Segment-oriented approach to liver resection

Impact of Minimally Invasive Surgery on Anatomic Liver Segmentectomy Using the Extrahepatic Glissonean Approach

Accurate minimally invasive anatomic liver (sub)segmentectomy (MIAS) is technically demanding and not yet standardized, and its surgical outcomes are undefined. To study the impact of the minimally invasive approach on perioperative outcomes of anatomic liver (sub)segmentectomy (AS), we retrospectively studied and compared perioperative outcomes of 99 open AS (OAS) and 112 MIAS (laparoscopic 77, robotic 35) cases using the extrahepatic Glissonean approach, based on the 1:1 propensity score matched analyses. After matching (71:71), MIAS was superior to OAS in terms of blood loss (p < 0.0001), maximum postoperative serum total bilirubin (p < 0.0001), C-reactive protein (p = 0.034) levels, R0 resection rate (p = 0.021), bile leak (p = 0.049), and length of hospital stay (p < 0.0001). The matched robotic and laparoscopic AS groups (30:30) had comparable outcomes in terms of operative time, blood loss, transfusion, open conversion, postoperative morbidity and mortality, R0 resection, and hospital stay, although the rate of Pringle maneuver application (p = 0.0002) and the postoperative aspartate aminotransferase level (p = 0.002) were higher in the robotic group. Comparing the matched posterosuperior (sub)segmentectomy cases or unmatched repeat hepatectomy cases between MIAS and OAS, we observed significantly less blood loss and shorter hospital stays in MIAS. Robotic AS yielded comparable outcomes with laparoscopic AS in the posterosuperior (sub)segmentectomy and repeat hepatectomy settings, despite the worse tumor and procedural backgrounds in robotic AS. In conclusion, various types of MIAS standardized by the extrahepatic Glissonean approach were feasible and safe with more favorable perioperative outcomes than those of OAS. Although robotic AS had almost comparable outcomes with laparoscopic AS, robotics may serve to decrease the surgical difficulty of MIAS in selected patients undergoing posterosuperior (sub)segmentectomy and repeat hepatectomy.

Role of Mesohepatectomy for Pediatric Centrally Located Liver Tumors

Background

Mesohepatectomy (MH) or central hepatectomy (CH) is a recognized surgical technique for centrally located pediatric liver tumors. This technique of liver resection avoids extended liver resections and thereby helps in the preservation of liver parenchyma. In this article, we aim to analyze our experience and outcome with this technique of liver resection.

Methods

A retrospective analysis of patients who underwent MH from January 2015 to June 2023 at our institute was performed. The variables analyzed include demographics, preoperative treatment, perioperative management, and postoperative outcome.

Results

A total of five patients underwent CH. Four patients had hepatoblastoma, and one patient had mesenchymal hamartoma. All four patients with hepatoblastoma received neoadjuvant chemotherapy. All five patients had negative surgical margins, and one of the five developed disease recurrences necessitating resurgery and ultimately died of metastasis. one patient sustained intraoperative major bile duct injuries, and one patient had postoperative Abnormal, well-circumscribed, extra-biliary collection of bile.

Conclusion

MH with clear margins is feasible in the selected subset of pediatric liver tumors involving segments IV, V, and VIII with outcomes equivalent to extended hepatic resections.

Prevalence and clinical significance of the Sg6/Sg7 intersegmental veins based on re-evaluation of the Couinaud classification for the right posterior portal vein

