Laparoscopic versus open hepatic resections for benign and malignant neoplasms--a meta-analysis

Minimally Invasive Hepatopancreatobiliary Surgery at a Large Regional Health System: Assessing the Safety of Program Expansion

BACKGROUND

Complex, minimally invasive hepatopancreatobiliary surgery (MIS HPB) is safe at high-volume centers, yet outcomes during early implementation are unknown. We describe our experience during period of rapid growth in an MIS HPB program at a large regional health system.

METHODS

During an increase in MIS HPB (60% greater from preceding year), hospital records of patients who underwent HPB surgery between 1/1/2019 and 12/31/2020 were reviewed. Operative time, estimated blood loss (EBL), conversion rates, length of stay (LOS), and perioperative outcomes were assessed.

RESULTS

267 patients' cases were reviewed. The population was 62 ± 13 years, 50% female, 90% white. MIS was more frequently performed for hepatic than pancreatic resections (59% vs 21%, P < .001). Open cases were more frequently performed for invasive malignancy in both pancreatic (70% vs 40%, P < .018) and hepatic (87% vs 70%, P = .046) resections. There was no difference in operative time between MIS and open surgery (293[218-355]min vs 296[199-399]min, P = .893). When compared to open, there was a shorter LOS (4[2-6]d vs 7[6-10]d, P < .001) and lower readmission rate (21% vs 37%, P = .005) following MIS. Estimated blood loss was lower in MIS liver resections, particularly when performed for benign disease (200[63-500]mL vs 600[200-1200]mL, P = .041). Overall 30-day mortality was similar between MIS and open surgery (1.0% vs 1.8%, P = 1.000).

DISCUSSION

During a surgical expansion phase within our regional health system, MIS HPB offered improved perioperative outcomes when compared to open surgery. These data support the safety of implementation even during intervals of rapid programmatic growth.

Impact of liver cirrhosis, the severity of cirrhosis, and portal hypertension on the outcomes of minimally invasive left lateral sectionectomies for primary liver malignancies

BACKGROUND

The impact of cirrhosis and portal hypertension on perioperative outcomes of minimally invasive left lateral sectionectomies remains unclear. We aimed to compare the perioperative outcomes between patients with preserved and compromised liver function (noncirrhotics versus Child-Pugh A) when undergoing minimally invasive left lateral sectionectomies. In addition, we aimed to determine if the extent of cirrhosis (Child-Pugh A versus B) and the presence of portal hypertension had a significant impact on perioperative outcomes.

METHODS

This was an international multicenter retrospective analysis of 1,526 patients who underwent minimally invasive left lateral sectionectomies for primary liver malignancies at 60 centers worldwide between 2004 and 2021. In the study, 1,370 patients met the inclusion criteria and formed the final study group. Baseline clinicopathological characteristics and perioperative outcomes of these patients were compared. To minimize confounding factors, 1:1 propensity score matching and coarsened exact matching were performed.

RESULTS

The study group comprised 559, 753, and 58 patients who did not have cirrhosis, Child-Pugh A, and Child-Pugh B cirrhosis, respectively. Six-hundred and thirty patients with cirrhosis had portal hypertension, and 170 did not. After propensity score matching and coarsened exact matching, Child-Pugh A patients with cirrhosis undergoing minimally invasive left lateral sectionectomies had longer operative time, higher intraoperative blood loss, higher transfusion rate, and longer hospital stay than patients without cirrhosis. The extent of cirrhosis did not significantly impact perioperative outcomes except for a longer duration of hospital stay.

CONCLUSION

Liver cirrhosis adversely affected the intraoperative technical difficulty and perioperative outcomes of minimally invasive left lateral sectionectomies.

Outcomes and Patient Selection in Laparoscopic vs. Open Liver Resection for HCC and Colorectal Cancer Liver Metastasis

Hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM) are the two most common malignant tumors that require liver resection. While liver transplantation is the best treatment for HCC, organ shortages and high costs limit the availability of this option for many patients and make resection the mainstay of treatment. For patients with CRLM, surgical resection with negative margins is the only potentially curative option. Over the last two decades, laparoscopic liver resection (LLR) has been increasingly adopted for the resection of a variety of tumors and was found to have similar long-term outcomes compared to open liver resection (OLR) while offering the benefits of improved short-term outcomes. In this review, we discuss the current literature on the outcomes of LLR vs. OLR for patients with HCC and CRLM. Although the use of LLR for HCC and CRLM is increasing, it is not appropriate for all patients. We describe an approach to selecting patients best-suited for LLR. The four common difficulty-scoring systems for LLR are summarized. Additionally, we review the current evidence behind the emerging robotically assisted liver resection technology.

Laparoscopic versus Robotic Hepatectomy: A Systematic Review and Meta-Analysis

This study aimed to assess the surgical outcomes of robotic compared to laparoscopic hepatectomy, with a special focus on the meta-analysis method. Original studies were collected from three Chinese databases, PubMed, EMBASE, and Cochrane Library databases. Our systematic review was conducted on 682 patients with robotic liver resection, and 1101 patients were operated by laparoscopic platform. Robotic surgery has a long surgical duration (MD = 43.99, 95% CI: 23.45-64.53, p = 0.0001), while there is no significant difference in length of hospital stay (MD = 0.10, 95% CI: -0.38-0.58, p = 0.69), blood loss (MD = -20, 95% CI: -64.90-23.34, p = 0.36), the incidence of conversion (OR = 0.84, 95% CI: 0.41-1.69, p = 0.62), and tumor size (MD = 0.30, 95% CI: -0-0.60, p = 0.05); the subgroup analysis of major and minor hepatectomy on operation time is (MD = -7.08, 95% CI: -15.22-0.07, p = 0.09) and (MD = 39.87, 95% CI: -1.70-81.44, p = 0.06), respectively. However, despite the deficiencies of robotic hepatectomy in terms of extended operation time compared to laparoscopic hepatectomy, robotic hepatectomy is still effective and equivalent to laparoscopic hepatectomy in outcomes. Scientific evaluation and research on one portion of the liver may produce more efficacity and more precise results. Therefore, more clinical trials are needed to evaluate the clinical outcomes of robotic compared to laparoscopic hepatectomy.

Outcomes of simultaneous laparoscopic, hybrid, and open resection in colorectal cancer with synchronous liver metastases: a propensity score-matched study

We aimed to compare the short- and long-term outcomes of simultaneous laparoscopic, hybrid, and open resection for colorectal cancer and synchronous liver metastases. We retrospectively analyzed the data of 647 patients with simultaneous resection of colorectal cancer and liver metastases between January 2006 and December 2018 at three tertiary referral hospitals. Patient’s baseline characteristics, perioperative outcomes, pathological examination results, liver-specific recurrence rate and survivals were compared between the propensity score-matched groups. Forty-two and 81 patients were selected for the laparoscopic vs. hybrid groups, and 48 and 136 patients for laparoscopic vs. open groups, respectively. The laparoscopic group had fewer wound complications (2.1 vs. 13.2%; p = 0.028) than the open group, and a shorter postoperative hospital stay than the hybrid and open groups (8 vs. 11 days, p < 0.001 for both). The 5-year liver-specific recurrence rates were 38.7% and 46.0% in the laparoscopic and hybrid groups, respectively (p = 0.270), and 34.0% and 37.0% in the laparoscopic and open groups, respectively (p = 0.391). Simultaneous laparoscopic resection for colorectal cancer and liver metastases can be performed safely with significantly enhanced postoperative recovery and comparable long-term outcomes compared to hybrid and open resection.

