Outcomes of laparoscopic right posterior sectionectomy in patients with hepatocellular carcinoma in the era of laparoscopic surgery

Indocyanine Green Fluorescence Imaging-Guided Laparoscopic Right Posterior Sectionectomy with Glissonean Approach and Modified Hanging Maneuver

BACKGROUND

In the era of innovating minimal invasive surgery, laparoscopic right posterior sectionectomy (RLPS) is considered a technically challenging procedure for its deeply anatomic location.1,2 Performed by experienced surgeons, it has been shown to be a safe and feasible procedure.3-6 The purpose of this video was to show the technique of a RLPS.

METHODS

This is the case of a 70-year-old man who was treated for a mid-rectum adenocarcinoma with two synchronous liver metastases located in the posterior sector of the right liver. Tumor board decision was chemoradiotherapy followed by a simultaneous rectal and hepatic surgery.

RESULTS

An extrahepatic Glissonian approach of the right posterior pedicle was performed. After selective clamping of the right posterior pedicle and injection of indocyanine green, the right portal fissure between the two sectors of the right liver appeared. The parenchymal transection performed in a caudal approach, along a perfectly marked plane. One metastasis was in contact with the right hepatic vein. Because R1 vascular surgery has demonstrated similar oncological outcomes to R0 resection, we detached the metastasis from the vein to preserve a good venous drainage of the remaining right liver.7 The procedure was completed with a laparoscopic anterior resection of the rectum. The duration of the liver resection was 200 min, and blood loss was 300 ml. Postoperative course was uneventful, and the patient was discharged on postoperative Day 10.

CONCLUSIONS

Laparoscopic right posterior sectionectomy is a safe and feasible procedure.3-6 However, it is technically challenging and requires advanced experience in liver and laparoscopic surgery.5,6.

Laparoscopic versus open in right posterior sectionectomy: a systematic review and meta-analysis

BACKGROUND

Laparoscopic liver resection (LLR) is now widely adopted for the treatment of liver tumors due to its minimally invasive advantages. However, multicenter, large-sample population-based laparoscopic right posterior sectionectomy (LRPS) has rarely been reported. We aimed to assess the advantages and drawbacks of right posterior sectionectomy compared with laparoscopic and open surgery by meta-analysis.

METHODS

Relevant literature was searched using the PubMed, Embase, Cochrane, Ovid Medline, and Web of Science databases up to September 12, 2021. Quality assessment was performed based on a modified version of the Newcastle-Ottawa Scale (NOS). The data were analyzed by Review Manager 5.3. The data were calculated by odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CI) for fixed-effects and random-effects models.

RESULTS

The meta-analysis included seven studies involving 739 patients. Compared with open right posterior sectionectomy (ORPS), the LRPS group had lower intraoperative blood loss (MD - 135.45; 95%CI - 170.61 to - 100.30; P < 0.00001) and shorter postoperative hospital stays (MD - 2.17; 95% CI - 3.03 to - 1.31; P < 0.00001). However, there were no statistically significant differences between LRPS and ORPS regarding operative time (MD 44.97; P = 0.11), pedicle clamping (OR 0.65; P = 0.44), clamping time (MD 2.72; P = 0.31), transfusion rate (OR 1.95; P = 0.25), tumor size (MD - 0.16; P = 0.13), resection margin (MD 0.08; P = 0.63), R0 resection (OR 1.49; P = 0.35), recurrence rate (OR 2.06; P = 0.20), 5-year overall survival (OR 1.44; P = 0.45), and 5-year disease-free survival (OR 1.07; P = 0.88). Furthermore, no significant difference was observed in terms of postoperative complications (P = 0.08), bile leakage (P = 0.60), ascites (P = 0.08), incisional infection (P = 0.09), postoperative bleeding (P = 0.56), and pleural effusion (P = 0.77).

CONCLUSIONS

LRPS has an advantage in the length of hospital stay and blood loss. LRPS is a very useful technology and feasible choice in patients with the right posterior hepatic lobe tumor.

Positioning of Minimally Invasive Liver Surgery for Hepatocellular Carcinoma: From Laparoscopic to Robot-Assisted Liver Resection

Laparoscopic liver resection (LLR) is widely accepted in the surgical treatment of hepatocellular carcinoma (HCC) through international consensus conferences and the development of difficulty classifications. LLR has been reported to result in earlier postoperative recovery and fewer postoperative complications than open liver resection (OLR) for HCC. However, the prevalence of liver cirrhosis, obesity, the elderly, HCC recurrence (repeat liver resection), and major resection must be considered for LLR for HCC. Some systematic reviews, meta-analysis studies, and large cohort studies indicated that LLR is technically feasible for selected patients with HCC with these factors that led to less intraoperative blood loss, fewer transfusions and postoperative complication incidences, and shorter hospital stays than OLR. Furthermore, some reported LLR prevents postoperative loss of independence. No difference was reported in long-term outcomes among patients with HCC who underwent LLR and OLR; however, some recent reports indicated better long-term outcomes with LLR. In recent years, robot-assisted liver resection (RALR) has gradually become popular, and its short- and long-term results for HCC are not different from those of LLR. Additionally, RALR is expected to become the mainstay of minimally invasive surgery in the future.

Caudodorsal approach combined with in situ split for laparoscopic right posterior sectionectomy

BACKGROUND

Laparoscopic right posterior sectionectomy (LRPS) was technically challenging and lack of standardization. There were some approaches for LRPS, such as caudal approach and dorsal approach. During our practice, we initiated pure LRPS using the caudodorsal approach with in situ split and present several advantages of this method.

METHODS

From April 2018 to December 2021, consecutive patients who underwent pure LRPS using the caudodorsal approach with in situ split at our institution entered into this retrospective study. The key point of the caudodorsal approach was that the right hepatic vein was exposed from peripheral branches toward the root and the parenchyma was transected from the dorsal side to ventral side. Specially, the right perihepatic ligaments were not divided to keep the right liver in situ before parenchymal dissection for each case.

RESULTS

11 patients underwent pure LRPS using the caudodorsal approach with in situ split. There were 9 hepatocellular carcinoma, 1 sarcomatoid hepatocellular carcinoma, and 1 hepatic hemangioma. Five patients had mild cirrhosis and 1 had moderate cirrhosis. All the procedures were successfully completed laparoscopically. The median operative time was 375 min (range of 290-505 min) and the median blood loss was 300 ml (range of 100-1000 ml). Five patients received perioperative blood transfusion, of which 1 patient received autologous blood transfusion and 2 patients received blood transfusion due to preoperative moderate anemia. No procedure was converted to open surgery. Two patients who suffered from postoperative complications, improved after conservative treatments. The median postoperative stay was 11 days (range of 7-25 days). No postoperative bleeding, hepatic failure, and mortality occurred.

CONCLUSION

The preliminary clinical effect of the caudodorsal approach with in situ split for LRPS was satisfactory. Our method was feasible and expected to provide ideas for the standardization of LRPS. Further researches are required due to some limitations of this study.

The safety and feasibility of laparoscopic right posterior sectionectomy vs. open approach: A systematic review and meta-analysis

Background

Laparoscopic right posterior sectionectomy (LRPS) is one of the most technically challenging and potentially hazardous procedures in laparoscopic liver resection. Although some available literature works demonstrated the safety and feasibility of LRPS, these data are limited to reports from a single institution and a small sample size without support from evidence-based medicine. So, we performed a meta-analysis to assess further the safety and feasibility of LRPS by comparing it with open right posterior sectionectomy (ORPS).

Methods

MEDLINE, Embase, and Cochrane Library were systematically searched for eligible studies comparing LRPS and open approaches. Random and fixed-effects models were used to calculate outcome measures.

