simple hepatic cyst treated with laparoscopic resection

Most hepatic cysts are asymptomatic, but complications occasionally occur. We describe a patient with biliary obstruction due to a huge simple hepatic cyst treated with laparoscopic resection. A 60-year-old Japanese woman was admitted to our hospital because of a nontender mass in the right upper quadrant of the abdomen. Laboratory tests revealed the following: serum total bilirubin, 0.6 mg/dL; serum aspartate aminotransferase, 100 IU/L; serum alanine aminotransferase, 78 IU/L; serum alkaline phosphatase, 521 IU/L; and serum gamma glutamic transpeptidase, 298 IU/L. Abdominal computed tomography, ultrasonography, and magnetic resonance cholangiopancreatography revealed a huge hepatic cyst, 13 cm in diameter, at the hepatic hilum, accompanied by dilatation of the intrahepatic bile duct and obstruction of the common bile duct. We diagnosed biliary obstruction due to a huge hepatic cyst at the hepatic hilum, and laparoscopic surgery was performed. A huge hepatic cyst was seen at the hepatic hilum. After needle puncture of the huge cyst, the anterior wall of the cyst was unroofed, and cholecystectomy was done. Intraoperative cholangiography through a cystic duct revealed stenosis of the duct. Subsequent decapsulation of the cyst was performed in front of the common bile duct. After this procedure, cholangiography revealed that the stenosis of the common bile duct had resolved. Histopathological examination of the surgical specimen confirmed the hepatic cyst was benign. The postoperative course was uneventful, and the results of liver function tests normalized. The patient was discharged 7 days after operation. Computed tomography 3 months after operation revealed disappearance of the hepatic cyst and no dilatation of the intrahepatic bile duct.

Laparoscopic liver resection--current update

An increasing number of studies are reporting the outcomes and benefits of laparoscopic liver resection. This article reviews the literature with emphasis on a recent consensus conference on laparoscopic liver resection in 2008, the learning curve for laparoscopic liver surgery, laparoscopic major hepatectomies, oncologic outcomes of laparoscopic liver resection for hepatocellular carcinoma and colorectal cancer liver metastases, and the comparative benefits of laparoscopic versus open liver resection. Current evidence suggests that minimally invasive hepatic resection is safe and feasible with short-term benefits, no economic disadvantage, and no compromise to oncologic principles.

Hepatic cysts and liver abscess

Benign pathologies of the liver often include several cystic diseases, such as simple cysts, autosomal dominant polycystic liver disease, and Caroli's disease. The differential of hepatic cysts also includes infectious pathologies, such as pyogenic liver abscess, hydatid cysts, and parasitic infections if the appropriate clinic setting. Understanding of the various causes, clinical presentation, and treatment options is required to ensure the appropriate surgical management of these patients.

[Laparoscopic treatment of liver cysts]

OBJECTIVE

The authors present their experience with the laparoscopic management of non-parasitic liver cysts.

METHODS

During the period from May 2003 to August 2006, thirteen patients with non-parasitic liver cysts underwent laparoscopic fenestration. Eleven patients were female (84.6%) and two (15.4%) were male. The average age at diagnosis was 48.3 years (range 35-72). The majority of patients presented with pain, discomfort, dyspepsia, or early satiety at diagnosis. Computed tomography scans were performed in all cases. The cysts were solitary in eleven patients (84.6%) and polycystic liver disease in two patients (15.4%). The average size of the solitary cysts was 11.3 cm (range 9.5-17 cm), and the polycystic liver disease was 10.6 cm (range 9.2-12.1 cm). Operation was indicated due to symptoms in all patients. The technique performed was laparoscopic cyst fenestration.

RESULTS

Laparoscopic fenestration was completed in all patients. Mean operative time was 85 minutes (range 53-110). Intraoperative complications were not detected and there was no death. Postoperative complications were observed in two patients (15.4%). Bile leakage was present in one patient, and ascites in another patient. Both cases were treated conservatively. The average hospital stay was 3.5 days (range 2-9 days). Mean follow-up was 36 months. There was one asymptomatic recurrence (7.6%) in a patient with polycystic liver disease after two years of follow-up.