Although Segment 6(Sg6) and Segment 7(Sg7) are two independent units, there are currently no clear anatomical boundary markers between Sg6 and Sg7. This study aimed to identify intersegmental veins (ISV) in the intersegmental plane of Sg6 and Sg7, and evaluate the prevalence of ISV, and its clinical significance in anatomical hepatectomy. We analyzed data from 180 patients undergoing abdominal computed tomography (CT) examination, and simultaneously performed 3D reconstruction models of the liver for each patient. The right posterior portal vein was analyzed and re-typed. Furthermore, the existence of ISV was defined, and prevalence and confluence patterns of ISV were analyzed. The author attempted to apply ISV to laparoscopic S6/S7 segmentectomy. We sorted data from the right posterior portal vein and divided it into six types. The ISV could be identified in 82.2% (148/180) of the patients, which were derived from the right hepatic vein (RHV) (91.9%) and right posterior inferior vein (IRHV) (8.1%). Ten ISV-guided laparoscopic Sg6/Sg7 segmentectomy were successfully carried out, seven patients underwent Sg6 segmentectomy, and three patients underwent Sg7 segmentectomy. There was no perioperative mortality. The median operative time was 223 min (range 181-260 min). The median blood loss was 200 ml (range 150-310 ml). The R0 resection rate was 100%. The ISV may be a candidate vessel to distinguish the boundary of the right posterior sector; it is expected to be a landmark in the liver parenchyma of anatomical hepatectomy.

Predictors of Early Postoperative Outcomes in 375 Consecutive Hepatectomies: A Single-institution Experience

Although the safety of hepatic resection has improved, it is still a highly morbid procedure. A retrospective cohort of 375 patients undergoing hepatectomy (2004 to 2012) was done. All procedures were performed by a single surgeon at a tertiary center. To help identify trends over time, two subgroups were identified: Group 1 (n = 195 from October 2004 to December 2010) and Group 2 (n = 180 from January 2011 to November 2012). The two study groups had similar patient characteristics except there were more patients with cirrhosis in Group 2 (10 vs 17%, P = 0.04). A similar number of major hepatectomies was noted. Median estimated blood loss was 400 mL versus 300 mL ( P = 0.04) in Group 2. Overall complications were more common in Group 1 (54 vs 45%). Fewer Grade 3 or greater Clavien complications (22 vs 13%, P = 0.04) and fewer hospital readmissions were noted in Group 2 (20 vs 8%, P = 0.002). Morbidity was associated with worse Eastern Cooperative Oncology Group (ECOG) performance status, age older than 60 years, and open surgery. Grade 3 or greater Clavien complications were also associated with age older than 60 years, higher American Society of Anesthesiologists class, and worse ECOG status and median estimated blood less greater than 400 mL. Higher Model for End-stage Liver Disease score and advanced ECOG status were correlated with mortality. Outcomes of hepatic resection improved time despite more complex patient characteristics and an equal number of major hepatectomies being performed. However, worse ECOG performance status was a major predictor of postoperative complications and increased mortality.

Stepwise evaluation of liver sectors and liver segments by endoscopic ultrasound

The liver has eight segments, which are referred to by numbers or by names. The numbering of the segments is done in a counterclockwise manner with the liver being viewed from the inferior surface, starting from Segment I (the caudate lobe). Standard anatomical description of the liver segments is available by computed tomographic scan and ultrasonography. Endoscopic ultrasound (EUS) has been used for a detailed imaging of many intra-abdominal organs and for the assessment of intra-abdominal vasculature. A stepwise evaluation of the liver segments by EUS has not been described. In this article, we have described a stepwise evaluation of the liver segments by EUS. This information can be useful for planning successful radical surgeries, preparing for biopsy, portal vein embolization, transjugular intrahepatic portosystemic shunt, tumour resection or partial hepatectomy, and for planning EUS guided diagnostic and therapeutic procedures.

Surgical techniques and strategies for the treatment of primary liver tumours: hepatocellular and cholangiocellular carcinoma

Background

Owing to remarkable improvements of surgical techniques and associated specialities, liver surgery has become the standard of care for hepatocellular carcinoma and cholangiocarcinoma. Although applied with much greater safety, hepatic resections for primary liver tumours remain challenging and need to be integrated in a complex multidisciplinary treatment approach.

Methods

This literature review gives an update on the recent developments regarding basics of open and laparoscopic liver surgery and surgical strategies for primary liver tumours.

Results

Single-centre reports and multicentre registries mainly from Asia and Europe dominate the surgical literature on primary liver tumours, but the numbers of randomized trials are slowly increasing. Perioperative outcomes of open liver surgery for hepatocellular and cholangiocellular carcinoma have vastly improved over the last decades, accompanied by some progress in terms of oncological outcome. The laparoscopic approach is increasingly being applied in many centres, even for patients with underlying liver disease, and may result in decreased morbidity. Liver transplantation represents a cornerstone in the treatment of early hepatocellular carcinoma and is indispensable to achieve long-term survival. In contrast, resection remains the gold standard for cholangiocarcinoma in most countries, but interventional techniques are on the rise.