Results

Four studies involving a total of 541 patients were identified for inclusion: 250 in the LRPS group and 291 in the ORPS group. The postoperative complication and margin were not statistically different between the two groups (OR: 0.49, 95% CI: 0.18 to 1.35, P = 0.17) (MD: 0.05, 95% CI: −0.47 to 0.57, P = 0.86), respectively. LRPS had a significantly longer operative time and shorter hospital stay (MD: 140.32, 95% CI: 16.73 to 263.91, P = 0.03) (MD: −1.64, 95% CI: −2.56 to −0.72, P = 0.0005) respectively.

Conclusion

Data from currently available literature suggest that LRPS performed by an experienced surgeon is a safe and feasible procedure in selected patients and is associated with a reduction in the hospital stay.

Laparoscopic versus open resections in the posterosuperior liver segments within an enhanced recovery programme (ORANGE Segments): study protocol for a multicentre randomised controlled trial

BACKGROUND

A shift towards parenchymal-sparing liver resections in open and laparoscopic surgery emerged in the last few years. Laparoscopic liver resection is technically feasible and safe, and consensus guidelines acknowledge the laparoscopic approach in the posterosuperior segments. Lesions situated in these segments are considered the most challenging for the laparoscopic approach. The aim of this trial is to compare the postoperative time to functional recovery, complications, oncological safety, quality of life, survival and costs after laparoscopic versus open parenchymal-sparing liver resections in the posterosuperior liver segments within an enhanced recovery setting.

METHODS

The ORANGE Segments trial is an international multicentre randomised controlled superiority trial conducted in centres experienced in laparoscopic liver resection. Eligible patients for minor resections in the posterosuperior segments will be randomised in a 1:1 ratio to undergo laparoscopic or open resections in an enhanced recovery setting. Patients and ward personnel are blinded to the treatment allocation until postoperative day 4 using a large abdominal dressing. The primary endpoint is time to functional recovery. Secondary endpoints include intraoperative outcomes, length of stay, resection margin, postoperative complications, 90-day mortality, time to adjuvant chemotherapy initiation, quality of life and overall survival. Laparoscopic liver surgery of the posterosuperior segments is hypothesised to reduce time to functional recovery by 2 days in comparison with open surgery. With a power of 80% and alpha of 0.04 to adjust for interim analysis halfway the trial, a total of 250 patients are required to be randomised.

DISCUSSION

The ORANGE Segments trial is the first multicentre international randomised controlled study to compare short- and long-term surgical and oncological outcomes of laparoscopic and open resections in the posterosuperior segments within an enhanced recovery programme.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03270917 . Registered on September 1, 2017. Before start of inclusion.

PROTOCOL VERSION

version 12, May 9, 2017.

Hand-Assisted Laparoscopic Surgery Is Superior to Open Liver Resection for Colorectal Liver Metastases in the Posterosuperior Segments

Introduction: Laparoscopic liver resections (LLR) of colorectal metastasis located in posterosuperior segments (1, 4A, 7 and 8) are challenging and highly demanding. The aim of our study is to determine the safety and feasibility of hand-assisted laparoscopic surgery (HALS) in the resections of the posterosuperior lesions and to compare the peri-operative, short-term and long-term outcomes with the open liver resection (OLR) approach.

Methods and Results: A retrospective study of patients who underwent either HALS or OLR for metastatic colorectal cancer (mCRC) located in the posterosuperior segments of the liver between 2008 and 2018 in two university affiliated medical centers.

Results: A total of 187 patients were identified, of whom 78 underwent HALS and 109 underwent OLR. There was no difference between the HALS and OLR with regard to preoperative factors (age, primary CRC tumor location, number and anatomical distribution of liver metastasis, pre-operative neo-adjuvant treatment, operative time, blood transfusion rate, and resection margins positivity). On the other hand, HALS compared to OLR had a significantly shorter mean hospital stay (4 vs. 6 days; P = 0.003), and a lower total complications rate (25 vs. 47% P = 0.006). Both groups had no 30-day mortality. Also, patients who underwent HALS vs. OLR had similar liver metastases recurrence (55 vs. 51%. P = 0.65) and 5-year survival (47 vs. 45%. P = 0.72).

Conclusions: HALS for mCRC located in posterosuperior liver segments is safe and feasible and it is a preferable approach due to its lower complication rate and shorter hospital stay while not compromising survival and disease recurrence.

Long-term outcomes of laparoscopic liver resection for hepatocellular carcinoma: A propensity score matched analysis of a high-volume North American center

BACKGROUND

Laparoscopic liver resections for malignancy are increasing worldwide, and yet data from North America are lacking. We aimed to assess the long-term outcomes of patients undergoing laparoscopic liver resection and open liver resection as a treatment for hepatocellular carcinoma.

METHODS

Patients undergoing liver resection for hepatocellular carcinoma between January 2008 and December 2019 were retrospectively studied. A propensity score matching was performed using patient demographics, laboratory parameters, etiology of liver disease, liver function, and tumor characteristics. Primary outcomes included overall survival and cumulative incidence of recurrence. Kaplan-Meier and competing risk cumulative incidence were used for survival analyses. Multivariable Cox regression and Fine-Gray proportional hazard regression were performed to determine hazard for death and recurrence, respectively.

RESULTS

Three hundred and ninety-one patients were identified (laparoscopic liver resection: 110; open liver resection: 281). After propensity score matching, 149 patients remained (laparoscopic liver resection: 57; open liver resection: 92). There were no significant differences between groups with regard to extent of hepatectomy performed and tumor characteristics. The laparoscopic liver resection group experienced a lower proportion of ≥Clavien-Dindo grade III complications (14% vs 29%; P = .01). In the matched cohort, the 1-, 3-, and 5-year overall survival rate in the laparoscopic liver resection versus open liver resection group was 90.9%, 79.3%, 70.5% vs 91.3%, 88.5%, 83.1% (P = .26), and the cumulative incidence of recurrence 31.1%, 59.7%, 62.9% vs 18.9%, 40.6%, 49.2% (P = .06), respectively.

CONCLUSION

This study represents the largest single institutional study from North America comparing long-term oncologic outcomes of laparoscopic liver resection and open liver resection as a treatment for primary hepatocellular carcinoma. The combination of reduced short-term complications and equivalent long-term oncologic outcomes favor the laparoscopic approach when feasible.

Laparoscopic versus open major liver resection for hepatocellular carcinoma: A case-matched analysis of short- and long-term outcomes

Background

The feasibility and safety of laparoscopic major hepatectomy (LMH) are still uncertain. The purpose of the present study is to compare the short- and long-term outcomes of LMH with those of open major hepatectomy (OMH) for hepatocellular carcinoma (HCC).

Method

Between January 2012 and December 2018, a total of 26 patients received laparoscopic major hepatectomy in our center. To minimize any confounding factors, a 1:3 case-matched analysis was conducted based on the demographics and extent of liver resection. Data of demographics, perioperative outcomes, and long-term oncologic outcomes were reviewed.

Results

Intraoperative blood loss (P = 0.007) was significantly lower in the LMH group. In addition, the LMH group exhibited a lower overall complication rate (P = 0.039) and shorter postoperative hospital stay (P = 0.024). However, no statistically significant difference was found between LMH and OMH regarding operation time (P = 0.215) and operative cost (P = 0.860). Two laparoscopic cases were converted to open liver resection. In regard to long-term outcomes, there was no significant difference between LMH and OMH regarding disease-free survival (DFS) (P = 0.079) and overall survival (OS) (P = 0.172).