Impact of Three-Dimensional (3D) Visualization on Laparoscopic Hepatectomy for Hepatocellular Carcinoma

BACKGROUND

The impact of three-dimensional (3D) visualization on laparoscopic hepatectomy for hepatocellular carcinoma is largely unknown.

METHODS

A retrospective review with propensity-score matched analysis of 3D and two-dimensional (2D) laparoscopic hepatectomy performed in a tertiary hepatobiliary surgery center.

RESULTS

Since the availability of 3D laparoscopy, the proportion of laparoscopic major hepatectomies has significantly expanded (1.7% vs. 24.0%, p < 0.0001) and the percentage of difficult resections among patients who underwent laparoscopic hepatectomy has also increased (12.6% vs. 40.0%, p = 0.0001). A total of 305 patients (92 in the 3D group and 213 in the 2D group) underwent laparoscopic hepatectomy between 2002 and 2019. The 3D group had better liver function, larger tumors at more difficult locations, more major resections, and more difficult surgeries. After propensity score matching, 144 patients were analyzed (72 in both the 3D and 2D groups). Patients were comparable in terms of liver status, tumor status, and complexity of liver surgery. Operative time (218 vs. 218 mins, p = 0.50) and blood loss (0.2 vs. 0.2L, p = 0.49) were comparable between the two groups, however overall complications were higher in the 2D group (1.4 vs. 11.1%, p = 0.03). Patients who underwent 3D laparoscopic major hepatectomy had a shorter hospital stay than their comparable counterparts operated through an open approach (7 vs. 6 days, p = 0.003).

CONCLUSIONS

3D visualization enhanced the feasibility of laparoscopic major hepatectomy and difficult laparoscopic liver resection. 3D resection was potentially associated with fewer operative morbidities and the 3D laparoscopic approach did not jeopardize the outcome of major hepatectomy.

Assessment for the minimal invasiveness of laparoscopic liver resection by interleukin-6 and thrombospondin-1

BACKGROUND

Laparoscopic surgery has been introduced as a minimally invasive technique for the treatment of various field. However, there are few reports that have scientifically investigated the minimally invasive nature of laparoscopic liver resection (LLR).

AIM

To investigate whether LLR is scientifically less invasive than open liver resection.

METHODS

During December 2011 to April 2015, blood samples were obtained from 30 patients who treated with laparoscopic (n = 10, 33%) or open (n = 20, 67%) partial liver resection for liver tumor. The levels of serum interleukin-6 (IL-6) and plasma thrombospondin-1 (TSP-1) were measured using ELISA kit at four time points including preoperative, immediate after operation, postoperative day 1 (POD1) and POD3. Then, we investigated the impact of the operative approaches during partial hepatectomy on the clinical time course including IL-6 and TSP-1.

RESULTS

Serum level of IL-6 on POD1 in laparoscopic hepatectomy was significantly lower than those in open hepatectomy (8.7 vs 30.3 pg/mL, respectively) (P = 0.003). Plasma level of TSP-1 on POD3 in laparoscopic hepatectomy was significantly higher than those in open hepatectomy (1704.0 vs 548.3 ng/mL, respectively) (P = 0.009), and have already recovered to preoperative level in laparoscopic approach. In patients with higher IL-6 Levels on POD1, plasma level of TSP-1 on POD3 was significantly lower than those in patients with lower IL-6 Levels on POD1. Multivariate analysis showed that open approach was the only independent factor related to higher level of IL-6 on POD1 [odds ratio (OR), 7.48; 95% confidence interval (CI): 1.28-63.3; P = 0.02]. Furthermore, the higher level of serum IL-6 on POD1 was significantly associated with lower level of plasm TSP-1 on POD3 (OR, 5.32; 95%CI: 1.08-32.2; P = 0.04) in multivariate analysis.

CONCLUSION

In partial hepatectomy, laparoscopic approach might be minimally invasive surgery with less IL-6 production compared to open approach.

Determination of surgical margins in laparoscopic parenchyma-sparing hepatectomy of neuroendocrine tumors liver metastases using indocyanine green fluorescence imaging

BACKGROUND

Neuroendocrine tumors (NETs) are a group of heterogenous tumors originating from neuroendocrine system. Approximately, 40 percent will go through liver metastases, and liver-directed therapy was proved to improve the survival outcome. Parenchyma-sparing hepatectomy is advocated for the resection of NETs liver metastases while the possible relatively low negative margin rate is concerned. Indocyanine green (ICG) fluorescence imaging provides a real-time navigation on determination of surgical margins in colorectal cancer liver metastases. However, there was no previous study that reported the applications of ICG fluorescence imaging in NETs liver metastases. The present study aimed to evaluate the feasibility and security of using ICG fluorescence imaging to determine surgical margins of NETs liver metastases during operation.

METHODS

A retrospective two-arm cohort study was performed on 25 consecutive patients with NETs liver metastases who underwent laparoscopic parenchyma-sparing hepatectomy (LPSH). Patients were divided into two groups according to whether or not the ICG fluorescence imaging was used. Data on sociodemographic characteristics, laboratory parameters, pathology results, and surgical outcomes were collected.

RESULTS

A total of 145 tumors pathologically diagnosed with NETs liver metastases were resected from 25 patients. The pathological results indicated negative margins in all tumors (102/102) in LPSH with ICG fluorescence imaging group. The negative margin rate was significantly higher in LPSH using the ICG fluorescence imaging (100% v.s 88.4%, p = 0.002). Surgical outcomes, including operation time, estimated blood loss, intraoperative transfusion rate, and postoperative morbidity, were comparable between LPSH with and without ICG fluorescence imaging groups.

CONCLUSION

ICG fluorescence imaging showed the potential to identify tumor boundaries and determine surgical margins. This technique may serve as a valuable intraoperative navigation in patients with NETs liver metastases.

Comparison of laparoscopic and open living donor hepatectomy: A meta-analysis

Laparoscopic donor hepatectomy (LDH), accepted as a minimally invasive approach, has become increasingly popular for living donor liver transplant. However, the outcomes of LDH remain to be fully clarified when compared with open living donor hepatectomy. Thus, our meta-analysis was designed to assess the efficacy of laparoscopic in comparison with conventional open donor hepatectomy.The PubMed, Cochrane, and Embase electronic databases were searched to identify the articles concerning the comparison of the efficacy of laparoscopic versus open surgery in treatment of living donor liver transplantation updated to March, 2020. The main search terms and medical Subject Heading terms were: "living donor," "liver donor," "minimally invasive," "laparoscopic surgery," and "open surgery." After rigorous evaluation on quality, the data was extracted from eligible publications. The outcomes of interest included intraoperative and postoperative results.The inclusion criteria were met by a total of 20 studies. In all, 2001 subjects involving 633 patients who received laparoscopic surgery and 1368 patients who received open surgery were included. According to the pooled result of surgery duration, the laparoscopic surgery was associated with shorter duration of hospital stay (MD = -1.07, 95% CI -1.85 to -0.29; P = .007), less blood loss (MD = -57.57, 95% CI -65.07 to -50.07; P < .00001), and less postoperative complications (OR = 0.61, 95% CI 0.44-0.85; P = .003). And the open donor hepatectomy achieved a trend of shorter operation time (MD = 30.31, 95% CI 13.93-46.69; P = .0003) than laparoscopic group. Similar results were found in terms of ALT (P = .52) as well as the AST (P = .47) peak level between the 2 groups.LDH showed the better perioperative outcomes as compared with open donor hepatectomy. The findings revealed that LDH may be a feasible and safe procedure for the living donor liver transplantation.

