Lessons learned from the first 100 laparoscopic liver resections: not delaying conversion may allow reduced blood loss and operative time

Factors Associated with and Impact of Open Conversion in Laparoscopic and Robotic Minor Liver Resections: An International Multicenter Study of 10,541 Patients

INTRODUCTION

Despite the increasing widespread adoption and experience in minimally invasive liver resections (MILR), open conversion occurs not uncommonly even with minor resections and as been reported to be associated with inferior outcomes. We aimed to identify risk factors for and outcomes of open conversion in patients undergoing minor hepatectomies. We also studied the impact of approach (laparoscopic or robotic) on outcomes.

METHODS

This is a post-hoc analysis of 20,019 patients who underwent RLR and LLR across 50 international centers between 2004-2020. Risk factors for and perioperative outcomes of open conversion were analysed. Multivariate and propensity score-matched analysis were performed to control for confounding factors.

RESULTS

Finally, 10,541 patients undergoing either laparoscopic (LLR; 89.1%) or robotic (RLR; 10.9%) minor liver resections (wedge resections, segmentectomies) were included. Multivariate analysis identified LLR, earlier period of MILR, malignant pathology, cirrhosis, portal hypertension, previous abdominal surgery, larger tumor size, and posterosuperior location as significant independent predictors of open conversion. The most common reason for conversion was technical issues (44.7%), followed by bleeding (27.2%), and oncological reasons (22.3%). After propensity score matching (PSM) of baseline characteristics, patients requiring open conversion had poorer outcomes compared with successful MILR cases as evidenced by longer operative times, more blood loss, higher requirement for perioperative transfusion, longer duration of hospitalization and higher morbidity, reoperation, and 90-day mortality rates.

CONCLUSIONS

Multiple risk factors were associated with conversion of MILR even for minor hepatectomies, and open conversion was associated with significantly poorer perioperative outcomes.

Association between Unplanned Conversion and Patient Survival after Laparoscopic Liver Resection for Hepatocellular Carcinoma: A Propensity Score Matched Analysis

Unplanned conversion (UPC) is considered to be a predictor of poor postoperative outcomes. However, the effects of UPC on the survival of patients with hepatocellular carcinoma (HCC) remain controversial. The aim of this study is to compare the outcomes between patients who underwent laparoscopic liver resection (LLR) and those who underwent UPC for HCC. Among 1029 patients with HCC who underwent hepatectomy between 2004 and 2021, 251 were eligible for the study. Of 251 patients who underwent hepatectomy for HCC in PS segments, 29 (26.0%) required UPC, and 222 underwent LLR. After 1:5 PSM, 25 patients were selected for the UPC group and 125 for the LLR group. Blood loss, transfusion rate, hospital stay, and postoperative complication were higher in the UPC group. Regarding oncologic outcomes, although the 5-year overall survival rate was similar in both groups (p = 0.544), the recurrence-free survival rate was lower in the UPC group (p < 0.001). UPC was associated with poor short-term as well as inferior long-term outcomes compared with LLR for HCC in PS segments. Therefore, surgeons must carefully select patients and consider early conversion if unexpected bleeding occurs to maintain safety and oncologic outcomes.

Circumstances and implications of conversion from minimally invasive to open liver resection: a multi-center analysis from the AMILES registry

BACKGROUND

Minimally invasive approaches to liver resection (MILR) are associated with favorable outcomes. The aim of this study was to determine the implications of conversion to an open procedure on perioperative outcomes.

METHODS

Patients who underwent MILR at 10 North American institutions were identified from the Americas Minimally Invasive Liver Resection (AMILES) database. Outcomes of patients who required conversion were compared to those who did not. Additionally, outcomes after conversion due to unfavorable findings (poor visualization/access, lack of progress, disease extent) versus intraoperative events (bleeding, injury, cardiopulmonary instability) were compared.