Conclusion

Liver surgery for primary tumours is complex, with a need for high expertise in a multidisciplinary team to achieve acceptable outcomes. Technical developments and clinical stratification tools have optimized individual care, but further improvements in oncological survival will likely require enhanced pre- and postoperative systemic and local treatment options.

Laparoscopic Anatomic Segment 6 Liver Resection Using the Glissonian Approach

INTRODUCTION

Laparoscopic liver resection has become important procedure for malignant liver disease. In this report, we describe the relevant technical maneuvers and perioperative outcomes in laparoscopic anatomic segment 6 liver resection using the Glissonian approach.

PATIENTS AND METHODS

From March 2003 and October 2015, 7 patients who diagnosed hepatocellular carcinoma had undergone laparoscopic anatomic segment 6 liver resection at the single institution. We performed retrospective analysis of the clinical and perioperative outcomes of these patients.

RESULTS

All patients were men with mean age of 62.3 years (range, 49 to 73 y). The mean operation time was 352.8 minutes (range, 180 to 435 min) and there was no case of open conversion. The mean estimated blood loss was 521.4 mL (range, 200 to 800 mL) and intraoperative transfusion needed in 1 patient. There was no postoperative morbidity and mortality. The mean postoperative hospital stay was 7.5 days (range, 5 to 12 d). All patients obtained negative resection margins. There was no patient had developed tumor recurrence during a median follow-up period of 43 months (range, 7 to 60.7 mo).

CONCLUSIONS

Laparoscopic anatomic segment 6 liver resection is a feasible operative procedure, being possible even in patients with limited liver function.

Anatomical resection of hepatocellular carcinoma: A critical review of the procedure and its benefits on survival

Hepatocellular carcinoma (HCC) is the sixth most common type of cancer and the third most frequent cause of cancer-related death. Advances in preoperative assessment of HCC (e.g., imaging studies and liver function tests), surgical techniques, and postoperative care have improved the surgical outcomes and survival of patients who undergo hepatic resection for HCC. However, in the last 20 years, the long-term survival after hepatectomy has remained unsatisfactory owing to the high rates of local recurrence and multicentric occurrence. Anatomical liver resection (AR) was introduced in the 1980s. Although several studies have revealed tangible benefits of AR for HCC, these benefits are still debated. Because most HCCs occur in patients with liver cirrhosis and poor hepatic function, there are many factors that affect survival, including the surgical method. Nevertheless, many studies have documented the perioperative and long-term benefits of AR in various conditions. In this article, we review the results of several recently published, well-designed comparative studies of AR, to investigate whether AR provides real benefits on survival outcomes. We also discuss the potential pitfalls associated with this approach.

An overview of imaging techniques for liver metastases management

Evaluation of liver metastases is one of the most common indications for liver imaging. Imaging plays a key role in the of assessment liver metastases. A variety of imaging techniques, including ultrasonography, computed tomography, MRI and PET combined with CT scan are available for diagnosis, planning treatment, and follow-up treatment response. In this paper, the authors present the role of imaging for the assessment of liver metastases and the contribution of each of the different imaging techniques for their evaluation and management. Following recent developments in the field of oncology, the authors also present the importance of imaging for the assessment of liver metastases response to therapy. Finally, future perspectives on imaging of liver metastases are presented.

