Laparoscopic liver resection: when to use the laparoscopic stapler device

A Sling Technique for Laparoscopic Resection of Segment Seven of the Liver

Introduction:

As the incidence of liver cancer continues to increase in the setting of cirrhosis, parenchyma-sparing liver resection is increasingly necessary. A technique is described that involves using a sling made from 1-inch-wide packing gauze to retract and rotate the liver to divide the right triangular and coronary ligaments and mobilize segment 7. The right lobe is rotated anteriorly and counterclockwise, allowing access and parenchymal transection of segment 7 under ultrasonographic guidance.

Case Presentation:

Seven patients with tumors in segment 7 underwent resection with the technique described above: 4 had Child's A cirrhosis and hepatocellular carcinoma (HCC), 1 had metastatic colon cancer, 1 had an adenoma, and 1 had a symptomatic hemangioma. Tumor size ranged between 2.5 and 7.7 cm. Blood loss during resection was between 150 and 500 mL. No patients required transfusion as a result of surgery. With the exception of 1 patient with Clostridium difficile colitis, the average hospital stay was 3.8 days.

Management and Outcome:

Parenchyma-sparing laparoscopic resection of segment 7 is feasible and can be safely performed using a sling for intracorporal hepatic retraction, manipulation, and positioning. Given the risk of HCC recurrence, laparoscopic liver resection may also be better suited for subsequent salvage liver transplant because of less perihepatic adhesions.

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.

Short and long-term outcomes of laparoscopic compared to open liver resection for colorectal liver metastases

BACKGROUND

Minimally invasive surgery (MIS) is now established as standard of care for a variety of gastrointestinal procedures for benign and malignant indications. However, due to concerns regarding superiority to open liver resection (OLR), the uptake of laparoscopic liver resection (LLR) has been slow. Data on long-term outcomes of LLR for colorectal liver metastases (CRLM) remain limited. We conducted a systematic review and meta-analysis of short and long-term outcomes of LLR compared to OLR for CRLM.

METHODS

Five electronic databases were systematically searched for studies comparing LLR and OLR for CRLM and reporting on survival outcomes. Two reviewers independently selected studies and extracted data. Primary outcomes were overall survival (OS) and recurrence free survival (RFS). Secondary outcomes were operative time, estimated blood loss, post-operative major morbidity, mortality, length of stay (LOS), and resection margins.

RESULTS

Eight non-randomized studies (NRS) were included (n=2,017 total patients). Six were matched cohort studies. LLR reduced estimated blood loss [mean difference: -108.9; 95% confidence interval (CI), -214.0 to -3.7) and major morbidity [relative risk (RR): 0.68; 95% CI, 0.56-0.83], but not mortality. No difference was observed in operative time, LOS, resection margins, R0 resections, and recurrence. Survival data could not be pooled. No studies reported inferior survival with LLR. OS varied from 36% to 60% for LLR and 37% to 65% for OLR. RFS ranged from 14% to 30% for LLR and 22% to 38% for OLR. According to the grade classification, the strength of evidence was low to very low for all outcomes. The use of parenchymal sparing resections with LLR and OLR could not be assessed.

CONCLUSIONS

Based on limited retrospective evidence, LLR offers reduced morbidity and blood loss compared to OLR for CRLM. Comparable oncologic outcomes can be achieved. Although LLR cannot be considered as standard of care for CRLM, it is beneficial for well-selected patients and lesions. Therefore, LLR should be part of the liver surgeon's armamentarium.

Laparoscopic hepatectomy: indications and results from 18 resectable cases

OBJECTIVE

To evaluate the early and late results from laparoscopic hepatectomy procedures at a tertiary hospital in Brasília (DF), Brazil.

METHODS

The authors report on a series of 18 patients (11 women) who underwent laparoscopic hepatectomy performed by a single surgical team at Santa Lúcia Hospital, in Brasília, between June 2007 and December 2010. Age ranged from 21 to 71 years (median = 43 years). There were eleven women and seven men. Nine patients had benign diseases and nine had malignant lesions. The lesion diameter ranged from 1.8 to 12 cm (mean: 4.96 cm).