RESULTS

Of 1675 patients who underwent MILR, 102 (6.1%) required conversion. Conversion rate ranged from 4.4% for left lateral sectionectomy to 10% for right hepatectomy. The primary reason for conversion was unfavorable findings in 67 patients (66%) and intraoperative adverse events in 35 patients (34%). By multivariable analysis, major resection, cirrhosis, prior liver surgery, and tumor proximity to major vessels were identified as risk factors for conversion (p < 0.05). Patients who required conversion had higher blood loss, transfusion requirements, operative time, and length of stay, (p < 0.05). They also had higher major complication rates (23% vs. 5.2%, p < 0.001) and 30-day mortality (8.8% vs. 1.3%, p < 0.001). When compared to those who required conversion due to unfavorable findings, patients who required conversion due to intraoperative adverse events had significantly higher major complication rates (43% vs. 14%, p = 0.012) and 30-day mortality (20% vs. 3.0%, p = 0.007).

CONCLUSIONS

Conversion from MILR to open surgery is associated with increased perioperative morbidity and mortality. Conversion due to intraoperative adverse events is rare but associated with significantly higher complication and mortality rates, while conversion due to unfavorable findings is associated with similar outcomes as planned open resection. High-risk patients may benefit from early conversion in a controlled fashion if difficulties are encountered or anticipated.

Risk Factors and Outcomes of Open Conversion During Minimally Invasive Major Hepatectomies: An International Multicenter Study on 3880 Procedures Comparing the Laparoscopic and Robotic Approaches

INTRODUCTION

Despite the advances in minimally invasive (MI) liver surgery, most major hepatectomies (MHs) continue to be performed by open surgery. This study aimed to evaluate the risk factors and outcomes of open conversion during MI MH, including the impact of the type of approach (laparoscopic vs. robotic) on the occurrence and outcomes of conversions.

METHODS

Data on 3880 MI conventional and technical (right anterior and posterior sectionectomies) MHs were retrospectively collected. Risk factors and perioperative outcomes of open conversion were analyzed. Multivariate analysis, propensity score matching, and inverse probability treatment weighting analysis were performed to control for confounding factors.

RESULTS

Overall, 3211 laparoscopic MHs (LMHs) and 669 robotic MHs (RMHs) were included, of which 399 (10.28%) had an open conversion. Multivariate analyses demonstrated that male sex, laparoscopic approach, cirrhosis, previous abdominal surgery, concomitant other surgery, American Society of Anesthesiologists (ASA) score 3/4, larger tumor size, conventional MH, and Institut Mutualiste Montsouris classification III procedures were associated with an increased risk of conversion. After matching, patients requiring open conversion had poorer outcomes compared with non-converted cases, as evidenced by the increased operation time, blood transfusion rate, blood loss, hospital stay, postoperative morbidity/major morbidity and 30/90-day mortality. Although RMH showed a decreased risk of conversion compared with LMH, converted RMH showed increased blood loss, blood transfusion rate, postoperative major morbidity and 30/90-day mortality compared with converted LMH.

CONCLUSIONS

Multiple risk factors are associated with conversion. Converted cases, especially those due to intraoperative bleeding, have unfavorable outcomes. Robotic assistance seemed to increase the feasibility of the MI approach, but converted robotic procedures showed inferior outcomes compared with converted laparoscopic procedures.

Conversion of Minimally Invasive Liver Resection for HCC in Advanced Cirrhosis: Clinical Impact and Role of Difficulty Scoring Systems

BACKGROUND

Minimally invasive liver resections (MILRs) in cirrhosis are at risk of conversion since cirrhosis and complexity, which can be estimated by scoring systems, are both independent factors for. We aimed to investigate the consequence of conversion of MILR for hepatocellular carcinoma in advanced cirrhosis.

METHODS

After retrospective review, MILRs for HCC were divided into preserved liver function (Cohort-A) and advanced cirrhosis cohorts (Cohort-B). Completed and converted MILRs were compared (Compl-A vs. Conv-A and Compl-B vs. Conv-B); then, converted patients were compared (Conv-A vs. Conv-B) as whole cohorts and after stratification for MILR difficulty using Iwate criteria.