CONCLUSION

Laparoscopic fenestration is the preferred method of treatment for non-parasitic liver cyst. This operation causes low morbidity and the recurrence is uncommon. Adequate selection of patients and the laparoscopic technique are important for the treatment.

Comparing the clinical and economic impact of laparoscopic versus open liver resection

BACKGROUND

Laparoscopic liver resection has thus far not gained widespread acceptance among liver surgeons. Valid questions remain regarding the relative clinical superiority of the laparoscopic approach as well as whether laparoscopic hepatectomy carries any economic benefit compared with open liver surgery.

OBJECTIVE

The aim of this work is to compare the clinical and economic impact of laparoscopic versus open left lateral sectionectomy (LLS).

METHODS

Between May 2002 and July 2008, 44 laparoscopic LLS and 29 open LLS were included in the analysis. Deviation-based cost modeling (DBCM) was utilized to compare the combined clinical and economic impact of the open and laparoscopic approaches.

RESULTS

The laparoscopic approach compared favorably with the open approach from both a clinical and economic standpoint. Not only was the median length of stay (LOS) shorter by 2 days in the laparoscopic group (3 versus 5 days, respectively, P = 0.001), but the laparoscopic cohort also benefited from a significant reduction in postoperative morbidity (P = 0.001). Because the groups differed significantly in age and ratio of benign to malignant disease, a subgroup analysis limited to patients with malignant disease was undertaken. The same reduction in LOS and postoperative morbidity was evident within the malignant subgroup undergoing laparoscopic LLS (P = 0.003). The economic impact of the laparoscopic approach was noteworthy, with the laparoscopic approach US$1,527-2,939 more cost efficient per patient compared with the open technique.

CONCLUSION

Our study seems not only to corroborate the safety and clinical benefit of the laparoscopic approach but also suggests a fiscally important cost advantage for the minimally invasive approach.

Laparoscopic major hepatectomy: an evolution in standard of care

OBJECTIVE

To analyze the results of 6 international surgical centers performing laparoscopic major liver resections.

SUMMARY BACKGROUND DATA

The safety and feasibility of laparoscopy for minor liver resections has been previously demonstrated. Major anatomic liver resections, initially considered to be unsuitable for laparoscopy, are increasingly reported by several centers worldwide.

METHODS

Prospective databases of 3 European, 2 U.S., and 1 Australian centers were combined. Between 1997 and 2008, 210 major liver resections were performed: 136 right and 74 left hepatectomies. Results and differences in surgical techniques between the 6 centers are outlined.

RESULTS

Surgical duration was 250 minutes (range: 90-655 minutes). Operative blood loss was 300 mL (range: 20-2500 mL). Thirty patients (14.3%) received blood transfusion. Conversion to open surgery was required in 26 patients (12.4%). Portal triad clamping was performed in 24 patients (11.4%). Median tumor size was 5.4 cm (range: 1-25 cm) and surgical margin was 10.5 mm (range: 0-70 mm). Two patients died during the postoperative period from pulmonary embolism and urosepsis. Liver-specific and general complications occurred in 17 (8.1%) and 29 patients (13.8%), respectively. Hospital length of stay was 6 days (range: 1-34 days). A further analysis of early (n = 90) and late (n = 120) experience showed improved surgical and postoperative results in the latter group.

CONCLUSIONS

This multicenter study demonstrates that laparoscopic major liver resections are feasible in selected patients and results improve with experience. However, proficiency in both open liver surgery and advanced laparoscopy is compulsory and surgeons must begin with minor laparoscopic resections.

World review of laparoscopic liver resection-2,804 patients

OBJECTIVE

To provide a review of the world literature on laparoscopic liver resection.