RESULTS

Six major hepatectomy procedures and 12 minor hepatectomy procedures were performed. The mean duration of the operation was 205 minutes (range: 90 to 360 minutes). The mean intraoperative blood loss was 300 mL (range: 100 to 1,500 mL). Two patients received a transfusion (11%). There was one conversion to open surgery. There was no death and no patient underwent reoperation. The postoperative morbidity rate was 11% (n = 2). One patient presented with a minor complication (lobar pneumonia) while other presented with two major complications (intraoperative bleeding and incisional hernia). The median length of hospital stay was 4 days (range: 2 to 11 days). The median time to return to normal activities was 13 days (range: 7 to 40 days).

CONCLUSION

Laparoscopic hepatectomy is a safe surgical approach for treating both benign and malignant hepatic lesions. This small series showed no mortality, low morbidity and good cosmetic results.

Segmentectomy: is minimally invasive surgery going to change a liver dogma?

Nowadays, the respective approach to hepatic resections (for malignant or benign liver lesions) is oriented toward minimal parenchymal resection. This surgical behavior is sustained by several observations that surgical margin width is not correlated with recurrence of malignancies. Parenchymal-sparing resection reduces morbidity without changing long-term results and allows the possibility of re-do liver resection in case of recurrence. Minimally invasive liver surgery (MILS) is performed worldwide and is considered a standard of care for many surgical procedures. MILS is associated with less blood loss, less analgesic requirements, and shorter length of hospital with a better quality of life. One of the more frequent criticisms to MILS is that it represents a more challenging approach for anatomical segmentectomies and that in most cases a non-anatomical resection could be performed with thinner resection margins compared with open surgery. But even in the presence of reduced surgical margins, oncological results in the short- and long-term follow-up seem to be the same such as open surgery. The purpose of this review is to try to understand whether chasing at any cost laparoscopic anatomical segmentectomies is still necessary whereas non-anatomical resections, with a parenchymal-sparing behavior, are feasible and overall recommended also in a laparoscopic approach. The message coming from this review is that MILS is opening more and more new frontiers that are still need to be supported by further experience.

What is the best technique in parenchymal transection in laparoscopic liver resection? Comprehensive review for the clinical question on the 2nd International Consensus Conference on Laparoscopic Liver Resection

The continuing evolution of technique and devices used in laparoscopic liver resection (LLR) has allowed successful application of this minimally invasive surgery for the treatment of liver disease. However, the type of instruments by energy sources and technique used vary among each institution. We reviewed the literature to seek the best technique for parenchymal transection, which was proposed as one of the important clinical question in the 2nd International Consensus Conference on LLR held on October 2014. While publications have described transection techniques used in LLR from 1991 to June 2014, it is difficult to specify the best technique and device for laparoscopic hepatic parenchymal transection, owing to a lack of randomized trials with only a small number of comparative studies. However, it is clear that instruments should be used in combination with others based on their functions and the depth of liver resection. Most authors have reported using staplers to secure and divide major vessels. Preparation for prevention of unexpected hemorrhaging particularly in liver cirrhosis, the Pringle's maneuver and prompt technique for hemostasis should be performed. We conclude that hepatobiliary surgeons should select techniques based on their familiarity with a concrete understanding of instruments and individualize to the procedure of LLR.

What kind of energy devices should be used for laparoscopic liver resection? Recommendations from a systematic review

Transection methods and hemostasis achievement have an impact on blood loss, and consequently on outcome and survival. However, no consensus exists on parenchymal transection or hemostasis techniques in laparoscopic liver resection (LLR). The aim of this review is to clarify the role of energy devices (ED) in LLR. ED is a generator of mechanic or electric energy transfer to an operating tool, used for transection, sealing or both. Searches were performed in PubMed, PubMed Central, Cochrane, Embase, Google Scholar in human or animal experimental models. Each study quality was graded following the GRADE system. From 1996 to 2014, 30 studies were found: five comparative, one prospective, two case-control, and 16 case series and some case reports, with level of evidence ranging from Moderate to Very Low. Since 2012, the Research and Development of new tools raised quicker than clinical studies could follow. The two main techniques emerged are blind transection versus sharp dissection: due to the low quality and heterogeneity of the studies, no firm conclusion can be drawn, but meticulous dissection of vessels usually never leads to vascular damage. As a matter of fact, ED, though efficient and reliable, cannot replace the basic skills of hepatic surgery: sharp dissection, vascular control and elective sealing.