Current evidence for the diagnostic value of gadoxetic acid-enhanced magnetic resonance imaging for liver metastasis

A variety of imaging techniques, including ultrasonography (US), multidetector computed tomography (MDCT), magnetic resonance imaging (MRI) and positron emission tomography combined with CT scan (PET/CT), are available for diagnosis and treatment planning in liver metastasis. Contrast-enhanced MDCT is a relatively non-invasive, widely available and standardized method for hepatic work-up. Gadoxetic acid (gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid; EOB Primovist®]) is a recently developed liver-specific hepatobiliary MR contrast agent that offers both dynamic imaging as well as liver-specific static hepatocyte imaging, referred to as the hepatobiliary phase. Following contrast injection, this technique reveals dynamic vascular phases (arterial, portal venous and delayed phases), in addition to the hepatobiliary phase upon uptake by functional hepatocytes. The overall sensitivity of gadoxetic acid-enhanced MRI was significantly higher than that of contrast-enhanced CT. Specifically, the higher sensitivity of gadoxetic acid-enhanced MRI was observed in lesions smaller than 1 cm in diameter. Gadoxetic acid-enhanced MRI is considered an extremely useful tool for the diagnosis of liver metastases. Future studies will focus on diagnostic algorithms involving combinations of modalities such as MRI, MDCT and/or (18) F-fluorodeoxyglucose PET/CT, which may impact the treatment plan for these patients.

Acute renal injury after partial hepatectomy

Currently, partial hepatectomy is the treatment of choice for a wide variety of liver and biliary conditions. Among the possible complications of partial hepatectomy, acute kidney injury (AKI) should be considered as an important cause of increased morbidity and postoperative mortality. Difficulties in the data analysis related to postoperative AKI after liver resections are mainly due to the multiplicity of factors to be considered in the surgical patients, moreover, there is no consensus of the exact definition of AKI after liver resection in the literature, which hampers comparison and analysis of the scarce data published on the subject. Despite this multiplicity of risk factors for postoperative AKI after partial hepatectomy, there are main factors that clearly contribute to its occurrence. First factor relates to large blood losses with renal hypoperfusion during the operation, second factor relates to the occurrence of post-hepatectomy liver failure with consequent distributive circulatory changes and hepatorenal syndrome. Eventually, patients can have more than one factor contributing to post-operative AKI, and frequently these combinations of acute insults can be aggravated by sepsis or exposure to nephrotoxic drugs.

Imaging of the postoperative liver: review of normal appearances and common complications

Several benign and malignant liver diseases may require surgical treatment for cure, including anatomical resections based on the segmental anatomy of the liver, non-anatomical (wedge) resections, and surgical management of biliary cysts. The type of surgery depends not only on the location and the nature of the disease, but also on the expertise of the surgeon. Whereas ultrasonography is often the first-line imaging examination in case of suspected postoperative complication, multidetector computed tomography (MDCT) is of greater value for identifying normal findings after surgery, early postoperative pathologic fluid collections and vascular thromboses, and tumor recurrence in patients who have undergone hepatic surgery. Magnetic resonance cholangiopancreatography (MRCP) is the imaging modality of choice for depicting early postoperative bile duct injuries and ischemic cholangitis that may occur in the late postoperative phase. Both MDCT and MRCP can accurately depict tumor recurrence. Radiologists should become familiar with these surgical procedures to better understand postoperative changes, and with the normal imaging appearances of various postoperative complications to better differentiate between complications and normal findings.

Central hepatectomy versus extended hepatectomy for liver malignancy: a matched cohort comparison

OBJECTIVE

To compare surgical outcomes between matched central hepatectomy (CH) and extended hepatectomy (EH) groups.

BACKGROUND

Surgical choices for centrally located liver tumours are limited. The traditional EH harbours substantial risks, whereas CH is an alternative parenchymal-sparing resection that may improve peri-operative morbidity.

METHODS

A review of 4661 liver resections at a single institution was performed. The cases (CH) were matched in a 1:1 ratio with EH controls.

RESULTS

The CH group was matched for demographic, tumour and laboratory factors with either right EH or combined (right/left) EH groups (n = 63 per group). Colorectal liver metastases were the most common diagnosis occurring in 70% of the patients. Higher intra-operative blood loss was observed in the right EH(P = 0.01) and combined EH groups (P < 0.01) compared with the CH group. There was a trend towards lower 90-day morbidity in the CH group (43%) compared with the right EH(59%, P = 0.1) and combined EH groups (56%, P = 0.2). The length of hospital stay was significantly longer in the control groups (P < 0.01 for both). The control groups had significantly higher post-operative bilirubin and International Normalized Ratio (INR) levels compared with the CH group. A post-operative bilirubin higher than 4 mg/dl was observed in 2% of the CH group compared with 39% of the right EH group (P < 0.01) and 52% of the combined EH group (P < 0.01). No differences in the rates of bile leak/biloma, post-hepatectomy liver failure or 90-day mortality were found.

