Laparoscopic liver resection under hemihepatic vascular inflow occlusion using the lowering of hilar plate approach

Hemihepatic versus total hepatic inflow occlusion for laparoscopic hepatectomy: A randomized controlled trial

BACKGROUND

An appropriate bleeding control technique for laparoscopic liver resection (LLR) is needed to decrease intraoperative blood loss and avoid large hemorrhages. To date, hemihepatic inflow occlusion (HIO) versus total hepatic inflow occlusion (TIO) for LLR is still controversial. Thus, we performed this randomized controlled trial (ChiCTR-IOR-17013866) to compare the perioperative outcomes between HIO and TIO for LLR.

METHODS

From December 2017 to August 2019, patients met the criteria via surgical exploration in the operation room and were randomly assigned to both groups. Perioperative data between both groups were recorded and compared, and subgroup analysis was further performed.

RESULTS

258 patients were allocated to the TIO (n = 129) and HIO (n = 129) groups, respectively. There was no significant difference between the two groups in terms of intraoperative blood loss, operative time, postoperative complications, changes in postoperative liver function or early mortality. However, for patients whose transection plane was located on the liver Cantlie's plane, subgroup analysis results indicated that TIO had a shorter operative time (median, 220 vs. 240 min, P = 0.030) and occlusion time (median, 45 vs. 60 min, P = 0.011) and less intraoperative blood loss (median, 200 vs. 300 ml, P = 0.002) than HIO, whereas the morbidity and mortality of the two groups were comparable.

CONCLUSION

Both the TIO and HIO approaches could be safely performed for LLR in selected patients when performed by experienced surgeons. The TIO technique for LLR had the advantage of being easier to master than the HIO approach. Additionally, when the transection plane was located on the liver Cantlie's plane, TIO seems to have some superior perioperative outcomes.

The efficacy and safety of controlled low central venous pressure for liver resection: a systematic review and meta-analysis

Background

Application of controlled low central venous pressure (LCVP) in liver resection growing in popularity, but its efficacy and safety are still controversial. Our objectives were to assess and compare the efficacy, feasibility, and safety of controlled LCVP in patients undergoing liver resection.

Methods

The PubMed, Cochrane library, and EMBASE databases were systematically searched for all the relevant studies regardless of study design. We evaluated the methodological quality of the included studies and excluded studies of poor quality. Moreover, we applied a systematic review and meta-analysis by using RevMan 5.3 software to compare the efficacy and safety of LCVP vs. standard CVP for liver resection. Outcomes included operation time, blood loss, blood infusion, fluid infusion, urinary volume, postoperative complication rates, and hospital stay.

Results

In total, 10 studies, involving 324 patients undergoing liver resection with controlled LCVP, were identified. Meta-analysis displayed that blood loss in the LCVP group was dramatically less than that in the control group (standard CVP group, mean difference (MD): -581.68; 95% CI: -886.32 to -277.05; P=0.0002). Moreover, blood transfusion in the LCVP group was also markedly less than that in the control group (MD: -179.16; 95% CI: -282.00 to -76.33; P=0.0006). However, there was no difference between LCVP group and control group in operation time (MD: -16.24; 95% CI: -39.56 to 7.09; P=0.17), fluid infusion (MD: -287.89; 95% CI: -1,054.47 to 478.69; P=0.46), urinary volume (MD: -26.88; 95% CI: -87.14 to 33.37; P=0.38), ALT (MD: -58.66; 95% CI: -153.81 to 36.50; P=0.23), TBIL (MD: -0.32; 95% CI: -3.93 to 3.28; P=0.86), BUN (MD: -0.13; 95% CI: -0.73 to 0.47; P=0.67), CR (MD: 1.87; 95% CI: -4.90 to 8.63; P=0.59), postoperative complication rates (MD: 0.62; 95% CI: 0.44 to 0.90; P=0.01) and hospital stay (MD: -0.61; 95% CI: -1.68 to 0.46; P=0.26).