Morbidity and mortality after liver surgery for colorectal liver metastases: a cohort study in a high-volume fast-track programme

BACKGROUND

For colorectal liver metastases, surgery is a high-risk procedure due to perioperative morbidity. The objective was to assess severity of complications after fast-track liver surgery for colorectal liver metastases and their impact on morbidity and mortality.

METHODS

All patients were treated according to the same fast-track programme. Complications were graded according to the Clavien-Dindo classification for patients undergoing surgery from 2013 to 2015. Correlation between complications and length of stay was analysed by multivariate linear regression.

RESULTS

564 patient cases were included of which three patients died within 3 months (0.53%, 95% CI: 0.17-1.64%). Complications were common with Grade ≤ 2 in 167 patients (30%) and ≥ Grade 3a in 93 (16%). Patients without complications had a mean length of stay of 4.1 days, which increased with complications: 1.4 days (95% CI: 1.3-1.5) for Grade 2, 1.7 days (1.5-2.0) for Grade 3a, 2.3 days (1.7-3.0) for Grade 3b, 2.6 days (1.6-4.2) for Grade 4a, and 2.9 days (2.8-3.1) for Grade 4b. Following were associated with increased length of stay: complication severity grade, liver insufficiency, ascites, biliary, cardiopulmonary, and infectious complications.

CONCLUSIONS

Complications after liver surgery for colorectal liver metastases, in a fast track setting, were associated with low mortality, and even severe complications only prolonged length of stay to a minor degree.

Robotic Isolated Caudate Lobectomy for Solitary Colorectal Liver Metastasis

BACKGROUND

Safety of liver resection for colorectal adenocarcinoma continues to improve due to decreased morbidity of resection. Minimally invasive techniques contribute greatly to this morbidity reduction. Isolated caudate lobectomy presents a unique technical challenge because of proximity to major vasculature. The video aims to review nuances of robotic isolated caudate lobectomy for metastatic colon adenocarcinoma.

Demarcating the Exact Midplane of the Liver Using Indocyanine Green Near-Infrared Fluorescence Imaging During Laparoscopic Donor Hepatectomy

Indocyanine green (ICG) near-infrared fluoroscopy has been recently implemented in pure laparoscopic donor hepatectomy (PLDH). This study aims to quantitatively evaluate the effectiveness of ICG fluoroscopy during liver midplane dissection in PLDH and to demonstrate that a single injection of ICG is adequate for both midplane dissection and bile duct division. Retrospective analysis was done with images acquired from recordings of PLDH performed without ICG (pre-ICG group) from November 2015 to May 2016 and with ICG (post-ICG group) from June 2016 to May 2017. 30 donors from the pre-ICG group were compared with 46 donors from the post-ICG group. The operation time was shorter (P = 0.002) and postoperative peak aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were lower (P = 0.031 and P = 0.019, respectively) in the post-ICG group than the pre-ICG group. Within the post-ICG group, the color intensity differences between the clamped versus nonclamped regions in the natural, black-and-white, and fluorescent modes were 39.7 ± 36.2, 89.6 ± 46.9, and 19.1 ± 36.8 (mean ± SD, P < 0.001), respectively. The luminosity differences were 37.2 ± 34.5, 93.8 ± 32.1, and 26.7 ± 25.7 (P < 0.001), respectively. Meanwhile, the time from when ICG was injected to when the near-infrared camera was turned on for bile duct visualization was 85.6 ± 25.8 minutes. All grafts received from the 46 donors were successfully transplanted. In conclusion, ICG fluoroscopy helps to reduce operation time and lower postoperative AST/ALT levels. ICG injection visualized with black-and-white imaging is most effective for demarcating the liver midplane during PLDH. A single intravenous injection of ICG is sufficient for midplane dissection as well as bile duct division.

Development of a mechanical decoupling surgical scissors for robot-assisted minimally invasive surgery

In minimally invasive surgery, surgical instruments with a wrist joint have better flexibility. However, the bending motion of the wrist joint causes a coupling motion between the end-effector and wrist joint, affecting the accuracy of the movement of the surgical instrument. Aiming at this problem, a new gear train decoupling method is proposed in the paper, which can automatically compensate for the coupled motion in real-time. Based on the performance tests of the instrument prototype, a series of decoupling effects tests are carried out. The test results show that the surgical instrument has excellent decoupling ability and stable performance.

A Systematic Review of Minimally Invasive Trans-thoracic Liver Resection to Examine Intervention Description, Governance, and Outcome Reporting of an Innovative Technique

INTRODUCTION

The number of laparoscopic liver resections undertaken has increased. However, lesions located postero-superiorly are difficult to access. This may be overcome by the novel use of trans-thoracic port(s). Methods for the safe and transparent introduction of new and modified surgical procedures are limited and a summary of these issues, for minimally invasive trans-thoracic liver resections (MITTLR), is lacking. This study aims to understand and summarize technique description, governance procedures, and reporting of outcomes for MITTLR.

METHODS

A systematic literature search to identify primary studies of all designs describing MITTLR was undertaken. How patients were selected for the new technique was examined. The technical components of MITTLR were identified and summarized to understand technique development over time. Governance arrangements (eg, Institutional Review Board approval) and steps taken to mitigate harm were recorded. Finally, specific outcomes reported across studies were documented.

RESULTS

Of 2067 screened articles, 16 were included reporting data from 145 patients and 6 countries. Selection criteria for patients was explicitly stated in 2 papers. No studies fully described the technique. Five papers reported ethical approval and 3 gave details of patient consent. No study reported on steps taken to mitigate harm.Technical outcomes were commonly reported, for example, blood loss (15/16 studies), operative time (15/16), and margin status (11/16). Information on patient-reported outcomes and costs were lacking.

CONCLUSIONS

Technical details and governance procedures were poorly described. Outcomes focussed on short term details alone. Transparency is needed for reporting the introduction of new surgical techniques to allow their safe dissemination.

Laparoscopic hepatectomy versus open hepatectomy for hepatocellular carcinoma: A propensity case-matched analysis of the long-term survival

Backgrounds/Aims

Despite the widespread popularity of laparoscopic surgery, laparoscopic liver resection (LLR) remains in evolution. This study aimed to compare the long-term outcomes for patients undergoing laparoscopic versus open hepatectomy for hepatocellular carcinoma (HCC) ≤7 cm.

Methods

Patients diagnosed with HCC treated by hepatectomy from October 2000 to May 2019 were included. Excluding tumors larger than 7 cm, 1:2 propensity score matching was performed between laparoscopic and open hepatectomies. The perioperative outcomes, 5-year overall survival (OS) and disease-free survival (DFS) of the two groups were compared.