RESULTS

637 MILRs were studied (474 Cohort-A, 163 Cohort-B). Conv-A MILRs had worse outcomes than Compl-A: more blood loss; higher incidence of transfusions, morbidity, grade 2 complications, ascites, liver failure and longer hospitalization. Conv-B MILRs exhibited the same worse perioperative outcomes than Compl-B and also higher incidence of grade 1 complications. Conv-A and Conv-B outcomes of low difficulty MILRs resulted in similar perioperative outcomes, whereas the comparison of more difficult converted MILRs (intermediate/advanced/expert) resulted in several worse perioperative outcomes for patients with advanced cirrhosis. However, Conv-A and Conv-B outcomes were not significantly different in the whole cohort where "advanced/expert" MILRs were 33.1% and 5.5% in Cohort A and B.

CONCLUSIONS

Conversion in the setting of advanced cirrhosis can be associated with non-inferior outcomes compared to compensated cirrhosis, provided careful patient selection is applied (patients elected to low difficulty MILRs). Difficulty scoring systems may help in identifying the most appropriate candidates.

The risk factors of intraoperative conversion during laparoscopic hepatectomy: a systematic review and meta-analysis

PURPOSE

Intraoperative conversion to laparotomy is a challenge during laparoscopic hepatectomy; however, the risk factors of conversion have been poorly elucidated.

METHODS

In this systematic review and meta-analysis, we computed pooled odds ratios (ORs) with 95% confidence intervals (CIs) for each risk factor and evaluated heterogeneity using a L'Abbe plot, Galbraith radial plot, Cochran's Q test, and I². An extended funnel plot was used to evaluate the robustness of the results of meta-analysis. Sensitivity analysis and subgroup analysis were performed to determine sources of heterogeneity. Egger's test and Begg's test were used to assess publication bias.

RESULTS

A total of 25 eligible studies were enrolled in the meta-analysis. Higher body mass index (OR 1.346, 95% CI 1.055-1.717), hypertension (OR 1.387, 95% CI 1.100-1.749), male sex (OR 1.278, 95% CI 1.072-1.523), cirrhosis (OR 1.378, 95% CI 1.062-1.788), major resection (OR 2.041, 95% CI 1.748-2.382), posterosuperior tumor location (OR 2.420, 95% CI 1.923-3.044), and larger tumor diameter (OR 1.618, 95% CI 1.270-2.061) were found to be significantly related to intraoperative conversion during laparoscopic hepatectomy. Malignant tumor (OR 1.253, 95% CI 0.970-1.619), higher American Society of Anesthesiologists stage (OR 1.186, 95% CI 0.863-1.631), multiple tumors (OR 1.273, 95% CI 0.866-1.871), and abdominal surgery history (OR 1.236, 95% CI 0.589-2.597) were not associated with conversion. A history of abdominal surgery showed significant heterogeneity with an I² of 80.8% (p < 0.001). Subgroup analysis indicated that heterogeneity was caused by the different number of patients among enrolled studies.

CONCLUSIONS

In this systematic review and meta-analysis, we identified a number of factors associated with intraoperative conversion during laparoscopic hepatectomy. Our findings can help patient risk evaluation to reduce the laparotomy conversion rate in laparoscopic hepatectomy.

Risk factors and long-term implications of unplanned conversion during laparoscopic liver resection for hepatocellular carcinoma located in anterolateral liver segments

PURPOSE

The impact of conversion on perioperative and long-term oncologic outcomes is controversial. Thus, we compared these outcomes between laparoscopic (Lap), unplanned conversion (Conversion), and planned open (Open) liver resection for hepatocellular carcinoma (HCC) located in anterolateral (AL) liver segments and aimed to identify risk factors for unplanned conversion.

METHODS

We retrospectively studied 374 patients (Lap, 299; Open, 62; Conversion, 13) who underwent liver resection for HCC located in AL segments between 2004 and 2018.

RESULTS

Compared to the Lap group, the Conversion group showed greater values for operation time (p < 0.001), blood loss (p = 0.021), transfusion rate (p = 0.009), postoperative complication rate (p = 0.008), and hospital stay (p = 0.040), with a lower R0 resection rate (p < 0.001) and disease-free survival (p = 0.001). Compared with the Open group, the Conversion group had a longer operation time (p = 0.012) and greater blood loss (p = 0.024). Risk factors for unplanned conversion were large tumor size (odds ratio [OR], 1.35; 95% confidence interval [CI], 1.05-1.74; p = 0.020), multiple tumors (OR, 5.95; 95% CI, 1.45-24.39; p = 0.013), and other organ invasion (OR, 15.32; 95% CI, 1.80-130.59; p = 0.013).