Rationale and surgical technique of laparoscopic left lateral sectionectomy using endoscopic staples

Purpose

Laparoscopic left lateral sectionectomy (LLLS) has been widely accepted due to benefits of minimally invasive surgery. Some surgeons prefer to isolate glissonian pedicles to segments II and III and to control individual pedicles with surgical clips, whereas opt like to control glissonian pedicles simultaneously using endoscopic stapling devices. The aim of this study was to find the rationale of LLLS using endoscopic staples.

Methods

We retrospectively analyzed and compared the clinical outcomes (operation time, drainage length, transfusion, hospital stay, and complication rate) of 35 patients that underwent LLLS between April 2004 and February 2012. Patients were dichotomized by surgical technique based on whether glissonian pedicles were isolated and controlled (the individual group, n = 21) or controlled using endoscopic staples at once (the batch group, n = 14).

Results

Mean operation time was 265.3 ± 21.3 minutes (mean ± standard deviation) in the individual group and 170 ± 22.9 minutes in the batch group. Operation time in the batch group was significantly shorter than the individual group (P = 0.007). Mean drainage length was 4.8 ± 1.6 and 2.6 ± 1.5 days in the individual and the batch group. There was significantly shorter in the batch group, also (P = 0.006). No transfusion was required in the batch group, but 4 patients in the individual group needed transfusion. Mean hospital stay was 10.7 ± 1.1 and 9.4 ± 0.8 days in the individual and the batch groups (P = 0.460). There were no significant complications or mortality in both groups.

Conclusion

LLLS using endoscopic staples (batch group) was found to be an easier and safer technique without morbidity or mortality.

Risk factors and management of conversions to an open approach in laparoscopic liver resection: analysis of 265 consecutive cases

BACKGROUND

As a consequence of continuous technical developments in liver surgery, laparoscopic liver resection (LLR) is increasingly performed worldwide.

METHODS

Between January 2004 and December 2011, 265 LLR were performed in 242 patients for various diseases. The experience of LLR is reported focusing on risk factors of conversion and their management.

RESULTS

The overall conversion rate was 17/265 (6.4%), equally distributed over the period of the study. Statistically significant factors for conversion were found to be LLR of the postero-superior (P-S) segments (SI, SIVa; SVII; SVIII) (12.7% converted versus 2.5% non-converted groups, P = 0.01) and a major compared with a minor hepatectomy (15.2% vs. 4.6%, P = 0.02 respectively). A R0 resection was achieved in 93.2% of cases. According to Dindo's classification, complications were recorded as grade I (n = 20); grade II (6); grade III (11) and grade IV(1) events (total morbidity rate of 14%). Univariate analysis identified a major hepatectomy and resection involving P-S segments as prognostic factors for conversion whereas multivariate analysis identified the latter as an independent risk factor [P = 0.003, odds ratio (OR) = 5.9, 95% confidence interval (CI) = 1.8-18.8].

CONCLUSIONS

LLR can be safely performed with low overall morbidity. According to this experience and irrespective of the learning curve, resections of P-S segments were identified as an independent risk factor for conversion in LLR.

Real-time image guidance in laparoscopic liver surgery: first clinical experience with a guidance system based on intraoperative CT imaging

BACKGROUND

Laparoscopic liver surgery is particularly challenging owing to restricted access, risk of bleeding, and lack of haptic feedback. Navigation systems have the potential to improve information on the exact position of intrahepatic tumors, and thus facilitate oncological resection. This study aims to evaluate the feasibility of a commercially available augmented reality (AR) guidance system employing intraoperative robotic C-arm cone-beam computed tomography (CBCT) for laparoscopic liver surgery.

METHODS

A human liver-like phantom with 16 target fiducials was used to evaluate the Syngo iPilot(®) AR system. Subsequently, the system was used for the laparoscopic resection of a hepatocellular carcinoma in segment 7 of a 50-year-old male patient.

RESULTS

In the phantom experiment, the AR system showed a mean target registration error of 0.96 ± 0.52 mm, with a maximum error of 2.49 mm. The patient successfully underwent the operation and showed no postoperative complications.

CONCLUSION

The use of intraoperative CBCT and AR for laparoscopic liver resection is feasible and could be considered an option for future liver surgery in complex cases.