Results

Forty-five patients who underwent LLR were matched to 90 open hepatectomy (OH) during the same period. LLR group had shorter median hospital stay (5 days vs. 9 days, p=0.00) but required longer operative time (326.0 minutes vs. 272.5 minutes, p=0.018) than the OH group. The 5-year overall survival was better in the LLR group (84.9% vs. 61.1%; p=0.036), though there was no significant difference in the 5-year disease free survival (20.0% vs. 22.2%, p=0.613). The rate of R0 resection was comparable between the 2 groups with a slightly better margin distance in the LLR (5 mm vs. 3 mm, p=0.043).

Conclusions

Laparoscopic liver resection is safe and feasible for cirrhotic patients with HCC size up to 7 cm. It has better short-term outcomes and comparable perioperative blood loss and complication rates. The resection margin is not jeopardized and the 5-year overall and disease-free survivals are comparable with the open group.

Laparoscopic isolated caudate lobe resection

Previously, isolated caudate lobectomy was rarely performed and the caudate lobe was usually resected along with other segments. Isolated caudate lobe resection is a challenging procedure even for an experienced surgeon. Our aim was to evaluate the feasibility, safety and outcomes of laparoscopic isolated caudate lobectomy and to compare these with the open technique. We retrospectively analyzed 21 patients who underwent isolated caudate lobectomy between January 2005 and December 2018 at Seoul National University Bundang Hospital. Patients who underwent either anatomical or non-anatomical resection of the caudate lobe were included. Patients were divided into two groups according to whether they underwent laparoscopic or open surgery. Intra-operative and postoperative outcomes were compared with a median follow-up of 43 months (4–149). A total of 21 patients were included in the study. Of these, 12 (57.14%) underwent laparoscopic and nine (42.85%) underwent open caudate lobectomy. Median operation time (204.5 vs. 200 minutes, p = 0.397), estimated blood loss (250 vs. 400 ml, p = 0.214) and hospital stay (4 vs. 7 days, p = 0.298) were comparable between laparoscopy and open group. The overall post operative complication rate was similar in both groups (p = 0.375). The 5-year disease free survival rate (42.9% vs 60.0%, p = 0.700) and the 5-year overall survival rate (76.2% vs 64.8%, p = 0.145) was similar between laparoscopy and open group. Our findings demonstrate that with increasing surgical expertise and technological advances, laparoscopic isolated caudate lobectomy can become a feasible and safe in selected patients.

Operative Time, Age, and Serum Albumin Predict Surgical Morbidity After Laparoscopic Liver Surgery

Background. Laparoscopic liver resection (LLR) has emerged as a considerable alternative to conventional liver surgery. However, the increasing complexity of liver resection raises the incidence of postoperative complications. The aim of this study was to identify risk factors for postoperative morbidity in a monocentric cohort of patients undergoing LLR. Methods. All consecutive patients who underwent LLR between 2015 and 2019 at our institution were analyzed for associations between complications with demographics and clinical and operative characteristics by multivariable logistic regression analyses. Results. Our cohort comprised 156 patients who underwent LLR with a mean age of 60.0 ± 14.4 years. General complications and major perioperative morbidity were observed in 19.9% and 9.6% of the patients, respectively. Multivariable analysis identified age>65 years (HR = 2.56; P = .028) and operation time>180 minutes (HR = 4.44; P = .001) as significant predictors of general complications (Clavien ≥1), while albumin<4.3 g/dl (HR = 3.66; P = .033) and also operative time (HR = 23.72; P = .003) were identified as predictors of major postoperative morbidity (Clavien ≥3). Conclusion. Surgical morbidity is based on patient- (age and preoperative albumin) and procedure-related (operative time) characteristics. Careful patient selection is key to improve postoperative outcomes after LLR.

[Robot-Assisted Right Hemihepatectomy for Hepatocellular Carcinoma]

Since the introduction of robot-assisted surgery, increasingly complex operations have been performed with this technique. Robot-assisted operations are also of increasing importance in hepatobiliary surgery. With articulated and scaled movements in a three-dimensional surgical field, permit precise preparation, as is needed for major hepatic resection. This video demonstrates the feasibility and precision of completely robotic surgery in right hemihepatectomy in hepatocellular carcinoma (HCC) of segments V - VIII in non-alcoholic steatohepatitis (NASH). The patient was 72 years old for the operation, with concomitant marked metabolic syndrome.

Comparative analysis of the safety and feasibility of laparoscopic versus open caudate lobe resection

PURPOSE

Laparoscopic hepatectomy has been used widely in liver disease due to its advantages as a minimally invasive surgery. However, laparoscopic caudate lobe resection (LCLR) has been reported rarely. We aimed to investigate the safety and feasibility of LCLR by comparing it with open liver surgery.

METHODS

A retrospective study was performed including all patients who underwent LCLR and open caudate lobe resection (OCLR) between January 2015 and August 2019. Twenty-two patients were involved in this study and divided into LCLR (n = 10) and OCLR (n = 12) groups based on preoperative imaging, tumor characteristics, and blood and liver function test. Patient demographic data and intraoperative and postoperative outcomes were compared between the two groups.

RESULTS

There were no significant inter-group differences between gender, age, preoperative liver function, American Society of Anesthesiologists (ASA) grade, and comorbidities (P > 0.05). The LCLR showed significantly less blood loss (50 vs. 300 ml, respectively; P = 0.004), shorter length of hospital stay (15 vs. 16 days, respectively; P = 0.034), and shorter operative time (216.50 vs. 372.78 min, respectively; P = 0.012) than OCLR, but hospital expenses (5.02 vs. 6.50 WanRMB, respectively; P = 0.208) showed no statistical difference between groups. There was no statistical difference in postoperative bile leakage (P = 0.54) and wound infection (P = 0.54) between LCLR and OCLR. Neither LCLR nor OCLR resulted in bleeding or liver failure after operation. There were no deaths.

CONCLUSION

LCLR is a very useful technology, and it is a feasible choice in selected patients with benign and malignant tumors in the caudate lobe.

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.

Feasibility of Laparoscopic Right Posterior Sectionectomy for Malignant Lesion Compared to Open Right Posterior Sectionectomy: Retrospective, Single Center Study

Purpose

We aimed to compare the operative outcomes of laparoscopic right posterior sectionectomy (RPS) and open RPS and evaluate the feasibility of laparoscopic RPS.

Methods

From January 2009 to December 2017, laparoscopic liver resections were performed in 235 patients at Chonnam National University Hwasun Hospital, South Korea. We retrospectively analyzed the clinical data of 16 patients who underwent laparoscopic RPS and compared the outcomes with those who underwent open RPS (n=17).

Results

The laparoscopic group had a mean tumor size of 3.82±1.73 cm (open group [OG]; 4.18±2.07 cm, p=0.596), mean tumor-free margin of 10.44±9.69 mm (OG; 10.06±10.62 mm, p=0.657), mean operation time of 412.2±102.2 min (OG; 275.0±60.5, p<0.001), mean estimated blood loss of 339.4±248.3 ml (OG; 236.4±102.7 ml, p=0.631), mean postoperative hospital stay of 11.63±2.58 days (OG; 14.71±4.69 days, p=0.027), and mean postoperative peaks of aspartate aminotransferase, alanine aminotransferase, total bilirubin, and prothrombin time of 545 mg/dl, 538 mg/dl, 1.39 mg/dl, 1.41 international normalized ratio (OG; 237 (p<0.001), 216 (p<0.001), 1.52 (p=0.817), and 1.45 (p=0.468)), respectively. There were no deaths or major complications in ether group. There were no cases of open conversion. Laparoscopic RPS was associated with a shorter hospital stay, prolonged operation time and lower complication rate. With long-term prognosis, no difference was found in overall survival rate and disease-free survival rate between the two groups.