CONCLUSION

In conclusion, patients who experienced unplanned conversion during LLR for HCC located in AL segments showed poor perioperative and long-term outcomes compared to those who underwent planned laparoscopic and open liver resection. Therefore, open liver resection should be considered in patients with risk factors for unplanned conversion.

How to minimize conversion to open surgery during laparoscopic liver resection: the point of view of hemostasis

It has been 30 years since laparoscopic liver resection was first introduced, and, in the beginning, wedge resection or nonanatomical liver resection was mainly performed. With the development of surgical techniques and instruments, many centers are currently performing major liver resections and even difficult anatomical liver resections such as segment VI, VII, and VIII and caudate segment. However, laparoscopic surgery has limitations in instrument manipulation, and due to the nature of liver resection surgery, massive bleeding may occur. Therefore, it is necessary to make efforts to minimize the bleeding and reduce the conversion to laparotomy due to bleeding.

Evolution and trends in the adoption of laparoscopic liver resection in Singapore: Analysis of 300 cases

ABSTRACT Introduction: The introduction of laparoscopic surgery has changed abdominal surgery. We evaluated the evolution and changing trends associated with adoption of laparoscopic liver resection (LLR) and the experience of a surgeon without prior LLR experience. Methods: A retrospective review of 310 patients who underwent LLR performed by a single surgeon from 2011 to 2020 was conducted. Exclusion criteria were patients who underwent laparoscopic liver surgeries such as excision biopsy, local ablation, drainage of abscesses and deroofing of liver cysts. There were 300 cases and the cohort was divided into 5 groups of 60 patients. Results: There were 288 patients who underwent a totally minimally invasive approach, including 28 robotic-assisted procedures. Open conversion occurred for 13 (4.3%) patients; the conversion rate decreased significantly from 10% in the initial period to 3.3% subsequently. There were 83 (27.7%) major resections and 131 (43.7%) resections were performed for tumours in the difficult posterosuperior location. There were 152 (50.7%) patients with previous abdominal surgery, including 52 (17.3%) repeat liver resections for recurrent tumours, and 60 patients had other concomitant operations. According to the Iwate criteria, 135 (44.7%) were graded as high/expert difficulty. Major morbidity (>grade 3a) occurred in 12 (4.0%) patients and there was no 30-day mortality. Comparison across the 5 patient groups demonstrated a significant trend towards older patients, higher American Society of Anesthesiologists (ASA) score, increasing frequency of LLR with previous abdominal surgery, increasing frequency of portal hypertension and huge tumours, decreasing blood loss and decreasing transfusion rate across the study period. Surgeon experience (≤60 cases) and Institut Mutualiste Montsouris (IMM) high grade resections were independent predictors of open conversion. Open conversion was associated with worse perioperative outcomes such as increased blood loss, transfusion rate, morbidity and length of stay. Conclusion: LLR can be safely adopted for resections of all difficulty grades, including major resections and for tumours located in the difficult posterosuperior segments, with a low open conversion rate. Keywords: Laparoscopic hepatectomy, laparoscopic liver resection, robotic hepatectomy, robotic liver resection, Singapore

The learning curve of laparoscopic liver resection utilising a difficulty score

BACKGROUND

This study aimed to quantitatively evaluate the learning curve of laparoscopic liver resection (LLR) of a single surgeon.

PATIENTS AND METHODS

A retrospective review of a prospectively maintained database of liver resections was conducted. 171 patients undergoing pure LLRs between April 2008 and April 2021 were analysed. The Halls difficulty score (HDS) for theoretical predictions of intraoperative complications (IOC) during LLR was applied. IOC was defined as blood loss over 775 mL, unintentional damage to the surrounding structures, and conversion to an open approach. Theoretical association between HDS and the predicted probability of IOC was utilised to objectify the shape of the learning curve.