CONCLUSIONS

CH, as compared with EH, was safe and associated with a shorter hospital stay and less post-operative liver dysfunction. CH should be considered in patients with centrally located tumours amenable to such a resection.

Perceived complexity of various liver resections: results of a survey of experts with development of a complexity score and classification

BACKGROUND

Liver resections have classically been distinguished as "minor" or "major" based on the number of segments removed. However, it is clear that the number of segments alone does not convey the complexity of a resection. To date, no study has formally assessed the complexity of various anatomic liver resections.

STUDY DESIGN

A 4-question survey was administered to 135 expert liver surgeons in 14 countries. The first 3 questions related to the country in which the surgeon was practicing and the surgeon's experience. In the fourth question, the experts were asked to rate the difficulty of various open, anatomic liver resections on a scale of 1 to 10.

RESULTS

Sixty-six of 135 (48.9%) surgeons responded to the survey. Twelve procedures were rated. The lowest mean score of 1.37-indicating least difficulty-was given to peripheral wedge resection. Left trisectionectomy with caudate resection was deemed most difficult, with a score of 8.28. The mean scores for the 2 procedures perceived as least difficult-peripheral wedge resection and left lateral sectionectomy-were lower than the mean scores of all the rest of the procedures at a highly statistically significant level (p < 0.0001). The 4 procedures with the highest scores shared the common attribute that they involved the right intersectional plane.

CONCLUSIONS

These data represent the first quantitative assessment of the perceived difficulty of a variety of liver resections. The complexity scores generated allow for separation of liver resections into 3 categories of complexity (low complexity, medium complexity, and high complexity) on a quantitative basis.

Endoscopic ultrasound description of liver segmentation and anatomy

Endoscopic ultrasound (EUS) can demonstrate the detailed anatomy of the liver from the transgastric and transduodenal routes. Most of the liver segments can be imaged with EUS, except the right posterior segments. The intrahepatic vascular landmarks include the major hepatic veins, portal vein radicals, hepatic arterial branches, and the inferior vena cava, and the venosum and teres ligaments are other important intrahepatic landmarks. The liver hilum and gallbladder serve as useful surface landmarks. Deciphering liver segmentation and anatomy by EUS requires orienting the scan planes with these landmarkstructures, and is different from the static cross-sectional radiological images. Orientation during EUS requires appreciation of the numerous scan planes possible in real-time, and the direction of scanning from the stomach and duodenal bulb. We describe EUS imaging of the liver with a curved linear probe in a step-by-step approach, with the relevant anatomical details, potential applications, and pitfalls of this novel EUS application.

Partial Preservation of Segment IV Confers No Benefit When Performing Extended Right Hepatectomy for Colorectal Liver Metastases

Introduction. Reducing the volume of resected liver parenchyma may lead to lower morbidity and mortality. The aim of this study was to determine whether partial preservation of segment IV leads to improved outcomes when undertaking extended right hepatectomy for colorectal liver metastases (CRLM). Materials and Methods. A retrospective analysis of patients undergoing right-sided hepatectomy for CRLM was performed. Rates of 90-day mortality and organ dysfunction were compared in 117 patients undergoing right hepatectomy (n = 85), partially extended right hepatectomy with preservation of part of segment IV (n = 20), and fully extended right hepatectomy (n = 12). Results. The 90-day mortality rate of those undergoing right hepatectomy (3/85) was similar to that of those undergoing extended right hepatectomy (0/12) (P = 1.000) but lower than that of those undergoing partially extended right hepatectomy (4/20) (P = 0.024). The rates of hepatic and renal dysfunction were similar between patients undergoing right hepatectomy, partially extended or extended hepatectomy. Discussion. Preservation of part of segment IV confers little clinical benefit when performing extended right hepatectomy for CRLM.