Conclusion

Laparoscopic RPS can be performed, but the problems of long operative time and decrease in liver function should be resolved.

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.

Minimally invasive hepatectomy is associated with decreased morbidity and resource utilization in the elderly

BACKGROUND

The aim of this study was to evaluate whether elderly patients undergoing elective hepatectomy experience increased morbidity/mortality and whether these outcomes could be mitigated by minimally invasive hepatectomy (MIH).

METHODS

15,612 patients from 2014 to 2017 were identified in the Hepatectomy Targeted Procedure Participant Use File of the American College of Surgeons National Surgical Quality Improvement Program. Multivariable logistic regression models were constructed to examine the effect of elderly status (age ≥ 75 years, N = 1769) on outcomes with a subgroup analysis of elderly only patients by open (OH) versus MIH (robotic, laparoscopic, and hybrid, N = 4044). Propensity score matching was conducted comparing the effect of MIH to OH in elderly patients to ensure that results are not the artifact of imbalance in baseline characteristics.

RESULTS

Overall, elderly patients had increased risk for 30-day mortality, major morbidity, prolonged length of hospital stay, and discharge to destination other than home. In the elderly subgroup, MIH was associated with decreased major morbidity (OR 0.71, P = 0.031), invasive intervention (OR 0.61, P = 0.032), liver failure (OR 0.15, P = 0.011), bleeding (OR 0.46, P < 0.001), and prolonged length of stay (OR 0.46, P < 0.001). Propensity score-matched analyses successfully matched 4021 pairs of patients treated by MIH vs. OH, and logistic regression analyses on this matched sample found that MIH was associated with decreased major complications (OR 0.69, P = 0.023), liver failure (OR 0.14, P = 0.010), bile leak (OR 0.46, P = 0.009), bleeding requiring transfusion (OR 0.46, P < 0.001), prolonged length of stay (OR 0.46, P < 0.001), and discharge to destination other than home (OR 0.691, P = 0.035) compared to OH.

CONCLUSION

MIH is associated with decreased risk of major morbidity, liver failure, bile leak, bleeding, prolonged length of stay, and discharge to destination other than home among elderly patients in this retrospective study. However, MIH in elderly patients does not protect against postoperative mortality.

Minimally invasive liver resection in the era of robotics: analysis of 214 cases

BACKGROUND

Minimally Invasive Liver Resection (MILR) techniques range from a hybrid-technique to full robotic approaches. When compared with open techniques, MILR has been shown to be advantageous by reducing pain, complications, length of stay and blood loss. The aim of this study was to compare clinical outcomes and hospital resource utilization between full laparoscopic, hand-assisted, and robotic liver resections among major (≥ 3 segments) and minor (≤ 2 segments) resections.

METHODS

A single-center comparative retrospective review was completed on 214 patients undergoing full laparoscopic, hand-assisted, or robotic liver resection procedures between 2005 and 2018.

RESULTS

Among minor resections: 85 full laparoscopic, 40 hand-assisted, and 35 robotic liver resection cases were analyzed; and among major resections: 13, 33, and 8 cases were analyzed, respectively. In the adjusted subgroup analysis of minor resections, OR time was significantly longer for the minor hand-assisted group ([Formula: see text] = 181 min; p < 0.05), and the average lesion size was smaller for the minor full laparoscopic group ([Formula: see text] = 4.2 cm; p < 0.05). Overall, direct hospital charges were lowest in the group of patients who underwent a minor resection using the full laparoscopic technique ([Formula: see text] = $39,054.90; p < 0.05), compared to the robotic technique. Due to the smaller sample size (n = 54) in the major resection subgroup, only two significant observations were made - the full laparoscopic group had the least amount of blood loss ([Formula: see text] = 227 cc; p < 0.05) and incurred the least amount of room and board charges compared to the other two techniques.

CONCLUSIONS

The robotic approach appears favorable for minor resections as evidenced by shorter length of stay but more costly than full laparoscopy. Clinical outcomes appear to be more dependent upon the magnitude of the resection (i.e. major vs. minor) than the MILR technique chosen. Randomized trials may be indicated to discern the best indications and advantages of each technique.

A meta-analysis of laparoscopic versus open left lateral hepatic sectionectomy

BACKGROUND

This study aimed to assess the perioperative outcomes of laparoscopic left lateral sectionectomy (LLLS) compared with an open (OLLS) approach.

METHOD

A systematic literature search was performed in PubMed, Scopus and Cochrane library, in accordance with the PRISMA guidelines. The Odds Ratio (ORs), the weighted mean difference (WMD) and 95% confidence interval (95% CI) were evaluated, by means of Random-Effects model.

RESULTS

Ten articles met the inclusion criteria and incorporated 2640 patients. This study reveals comparable mean operative time, mean operative margin size and rate of R1 resection between LLLS and OLLS. The intraoperative mean blood loss, mean length of ICU stay, mean hospital stay were significantly increased in the OLLS group (p < 0.05). Complications were assessed according to the Clavien-Dindo classification. The incidence of grade I-II complications was similar between the two groups. The incidence of grade III-V complications was increased in the OLLS group (p = 0.008). The mean perioperative cost was similar between the two techniques.

CONCLUSION

These outcomes for left lateral sectionectomy suggest that both approaches are feasible and safe. However, the results should be treated with caution given the small number of the included randomized controlled studies and potential for selection bias between the two techniques.

Minimally Invasive Surgery in Pediatric Surgical Oncology

The application of minimally invasive surgery (MIS) to resect pediatric solid tumors offers the potential for reduced postoperative morbidity with smaller wounds, less pain, fewer surgical site infections, decreased blood loss, shorter hospital stays, and less disruption to treatment regimens. However, significant controversy surrounds the question of whether a high-fidelity oncologic resection of childhood cancers can be achieved through MIS. This review outlines the diverse applications of MIS to treat pediatric malignancies, up to and including definitive resection. This work further summarizes the current evidence supporting the efficacy of MIS to accomplish a definitive, oncologic resection as well as appropriate patient selection criteria for the minimally invasive approach.

Long-Term Oncologic Outcomes Following Robotic Liver Resections for Primary Hepatobiliary Malignancies: A Multicenter Study

OBJECTIVE

Robotic liver surgery (RLS) has emerged as a feasible alternative to laparoscopic or open resections with comparable perioperative outcomes. Little is known about the oncologic adequacy of RLS. The purpose of this study was to investigate the long-term oncologic outcomes for patients undergoing RLS for primary hepatobiliary malignancies.

METHODS

We performed an international, multicenter, retrospective study of patients who underwent RLS for hepatocellular carcinoma (HCC), cholangiocarcinoma (CC), or gallbladder cancer (GBC) between 2006 and 2016. Age, gender, histology, resection margin status, extent of surgical resection, disease-free survival (DFS), and overall survival (OS) were retrospectively collected and analyzed.