Conclusion

LMH can be an effective and safe alternative to OMH for selected patients with liver cancer in short- and long-term outcomes.

Laparoscopic hepatectomy versus open hepatectomy for tumors located in right posterior segment: A single institution study

OBJECT

With the gradual advancement of laparoscopic technology, surgeries can be successfully performed with the help of laparoscopy increasingly. This study initially explored the difference between laparoscopic right posterior sectionectomy (LRPS) and open right posterior sectionectomy (ORPS)of liver in our center, discussed the effectiveness, benefits and safety of LRPS and introduce some surgical techniques in our center.

MATERIALS AND METHODS

We retrospectively analyze 96 cases of liver tumor located in the right posterior lobe of liver in our institution from January 2015 to January 2018. There were 46 cases performed the LRPS surgery and 50 cases performed the ORPS surgery. Through analysis of the perioperative outcomes of these two groups by a case control study, we compare the differences between these two groups.

RESULTS

There was no significant difference between the LRPS and ORPS group in demographic and baseline characteristics before surgery. Patients in the LRPS group were significantly superior to ORPS in terms of postoperative liver function recovery, postoperative inflammatory factor level, pain sensation (3.03 ± 0.79 vs 4.58 ± 1.25), abdominal incision length (6.25 ± 2.34 vs 32.15 ± 3.21), carrying abdominal drainage tube time (3.26 ± 0.77 vs 4.83 ± 0.76), recovery of bowel function time (1.6 ± 0.61 VS 3.05 ± 0.85)and postoperative hospital stay (5.73 ± 0.99 vs 7.16 ± 0.95) (P < 0.05).

CONCLUSION

Compared with the traditional ORPS, LRPS has the advantages of minor injury, faster recovery and mild inflammatory reaction. The LRPS is safe and feasible, and it should be gradually promoted in clinical practice.

Laparoscopic Versus Open Liver Resection for Tumors in the Posterosuperior Segments: A Systematic Review and Meta-analysis

OBJECTIVE

The objective of this study was to compare the outcomes of laparoscopic and open liver resection for tumors in the posterosuperior segments.

METHODS

We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. We conducted a search of electronic information sources to identify all studies comparing outcomes of laparoscopic and open liver resection for tumors in the posterosuperior segments. We used the Risk Of Bias In Nonrandomized Studies-of Interventions (ROBINS-I) tool to assess the risk of bias of the included studies. Fixed-effect or random-effects models were applied to calculate pooled outcome data.

RESULTS

We identified 11 observational studies, enrolling a total of 1023 patients. The included population in both groups were comparable in terms of baseline characteristics. Laparoscopic approach was associated with lower risks of total complications [odds ratio (OR): 0.45; 95% confidence interval (CI): 0.33, 0.61; P<0.00001], major complications (Dindo-Clavien III or more) (OR: 0.52; 95% CI: 0.36, 0.73; P=0.0002), and intraoperative blood loss [mean difference (MD): -114.71; 95% CI: -165.64, -63.79; P<0.0001]. Laparoscopic approach was associated with longer operative time (MD: 50.28; 95% CI: 22.29, 78.27; P=0.0004) and shorter length of hospital stay (MD: -2.01; 95% CI: -2.09, -1.92; P<0.00001) compared with open approach. There was no difference between the 2 groups in terms of need for blood transfusion (OR: 1.23; 95% CI: 0.75, 2.02; P=0.41), R0 resection (OR: 1.09; 95% CI: 0.66, 1.81; P=0.72), postoperative mortality (risk difference: -0.00; 95% CI: -0.02, 0.02; P=0.68), and need for readmission (OR: 0.70; 95% CI: 0.19, 2.60; P=0.60). In terms of oncological outcomes, there was no difference between the groups in terms disease recurrence (OR: 1.58; 95% CI: 0.95, 2.63; P=0.08), overall survival (OS) at maximum follow-up (OR: 1.09; 95% CI: 0.66, 1.81; P=0.73), 1-year OS (OR: 1.53; 95% CI: 0.48, 4.92; P=0.47), 3-year OS (OR: 1.26; 95% CI: 0.67, 2.37; P=0.48), 5-year OS (OR: 0.91; 95% CI: 0.41, 1.99; P=0.80), disease-free survival (DFS) at maximum follow-up (OR: 0.91; 95% CI: 0.65, 1.27; P=0.56), 1-year DFS (OR: 1.04; 95% CI: 0.60, 1.81; P=0.88), 3-year DFS (OR: 1.13; 95% CI: 0.75, 1.69; P=0.57), and 5-year DFS (OR: 0.73; 95% CI: 0.44, 1.24; P=0.25).

CONCLUSIONS

Compared with the open approach in liver resection for tumors in the posterosuperior segments, the laparoscopic approach seems to be associated with a lower risk of postoperative morbidity, less intraoperative blood loss, and shorter length of hospital stay with comparable survival and oncological outcomes. The best available evidence is derived from observational studies with moderate quality; therefore, high-quality randomized controlled trials with adequate statistical power are required to provide a more robust basis for definite conclusions.

Laparoscopic versus open right posterior sectionectomy: an international, multicenter, propensity score-matched evaluation

Background

Although laparoscopic liver resection has become the standard for minor resections, evidence is lacking for more complex resections such as the right posterior sectionectomy (RPS). We aimed to compare surgical outcomes between laparoscopic (LRPS) and open right posterior sectionectomy (ORPS).

Methods

An international multicenter retrospective study comparing patients undergoing LRPS or ORPS (January 2007—December 2018) was performed. Patients were matched based on propensity scores in a 1:1 ratio. Primary endpoint was major complication rate defined as Accordion ≥ 3 grade. Secondary endpoints included blood loss, length of hospital stay (LOS) and resection status. A sensitivity analysis was done excluding the first 10 LRPS patients of each center to correct for the learning curve. Additionally, possible risk factors were explored for operative time, blood loss and LOS.

Results

Overall, 399 patients were included from 9 centers from 6 European countries of which 150 LRPS could be matched to 150 ORPS. LRPS was associated with a shorter operative time [235 (195–285) vs. 247 min (195–315) p = 0.004], less blood loss [260 (188–400) vs. 400 mL (280–550) p = 0.009] and a shorter LOS [5 (4–7) vs. 8 days (6–10), p = 0.002]. Major complication rate [n = 8 (5.3%) vs. n = 9 (6.0%) p = 1.00] and R0 resection rate [144 (96.0%) vs. 141 (94.0%), p = 0.607] did not differ between LRPS and ORPS, respectively. The sensitivity analysis showed similar findings in the previous mentioned outcomes. In multivariable regression analysis blood loss was significantly associated with the open approach, higher ASA classification and malignancy as diagnosis. For LOS this was the open approach and a malignancy.

Conclusion

This international multicenter propensity score-matched study showed an advantage in favor of LRPS in selected patients as compared to ORPS in terms of operative time, blood loss and LOS without differences in major complications and R0 resection rate.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-08109-y) contains supplementary material, which is available to authorized users.

Laparoscopic versus open liver resections of posterolateral liver segments - a systematic review and meta-analysis

INTRODUCTION

Laparoscopic resection has become an accepted approach to liver tumour surgery. However, it is considered difficult, especially in unfavourably located lesions.

AIM

To compare the outcomes of laparoscopic (LLR) and open liver resection (OLR) of posterolateral segments.

MATERIAL AND METHODS

We searched the PubMed, EMBASE, and Scopus databases from inception to 30 September 2019. Full text articles and conference abstracts were included for further analysis. This review follows the PRISMA guidelines.