Evaluation of stapler hepatectomy during a laparoscopic liver resection

METHODS

An international database of 1499 laparoscopic liver resections was analysed using multivariate and Kaplan-Meier analysis.

RESULTS

In total, 764 stapler hepatectomies (SH) were compared with 735 electrosurgical resections (ER). SH was employed in larger tumours (4.5 versus 3.8 cm; P < 0.003) with decreased operative times (2.6 versus 3.1 h; P < 0.001), blood loss (100 versus 200 cc; P < 0.001) and length of stay (3.0 versus 7.0 days; P < 0.001). SH incurred a trend towards higher complications (16% versus 13%; P = 0.057) including bile leaks (26/764, 3.4% versus 16/735, 2.2%: P = 0.091). To address group homogeneity, a subset analysis of lobar resections confirmed the benefits of SH. Kaplan-Meier analysis in non-cirrhotic and cirrhotic patients confirmed equivalent patient (P = 0.290 and 0.118) and disease-free survival (P = 0.120 and 0.268). Multivariate analysis confirmed the parenchymal transection technique did not increase the risk of cancer recurrence, whereas tumour size, the presence of cirrhosis and concomitant operations did.

CONCLUSIONS

A SH provides several advantages including: diminished blood loss, transfusion requirements and shorter operative times. In spite of the smaller surgical margins in the SH group, equivalent recurrence and survival rates were observed when matched for parenchyma and extent of resection.

Adopting Gayet's Techniques of Totally Laparoscopic Liver Surgery in the United States

Professor Brice Gayet of the Institut Mutualiste Montsouris in Paris, France, has developed totally laparoscopic techniques for all segments of the liver. As a pioneer in the field of minimally invasive hepato-pancreato-biliary surgery, he started a Minimally Invasive Hepato-Pancreato-Biliary Fellowship in 2006. A retrospective review of all hepatic cases performed by a single surgeon since completing this Fellowship was undertaken. From November 2007 to October 2012, a total of 80 liver resections were done, of which 73 were begun with the intention of completing the case laparoscopically. Of these, more than 90% were completed laparoscopically and 88% were for malignant disease. One of the foundations of Professor Gayet's techniques is the low lithotomy or 'French' position and the utilization of a small robotically controlled laparoscope holder that is sterilizeable and considerably more economic than complete surgical systems. Prototypes exist of robotically controlled hand-held laparoscopic instruments that, unlike the complete surgical system, enable surgeons to maintain a sense of touch (haptics). Proper training in minimally invasive hepato-pancreato-biliary techniques can be obtained with surgeons able to independently perform laparoscopic major hepatectomies without senior minimally invasive backup. Furthermore, miniature and more affordable robotics may enable more surgeons to enjoy the benefits of minimally invasive surgery while maintaining patient safety and minimizing the rising burden of health-care costs worldwide.

Minimally invasive approaches to extrapancreatic cholangiocarcinoma

BACKGROUND

Due to the perceived difficulty in dissecting gallbladder cancers and extrapancreatic cholangiocarcinomas off of the portal structures and in performing complex biliary reconstructions, very few centers have used minimally invasive techniques to remove these tumors. Furthermore, due to the relative rarity of these tumors when compared to hepatocellular carcinoma, only a few reports have focused on short- and long-term results.

METHODS

We performed a review by combining the experience of three international centers with expertise in complex minimally invasive hepatobiliary surgery. Patients were entered into a database prospectively. All patients with gallbladder cancer and cholangiocarcinoma were analyzed; patients with distal cholangiocarcinomas who underwent laparoscopic pancreatoduodenectomies were excluded. Patients were divided according to if they had gallbladder cancer, hilar cholangiocarcinoma, or intrahepatic cholangiocarcinoma.