Conclusions

Compared with the control, controlled LCVP showed comparable efficacy and safety for the treatment during liver resection.

Extra-Glissonian Approach for Laparoscopic Liver Right Anterior Sectionectomy

Background:

Open right anterior sectionectomy, which involves resection of liver segments 5 and 8, has been reported to have similar postoperative mortality rates as right hepatectomy, but it has a decreased risk in developing posthepatectomy liver failure. Totally laparoscopic right anterior sectionectomy is technically demanding and has rarely been reported in hepatocellular carcinoma (HCC) patients with cirrhosis.

Methods:

Our experience in carrying out totally laparoscopic right anterior sectionectomy on four consecutive HCC patients with cirrhosis from November 2016 to August 2017 using the extraglissonian approach formed the basis of this report.

Results:

All four patients had hepatitis B–related HCC. The mean operation time was 502 ± 55 minutes. All patients underwent intermittent Pringle's Maneuver with cycles of clamp/unclamp times of 15/5 minutes for the left-sided liver transection plane, and intermittent right hemihepatic vascular inflow occlusion with cycles of clamp/unclamp times of 30/5 minutes for the right-sided liver transection plane. The mean Pringle's Maneuver time was 58.8 ± 11.4 minutes and the mean right hemihepatic vascular inflow occlusion time was 66.3 ± 11.1 minutes. The mean intraoperative blood loss was 512 ± 301 mL. No patients required any blood transfusion. There was no conversion to open surgery. Postoperative complications included intra-abdominal bleeding requiring reoperation for hemostasis (n = 1), intra-abdominal collection requiring percutaneous drainage (n = 1), and right pleural effusion requiring percutaneous drainage (n = 1). There was no 90-day postoperative mortality. The mean hospital stay was 10.7 ± 2.9 days. After a median follow-up of 10 (range, 6–16) months, one patient developed HCC recurrence in the liver remnant.

Conclusion:

Totally laparoscopic right anterior sectionectomy using the extraglissonian approach was technically feasible and safe in expert hands. More data are needed to assess the long-term oncological survival outcomes.

Does liver cirrhosis have an impact on the results of different hepatic inflow occlusion methods in laparoscopic liver resection? a propensity score analysis

BACKGROUND

Few studies have analyzed the impact of liver cirrhosis on different hepatic inflow occlusion methods in laparoscopic liver resection (LLR). Intermittent Pringle (IP) was compared to continuous hemihepatic vascular inflow occlusion (CHVIO) in LLR in patients with or without cirrhosis.

METHODS

Patients who underwent LLR at the West China Hospital of Sichuan University form January 2015 to October 2017 were grouped according to occlusion methods and severity of cirrhosis. A matched propensity score analysis was performed.

RESULTS

Among patients without cirrhosis, there were no significant differences in blood loss (238 ± 30 ml VS 265 ± 46 ml, P = 0.653), operative time (228 ± 9 min VS 265 ± 20 min, P = 0.437) or other postoperative results between the IP and CHVIO groups after propensity score matching. Among patients with cirrhosis, blood loss (279 ± 24 ml VS 396 ± 35 ml, P = 0.012) and operative time (237 ± 11 min VS 285 ± 24 min, P = 0.041) were significantly lower in the IP group, while postoperative liver function did not significantly differ between the two groups after propensity score matching.

CONCLUSIONS

In patients without cirrhosis, IP is as efficient and as safe as CHVIO in cirrhotic patients. IP offers the advantages of shorter operative time and less blood loss and does not result in worse postoperative liver function.

Laparoscopic Right Hepatectomy Via an Anterior Approach for Hepatocellular Carcinoma

Background and Objectives

In the past, right hepatectomy via the anterior approach has been regarded as one of the many standard approaches for hepatectomy. However, total laparoscopic right hepatectomy from the anterior approach has been regarded as technically challenging. We report our experience in using the anterior approach in total laparoscopic right hepatectomy for hepatocellular carcinoma (HCC).