RESULTS

From 643 articles, 15 studies (N = 1196 patients) were included in the meta-analysis. All of them were non-randomised. Our findings showed that LLR had significantly lowered overall morbidity compared to OLR (MD = 0.66; 95% CI: 0.51-0.86; p = 0.002). Length of hospital stay (MD = 2.48; 95% CI: -3.87, -1.08; p < 0.001) was also shorter in the LLR group. Operative time (MD = 55.65; 95% CI: 24.14-87.16; p < 0.001) was significantly shorter in the OLR group. In terms of blood loss, major complications, R0 resection rates, and resection margin, there were no significant differences.

CONCLUSIONS

Our meta-analysis showed that the laparoscopic approach to resections of posterolateral liver segments is beneficial. However, the results are based on non-randomised trials, and further research is needed to fully establish their clinical application.

Anatomic Laparoscopic Liver Resection in the Scenario of the Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

Aim: To assess the impact of the laparoscopic anatomic resections (LARs) on hepatocellular carcinoma (HCC) patients, analyzing the pooled short- and long-term outcomes of this technique and comparing it with the standard open approach [open anatomic resections (OAR)]. Material and Methods: A systematic literature search was performed in PubMed, Embase, and Scopus for studies published between 2010 and 2020 concerning LAR for HCC. Results: After screening 311 articles, 10 studies with a total of 398 patients who underwent LAR for HCC were included. The pooled cohort included mostly male (76.6%), Child A (98.2%), with hepatitis B virus (HBV)-related disease (60.5%). The pooled conversion rate was 7.3%. The pooled overall complication rate was 10.2 with a mortality rate of 1.0%. In the pooled analyses of only comparative studies, LAR group included 378 versus 455 in OAR. Operative time was longer in the LAR group (329 minutes versus 248; P = .001). Blood loss (179 versus 331 mL; P = .018) was lower in the LAR group. The pooled mean length of hospital stay was 8.4 days in LARs and 11.3 in OARs (P = .002). The pooled rate of postoperative complications was higher in the OAR group (25.3 versus 13.8; P = .009), while mortality rates were similar. The LAR group had a pooled 3- and 5-year overall survival of 90.1 and 81.9 versus 83.5 and 80.7 of the OARs (P > .05), respectively. Conclusions: In conclusion, the LAR for HCC is safe and associated with decreased blood loss and length of hospital stay. Survival rates are comparable with those of the conventional open approach.

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.

Solo single-incision laparoscopic liver resection: a cohort series

BACKGROUND

Single-incision laparoscopic liver resection (SILLR) is still challenging due to the unstable surgical view, the crowding instruments and its crossover. In this study, we present a new option of solo SILLR for various liver tumours in order to overcome those difficulties.

METHODS

Solo SILLR is indicated for liver tumours located in the left liver or in the superficial right liver. Data for 54 consecutive patients, who underwent solo SILLR between October 2015 and October 2018, were collected and analysed prospectively.

RESULTS

A total of 30 patients (55.5%) underwent non-anatomical resection. Left hemi-hepatectomy was performed in 11 patients (20.4%) and left lateral was performed in 13 patients (24.1%). The median operative time was 114 (range 30-335) min with median blood loss of 400 (50-750) mL with no need of blood transfusion and no intraoperative complications. The median length of hospital stay was 3 (range 1-19) days. There was one case of post-operative intra-abdominal fluid collection and one case of incisional hernia during the follow-up.

CONCLUSION

Solo SILLR is more feasible and safer for liver tumours located in the superficial right liver or in the left one. Therefore, solo surgery can be an option in SILLR.

Surgical and oncological outcomes after laparoscopic vs. open major hepatectomy for hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

The short- and long-term prognoses are unclear following laparoscopic major hepatectomy (LMH) for hepatocellular carcinoma (HCC). We performed a meta-analysis to compare the surgical and oncological outcomes of LMH vs. open major hepatectomy (OMH) in patients with HCC.

METHODS

All studies comparing LMH with OMH for HCC published until April 2019 were identified independently by searching PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials. We analyzed data for surgical and oncological outcomes, namely, operative time, intraoperative blood loss, blood transfusion rate, postoperative morbidity, major complications, mortality, hospital stay, margin distance, negative margin rate, long-term overall survival, and corresponding disease-free survival (DFS).

RESULTS

We included 13 studies involving 1,225 patients with HCC (LMH: 534 patients; OMH: 691 patients) in the meta-analysis. Regarding short-term outcomes, the pooled data showed that LMH was associated with longer operative time [weighted mean difference (WMD): 72.14 min; 95% confidence interval (CI): 43.07-101.21; P<0.00001], less blood loss (WMD: -102.32 mL; 95% CI: -150.99 to -53.64; P<0.0001), shorter hospital stay (WMD: -3.77 d; 95% CI: -4.95 to -2.60; P<0.00001), lower morbidity [risk difference (RD): -0.01; 95% CI: -0.16 to -0.06; P<0.00001], and lower major complication rates (RD: -0.08; 95% CI: -0.11 to -0.05; P<0.00001). However, the need for blood transfusion (RD: -0.01; 95% CI: -0.06 to 0.05; P=0.78), mortality (RD: -0.01; 95% CI: -0.02 to 0.01; P=0.57), margin distance (WMD: 0.05 mm; 95% CI: -0.1 to 0.19; P=0.52), and negative margin rate (RD: 0.01; 95% CI: -0.03 to 0.05; P=0.65) were significantly comparable between the two groups. Regarding long-term outcomes, there was no difference in 3-year DFS [hazard ratio (HR): 0.99; 95% CI: 0.72-1.37; P=0.95], 3-year overall survival (HR: 1.25; 95% CI: 0.70-2.21; P=0.45), 5-year DFS (HR: 0.94; 95% CI: 0.64-1.38; P=0.76), and 5-year overall survival (HR: 0.94; 95% CI: 0.45-1.99; P=0.88).

CONCLUSIONS

LMH can be performed as safely as OMH in select patients and provides improved short-term surgical outcomes without affecting long-term survival. However, confirming our results requires more evidence from high-quality and prospective randomized controlled trials.

Advanced laparoscopic HPB surgery: Experience in Seoul National University Bundang Hospital

The worldwide trend in surgery has moved from open surgery to minimally invasive surgery. Likewise, the application of minimally invasive surgery in the hepato-pancreato-biliary (HBP) field is also rapidly expanding. The field of HBP surgery can be divided into liver, pancreas and biliary fields. Minimally invasive liver surgery is recently developed. However, laparoscopic liver resection in difficult areas is challenging. However, with the accumulation of experiences, laparoscopic liver resection for difficult areas is performed more than before. With more propagation, more and more liver resection will be performed by laparoscopic approach. In minimally surgery for the pancreas, distal pancreatectomy has become a well-recommended procedure in benign and borderline malignancy. There have been several systemic reviews that show advantages of laparoscopic distal pancreatectomy. The reports on laparoscopic pancreaticoduodenectomy (PD) are slowly increasing in spite of technical difficulty, with several systemic reviews showing advantages of the procedure. However, more PD will be performed as robotic-assisted procedures in the future. The laparoscopic surgery for biliary tract malignancy is still in early stages. The laparoscopic surgery for gallbladder cancer has been contraindicated, although there have been encouraging reports from expert centers. The laparoscopic surgery for Klatskin tumor is still an experimental procedure. Robotic-assisted procedures for the surgery of cholangiocarcinoma will be the future. Robotic-assisted surgery for the HBP field is still not well-developed. However, with the necessity of more precise manipulation like intracorporeal suturing, robotic-assisted surgery will be used more often in the field of HBP surgery.