RESULTS

A total of 15 patients underwent laparoscopic resection for gallbladder cancer and 10 for preoperatively suspected gallbladder cancer, and 5 underwent laparoscopic completion procedures. An average of four lymph nodes (range = 1-11) were retrieved and all patients had an R0 resection. One patient (7 %) required conversion to an open procedure. No patients developed a biliary fistula, required percutaneous drainage, or had endoscopic stent placement. One patient had a recurrence at 3 months despite a negative final pathological margin, and a second patient had a distant recurrence at 20 months with a mean follow-up of 23 months. Nine patients underwent laparoscopic hepatectomy for intrahepatic cholangiocarcinoma. All anastomoses were completed laparoscopically. Biliary fistula was seen in two patients, one of which died after a transhepatic percutaneous biliary drain resulted in uncontrollable intra-abdominal hemorrhage despite reoperation. A third patient developed a pulmonary embolism. Thus, the morbidity and mortality rates were 33 and 11 %, respectively. One patient was converted to open and six patients (66 %) are alive with a median follow-up of 22 months. Five patients underwent minimally invasive resection for hilar cholangiocarcinoma; of these, two also required laparoscopic major hepatectomy. The mean estimated blood loss (EBL) was 240 mL (range = 0-400 mL) and the median length of stay (LOS) was 15 days (range = 11-21 days). All patients are alive with a median follow-up of 11 months (range = 3-18 months). None of the 29 patients developed port site recurrences.

CONCLUSION

Minimally invasive approaches to gallbladder cancer and intrahepatic and extrahepatic cholangiocarcinoma seem feasible and safe in the short term. Larger series with longer follow-up are needed to see if there are any long-term disadvantages or advantages to laparoscopic resection of extrapancreatic cholangiocarcinoma.

Current status of laparoscopic liver resection in Korea

Since laparoscopic liver resection was first introduced in 2001, Korean surgeons have chosen a laparoscopic procedure as one of the treatment options for benign or malignant liver disease. We distributed and analyzed a nationwide questionnaire to members of the Korean Laparoscopic Liver Surgery Study Group (KLLSG) in order to evaluate the current status of laparoscopic liver resection in Korea. Questionnaires were sent to 24 centers of KLLSG. The questionnaire consisted of operative procedure, histological diagnosis of liver lesions, indications for resection, causes of conversion to open surgery, and postoperative outcomes. A laparoscopic liver resection was performed in 416 patients from 2001 to 2008. Of 416 patients, 59.6% had malignant tumors, and 40.4% had benign diseases. A total laparoscopic approach was performed in 88.7%. Anatomical laparoscopic liver resection was more commonly performed than non-anatomical resection (59.9% vs 40.1%). The anatomical laparoscopic liver resection procedures consisted of a left lateral sectionectomy (29.3%), left hemihepatectomy (19.2%), right hemihepatectomy (6%), right posterior sectionectomy (4.3%), central bisectionectomy (0.5%), and caudate lobectomy (0.5%). Laparoscopy-related serious complications occurred in 12 (2.8%) patients. The present study findings provide data in terms of indication, type and method of liver resection, and current status of laparoscopic liver resection in Korea.

Initial experience with laparoscopic hepatic resection at a comprehensive cancer center

BACKGROUND

Over the past few years, surgeons have been able to obtain training in advanced minimally invasive surgery (MIS) for hepatic, pancreatic, and biliary (HPB) cases instead of having to teach themselves these complex techniques. As a result, the initial experience of a surgeon with advanced MIS HPB training at a national cancer center was reviewed.

METHODS

The experience of a surgeon with the first 50 laparoscopic hepatectomies for cancer was reviewed retrospectively. All cases begun with the intention to complete the hepatectomy laparoscopically were included in the laparoscopic group.

RESULTS

From November 2008 to October 2010, a total of 57 hepatectomies were performed, with 53 attempted laparoscopically. Of these 57 hepatectomies, 46 (87%) were completed laparoscopically, 4 (7%) required hand assistance, and 3 (6%) were converted to an open approach. Laparoscopic minor hepatectomies were performed for 28 patients and laparoscopic major hepatectomies for 25 patients. The mean operative time was 265 min, and the mean estimated blood loss was 300 ml. The mean hospital stay was 7 days. Complications occurred for six patients (11%) (2 bile leaks, 2 hemorrhages requiring conversion, 1 hernia requiring a hernia repair on postoperative day 7, and 1 ileus managed nonoperatively).

CONCLUSIONS

Surgeons with advanced MIS HPB training may be able to perform a higher percentage of their hepatectomies laparoscopically. Training in both open and laparoscopic HPB surgery is advisable before these techniques are performed.