RESULTS

Of the 61 included patients, 34 (56%) had RLS performed for HCC, 16 (26%) for CC, and 11 (18%) for GBC. The majority of resections were nonanatomical or segmental resections (39.3%), followed by central hepatectomy (18%), left-lateral sectionectomy (14.8%), left hepatectomy (13.1%), right hepatectomy (13.1%), and right posterior segmentectomy (1.6%). R0 resection was achieved in 94% of HCC, 68% of CC, and 81.8% of GBC patients. Median hospital stay was 5 days, and conversion to open surgery was needed in seven patients (11.5%). Grade III-IV Dindo-Clavien complications occurred in seven patients with no perioperative mortality. Median follow-up was 75 months (95% confidence interval 36-113), and 5-year OS and DFS were 56 and 38%, respectively. When stratified by tumor type, 3-year OS was 90% for HCC, 65% for GBC, and 49% for CC (p = 0.01).

CONCLUSIONS

RLS can be performed for primary hepatobiliary malignancies with long-term oncologic outcomes comparable to published open and laparoscopic data.

Minimally invasive donor hepatectomy, are we ready for prime time?

Minimally invasive surgery potentially reduces operative morbidities. However, pure laparoscopic approaches to donor hepatectomy have been limited by technical complexity and concerns over donor safety. Reduced-wound donor hepatectomy, either in the form of a laparoscopic-assisted technique or by utilizing a mini-laparotomy wound, i.e., hybrid approach, has been developed to bridge the transition to pure laparoscopic donor hepatectomy, offering some advantages of minimally invasive surgery. To date, pure laparoscopic donor left lateral sectionectomy has been validated for its safety and advantages and has become the standard in experienced centres. Pure laparoscopic approaches to major left and right liver donation have been reported for their technical feasibility in expert hands. Robotic-assisted donor hepatectomy also appears to be a valuable alternative to pure laparoscopic donor hepatectomy, providing additional ergonomic advantages to the surgeon. Existing reports derive from centres with tremendous experience in both laparoscopic hepatectomy and donor hepatectomy. The complexity of these procedures means an arduous transition from technical feasibility to reproducibility. Donor safety is paramount in living donor liver transplantation. Careful donor selection and adopting standardized techniques allow experienced transplant surgeons to safely accumulate experience and acquire proficiency. An international prospective registry will advance the understanding for the role and safety of pure laparoscopic donor hepatectomy.

Systematic review and meta-analysis of robotic versus open hepatectomy

BACKGROUND

To date, there are few studies comparing the outcomes of robotic hepatectomy (RH) versus open hepatectomy (OH). We report the first systematic review and meta-analysis comparing the outcomes of RH versus OH.

METHODS

A systemic review was performed of all comparative studies of RH versus OH that reported the perioperative outcome(s) of interest.

RESULTS

Seven retrospective cohort studies were included. There was no significant difference in patients' baseline characteristics. RH was associated with a longer operation time (mean difference (MD) 61.47 min; 95% confidence interval (CI) (7.03, 115.91); P = 0.03), shorter hospital stay (MD -2.57 days; 95% CI (-3.31, -1.82); P < 0.001), lower costs, less overall (risk ratio (RR) 0.63; 95% CI (0.46, 0.86); P = 0.004), minor (RR 0.64; 95% CI (0.43, 0.95); P = 0.03) and major (RR 0.45; 95% CI (0.22, 0.94); P = 0.03) post-operative complications compared to OH.

CONCLUSION

RH had superior perioperative outcomes and was not cost prohibitive compared to OH, but had longer operation times.

Long term outcomes of simultaneous laparoscopic versus open resection for colorectal cancer with synchronous liver metastases

BACKGROUND/OBJECTIVE

Because of the advancements in the surgical techniques of liver resection and improvements in anesthesia and postoperative critical care, the simultaneous resection of synchronous colorectal cancer with liver metastasis either by the laparoscopic procedure or by the open resection method has been considered as a safe and acceptable option. However, there is limited information on the comparison of postoperative outcomes between laparoscopic surgery and open surgery. This study investigated the clinical results and postoperative outcomes of laparoscopic simultaneous resection of synchronous colorectal cancer with liver metastasis in comparison with those of open surgery.

METHODS

Patients with synchronous colorectal cancer and liver metastasis who underwent simultaneous resection at Shuang Ho Hospital from 2009 to 2017 were identified. The patient demographics, perioperative morbidity, and survival rates were analyzed.

RESULTS

A total of 38 patients underwent simultaneous resection of synchronous colorectal cancer with liver metastasis. Laparoscopic procedure was performed for 16 patients, and the remaining 22 patients underwent open surgery. No significant differences were observed in the patient characteristics between the two groups. There was no perioperative mortality in both groups. The 1- and 3-year disease-free survival rates were 56% and 35% in the laparoscopic group and 70% and 15% in the open surgery group, respectively. The 1- and 3-year overall survival rates were 100% and 84% in the laparoscopic group and 73% and 48% in the open surgery group, respectively.

CONCLUSION

In selected patients, laparoscopic surgery for simultaneous resection of synchronous colorectal cancer with liver metastasis seems to be safe and had a similar outcome to that of open surgery.

Maintaining oncologic integrity with minimally invasive resection of pediatric embryonal tumors

BACKGROUND

Embryonal tumors arise typically in infants and young children and are often massive at presentation. Operative resection is a cornerstone in the multimodal treatment of embryonal tumors but potentially disrupts therapeutic timelines. When used appropriately, minimally invasive surgery can minimize treatment delays. The oncologic integrity and safety attainable with minimally invasive resection of embryonal tumors, however, remains controversial.

METHODS

Query of the Vanderbilt Cancer Registry identified all children treated for intracavitary, embryonal tumors during a 15-year period. Tumors were assessed radiographically to measure volume (mL) and image-defined risk factors (neuroblastic tumors only) at time of diagnosis, and at preresection and postresection. Patient and tumor characteristics, perioperative details, and oncologic outcomes were compared between minimally invasive surgery and open resection of tumors of comparable size.

RESULTS

A total of 202 patients were treated for 206 intracavitary embryonal tumors, of which 178 were resected either open (n = 152, 85%) or with minimally invasive surgery (n = 26, 15%). The 5-year, relapse-free, and overall survival were not significantly different after minimally invasive surgery or open resection of tumors having a volume less than 100 mL, corresponding to the largest resected with minimally invasive surgery (P = .249 and P = .124, respectively). No difference in margin status or lymph node sampling between the 2 operative approaches was detected (p = .333 and p = .070, respectively). Advantages associated with minimally invasive surgery were decreased blood loss (P < .001), decreased operating time (P = .002), and shorter hospital stay (P < .001). Characteristically, minimally invasive surgery was used for smaller volume and earlier stage neuroblastic tumors without image-defined risk factors.

CONCLUSION

When selected appropriately, minimally invasive resection of pediatric embryonal tumors, particularly neuroblastic tumors, provides acceptable oncologic integrity. Large tumor volume, small patient size, and image-defined risk factors may limit the broader applicability of minimally invasive surgery.

Meta-analysis of laparoscopic versus open liver resection for colorectal liver metastases

Background

To compare surgical and oncological outcomes of laparoscopic versus open liver resection for colorectal liver metastases.