A novel exposure maneuver in laparoscopic right hepatectomy

BACKGROUND AND OBJECTIVES

Laparoscopic access to the posterosuperior and lateral parts of the right liver is difficult for blocked and deep surgical situations. We invented a novel water bag device (WBD) to improve the exposure of the right liver.

METHODS

Eighteen consecutive patients with lesions isolated to the posterosuperior or lateral right liver were included in our research. They underwent laparoscopic right hepatectomy with the help of the device and were compared with previous similar laparoscopic cases of our operating surgeon.

RESULTS

The device was successfully employed without related complications and provided enhanced and stable surgical exposure. All patients were operated on without the need for blood transfusions or laparotomy conversion. The median operation time and estimated blood loss were 227 minutes (range, 114-568) and 88 mL (range, 25-250), respectively. In all cases, tumor-free surgical margins were confirmed and no major complications were observed. The results were better than those in previous similar laparoscopic cases.

CONCLUSIONS

The WBD is safe and effective for laparoscopic exposure when lesions are located in the posterosuperior and lateral parts of the right liver. With the help of the device, laparoscopic right liver resection is easier to perform instead of undergoing open hepatectomy.

Laparoscopic versus open major liver resection for hepatocellular carcinoma: systematic review and meta-analysis of comparative cohort studies

Background

The application of laparoscopic liver resection (LLR) has expanded rapidly in recent decades. Although multiple authors have reported LLR shows improved safety and efficacy in treating hepatocellular carcinoma (HCC) compared with open liver resection (OLR), laparoscopic (LMLR) and open (OMLR) major liver resections for HCC treatment remain inadequately evaluated. This work aimed to test the hypothesis that LMLR is safer and more effective than OMLR for HCC.

Methods

Comparative cohort and registry studies on LMLR and OMLR, searched in PubMed, the Science Citation Index, EMBASE, and the Cochrane Library, and published before March 31, 2018, were collected systematically and meta-analyzed. Fixed- and random-effects models were employed for generating pooled estimates. Heterogeneity was assessed by the Q-statistic.

Results

Nine studies (1173 patients) were included. Although the pooled data showed operation time was markedly increased for LMLR in comparison with OMLR (weighted mean difference [WMD] 74.1, 95% CI 35.1 to 113.1, P = 0.0002), blood loss was reduced (WMD = − 107.4, 95% CI − 179.0 to − 35.7, P = 0.003), postoperative morbidity was lower (odds ratio [OR] 0.47, 95% CI 0.35 to 0.63, P <  0.0001), and hospital stay was shorter (WMD = − 3.27, 95% CI − 4.72 to − 1.81, P <  0.0001) in the LMLR group. Although 1-year disease-free survival (DFS) was increased in patients administered LMLR (OR = 1.55, 95% CI 1.04 to 2.31, P = 0.03), other 1-, 3-, and 5-year survival outcomes (overall survival [OS] and/or DFS) were comparable in both groups.

Conclusions

Compared with OMLR, LMLR has short-term clinical advantages, including reduced blood loss, lower postsurgical morbidity, and shorter hospital stay in HCC, despite its longer operative time. Long-term oncological outcomes were comparable in both groups.

Pure laparoscopic right posterior sectionectomy using the caudate lobe-first approach

BACKGROUND

In our process of standardizing laparoscopic right-sided anatomical hepatectomy, we found several advantages of the caudate lobe-first approach. We herein describe our standardized procedure of laparoscopic right posterior sectionectomy (Lap-RPS) using this approach.

METHODS

Between January 2011 and January 2018, 31 patients underwent pure Lap-RPS in our hospital. The mean patient age was 68 years (range 47-85 years), and the number of male patients was more than that of female patients (64.5%). Of 31 patients, 20 had metastatic liver tumor, 7 had hepatocellular carcinoma, 3 had intrahepatic cholangiocellular carcinoma, and 1 had hemangioma. All 31 patients had Child-Pugh class A liver function. The surgical technique was recorded on video. Cumulative sum (CUSUM) analyses were applied to assess the learning curve.

RESULTS

The mean operative time was 420 min (range 263-639 min), and the mean amount of blood loss was 304 g (range 10-900 g). No procedure was converted to open surgery. Postoperative bleeding, bile leakage, hepatic failure, and mortality did not occur. CUSUM analyses showed a decrease in the operative time and blood loss after using the caudate lobe-first approach.

CONCLUSION

Our standardized procedure of Lap-RPS using the caudate lobe-first approach is not only feasible but also expected to provide an advantage for laparoscopic anatomical hepatectomy.

Pure Laparoscopic Right Posterior Sectionectomy Using the Glissonean Approach and a Modified Liver Hanging Maneuver (Video)

BACKGROUND

Laparoscopic right posterior sectionectomy is technically challenging secondary to poor exposure of the surgical field and difficulty with controlling hemorrhage during deeper parenchymal transection Cho et al., Surgery 158:135-141, 2015; Lee et al., Surgery 160:1219-1226, 2016. We present laparoscopic right posterior sectionectomy using the Glissonean approach and a modified liver hanging maneuver.

METHODS

A 57-year-old man presented with a single mass in segment 7 of the liver. He was placed in the lithotomy position, and five trocars were used in the upper abdomen. The hepatoduodenal ligament was encircled using an umbilical tape to perform the intermittent Pringle maneuver. After detachment of the hilar plate, the right posterior Glissonean pedicle was dissected and clamped to confirm ischemic delineation Takasaki, J Hepato-Biliary-Pancreat Surg 5:286-291, 1998. After complete mobilization of the right liver, the hanging tape was placed along the inferior vena cava between the caval ligament and the right hepatic vein. The hanging tape elevates the liver and guides the surgeon to achieve an accurate transection plane Belghiti et al., J Am Coll Surg 193:109-111, 2001; Kim et al., Surg Endosc 30:3611-3617, 2016; Kim, Choi, J Gastrointest Surg 21:1181-1185, 2017; Kim et al., Langenbecks Arch Surg 403:131-135, 2018 . The transection plane used during a right posterior sectionectomy is horizontal and follows the inferior vena cava. However, with the liver hanging maneuver, the horizontal transection plane becomes vertical.

RESULT

The operation time was 290 min, the estimated blood loss was 120 mL, and the total Pringle maneuver time was 60 min. Final histopathological diagnosis showed a 1.7-cm-sized hepatocellular carcinoma with the resection margin measuring 1.5 cm. The patient was discharged on postoperative day 7 without any complications.

CONCLUSION

A Glissonean approach with a modified liver hanging maneuver is feasible and useful for laparoscopic right posterior sectionectomy.

Laparoscopic Right Hepatectomy for Hepatocellular Carcinoma: A Propensity Score Matching Analysis of Outcomes Compared with Conventional Open Surgery

BACKGROUND

The application of laparoscopic hepatectomy is gaining momentum. However, the safety and efficacy of laparoscopic right hepatectomy (LRH) on hepatocellular carcinoma (HCC) are yet to be adequately evaluated. We aimed to assess the surgical and oncological outcomes of LRH for HCC by comparing it with open right hepatectomy (ORH).

MATERIALS AND METHODS

Data of patients who underwent hepatectomy for HCC from May 2007 to January 2018 in our hospital were obtained. Baseline characteristics, postoperative recovery, and survival outcomes were compared. One-to-one propensity score matching (PSM) was used to minimize selection biases by balancing factors, including age, sex, preoperative therapy, tumor size, and pattern.