RESULTS

The obtained learning curve has resulted from thirteen years of surgical effort of a single surgeon. It consists of an absolute and a relative part in the mathematical description of the additive function described by the logarithmic function (absolute complexity) and fifth-degree regression curve (relative complexity). The obtained learning curve determines the functional dependency of the learning outcome versus time and indicates several local extreme values (peaks and valleys) in the learning process until proficiency is achieved.

CONCLUSIONS

This learning curve indicates an ongoing learning process for LLR. The proposed mathematical model can be applied for any surgical procedure with an existing difficulty score and a known theoretically predicted association between the difficulty score and given outcome (for example, IOC).

Body mass index and surgical outcomes in laparoscopic liver resections: a systematic review

BACKGROUND

Laparoscopic liver resection is gaining momentum; however, there is limited evidence on its efficacy and safety in obese patients. The aim of this study was to examine the relationship between BMI and outcomes after laparoscopic liver resection (LLR) using a systematic review of the existing literature.

METHODS

A systematic search of Medline (Ovid 1946-present), PubMed (NCBI), Embase (Ovid 1966-present) and Cochrane Library was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for parameters of LLR and BMI. Operative, post-operative and oncological outcomes were recorded.

RESULTS

Of 1460 abstracts, seven retrospective studies were analysed, published between 2015 and 2017 (study periods 1998-2017). Total patient cohort were classified as 481 obese and 1180 non-obese with a median age range of 42.5-69.4 years. Variations existed in definitions of obesity (Asia BMI >25 kg/m² , Western BMI >30 kg/m² ). Rates of conversion were examined in four studies (0-31%) with one reporting BMI >28 kg/m² as an independent risk factor. Estimated blood loss and transfusion rates were similar. Operative time was increased in obese patients in one study (P = 0.02). Mortality rates ranged from 0% to 4.3% with no difference between BMI classes. No difference in major morbidity was demonstrated. Bile leak rates were increased in obese groups in one study (0-3.44%, P < 0.05). Wound infections were reported in five studies, with higher rates in obese patients (0-5.8% versus 0-1.9%). Tumour size was comparable in both groups. Completeness of resection was analysed in four studies with one study reporting increased R0 rates in obese patients (P = 0.012).

CONCLUSION

This systematic review highlights that current evidence shows LLR in obese patients is safe, however, further studies are required.

Predicting the Risk of Postoperative Complications in Patients Undergoing Minimally Invasive Resection of Primary Liver Tumors

Minimal-invasive techniques are increasingly applied in clinical practice and have contributed towards improving postoperative outcomes. While comparing favorably with open surgery in terms of safety, the occurrence of severe complications remains a grave concern. To date, no objective predictive system has been established to guide clinicians in estimating complication risks as the relative contribution of general patient health, liver function and surgical parameters remain unclear. Here, we perform a single-center analysis of all consecutive patients undergoing laparoscopic liver resection for primary hepatic malignancies since 2010. Among the 210 patients identified, 32 developed major complications. Several independent predictors were identified through a multivariate analysis, defining a preoperative model: diabetes, history of previous hepatectomy, surgical approach, alanine aminotransferase levels and lesion entity. The addition of operative time and whether conversion was required significantly improved predictions and were thus incorporated into the postoperative model. Both models were able to identify patients with major complications with acceptable performance (area under the receiver-operating characteristic curve (AUC) for a preoperative model = 0.77 vs. postoperative model = 0.80). Internal validation was performed and confirmed the discriminatory ability of the models. An easily accessible online tool was deployed in order to estimate probabilities of severe complication without the need for manual calculation.

Pure laparoscopic right hepatectomy: A risk score for conversion for the paradigm of difficult laparoscopic liver resections. A single centre case series

BACKGROUND

Converted laparoscopic hepatectomies are known to lose some advantages of the minimally-invasiveness, and factors are identified to predict patients at risk. Specific evidence for laparoscopic right hepatectomy is expected of usefulness in clinical practice, given its technical peculiarities. The purpose of the study was the identification of risk factors and the development of a risk score for conversion of laparoscopic right hepatectomy.