Laparoscopic right hepatectomy with intrahepatic transection of the right bile duct

BACKGROUND

Although our earlier videos demonstrated extrahepatic control of the hepatic arterial, portal venous, and biliary system, we have begun transecting the biliary system intraparenchymally for lesions distant from hilar plate and the confluence of the right and left hepatic ducts.1 (-) 3

METHODS

The patient was a 50-year old gentleman with synchronous colorectal hepatic metastasis, who underwent 6 cycles of neoadjuvant chemotherapy with a Folfox-based regimen followed by laparoscopic right hepatectomy plus wedge resection of segment 4 and microwave ablation for a lesion in segment 2. This was followed 1 month later by laparoscopic proctocolectomy. Of note, the patient was also treated with Avastin for 1 month, which was stopped 2 months prior to his liver surgery. Pneumoperitoneum was obtained with the Veress needed; alternatively, the open technique may need to be used in patients who have undergone previous surgery. A 12-mm blunt tip balloon trocar was placed approximately 1 hand-breadth below the right costal margin. Two 12-mm working trocars were placed to the left and right of this optic trocar, and trocars were then placed in the left sub xiphoid region and in the right flank for the assistants. The right hepatic artery was triply clipped proximally and twice distally prior to being sharply transected. The right hepatic portal vein was then transected using a laparoscopic vascular GIA stapler device (TriStapler, Covidien, Norwalk, CT). The anterior surface of the liver was examined, and there was a clear line of demarcation along Cantlie's line. Using the ultrasonic shears (Harmonic Scalpel, Ethicon, Cincinnati, OH), the liver parenchyma was then transected. In the area of the right hepatic duct, the liver parenchyma was transected with a single firing of the laparoscopic GIA vascular stapler device. The right hepatic vein was then identified and similarly transected with a single firing of the laparoscopic vascular GIA stapler device. Hemostasis along the hepatic parenchyma was reinforced with the laparoscopic bipolar device. The two trocars on the right of the patient are connected into 1 incision, and a gel port is placed to facilitate removal of the specimen; alternatively, an old incision can be used. For patients who will need a laparoscopic or open colectomy, a lower midline incision is made.

RESULTS

From Jan 2009 to Oct 2010, 13 patients underwent right hepatectomy. The average age was 63.5 years (range, 46-87 years). The indication for surgery were all for cancer including 11 colorectal metastasis, 1 anal cancer metastasis, and 1 cholangiocarcinoma. In these 13 patients, 1 patient (7.7%) required conversion to an open approach because of bleeding, 1 additional patient required laparoscopic hand assistance, and the remaining patients were completed laparoscopically. There were no surgical mortalities at 30 or 90 days. Complications occurred in 2 (15%) patients, and included 1 patient who was converted to an open procedure because of hemorrhage and was complicated by a bile leak; the second patient with complication also developed a 1-bile leak, both of which responded to percutaneous treatments. The mean hospital stay was 7.7 days (range, 5-17 days). The mean operative time was 401 min (range, 220-600 min). The mean estimated blood loss was 878 cm(3) (range, 100-3,000 cm(3)). All patients underwent an R0 resection.

DISCUSSION

Laparoscopic major hepatectomy is feasible. As in open hepatectomies, intrahepatic transection of the right bile duct may be safer because there is a decreased risk of injury to the left hepatic duct.4 (,) 5 Larger series with longer-term follow-up are necessary.

Laparoscopic liver surgery: new frontiers

Laparoscopic liver resection (LHR) has shown classical advantages of minimally invasive surgery over open counterpart. In spite of introduction in early 1990's only few centres worldwide adapted LHR to routine practice. It was due to considerable technical challenges and uncertainty about oncologic outcomes. Surgical instrumentation and accumulation of surgical experience has largely enabled to solve many technical considerations. Intraoperative navigation options have also been improved. Consequently indications have been drastically expanded nearly reaching criteria equal to open liver resection in expert centres. Recent studies have verified oncologic integrity of LHR. However, mastering of LHR is still a quite demanding task limiting expansion of this patient friendly technique. This emphasizes the necessity of systematic training for laparoscopic liver surgery. This article reviews the state of the art of laparoscopic liver surgery lightening burning issues of research and clinical practice.