RESULTS

The original cohort included 109 patients (LRH, 41 patients; ORH, 68 patients). Of the 41 patients who underwent LRH, 8 patients (19.5%) required conversion to laparotomy. The overall morbidity was 19.5%, and no mortality in LRH was noted. After PSM, LRH was associated with a tendency of prolonged operative time (255.5 ± 93.4 minutes versus 225.9 ± 39.8 minutes, P = .08) and less intraoperative blood loss [300 (100-1200) versus 500 (200-2000) mL, P < .01]. LRH showed up a trend of less overall morbidity without statistical significance (18.4% versus 26.3%, P = .41). Moreover, the 3-year overall and disease-free survival did not differ significantly between the groups during a median follow-up of 19 (3-58) months for the LRH group and 23 (3-97) months for the ORH group.

CONCLUSIONS

LRH can be performed as safe and effective as ORH for HCC in regard to both surgical and oncological outcomes. LRH holds the benefit in less intraoperative blood loss and appears to achieve less postoperative morbidity, which could serve as a promising alternative to ORH in selected individuals.

Surgical outcomes of hand-assisted laparoscopic liver resection vs. open liver resection: A retrospective propensity score-matched cohort study

Objective

Hand-assisted laparoscopic liver resection has the advantages of open and laparoscopic surgeries. There is still lack of comparison of surgical outcomes between hand-assistied laparoscopic liver resection (HALLR) and open liver resection (OLR). This study compared the surgical outcomes of the two approaches between well-matched patient cohorts.

Methods

Patients who received liver resection during January 2014 and October 2017 in Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College were included in this retrospective study. Propensity score matching (PSM) was performed to reduce selection bias between the two groups. Operation and short-term surgical outcomes were compared between the well matched groups.

Results

During this period, 232 patients with a median age of 55.1 years old received OLR, while 49 patients with a median age of 54.7 years old received HALLR. Compared with HALLR group, OLR group has a higher proportion in male patients (190/232, 81.9% vs. 34/49, 69.4%, P=0.048) and lower albumin (43.2±4.5 vs. 44.8±3.7, P=0.020). After PSM, 49 patients from each group were included in the following analysis. Two groups were well balanced in their baseline characteristics, liver functions, preoperative treatments, abdominal surgery history, and surgical difficulty. None perioperative mortality was observed in both groups. Operation time and postoperative complications were similar in two groups (P=0.935, P=0.056). The HALLR group showed less bleeding amount (177.8±217.1 mL vs. 283.1±225.0 mL, P=0.003) and shorter postoperative stay period (6.9±2.2 d vs. 9.0±3.5 d, P=0.001).

Conclusions

We demonstrated that hand-assisted laparoscopic surgery is feasible and safe for liver resection, including some difficult cases. HALLR can provide better bleeding control and faster recovery after surgery.

Surgical outcomes between patients with and without a cirrhotic liver undergoing laparoscopic liver resection: A meta-analysis

BACKGROUND

Laparoscopic surgery in patients with liver cirrhosis (CL) is considered to be challenging. Recent studies have shown that laparoscopic liver resection (LLR) is more beneficial of reduced operative stress and postoperative complications in patients with CL.

AIM

A meta-analysis was done to review the currently available published data comparing LLR for patients with CL versus those non-cirrhosis of the liver (NCL).

METHODS

The electronic databases of PubMed, Wiley, Web of Science, Embase, and the Cochrane Library were searched from date of inception to January 29, 2018. Studies reporting a comparison of outcomes and methods of LLR in CL and NCL groups were included. The studies were evaluated using the modified Newcastle-Ottawa Scale.

RESULTS

A total of 1573 patients from six cohort studies were included in final analysis. The CL group had a slightly shorter operative time compared with the NCL group (weighted mean difference [WMD], 18.78min shorter; 95% confidence interval [CI], -43.54-5.98; P=0.14) and delayed hospital stay (WMD, 1.26 days longer; 95% CI, -0.05-2.56; P=0.06). Blood loss, blood transfusion rate, mortality, and conversion rate did not differ significantly between the groups.

CONCLUSIONS

LLR is safe and feasible in the CL compared with the NCL groups. Our present review indicates that LLR should be considered when selecting surgery for patients with CL.

Laparoscopic Versus Open Right Posterior Sectionectomy for Hepatocellular Carcinoma in a High-Volume Center: A Propensity Score Matched Analysis

BACKGROUND

While minimal invasive surgery is becoming popular in liver resection, right posterior sectionectomy (RPS) is still considered as a difficult procedure. We summarize the clinical data and investigate the feasibility of laparoscopic right posterior sectionectomy (LRPS) in hepatocellular carcinoma (HCC) by comparing its outcomes with those of open right posterior sectionectomy (ORPS).

METHODS

We retrospectively reviewed 191 patients who underwent RPS for HCC during January 2009 to August 2016 at Samsung Medical Center. After 1:2 propensity score matching, 53 patients in LRPS group were matched to 97 patients in ORPS group.

RESULTS

There was no statistical difference in preoperative data. While operation time was significantly longer in LRPS group (381.1 ± 118.7 vs. 234.4 ± 63.7 min, P < 0.001), transfusion rate (13.2 vs. 2.1%, P = 0.061) and complication rate (9.4 vs. 8.3%, P = 0.709) were not statistically different between groups. Clustered Cox proportional hazards regression analysis for matched paired data showed no difference in both disease-free survival (P = 0.607) and overall survival (P = 0.858).

CONCLUSIONS

In HCC, LRPS can be performed safely compared to ORPS, regarding the operative outcome, patient recovery, and oncological outcomes.

A Systematic Review and Meta-Analysis Comparing the Short- and Long-Term Outcomes for Laparoscopic and Open Liver Resections for Hepatocellular Carcinoma: Updated Results from the European Guidelines Meeting on Laparoscopic Liver Surgery, Southampton, UK, 2017

BACKGROUND

The laparoscopic approach to liver resection has experienced exponential growth in recent years; however, its application is still under debate and objective, evidence-based guidelines for its safe future progression are needed.

OBJECTIVE

The aim of this study was to perform a systematic review and meta-analysis comparing the short- and long-term outcomes of laparoscopic and open liver resections for hepatocellular carcinoma (HCC).

METHODS

To identify all the comparative manuscripts reporting on laparoscopic and open liver resection for HCC, all published English-language studies with more than 10 cases were screened. In addition to the primary meta-analysis, four specific subgroup analyses were performed on patients with Child-Pugh A cirrhosis, resections for solitary tumors, and those undergoing minor and major resections. The quality of the studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) methodology and the Newcastle-Ottawa Scale.

RESULTS

From the initial 361 manuscripts, 28 were included in the meta-analysis. Five of these 28 manuscripts were specific to patients with Child-Pugh A cirrhosis (321 cases), 11 focused on solitary tumors (1003 cases), 16 focused on minor resections (1286 cases), and 3 focused on major resections (164 cases). Three manuscripts compared 1079 cases but could not be assigned to any of the above subanalyses. In general terms, short-term outcomes were favorable when using a laparoscopic approach, especially in minor resections. The only advantage seen with an open approach was reduced operative time during major liver resections. No differences in long-term outcomes were observed between the approaches.

CONCLUSIONS

Laparoscopic liver resection for HCC is feasible and offers improved short-term outcomes, with comparable long-term outcomes as the open approach.

Meta-analysis of short- and long-term outcomes after pure laparoscopic versus open liver surgery in hepatocellular carcinoma patients

Background

The advantages of laparoscopy are widely known. Nevertheless, its legitimacy in liver surgery is often questioned because of the uncertain value associated with minimally invasive methods. Our main goal was to compare the outcomes of pure laparoscopic (LLR) and open liver resection (OLR) in patients with hepatocellular carcinoma.