Methods

From June 2013 through December 2015, five consecutive patients underwent total laparoscopic right hepatectomy using the anterior approach, but without the hanging maneuver.

Results

The mean operative time was 360 (range, 300-480) minutes, and the mean blood loss was 340 (110-600) mL. No patient needed any blood transfusion. There was no conversion to open surgery. Ascites, pleural effusion, and bile leakage occurred in 2, 1, and 1 patients, respectively. No patients expired as a result of the surgery or liver failure. The mean hospital stay was 7 (4-15) days. All patients had R0 resection. After a mean follow-up of 22 (8-33) months, no patients experienced recurrence of disease.

Conclusion

Total laparoscopic right hepatectomy using the anterior approach is feasible and safe.

Glissonian approach combined with major hepatic vein first for laparoscopic anatomic hepatectomy

BACKGROUND

Laparoscopic anatomic hepatectomy remains challenging because of the complex interior structures of the liver. Our novel strategy includes the Glissonian approach and the major hepatic vein first, which serves to define the external and internal landmarks for laparoscopic anatomic hepatectomy.

METHODS

Eleven cases underwent laparoscopic anatomic hepatectomy, including three right hepatectomies, three left hepatectomies, three right posterior hepatectomies, and two mesohepatectomies. The Glissonian approach was used to transect the hepatic pedicles as external demarcation. The major hepatic vein near the hepatic portal was exposed and served as the internal landmark for parenchymal transection. The liver parenchyma below and above the major hepatic vein was transected along the major hepatic vein. Fifty-nine subjects were used to compare the distance between the major hepatic vein and secondary Glisson pedicles among different liver diseases.

RESULTS

The average operative time was 327 min with an estimated blood loss of 554.55 mL. Only two patients received three units of packed red blood cells. The others recovered normally and were discharged on postoperative day 7. The distance between right posterior Glissonian pedicle and right hepatic vein was shorter in the patients with cirrhosis than that without cirrhosis, and this distance was even shorter in patients with hepatocellular carcinoma.

CONCLUSION

The Glissonian approach with the major hepatic vein first is easy and feasible for laparoscopic anatomic hepatectomy, especially in patients with hepatocellular carcinoma and cirrhosis.

Intermittent Pringle Versus Continuous Half-Pringle Maneuver for Laparoscopic Liver Resections of Tumors in Segment 7

Segment 7 is considered an unfavorable portion for laparoscopic hepatectomy because of technical difficulties in exposure and controlling bleeding. We compared intermittent Pringle with continuous half-Pringle maneuver in laparoscopic liver resections of tumors in segment 7. A retrospective analysis was conducted in a total of 36 consecutive patients with tumors in segment 7 undergoing laparoscopic liver resections between July 2011 and February 2016 (16 in the Pringle group versus 20 in the half-Pringle group). The two groups were well matched in baseline characteristics. The operative time (274.5 ± 34.3 versus 237.6 ± 41.8 min), overall declamping time (28.4 ± 8.6 versus 2.3 ± 2.5 min), and ischemic duration (69.7 ± 16.5 versus 52.7 ± 13.2 min) were significantly longer in the Pringle group (P < 0.05). The amount of intraoperative blood loss (612.5 ± 222.3 versus 417.4 ± 163.8 mL) and transfusion (335.2 ± 58.7 versus 224.8 ± 76.2 mL) was significantly greater in the Pringle group (P < 0.05). The Pringle group was associated with significantly lower postoperative albumin and higher C-reactive protein levels on postoperative days 1, 3, and 7 (P < 0.05). Laparoscopic hepatectomy for tumors in segment 7 can be performed safely and effectively with successful exposure of surgical field and proper hepatic blood flow occlusion. Continuous half-Pringle maneuver offers the advantages of less operative time and blood loss, less injury, and better recovery.