MATERIALS AND METHODS

Laparoscopic right hepatectomy performed at a single hepatobiliary surgical center were analyzed. The cohort was split in half to obtain a derivation and a validation set. Risk factors for conversion were identified by uni- and multivariable analysis. A "conversion risk score" was built assigning each factor 1 point and comparing the score with the conversion status for each patient. The accuracy was assessed by the area-under-the-receiver-operator-characteristic-curve.

RESULTS

Among 130 operations, 22 were converted (16.9%). Reasons were: 45.5% oncologic inadequacy, 31.8% bleeding, 9.1% adhesions, 9.1% biliostasis, 4.5% anaesthesiological problems. Independent risk factors for conversion were: previous laparoscopic liver surgery (Hazard Ratio 4.9, p 0.011), preoperative chemotherapy ( Hazard Ratio 6.2, p 0.031), malignant diagnosis (Hazard Ratio 3.3, p 0.037), closeness to hepatocaval confluence or inferior vena cava (Hazard Ratio 4.1, p 0.029), tumor volume (Hazard Ratio 2.9, p 0.024). Conversion rates correlated positively with the score, raising from 0 to 100% when the score increased from 0 to 5 (Spearman: p 0.032 in the derivation set, p 0.020 in the validation set). The risk of conversion showed a sharp increase passing from class 3 to 4, reaching a probability estimated between 60 and 71.4%. The score showed good accuracy (area-under-the-receiver-operator-characteristic-curve 0.82).

CONCLUSION

Specific risk factors for conversion are identified for laparoscopic right hepatectomy. This score may help in standardizing the choice of a pure laparoscopic or open approach for such challenging resections.

Liver resection in Cirrhotic liver: Are there any limits?

Liver resection remains one of the most technically challenging surgical procedure in abdominal surgery due to the complex anatomical arrangement in the liver and its rich blood supply that constitutes about 20% of the cardiac output per cycle. The challenge for resection in cirrhotic livers is even higher because of the impact of surgical stress and trauma imposed on borderline liver function and the impaired ability for liver regeneration in cirrhotic livers. Nonetheless, evolution and advancement in surgical techniques as well as knowledge in perioperative management of liver resection has led to a substantial improvement in surgical outcome in recent decade. The objective of this article was to provide updated information on the recent developments in liver surgery, from preoperative evaluation, to technicality of resection, future liver remnant augmentation and finally, postoperative management of complications.

Unplanned conversion during minimally invasive liver resection for hepatocellular carcinoma: risk factors and surgical outcomes

Purpose

Unplanned conversion is sometimes necessary during minimally invasive liver resection (MILR) of hepatocellular carcinoma (HCC). The aims of this study were to compare surgical outcomes of planned MILR and unplanned conversion and to investigate the risk factors after unplanned conversion.

Methods

We retrospectively analyzed 286 patients who underwent MILR with HCC from January 2006 to December 2017. All patients were divided into a MILR group and an unplanned conversion group. The clinicopathologic characteristics and outcomes were compared between the 2 groups. In addition, surgical outcomes in the conversion group were compared with the planned open surgery group (n = 505). Risk factors for unplanned conversion were analyzed.

Results

Of the 286 patients who underwent MILR, 18 patients (6.7%) had unplanned conversion during surgery. The unplanned conversion group showed statistically more blood loss, higher transfusion rate and postoperative complication rate, and longer hospital stay compared to the MILR group, whereas no such difference was observed in comparison with the planned open surgery group. There were no significant differences in overall and disease-free survival among 3 groups. The right-sided sectionectomy (right anterior and posterior sectionectomy), central bisectionectomy and tumor size were risk factors of unplanned conversion.

Conclusion

Unplanned conversion during MILR for HCC was associated with poor perioperative outcomes, but it did not affect long-term oncologic outcomes in our study. In addition, when planning right-sided sectionectomy or central bisectionectomy for a large tumor (more than 5 cm), we should recommend open surgery or MILR with an informed consent for unplanned open conversions.

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.