Methods

We searched EMBASE, MEDLINE, Web of Science, and The Cochrane Library databases to find eligible studies. The most recent search was performed on December 1, 2017. Studies were regarded as suitable if they reported morbidity in patients undergoing LLR versus OLR. Extracted data were pooled and subsequently used in a meta-analysis with a random-effects model. Clinical applicability of results was evaluated using predictive intervals. Review was reported following the PRISMA guidelines.

Results

From 2085 articles, forty-three studies (N = 5100 patients) were included in the meta-analysis. Our findings showed that LLR had lower overall morbidity than OLR (15.59% vs. 29.88%, p < 0.001). Moreover, major morbidity was reduced in the LLR group (3.78% vs. 8.69%, p < 0.001). There were no differences between groups in terms of mortality (1.58% vs. 2.96%, p = 0.05) and both 3- and 5-year overall survival (68.97% vs. 68.12%, p = 0.41) and disease-free survival (46.57% vs. 44.84%, p = 0.46).

Conclusions

The meta-analysis showed that LLR is beneficial in terms of overall morbidity and non-procedure-specific complications. That being said, these results are based on non-randomized trials. For these reasons, we are calling for randomization in upcoming studies. Systematic review registration: PROSPERO registration number CRD42018084576.

Electronic supplementary material

The online version of this article (10.1007/s00464-018-6431-6) contains supplementary material, which is available to authorized users.

Outcomes of major laparoscopic liver resection for hepatocellular carcinoma

BACKGROUND

To compare the surgical outcomes of major laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC).

METHODS

We retrospectively reviewed the medical records of 177 patients who underwent major liver resection for HCC between January 2004 and June 2015. We divided the 177 patients into two groups according to the type of procedure: major LLR (LLR group; n = 67) and major OLR (OLR group; n = 110).

RESULTS

Procedures in the LLR group were right hepatectomy (30 patients), right posterior sectionectomy (28), left hepatectomy (11), right anterior sectionectomy (6), extended right hepatectomy (6), and central bisectionectomy (2). Tumor size was greater in the OLR group than in the LLR group (6.3 ± 3.8 vs 4.1 ± 2.4 cm; P = 0.016). The mean indocyanine green retention rate at 15 min (P = 0.698) and serum α-fetoprotein (P = 0.186) were similar in both groups. The mean operation time was longer in the LLR group (416.6 ± 166.9 vs 332.5 ± 105.4 min; P = 0.002). Blood loss (P = 0.319), transfusion rate (P = 0.260), and R0 rate (P = 0.255) were similar in both groups. Hospital stay was shorter (11.3 ± 8.3 vs. 18 ± 21.4 days; P = 0.007) and the complication rate was lower (20.5% vs. 38.7%; P = 0.005) in the LLR group. The 5-year overall survival (77.3% vs 60.2%; P = 0.087) and disease-free survival (50.8% vs 40.1%; P = 0.139) rates were comparable in both groups.

CONCLUSION

Major LLR of HCC is feasible and oncologically safe when performed by experienced surgeons. Further refinements of the surgical technique are needed to reduce operation time.

Laparoscopic right posterior sectionectomy (LRPS): surgical techniques and clinical outcomes

BACKGROUND

Right posterior sectionectomy is one of the most technically challenging laparoscopic liver resections. Currently, there is limited published data regarding the technique and results required to better understand its safety and feasibility.

AIM

To report our experience, results and techniques, highlighting a variety of tips and tricks to facilitate this resection. A video is attached for technical demonstration.

METHODS

Retrospective review of prospectively maintained databases from June 2006 to June 2016. Three different techniques were used: resection following hilar inflow control, inflow control at Rouviere's sulcus and resection with intra parenchymal control.

RESULTS

29 LRPS were performed over a 10-year period. Median operative time was 240 min (150-480). Pringle's manoeuvre was performed in 19 (65.5%) with a median total duration of 35 (20-75) min. Median perioperative blood loss was 600 (100-2500) ml. Additional liver resections were performed in 16 (55.1%). There were two(6.9%) laparoscopic to open conversions. Median postoperative hospital stay was 5 (2-30) days. The median size of the tumour resected was 25 (10-54) mm with median number of resected lesions were 2 (1-4), median free resection margin was 9.5 (1-45) mm, margins were infiltrated (R1) in two (6.7%) cases. There was one death within 30-days (3.4%).

CONCLUSION

LRPS is feasible, efficient and safe. However, it is a technically challenging procedure and requires advance skills in liver and laparoscopic surgery. Surgeons should be familiar with a variety of approaches as each offers different advantages depending on the location and nature of the lesion, surgical preference and intraoperative findings.

Prediction of surgical outcomes of laparoscopic liver resections for hepatocellular carcinoma by defining surgical difficulty

BACKGROUND

Several classification systems for assessing the surgical difficulty of laparoscopic liver resection (LLR) have been proposed. We evaluated three current classification systems, including traditional Major/Minor Classification, Complexity Classification, and the Difficulty Scoring System for predicting the surgical outcomes after LLR.

METHODS

We reviewed the clinical data of 301 patients who underwent LLR for hepatocellular carcinoma between March 1, 2004 and June 30, 2015. We compared the intraoperative, pathologic, and postoperative outcomes according to the three classifications. We also compared the prognostic value of the three classifications using receiver operating characteristic (ROC) curves.

RESULTS

The Major/Minor Classification, Complexity Classification, and the Difficulty Scoring System efficiently differentiated surgical difficulty in terms of blood loss (P = 0.001, P = 0.009, and P < 0.001, respectively) and operation time (all P < 0.001). Regarding intraoperative outcomes, the Difficulty Scoring System and Complexity Classification successfully differentiated the transfusion rate (P = 0.001 and P < 0.001, respectively). However, only the Complexity Classification adequately predicted severe postoperative complications (P = 0.032), the severity of complications (P < 0.001), and the length of hospital stay (P = 0.005). In ROC curve analysis, the Complexity Classification (area under the curve [AUC] = 0.611) outperformed the Major/Minor Classification (AUC = 0.544) and the Difficulty Scoring System (AUC = 0.530) for predicting severe postoperative complications. None of the classification systems predicted recurrence or patient survival.

CONCLUSION

The Complexity Classification was superior to the other methods for assessing surgical difficulty and predicting complications after LLR for hepatocellular carcinoma.

Meta-analysis of laparoscopic vs open liver resection for hepatocellular carcinoma

Laparoscopic liver resections (LLR) are widely accepted as safe and effective procedures for the management of hepatocellular carcinoma (HCC) in the hands of experienced surgeons. The efficacy and extent of benefits of pure as well as hand-assisted laparoscopic and laparoscopy-assisted liver resection over open liver resection (OLR) have been investigated by numerous studies during the last 10 years. The aim of our meta-analysis is to investigate the effect of LLR in short- and long-term outcomes compared to OLR in patients operated for HCC. A total of 5203 patients from forty-four studies were included in our meta-analysis reporting for short- and long-term results for both LLR and OLR for HCC. Among them, 1830 underwent pure laparoscopic hepatectomy, 282 underwent pure laparoscopic or hand-assisted laparoscopic or laparoscopy-assisted hepatectomy, and 3091 were operated through open approach. LLRs were found to be significantly associated with lower blood loss, need for blood transfusion, successful achievement of R0 resection as well as wider resection margin, shorter hospital stay, lower morbidity and 30-day mortality rates. Operative time, tumor recurrence, 1-, 3-, and 5-year overall survival as well as 1-, 3-, and 5-year disease-free survival were not found different between the groups. This meta-analysis clearly demonstrates the superiority of laparoscopic resection over the open approach for patients with small HCC.