SUMMARY BACKGROUND DATA

Initially described for peripheral, benign tumors resected by nonanatomic wedge resections, minimally invasive liver resections are now being performed more frequently, even for larger, malignant tumors located in challenging locations. Although a few small review articles have been reported, a comprehensive review on laparoscopic liver resection has not been published.

METHODS

We conducted a literature search using Pubmed, screening all English publications on laparoscopic liver resections. All data were analyzed and apparent case duplications in updated series were excluded from the total number of patients. Tumor type, operative characteristics, perioperative morbidity, and oncologic outcomes were tabulated.

RESULTS

A total of 127 published articles of original series on laparoscopic liver resection were identified, and accounted for 2,804 reported minimally invasive liver resections. Fifty percent were for malignant tumors, 45% were for benign lesions, 1.7% were for live donor hepatectomies, and the rest were indeterminate. Of the resections, 75% were performed totally laparoscopically, 17% were hand-assisted, and 2% were laparoscopic-assisted open hepatic resection (hybrid) technique, with the remainder being other techniques or conversions to open hepatectomies. The most common laparoscopic liver resection was a wedge resection or segmentectomy (45%) followed by anatomic left lateral sectionectomy (20%), right hepatectomy (9%), and left hepatectomy (7%). Conversion from laparoscopy to open laparotomy and from laparoscopy to hand-assisted approach occurred in 4.1% and 0.7% of reported cases, respectively. Overall mortality was 9 of 2,804 patients (0.3%), and morbidity was 10.5%, with no intraoperative deaths reported. The most common cause of postoperative death was liver failure. Postoperative bile leak was observed in 1.5% of cases. For cancer resections, negative surgical margins were achieved in 82% to 100% of reported series. The 5-year overall and disease-free survival rates after laparoscopic liver resection for hepatocellular carcinoma were 50% to 75% and 31% to 38.2%, respectively. The 3-year overall and disease-free survival rates after laparoscopic liver resection for colorectal metastasis to the liver were 80% to 87% and 51%, respectively.

CONCLUSION

In experienced hands, laparoscopic liver resections are safe with acceptable morbidity and mortality for both minor and major hepatic resections. Oncologically, 3- and 5-year survival rates reported for hepatocellular carcinoma and colorectal cancer metastases are comparable to open hepatic resection, albeit in a selected group of patients.

Ressecões hepáticas por videolaparoscopia

INTRODUÇÃO: As ressecções hepáticas representam umas das últimas fronteiras vencidas pela cirurgia videolaparoscópica. Apesar da complexidade do procedimento, da demanda de grande incorporação de tecnologia e necessidade de experiência em cirurgia hepática e laparoscópica, a indicação do método tem crescido de forma expressiva nos últimos anos. OBJETIVO: Realizar análise crítica do método, baseada nos trabalhos existentes na literatura, ressaltando o estado atual de suas indicações, exequibilidade, segurança, resultados e aspectos técnicos primordiais. MÉTODO: Foram identificados e analisados os trabalhos pertinentes nas bases de dados LILACS e PUBMED até dezembro de 2009, utilizando-se os descritores "liver resection", "laparoscopic" e "liver surgery". Não foram encontrados trabalhos prospectivos e randomizados sobre o tema, sendo os dados disponíveis provenientes de série de casos, estudos caso-controle e alguns estudos multicêntricos e metanálises. CONCLUSÃO: A hepatectomia por videolaparoscopia é hoje operação segura e factível, mesmo para as ressecções hepáticas maiores, com baixo índice de morbimortalidade. O método pode ser utilizado para lesões malignas sem prejuízo dos princípios oncológicos e com vantagens nos pacientes com cirrose ou disfunção hepática. A melhor indicação recai sobre as lesões benignas, em especial o adenoma hepatocelular. Em mãos experientes e casos selecionados, como as lesões benignas localizadas nos segmentos anterolaterais hepáticos, principalmente no segmento lateral esquerdo, a ressecção videolaparoscópica pode ser considerada hoje como tratamento padrão.