Improving Outcomes Defending Patient Safety: The Learning Journey in Robotic Liver Resections

Background

While laparoscopy is currently adopted for hepatic resections, robotic approaches to the liver have not gained wide acceptance. We decided to analyze the learning curve in the field of robotic liver surgery comparing short-term outcomes between the first and the second half of our series.

Methods

We retrospectively reviewed demographics and clinical data of patients who underwent robotic liver resection at our institution from July 2014 through September 2017. 60 patients diagnosed with primary or secondary liver neoplasms or hydatid disease were included in this study. ASA PS >3, heart failure, respiratory insufficiency, and general contraindication to pneumoperitoneum were exclusion criteria.

Results

60 patients were included. We observed a statistically significant decrease in operative time (p<0.001), intraoperative blood loss (p=0.01), and postoperative complications (p<0.001) after 30 cases. From the interpretation of the CUSUM curve, the time of operation appears to be significantly reduced after the first 30 operations.

Discussion

This is the first European analysis of the learning curve for robotic liver resection in an HPB and liver transplant referral center. However, more studies are needed to confirm such results outside a HPB referral center. This is crucial to develop formal credentialing protocols for both junior and senior surgeons.

Low conversion rate during minimally invasive major hepatectomy: Ten-year experience at a high-volume center

BACKGROUND

Minimally invasive approaches for major hepatectomy have been marred by significant rates of conversion and associated morbidity. This study aimed to determine risk factors for conversion as well as postoperative morbidity in patients undergoing minimally invasive right-sided hepatectomy (MIRH).

METHODS

Data for patients undergoing MIRH between 2008 and 2017 at Emory University were reviewed. Risk factors for conversion were determined using multivariate regression analysis. Outcomes of conversion patients were compared with those who underwent successful MIRH or elective open surgery.

RESULTS

Unplanned conversion occurred in 7 (6.25%) of 112 patients undergoing MIRH. Primary reason for conversion was difficult dissection secondary to inflammation and severe adhesions. No preoperative clinical factor was identified that predicted conversions. Converted cases had higher EBL and pRBC transfusion compared to non-converted cases however morbidity was similar to those undergoing primary open surgery.

CONCLUSION

Difficult dissection and adhesions remained the only clinically applicable parameter leading to unplanned conversions. While these did offset benefits of a successful minimally invasive approach, it did not increase risk of postoperative complications compared with planned open surgery.

Changing trends and outcomes associated with the adoption of minimally invasive hepatectomy: a contemporary single-institution experience with 400 consecutive resections

BACKGROUND

Several studies published mainly from pioneers and early adopters have documented the evolution of minimally invasive hepatectomy (MIH). However, questions remain if these reported experiences are applicable and reproducible today. This study examines the changing trends, safety, and outcomes associated with the adoption of MIH based on a contemporary single-institution experience.

METHODS

This is a retrospective review of 400 consecutive patients who underwent MIH between 2006 and 2017 of which 360 cases (90%) were performed since 2012. To determine the evolution of MIH, the study population was stratified into four equal groups of 100 patients. Analyses were also performed of predictive factors and outcomes of open conversion.

RESULTS

Four hundred patients underwent MIH of which 379 (94.8%) were totally laparoscopic/robotic. Eighty-eight (22.0%) patients underwent major hepatectomy and 160 (40.0%) had resection of tumors located in the posterosuperior segments. There were 38 (9.5%) open conversions. Comparison across the four groups demonstrated that patients were older, had higher ASA score, and had increased frequency of previous abdominal surgery and repeat liver resections. There was also an increase in the proportion of patients who underwent totally laparoscopic/robotic surgery, major liver resection, resection of ≥ 3 segments, and multiple resections. Comparison of outcomes demonstrated that there was a significant decrease in open conversion rate, longer operation time, and increased use of Pringles maneuver. The presence of cirrhosis and institution experience (1st 100 cases) were independent predictors of open conversion. Patients who required open conversion had significantly increased operation time, blood loss, blood transfusion rate, morbidity, and mortality.

CONCLUSION

The case volume of MIH performed increased rapidly at our institution over time. Although the indications of MIH expanded to include higher risk patients and more complex hepatectomies, there was a decrease in open conversion rate and no change in other perioperative outcomes.