Extra-glissonian Approach for Total Laparoscopic Left Hepatectomy: A Prospective Cohort Study

Laparoscopic liver resection under hemihepatic vascular inflow control has advantages over Pringle's maneuver, especially in patients with cirrhosis. From January 2016 to August 2016, 7 patients who underwent total laparoscopic left hepatectomy under hemihepatic vascular inflow occlusion using the extra-glissonian approach were included in this study. All were hepatitis B carriers and 4 had cirrhosis. The mean operation time was 247 minutes. The mean transection time was 110 minutes. No patient needed additional Pringle's maneuver. The mean intraoperative blood loss was 74 ml and no patient required blood transfusion. No open conversion happened. Postoperatively, no patient developed complications and there was no perioperative mortality. The mean resection margin was 2 cm. The mean hospital stay was 6 days. Upon a mean follow-up of 9 months, no patient developed tumor recurrence. The technique of total laparoscopic left hepatectomy using extra-glissonian approach was safe and feasible. The early surgical outcomes were good.

Laparoscopic Pringle maneuver: how we do it?

Laparoscopic liver resection (LLR) is technically possible with new devices which allow a relatively bloodless liver parenchymal transection. Despite, the main concern remains intraoperative hemorrhage. Currently, perioperative excessive blood loss during LLR is difficult to control with necessity of laparotomy conversion. Moreover, major blood loss requires transfusion and increases postoperative morbidity and mortality. When in-flow is limited by the hepatic pedicle clamping, it reduces intraoperative blood loss. The Pringle maneuver, first described in 1908, is the simplest method of inflow occlusion and currently can be achieved during LLR. The purpose of this note was to describe two different modalities of Pringle maneuver used by two different teams during LLR.

Intermittent Pringle maneuver versus continuous hemihepatic vascular inflow occlusion using extra-glissonian approach in laparoscopic liver resection

BACKGROUND

Despite accumulated experience and advancing techniques for laparoscopic hepatectomy, bleeding remains the major concern during parenchymal transection. The vascular inflow control technique is still important to decrease intraoperative blood loss. The objective of this study was to compare intermittent Pringle with continuous hemihepatic vascular inflow occlusion using extra-glissonian approach in laparoscopic liver resection.

METHODS

Between January 2011 and January 2015, a total of 79 consecutive patients with tumors locating either in the right or in the left hemiliver were included into this retrospective study (45 in the Pringle group vs. 34 in the half-Pringle group). Preoperative clinical characteristics, intraoperative details, postoperative complications and outcomes of patients were compared.

RESULTS

The two groups were well matched according to clinical characteristics, tumor features, types of liver resection and histopathology (P > 0.05). The mean operative time (247.5 ± 61.3 vs. 221.4 ± 48.7 min, P = 0.0446), ischemic duration (62.8 ± 28.3 vs. 44.1 ± 20.5 min, P = 0.0017) and overall declamping time (21.2 ± 8.2 vs. 0.9 ± 1.9 min, P < 0.05) were significantly longer in the Pringle group than in the half-Pringle group. The mean amount of intraoperative blood loss (568.2 ± 325.1 vs. 420.7 ± 307.2 mL, P = 0.0444) and transfusion (266.1 ± 123.4 vs. 203.2 ± 144.6 mL, P = 0.0406) were significantly greater in the Pringle group. The overall operative morbidity rate was significantly higher in the Pringle group (40 vs. 17.6%, P = 0.0324). The Pringle group was associated with significantly higher alanine aminotransferase and aspartate transaminase levels on postoperative day (POD) 7 and lower albumin levels on PODs 1 and 3 (P < 0.05). The C-reactive protein levels were significantly higher in the Pringle group than in the half-Pringle group on POD 1 (37.5 ± 21.4 vs. 28.2 ± 19.0 mg/L, P = 0.0484), POD 3 (114.0 ± 53.4 vs. 90.6 ± 47.9 mg/L, P = 0.0474) and POD 7 (54.9 ± 29.8 vs. 40.1 ± 26.4 mg/L, P = 0.0245).

CONCLUSION

Continuous hemihepatic vascular inflow occlusion using extra-glissonian approach offers the advantages of less operative time and blood loss, less injury and better recovery in laparoscopic liver resection.