Video: laparoscopic right hepatectomy and partial resection of the diaphragm for liver metastases

BACKGROUND

Indications for minimally invasive major hepatectomies have been increasing as experience with these techniques grows. Invasion into the diaphragm is considered a contraindication to the laparoscopic approach. At their institution, the authors have begun approaching all tumors laparoscopically. This report presents the techniques necessary to perform right hepatectomy, partial diaphragm resection, and repair using totally laparoscopic techniques.

METHODS

Five trocars are placed in a semilunar fashion approximately one handbreadth apart along a line one handbreadth below the right subcostal margin. The hepatic inflow is taken extraparenchymally before transection of the hepatic parenchyma in an anterior-to-posterior fashion. The hepatic inflow then is transected, and the involved portion of diaphragm is transected with ultrasonic shears. Next, the diaphragm is repaired primarily and buttressed with an absorbable material to decrease the incidence of recurrent diaphragmatic hernia.

RESULTS

Laparoscopic treatment was attempted for ten patients and successfully completed for nine of these patients (90%). All 10 patients had secondary liver tumors. Three patients required concomitant partial diaphragm resection. The median estimated blood loss (EBL) was 500 ml (range, 300-3,000 ml). All margins were negative, and the average hospital stay was 8 days (range, 5-17 days). Two patients (20%) experienced complications, which consisted of biliary leaks, which were treated with percutaneous drainage. One of these patients underwent conversion to an open procedure due to an inferior vena cava injury. No mortality occurred at 30 or 90 days of follow-up evaluation.

CONCLUSION

The minimally invasive approach to secondary tumors requiring right hepatectomy is feasible and safe even when there is diaphragmatic involvement. Larger series with long-term follow-up evaluation are needed to determine whether these short-term results translate into durable benefits.

Milestones in the evolution of hepatic surgery

This paper describes the rapid evolution of modern liver surgery, starting in the middle of the twentieth century. Claude Couinaud studied and described the segmental anatomy of the liver, Thomas Starzl performed the first liver transplantations, and Henri Bismuth introduced the concept of anatomical resections. Hepatic surgery has developed significantly since those early days. To date, innovative techniques are applied, using cutting-edge technologies: Intraoperative ultrasound, techniques of vascular exclusion of the liver, new devices for performing homeostasis and dissection, laparoscopy for resections, and new drugs that allow the resection of previously unresectable tumors. The next stage in liver surgery will probably be the implementation of a multidisciplinary holistic approach to the liver-diseased patient that will ensure the best and most efficient treatments in the future.

Setorectomia posterior direita laparoscópica no tratamento dos tumores hepáticos

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

Evolution of laparoscopic left lateral sectionectomy without the Pringle maneuver: through resection of benign and malignant tumors to living liver donation

Background

Laparoscopic left lateral sectionectomy (LLS) has gained popularity in its use for benign and malignant tumors. This report describes the evolution of the authors’ experience using laparoscopic LLS for different indications including living liver donation.

Methods

Between January 2004 and January 2009, 37 consecutive patients underwent laparoscopic LLS for benign, primary, and metastatic liver diseases, and for one case of living liver donation. Resection of malignant tumors was indicated for 19 (51%) of the 37 patients.

Results

All but three patients (deceased due to metastatic cancer disease) are alive and well after a median follow-up period of 20 months (range, 8–46 months). Liver cell adenomas (72%) were the main indication among benign tumors, and colorectal liver metastases (84%) were the first indication of malignancy. One case of live liver donation was performed. Whereas 16 patients (43%) had undergone a previous abdominal surgery, 3 patients (8%) had LLS combined with bowel resection. The median operation time was of 195 min (range, 115–300 min), and the median blood loss was of 50 ml (range, 0–500 ml). Mild to severe steatosis was noted in 7 patients (19%) and aspecific portal inflammation in 11 patients (30%). A median free margin of 5 mm (range, 5–27 mm) was achieved for all cancer patients. The overall recurrence rate for colorectal liver metastases was of 44% (7 patients), but none recurred at the surgical margin. No conversion to laparotomy was recorded, and the overall morbidity rate was 8.1% (1 grade 1 and 2 grade 2 complications). The median hospital stay was 6 days (range, 2–10 days).

Conclusions

Laparoscopic LLS without portal clamping can be performed safely for cases of benign and malignant liver disease with minimal blood loss and overall morbidity, free resection margins, and a favorable outcome. As the ultimate step of the learning curve, laparoscopic LLS could be routinely proposed, potentially increasing the donor pool for living-related liver transplantation.