Anatomy and surgical relevance of Rouviere's sulcus

Rouviere's sulcus (RS) (i.e., incisura hepatis dextra, Gans incisura) represents an important anatomical landmark. The aim of the study was to determine the frequency of the RS, its description, its location, its relations to the right portal pedicle and to the plane of the common bile duct, and the evaluation of the surgical relevance of the obtained data. Forty macroscopically healthy and undamaged livers were removed during autopsies from cadavers of both sexes. The RS was present in 82% of the cases and in these the open RS was identified in 70% of the livers. The fused type was observed in 12% of the cases; 18% of the livers had no sulcus. The mean length of the open type RS was 28 ± 2 mm (range 24-32 mm) and its mean depth was 6 ± 2 mm (range 4-8 mm). The right posterior sectional pedicle was found in the RS in 70% of the cases. In 5% of the livers, we also dissected a branch of the anterior sectional pedicle. Inside 25% of the RS, we found the vein of segment 6. The RS identification may avoid bile duct injury during laparoscopic cholecystectomy and enables elective vascular control during the right liver resection.

Interventional planning of liver resections: an overview

Liver cancer is the third most common type of cancer. Among available treatment options, a surgical resection offers the best prognosis for long-term survival. It is important that such a surgical procedure is carefully prepared. Modern computer technology offers convenient ways to simulate different resection scenarios and help to determine the best treatment for a given case. This paper provides a non-exhaustive overview of existing computer-based systems for interventional planning of liver resections. They are reviewed according to their medical use case, e.g. if they support typical or atypical resections.

Electronic beam steering used with a toroidal HIFU transducer substantially increases the coagulated volume

Treatment with high-intensity focused ultrasound is well established but requires extended treatment time. A device composed of 256 elements arranged on a toroidal transducer was developed to increase the coagulated volume. When all the elements are working in phase for 40 s, a volume of 6-8 cm(3) can be ablated. However, the mechanical juxtaposition of single lesions is still necessary for treating one tumor with a diameter of 2 cm. The objective of this study was to combine this toroidal transducer geometry with electronic beam steering to ablate tumors with adequate normal tissue margins and without any mechanical displacement of the high-intensity focused ultrasound device. In vitro tests demonstrated that the coagulated volume obtained from 130 s of total exposure has an average diameter of 41.4 ± 4.0 mm and an average length of 53.3 ± 6.1 mm. This single lesion can be used to treat various size of metastasis, located at depths in the liver ranging 5-45 mm.

Central hepatectomy under sequential hemihepatic control

PURPOSE

Central hepatectomy is a complex, parenchymal-sparing procedure which has been associated with increased blood loss, prolonged operating time, and increased duration of remnant hypoxia. In this report, we compare two different techniques of vascular control, namely sequential hemihepatic vascular control (SHHVC) and selective hepatic vascular exclusion (SHVE) in central hepatectomies.

METHODS

From January 2000 to September 2011, 36 consecutive patients underwent a central hepatectomy. SVHE was applied in 16 consecutive patients, and SHHVC was applied in 20 patients. Both groups were comparable regarding their demographics.

RESULTS

Total operative time and morbidity rates were similar in both groups. Warm ischemia time was significantly longer in SVHE patients (46 min vs 28 min, p = 0.03). Total blood loss and number of transfusions per patient were also higher in the SVHE group (650 vs. 400 mL, p = 0.04 and 2.2 vs. 1.2 units, p = 0.04, respectively). AST values were significantly higher in SVHE on days 1 and 3 compared to SHHVC patients (650 vs. 400, p = 0.04 and 550 vs. 250, p = 0.001, respectively).

CONCLUSION

Sequential hemihepatic vascular control is a safe technique for central hepatectomies. Decreased intraoperative blood loss and transfusions and attenuated liver injury are the main advantages of this approach.