Results

A total of 14 retrospective studies with 1679 colorectal liver metastases patients were analyzed: 683 patients treated with laparoscopic liver resection and 996 patients with open liver resection. With respect to surgical outcomes, laparoscopic compared with open liver resection was associated with lower blood loss (MD, -216.7, 95% CI, -309.4 to -124.1; P < 0.00001), less requiring blood transfusion (OR, 0.36; 95% CI, 0.23 to 0.55; P < 0.00001), lower postoperative complication morbidity (OR, 0.61; 95% CI, 0.47 to 0.80; P = 0.003), and shorter hospitalization time (MD, -3.85, 95% CI, -5.00 to -2.71; P < 0.00001). However, operation time and postoperative mortality were no significant difference between the two approaches. With respect to oncological outcomes, laparoscopic liver resection group was prone to lower recurrence rate (OR, 0.78; 95% CI, 0.61−0.99; P = 0.04), but surgical margins R0, overall survival and disease-free survival were no significant difference.

Materials and Methods

We performed a systematic search in MEDLINE, EMBASE, and CENTRAL for all relevant studies. All statistical analysis was performed using Review Manager version 5.3. Dichotomous data were calculated by odds ratio (OR) and continuous data were calculated by mean difference (MD) with 95% confidence intervals (CI).

Conclusions

Laparoscopic and open liver resection for colorectal liver metastases have the same effect on oncological outcomes, but laparoscopic liver resection achieves better surgical outcomes.

Advances and challenges in laparoscopic surgery in the management of hepatocellular carcinoma

Hepatocellular carcinoma is the fifth most common malignancy and the third most common cause of cancer-related mortality worldwide. From the wide variety of treatment options, surgical resection and liver transplantation are the only therapeutic ones. However, due to shortage of liver grafts, surgical resection is the most common therapeutic modality implemented. Owing to rapid technological development, minimally invasive approaches have been incorporated in liver surgery. Liver laparoscopic resection has been evaluated in comparison to the open technique and has been shown to be superior because of the reported decrease in surgical incision length and trauma, blood loss, operating theatre time, postsurgical pain and complications, R0 resection, length of stay, time to recovery and oral intake. It has been reported that laparoscopic excision is a safe and feasible approach with near zero mortality and oncologic outcomes similar to open resection. Nevertheless, current indications include solid tumors in the periphery < 5 cm, especially in segments II through VI, while according to the consensus laparoscopic major hepatectomy should only be performed by surgeons with high expertise in laparoscopic and hepatobiliary surgery in tertiary centers. It is necessary for a surgeon to surpass the 60-cases learning curve observed in order to accomplish the desirable outcomes and preserve patient safety. In this review, our aim is to thoroughly describe the general principles and current status of laparoscopic liver resection for hepatocellular carcinoma, as well as future prospects.

Laparoscopic versus open liver resection for colorectal liver metastases: a systematic review

BACKGROUND

Laparoscopic liver resection (LLR) has been proposed as a safe and feasible treatment option for colorectal liver metastasis (CRLM). However, the short-term and oncologic outcomes of LLR versus open liver resection (OLR) for CRLM have not been adequately assessed. Thus, we herein provide an updated systematic review comparing short-term and oncologic outcomes of CRLM patients undergoing LLR versus OLR.

METHODS

A systematic literature search was performed in the Pubmed, Embase, and Cochrane Library databases (until November 2, 2016) with a limitation to the publications in English. Quality assessment was performed based on the modification of the Newcastle-Ottawa Scale. Dichotomous data were calculated by odds ratio (OR), and continuous data were calculated by weighted mean difference (WMD) with 95% confidence intervals (CIs).

RESULTS

A total of 28 studies enrolling 4591 patients with CRLM were included. With respect to short-term outcomes, patients in LLR group showed significantly reduced blood loss (WMD: -143.64; 95% CI: -180.56 to -106.73; I2 = 86%; P < 0.001), lower operative transfusion requirement (OR: 0.40; 95% CI: 0.30-0.53; I2 = 0%; P < 0.001), shorter hospital stay (WMD: -2.47; 95% CI: -2.99 to -1.94; I2 = 82%; P < 0.001), reduced overall postoperative morbidity (OR: 0.53; 95% CI: 0.42-0.66; I2 = 38%; P < 0.001) and reduced severe morbidity (OR: 0.44; 95% CI: 0.32-0.60; I2 = 35%; P < 0.001). Regarding oncologic outcomes, there were no significant differences between the two surgical procedures in recurrence and 1-, 3-, and 5-overall survival and disease-free survival except for slightly higher R0 resection rate in LLR group was slightly higher than that of OLR group (OR: 1.43; 95% CI: 1.03-1.97; I2 = 37%; P = 0.03).

CONCLUSIONS

LLR should be the standard approach for selected patients with CRLM, and further research should focus on determining which patients would benefit most from LLR.

Laparoscopic Versus Open Hepatic Resection for Solitary Hepatocellular Carcinoma Less Than 5 cm in Cirrhotic Patients: A Randomized Controlled Study

BACKGROUND

Current literature is lacking level 1 evidence for surgical and oncologic outcomes of hepatocellular carcinoma (HCC) undergoing laparoscopic versus open hepatectomy. Aim was to compare feasibility, safety, and surgical and oncologic efficiency of laparoscopic versus open liver resection (OLR) in management of solitary small (<5 cm) peripheral HCC in Child A cirrhotic patients.

METHODS

Patients were randomly assigned to either OLR group (25 patients) or laparoscopic liver resection (LRR) group (LRR: 25 patients). All were treated with curative intent aiming at achieving R0 resection using radiofrequency-assisted technique.

RESULTS

LLR had significantly less operative time (120.32 ± 21.58 versus 146.80 ± 16.59 minutes, P < .001) and shorter duration of hospital stay (2.40 ± 0.58 versus 4.28 ± 0.79 days, P < .001), with comparable overall complications (25 versus 28%, P = .02). LLR had comparative resection time (66.56 ± 23.80 versus 59.56 ± 14.74 minutes, P = .218), amount of blood loss (250 versus 230 mL, P = .915), transfusion rate (P = 1.00), and R0 resection rate when compared with OLR. After median follow-up of 34.43 (31.67-38.60) months, LLR achieved similar adequate oncological outcome of OLR, no local recurrence, with no significant difference in early recurrence or number of de novo lesions (P = .49). One-year and 3-year disease free survival (DFS) rates, 88% and 59%, in the LLR were comparable to corresponding rates of 84% and 54% in OLR (P = .9).

CONCLUSION

LLR is superior to the OLR with significantly shorter duration of hospital stay and does not compromise the oncological outcomes.

Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a multimodal pathway developed to overcome the deleterious effect of perioperative stress after major surgery. In colorectal surgery, ERAS pathways reduced perioperative morbidity, hospital stay and costs. Similar concept should be applied for liver surgery. This study presents the specific ERAS Society recommendations for liver surgery based on the best available evidence and on expert consensus.

METHODS

A systematic review was performed on ERAS for liver surgery by searching EMBASE and Medline. Five independent reviewers selected relevant articles. Quality of randomized trials was assessed according to the Jadad score and CONSORT statement. The level of evidence for each item was determined using the GRADE system. The Delphi method was used to validate the final recommendations.

RESULTS

A total of 157 full texts were screened. Thirty-seven articles were included in the systematic review, and 16 of the 23 standard ERAS items were studied specifically for liver surgery. Consensus was reached among experts after 3 rounds. Prophylactic nasogastric intubation and prophylactic abdominal drainage should be omitted. The use of postoperative oral laxatives and minimally invasive surgery results in a quicker bowel recovery and shorter hospital stay. Goal-directed fluid therapy with maintenance of a low intraoperative central venous pressure induces faster recovery. Early oral intake and mobilization are recommended. There is no evidence to prefer epidural to other types of analgesia.