A comparison of laparoscopic resection of posterior segments with formal laparoscopic right hepatectomy for colorectal liver metastases: a single-institution study

INTRODUCTION

The benefit of by laparoscopic resection for lesions located in postero-superior segments is unclear. The present series aimed at comparing intraoperative and post-operative results in patients undergoing either laparoscopic RPS or laparoscopic RH for colorectal liver metastases located in the right postero-superior segments.

METHODS

From 2000 to 2015, patients who underwent laparoscopic resection of segment 6 and/or 7 (RPS group) were compared with those with right hepatectomy (RH group) in terms of tumour characteristics, surgical treatment, and short-term outcomes.

RESULTS

Among the 177 selected patients, 78 (44.1 %) had laparoscopic RPS and 99 (55.9 %) a laparoscopic RH. Among RPS patients, 26 (33.3 %) underwent anatomical resection of either segment 7, 8 or both. Three (3 %) patients undergoing RH died in the post-operative course and none in the RPS group. Sixty-three (35.5 %) patients experienced post-operative complications, including major complications in 24 (13.5 %) patients. Liver failure (17.1 vs. 0 %, p = 000.1), biliary leakage (6.0 vs. 1.2 %, p = 00.1), intra-abdominal collection (19.1 vs. 2.5 %, p = 000.1), and pulmonary complication (16.1 vs. 1.2 %, p = 000.1) were significantly increased in the RH group.

CONCLUSION

The present series suggests that patients who underwent laparoscopic resection of CRLM located in the postero-superior segments developed significantly less complications than patients undergoing formal RH.

Comparison of laparoscopic liver resection for hepatocellular carcinoma located in the posterosuperior segments or anterolateral segments: A case-matched analysis

BACKGROUND

Laparoscopic liver resection is an attractive option for treating liver tumors. Laparoscopic liver resection is more difficult for hepatocellular carcinomas located in the posterosuperior segments than for hepatocellular carcinomas in the anterolateral segments. We compared perioperative and long-term outcomes between laparoscopic liver resection for hepatocellular carcinomas located in the posterosuperior and anterolateral segments.

METHODS

We retrospectively reviewed the clinical data for 230 patients who underwent laparoscopic liver resection for hepatocellular carcinomas between September 2003 and July 2014. Of these, 116 patients were selected by case-matched analysis using age, sex, tumor number and size, Child-Pugh class, and extent of liver resection. Patients were classified into 2 groups according to tumor location: the anterolateral group (n = 58) and the posterosuperior group (n = 58).

RESULTS

Operation time (355 minutes vs 212 minutes, P < .005), intraoperative blood loss (600 mL vs 410 mL, P < .001), and hospital stay (8.5 days vs 7 days, P = .040) were significantly greater in the posterosuperior group than in the anterolateral group. The open conversion (13.8% vs 10.3%, P = .777), postoperative complication (17.2% vs 10.3%, P = .420), 5-year overall survival (88.5% vs 85.7%, P = .370), and 5-year, recurrence-free survival (47.6% vs 40.9%, P = .678) rates were not significantly different between the posterosuperior and anterolateral groups.

CONCLUSION

Although laparoscopic liver resection is more difficult for hepatocellular carcinomas located in the posterosuperior segment, there were no differences in the short- and long-term outcomes between the posterosuperior and anterolateral groups. The perceived impact of tumor location on patient outcomes could be overcome by experience and technical improvements.

Current status and future perspective of laparoscopic surgery in hepatobiliary disease

Recent advances in minimally invasive surgery include laparoscopic and robotic surgery. These surgical techniques have changed the paradigm of surgical treatment for hepatobiliary diseases. Minimally invasive surgery has the advantages of minimal wound extension for cosmetic effect, early postoperative recovery, and few postoperative complications in patients. For laparoscopic liver resection, the indications have been expanded and oncological outcome was proven to be similar with open surgery in the malignant disease. Laparoscopic cholecystectomy is a classical operation for benign gallbladder diseases and the effort to decrease the surgical wound resulted to perform single incision laparoscopic cholecystectomy. For choledochal cyst, laparoscopic surgery is applied gradually despite of the difficulties associated with anastomosis, and robotic surgery for hepatobiliary disease is also performed for more minimally invasive surgery; however, while admitting the advantage of robotic surgery, robotic technology should be improved for development of more convenient and cheaper instrument and continuous efforts to enhance surgical technique to overcome long operation is necessary. In this review, the status and future perspectives of minimally invasive surgery for hepatobiliary diseases are summarized and discussed.

Laparoscopic liver resection for hepatocellular carcinoma with cirrhosis in a single institution

BACKGROUND

In a statement by the second International Consensus Conference for Laparoscopic Liver Resection (LLR), minor LLR was confirmed to be a standard surgical practice, as it has become adopted by an increasing proportion of surgeons. However, it is unclear whether this applies to the more complex group of patients suffering from cirrhosis. Therefore, the aim of this retrospective study was to compare the feasibility and safety of LLR for hepatocellular carcinoma (HCC) between non-liver cirrhosis (NLC) patients and liver cirrhosis (LC) patients at a single high-volume laparoscopy center.

METHODS

From the beginning of 2000 to the end of 2013, open liver resection (OLR) was performed in 99 HCC patients, and LLR was in 118. The HCC patients who underwent LLR were divided into NLC-LLR (n=60) and LC-LLR (n=58) groups, and we compare the short-term outcomes between them.

RESULTS

There was no significant difference in the incidence of blood loss and transfusion requirements between the NLC-LLR group and the LC-LLR group, although wedge resection was mainly performed in the LC-LLR group. There was no significant difference in the complication rate between the two groups, and the remarkable finding was that there was a significantly lower incidence of postoperative ascites in the LC-LLR group than in the NLC-LLR group.

CONCLUSIONS

According to our experience, it appears that LLR for selected HCC patients with cirrhosis is a feasible and promising procedure that is associated with less blood loss and fewer postoperative complications, especially the incidence of postoperative ascites. Further investigations are clearly warranted.

Minimally Invasive Surgery of the Liver

Operations on the liver have been undertaken for centuries for numerous indications including trauma, infections, and even for malignancy, but it was not until the past few decades that rates dramatically increased. This expanse in liver operations is due to a multitude of factors, including broader indications as well as improved safety. Our understanding of metastatic disease to the liver, especially colorectal cancer metastases, has vastly amplified the number of patients who would be candidates for hepatic resections and liver-directed therapies. We will focus our discussion here on planned minimally invasive operations for benign and malignant tumors as the majority of the literature relates to this setting.

Effects of Marsdenia tenacissima polysaccharide on the immune regulation and tumor growth in H22 tumor-bearing mice

One water-soluble polysaccharide (Marsdenia tenacissima polysaccharide, MTP), with an average molecular weight of 4.9 × 10(4) Da, was isolated from the dried rattan of M. tenacissima. MTP contained 93.8% carbohydrates, 5.6% proteins and 21.3% uronic acid, and were composed of arabinose, mannose, galactose, xylose, glucuronic acid at a molar ratio of 9.1, 17.7, 30.2, 22.4 and 20.6. The experiments on the animals showed that MTP could increase the serum hemolysin, promote the formation of antibody-forming cells and improve the phagocytosis of mononuclear macrophage in normal mice. Meanwhile, MTP could also inhibit the growth of tumor in H22 tumor-bearing mice dose-dependently, and increase the spleen index, thymus index and serum albumin level in the mice. In addition, MTP could elevate the serum level of TNF-α and IL-2, increase the activity of GSH-Px, CAT and SOD in the liver tissue, and reduce the content of VEGF and MDA. These results suggest that MTP can regulate the immune function in mice and suppress the growth of tumor in H22 tumor-bearing mice, and its antitumor activity may be related to its antioxidant and immunomodulatory effects.