Extrahepatic Portal Vein Ligation in Major Hepatectomies Performed under Selective Vascular Exclusion: A Case–Control Study

The aim of our study is to assess the effect of extrahepatic ipsilateral portal vein branch ligation in hepatectomies conducted under selective hepatic vascular exclusion with sharp transection of the liver parenchyma. Twenty-six patients (Group A) underwent major hepatectomy from January 2007 to December 2009, and hemostasis was achieved by ligation of the ipsilateral portal vein branch in addition to suture ligation of the cut surface vessels. A control group (Group B) was composed of 26 matched patients picked from our hospital's database, in which hemostasis was achieved by suture ligation of the cut surface vessels only. Warm ischemia time, intraoperative blood loss, blood transfusions, and liver function were compared. Reduced blood loss (450 vs 680 mL, P = 0.03), less transfusions (8 vs 20% of the patients, P = 0.04), and decreased warm ischemia time (34 vs 42 minutes, P = 0.04) were observed in Group A. Extrahepatic ligation of the ipsilateral portal vein branch is simple, safe, and effective in reducing blood loss and warm ischemia time in major hepatectomies performed under selective vascular exclusion.

Setorectomia posterior direita laparoscópica no tratamento dos tumores hepáticos

INTRODUÇÃO: A ressecção de neoplasias no setor posterior direito costuma ser um desafio técnico pela dificuldade de sua abordagem. Adicionalmente, as hepatectomias laparoscópicas tem se tornado alternativa interessante em virtude de muitas vantagens (baixa morbidade, curto tempo de internação, retorno precoce as atividades laborais e bons resultados cosméticos). OBJETIVO: Relatar experiência em doentes submetidos à setorectomia posterior direita laparoscópica por uma única equipe. MÉTODOS: Cinco doentes foram operados entre novembro de 2008 a agosto de 2010. A idade variou de 21 a 63 anos com mediana de 43 anos. Foram quatro mulheres e um homem. A causa das neoplasias foi: adenoma (n=2), hepatocarcinoma (n=1) e metástases (n=2). A lesão foi solitária em três casos (60 %). A média do tamanho das lesões foi 3,3 cm (1,8-5). Foram analisados: tempo cirúrgico, sangramento operatório, morbimortalidade, tempo de internação e tempo de retorno à atividade habitual. RESULTADOS: A média de tempo cirúrgico foi de 160 minutos (90-260). A de sangramento intra-operatório foi de 200 ml (0-500). Nenhum doente foi transfundido. Não houve mortalidade e a morbidade foi nula. A mediana de internação foi de três dias (2-5). A mediana de retorno às atividades cotidianas foi de 12 dias (7-20). A mediana de seguimento foi de 13 meses (1-20). Não houve recidiva de lesão. CONCLUSÃO: A setorectomia posterior direita laparoscópica representa boa opção tática para o tratamento dos tumores hepáticos situados no setor posterior do lobo direito. É opção segura que evita grandes incisões com morbimortalidade. Também apresenta bom resultado cosmético e retorno precoce ao trabalho.

Current management of hepatic trauma

With the shift toward nonoperative management, most hepatic injuries are managed nonoperatively. On the other hand, up to two-thirds of high-grade hepatic injuries require laparotomy; these cases are technically difficult and challenging. Damage-control approaches, understanding of liver anatomy, and advances in technology have dramatically changed the approach to hepatic trauma, with improved outcomes. Anatomic or nonanatomic liver resection is required in 2% to 5% of liver injuries. Mortality with liver injury following resection is 9% with current advances.

Anatomic resection of segment VIII of liver for hepatocellular carcinoma in cirrhotic patients based on an intrahepatic Glissonian approach

BACKGROUND

Isolated segmentectomy VIII is a technically demanding operative procedure and is reported only rarely. To our knowledge, no reports on anatomic segmentectomy based on an intrahepatic approach have been described. For cirrhotic patients with hepatocellular carcinoma (HCC) limited to segment VIII, this is a parenchyma-preserving hepatectomy that can be tolerated.

METHODS

Eighteen patients with HCC underwent anatomic segment VIII segmentectomy from January 2005 to January 2008 in our institution. The operative techniques, postoperative, and oncologic outcomes were reviewed.

RESULTS

Anatomic segmentectomy VIII was feasible with the technology described herein in all patients. The perioperative and oncologic outcomes were comparable with those of other similar hepatic resections. The median follow-up time was 28 months. The 3-year survival rate was 65%.