CONCLUSIONS

The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.

Laparoscopic Versus Open Liver Resection for Colorectal Metastases in Elderly and Octogenarian Patients: A Multicenter Propensity Score Based Analysis of Short- and Long-term Outcomes

OBJECTIVE

This study aims to compare the perioperative and oncological outcomes of laparoscopic and open liver resection for colorectal liver metastases in the elderly.

BACKGROUND

Laparoscopic liver resection has been associated with less morbidity and similar oncological outcomes to open liver resection for colorectal liver metastases (CRLMs). It has been reported that these benefits continue to be observed in elderly patients. However, in previous studies, patients over 70 or 75 years were considered as a single, homogenous population raising questions regarding the true impact of the laparoscopic approach on this diverse group of elderly patients.

METHOD

Prospectively maintained databases of all patients undergoing liver resection for CRLM in 5 tertiary liver centers were included. Those over 70-years old were selected for this study. The cohort was divided in 3 subgroups based on age. A comparative analysis was performed after the implementation of propensity score matching on the 2 main cohorts (laparoscopic and open groups) and also on the study subgroups.

RESULTS

A total of 775 patients were included in the study. After propensity score matching 225 patients were comparable in each of the main groups. Lower blood loss (250 vs 400 mL, P = 0.001), less overall morbidity (22% vs 39%, P = 0.001), shorter High Dependency Unit (2 vs. 6 days, P = 0.001), and total hospital stay (5 vs. 8 days, P = 0.001) were observed after laparoscopic liver resection. Comparable rates of R0 resection (88% vs 88%, P = 0.999), median recurrence-free survival (33 vs 27 months, P = 0.502), and overall survival (51 vs 45 months, P = 0.671) were observed. The advantages seen with the laparoscopic approach were reproduced in the 70 to 74-year old subgroup; however there was a gradual loss of these advantages with increasing age.

CONCLUSIONS

In patients over 70 years of age laparoscopic liver resection, for colorectal liver metastases, offers significant lower morbidity, and a shorter hospital stay with comparable oncological outcomes when compared with open liver resection. However, the benefits of the laparoscopic approach appear to fade with increasing age, with no statistically significant benefits in octogenarians except for a lower High Dependency Unit stay.

Different techniques for harvesting grafts for living donor liver transplantation: A systematic review and meta-analysis

AIM

To perform a systematic review and meta-analysis on minimally vs conventional invasive techniques for harvesting grafts for living donor liver transplantation.

METHODS

PubMed, Web of Science, EMBASE, and the Cochrane Library were searched comprehensively for studies comparing MILDH with conventional living donor hepatectomy (CLDH). Intraoperative and postoperative outcomes (operative time, estimated blood loss, postoperative liver function, length of hospital stay, analgesia use, complications, and survival rate) were analyzed in donors and recipients. Articles were included if they: (1) compared the outcomes of MILDH and CLDH; and (2) reported at least some of the above outcomes.

RESULTS

Of 937 articles identified, 13, containing 1592 patients, met our inclusion criteria and were included in the meta-analysis. For donors, operative time [weighted mean difference (WMD) = 20.68, 95%CI: -6.25-47.60, P = 0.13] and blood loss (WMD = -32.61, 95%CI: -80.44-5.21, P = 0.18) were comparable in the two groups. In contrast, analgesia use (WMD = -7.79, 95%CI: -14.06-1.87, P = 0.01), postoperative complications [odds ratio (OR) = 0.62, 95%CI: 0.44-0.89, P = 0.009], and length of hospital stay (WMD): -1.25, 95%CI: -2.35-0.14, P = 0.03) significantly favored MILDH. No differences were observed in recipient outcomes, including postoperative complications (OR = 0.93, 95%CI: 0.66-1.31, P = 0.68) and survival rate (HR = 0.96, 95%CI: 0.27-3.47, P = 0.95). Funnel plot and statistical methods showed a low probability of publication bias.

CONCLUSION

MILDH is safe, effective, and feasible for living donor liver resection with fewer donor postoperative complications, reduced length of hospital stay and analgesia requirement than CLDH.

Laparoscopic Versus Open Liver Resection for Colorectal Liver Metastases: A Comprehensive Systematic Review and Meta-analysis

The effects of laparoscopic liver resection (LLR) and open liver resection (OLR) on oncological outcomes for colorectal cancer liver metastases (CCLM) remain inconclusive. Major databases were searched from January 1992 to October 2016. Effects of LLR vs OLR were determined. The primary endpoints were oncological outcomes. In total, 32 eligible non-randomized studies with 4697 patients (LLR: 1809, OLR: 2888) were analyzed. There were higher rates of clear surgical margins (OR: 1.64, 95%CI: 1.32 to 2.05, p < 0.00001) in the LLR group, without significant differences in disease recurrence, 3- or 5-year overall survival(OS) and disease free survival(DFS) between the two approaches. LLR was associated with less intraoperative blood loss (WMD: −147.46 [−195.78 to −99.15] mL, P < 0.00001) and fewer blood transfusions (OR: 0.41 [0.30–0.58], P < 0.00001), but with longer operation time (WMD:14.44 [1.01 to 27.88] min, P < 0.00001) compared to OLR. Less overall morbidity (OR: 0.64 [0.55 to 0.75], p < 0.00001) and shorter postoperative hospital stay (WMD: −2.36 [−3.06 to −1.66] d, p < 0.00001) were observed for patients undergoing LLR, while there was no statistical difference in mortality. LLR appears to be a safe and feasible alternative to OLR in the treatment of CCLM in selected patients.

Robotics in hepatobiliary surgery-initial experience, first reported case series from India

•

Utility of robotic system for heterogenous mix of hepatobiliary cases.

•

Ability of robotic system to perform complex hepatobiliary cases.

•

Advantages of minimal access surgery but at a higher cost.

Introduction

Robotic surgical system's ability to perform complex hepatobiliary surgeries is gaining momentum with outcomes similar to open surgery and advantages of minimal access surgery. The authors present their initial experience of a heterogenous spectrum of robotic hepatobiliary cases and the first reported case series from India.

Methods

Retrospective review of hepatobiliary cases done robotically from February 2015 to January 2016 was done.

Results

The series has ten patients; with median age of 45 years (range 15–72). Etiologies were choledochal cyst type IVa, benign lower end common bile duct stricture (biliary reconstruction group); incidental gallbladder carcinoma, hepatocellular carcinoma, recurrent pyogenic cholangitis, polycystic liver disease, hemangioma, liver metastases, hydatid cyst (resection group). Median operative duration was 510 min; one patient needed intra-operative blood transfusion and there were no conversions to open surgery. One patient developed bile leak which was managed by biliary stenting and another thrombotic thrombocytopenic purpura during post-operative period. Median length of hospital stay was 6 days with average cost of robotic surgery being $1700 USD more for major hepatectomy and $900 USD more for biliary reconstruction compared to open procedure.

Conclusion

This initial series adds to existing data on the feasibility of robotic hepatobiliary cases with inherent advantages of minimal invasive surgery, however with limitation of availability and use of devices like cavitron ultrasonic surgical aspirator (CUSA) and higher operative cost.