Vascular clamping in liver surgery: physiology, indications and techniques

This article reviews the historical evolution of hepatic vascular clamping and their indications. The anatomic basis for partial and complete vascular clamping will be discussed, as will the rationales of continuous and intermittent vascular clamping.

Specific techniques discussed and described include inflow clamping (Pringle maneuver, extra-hepatic selective clamping and intraglissonian clamping) and outflow clamping (total vascular exclusion, hepatic vascular exclusion with preservation of caval flow). The fundamental role of a low Central Venous Pressure during open and laparoscopic hepatectomy is described, as is the difference in their intra-operative measurements. The biological basis for ischemic preconditioning will be elucidated. Although the potential dangers of vascular clamping and the development of modern coagulation devices question the need for systemic clamping; the pre-operative factors and unforseen intra-operative events that mandate the use of hepatic vascular clamping will be highlighted.

Laparoscopic liver surgery

Great advances have occurred in the field of laparoscopic hepatic surgery. It is now clear that in experienced hands, the laparoscopic method of liver resection is as safe as an open procedure. The key phrase in this last sentence is "in experienced hands". The new devices that are available might make an inexperienced hepatic surgeon, well-trained in laparoscopic surgery, embark on hepatic resection without thorough knowledge of hepatic anatomy. The converse may also be true. As no criteria for credentialing of laparoscopic hepatic surgeons exist, the decision as to who is sufficiently trained to perform these procedures is left to individual hospital credentialing boards. While a certification procedure defined by leaders in this field and supported by surgical societies would be welcomed, the ability to achieve and enforce these guidelines appear to be more of a challenge. In addition, while most comparison studies in this area conclude by suggesting that a randomized, clinical trial would be needed to definitively arrive at an answer regarding the benefits of minimally invasive liver surgery compared with open surgery, it would likely be extremely difficult to accrue patients, given the data presented in articles regarding the success of laparoscopic hepatic resections. The authors conclude that an internationalregistry of all laparoscopic cases should b e established to insure patient safety and a mechanism for self-monitoring.

Laparoscopic left liver sectoriectomy of Caroli's disease limited to segment II and III

Caroli's disease is defined as a abnormal dilatation of the intra-hepatica bile ducts: Its incidence is extremely low (1 in 1,000,000 population) and in most of the cases the whole liver is interested and liver transplantation is the treatment of choice. In case of dilatation limited to the left or right lobe, liver resection can be performed. For many year the standard approach for liver resection has been a formal laparotomy by means of a large incision of abdomen that is characterized by significant post-operatie morbidity. More recently, minimally invasive, laparoscopic approach has been proposed as possible surgical technique for liver resection both for benign and malignant diseases. The main benefits of the minimally invasive approach is represented by a significant reduction of the surgical trauma that allows a faster recovery a less post-operative complications. This video shows a case of Caroli s disease occured in a 58 years old male admitted at the gastroenterology department for sudden onset of abdominal pain associated with fever (> 38 C degrees), nausea and shivering. Abdominal ultrasound demonstrated a significant dilatation of intra-hepatic left sited bile ducts with no evidences of gallbladder or common bile duct stones. Such findings were confirmed abdominal high resolution computer tomography. Laparoscopic left sectoriectomy was planned. Five trocars and 30 degrees optic was used, exploration of the abdominal cavity showed no adhesions or evidences of other diseases. In order to control blood inflow to the liver, vascular clamp was placed on the hepatic pedicle (Pringle s manouvre), Parenchymal division is carried out with a combined use of 5 mm bipolar forceps and 5 mm ultrasonic dissector. A severely dilated left hepatic duct was isolated and divided using a 45 mm endoscopic vascular stapler. Liver dissection was continued up to isolation of the main left portal branch that was then divided with a further cartridge of 45 mm vascular stapler. At his point the left liver remains attached only by the left hepatic vein: division of the triangular ligament was performed using monopolar hook and the hepatic vein isolated and the divided using vascular stapler. Haemostatis was refined by application of argon beam coagulation and no bleeding was revealed even after removal of the vascular clamp (total Pringle s time 27 minutes). Postoperative course was uneventful, minimal elevation of the liver function tests was recorded in post-operative day 1 but returned to normal at discharged on post-operative day 3.