CONCLUSION

Although complex and technically demanding, an intrahepatic Glissonian approach for anatomic segmentectomy of segment VIII is an oncologically radical but parenchyma-sparing hepatic resection. In terms of preserving greater functioning liver parenchyma, it may be a safe and effective alternative to extensive hepatectomy.

Laparoscopic liver surgery for everyone: the hybrid method

Minimally invasive techniques have been described recently for liver resections. We have developed a surgical approach to liver resection that combines the benefits of minimally invasive surgery with the safety of open liver resection. We have applied this hybrid approach to selected cases, and we feel that it can be adopted by most hepatobiliary surgeons, even those with minimal or no laparoscopic experience. Briefly, this technique consists of laparoscopic mobilization of the target liver lobe, followed by standard open liver resection through the extraction site. The required incisions parallel those needed for hand-assisted laparoscopic liver resections. We have compared these hybrid procedures with contemporaneous laparoscopic, hand-assisted, and open liver resections at our institution and have found that they compare favorably with minimally invasive procedures. A wider utilization of this approach by both general and hepatobiliary surgeons will result in a more generalized acceptance of minimally invasive liver resection that ultimately will advance the field and benefit patients in need of liver surgery.

Techniques for liver resection: a review

Improvement in surgical outcomes of liver resection has been achieved in the past decade. Among other factors, a gradual change of technology platforms and refinement of surgical techniques have played significant roles. In this review, the various surgical approaches, operative techniques, operative instruments, and adjunctive measures as applied in liver resection are described, along with discussion of the pros and cons of each of these attributes. A brief description of laparoscopic liver resection is also included to address this important and emerging area in liver surgery.

Liver resection for colorectal liver metastasis

At some point in the natural course of colorectal cancer up to 50% of patients will develop metastasis to the liver. Historically only 20% of these patients would have to be deemed resectable, with an intent to cure, at the time of presentation. But with recent improvements in cross-sectional imaging, chemotherapeutic agents and advances in the techniques of surgical resection the emphasis of resection has now changed to 'who is not resectable' as opposed to 'who is resectable'. There are few contraindications to liver resection on the proviso that the patient is fit enough. As a result of this paradigm shift, 5 year survival rates are approaching 60%. Historically liver resection was perceived as a formidable operation but now liver resection for CRLM is safe and specialist centres are reporting mortality rates of less than 1%. This review briefly covers the standard techniques currently employed and some of the recent innovations being developed to improve resectability.

Anatomic resection independently improves long-term survival in patients with T1-T2 hepatocellular carcinoma

BACKGROUND

This study aimed to evaluate the effect of anatomic resection on long-term outcomes in patients with pathologic T1-T2 (pT1-T2) hepatocellular carcinoma.

METHODS

A retrospective analysis of 158 consecutive patients who underwent either anatomic (n = 95) or nonanatomic (n = 63) resection for pT1-T2 hepatocellular carcinoma was conducted. Anatomic resection was defined as the complete removal of at least one Couinaud segment containing the tumor; nonanatomic resection was defined as removal of the tumor plus a rim of nonneoplastic liver parenchyma. The median follow-up time was 83 months.

RESULTS

Patients who underwent anatomic resection were characterized by lower prevalence of cirrhosis (P = .015), more favorable hepatic function (P = .001), larger tumor size (P = .029), and higher prevalence of vascular invasion (P = .008) compared with patients who underwent nonanatomic resection. Anatomic resection provided better survival (median survival time, 122 months) than nonanatomic resection (median survival time, 76 months; P = .0358). Patients who underwent anatomic resection had better disease-free survival (P = .0121). Anatomic resection independently improved both survival (hazard ratio, .46; P = .003) and disease-free survival (hazard ratio, .55; P = .008). When stratified for pT classification, the effectiveness of anatomic resection remained only in patients with pT2 tumors in terms of survival (P = .0012) and disease-free survival (P = .0004).

CONCLUSIONS

Anatomic resection independently improves long-term survival in patients with T1-T2 hepatocellular carcinoma, probably because of the clearance of venous tumor thrombi within the resected domain.