Development and validation of a difficulty score to predict intraoperative complications during laparoscopic liver resection

Background

Previous studies have demonstrated that patient, surgical, tumour and operative variables affect the complexity of laparoscopic liver resections. However, current difficulty scoring systems address only tumour factors. The aim of this study was to develop and validate a predictive model for the risk of intraoperative complications during laparoscopic liver resections.

Methods

The prospectively maintained databases of seven European tertiary referral liver centres were compiled. Data from two-thirds of the patients were used for development and one-third for validation of the model. Intraoperative complications were based on a modified Satava classification. Using the methodology of the Framingham Heart Study, developed to identify risk factors that contribute to the development of cardiovascular disease, factors found to predict intraoperative complications independently were assigned points, and grouped into low-, moderate-, high- and extremely high-risk groups based on the likelihood of intraoperative complications.

Results

A total of 2856 patients were included. Neoadjuvant chemotherapy, lesion type and size, classification of resection and previous open liver resection were found to be independent predictors of intraoperative complications. Patients with intraoperative complications had a longer duration of hospital stay (5 versus 4 days; P &lt; 0·001), higher complication rates (32·5 versus 15·5 per cent; P &lt; 0·001), and higher 30-day (3·0 versus 0·3 per cent; P &lt; 0·001) and 90-day (3·8 versus 0·8 per cent; P &lt; 0·001) mortality rates than those who did not. The model was able to predict intraoperative complications (area under the receiver operating characteristic (ROC) curve (AUC) 0·677, 95 per cent c.i. 0·647 to 0·706) as well as postoperative 90-day mortality (AUC 0·769, 0·681 to 0·858).

Conclusion

This comprehensive scoring system, based on patient, surgical and tumour factors, and developed and validated using a large multicentre European database, helped estimate the risk of intraoperative complications.

Are the current difficulty scores for laparoscopic liver surgery telling the whole story? An international survey and recommendations for the future

BACKGROUND

Recent studies have suggested that the difficulty of laparoscopic liver resections are related to both patient and tumour factors, however the available difficulty scoring systems only incorporate tumour factors. The aim of this study was to assess the opinion of laparoscopic liver surgeons regarding the factors that affect the perceived difficulty of laparoscopic liver resections.

METHOD

Using a Visual Analogue Scale an international survey of laparoscopic liver surgeons was undertaken to assess the perceived difficulty of 26 factors previously demonstrated to affect the difficulty of a laparoscopic liver resection.

RESULTS

80 surgeons with a combined experience of over 7000 laparoscopic liver resections responded to the survey. The difficulty of laparoscopic liver surgery was suggested to be increased by a BMI > 35 by 89% of respondents; neo-adjuvant chemotherapy by 79%; repeated liver resection by 99% and concurrent procedures by 59% however these factors have not been included in the previous difficulty scoring systems.

CONCLUSION

The results suggests that the difficulty of laparoscopic liver surgery is not fully assessed by the available difficulty scoring systems and prompts the development of a new difficulty score that incorporates all factors believed to increase difficulty.

Minimally invasive hepatectomy conversions: an analysis of risk factors and outcomes

BACKGROUND

Surgical approach may influence morbidity following hepatectomy. This study sought to compare outcomes in minimally invasive surgery (MIS), conversion from MIS to open, and planned open hepatectomy patients and analyze factors leading to conversion.

METHODS

The 2014 National Surgical Quality Improvement Program dataset was queried for patients undergoing hepatectomy. Patients were divided into three cohorts: MIS, open, or conversion. Propensity matching was performed to compare MIS vs. conversion (3:1) and open vs. conversion (8:1). The logistic regression model was used to identify odds ratios for conversion.

RESULTS

Patients undergoing conversion had a higher transfusion rate (26% vs. 9%, p < 0.001), longer length of stay (5 vs. 3 days, p < 0.001), and higher morbidity (38% vs. 18%, p < 0.001) than MIS patients. Patients who underwent conversion had similar short-term outcomes to those who had planned open procedures. Independent predictors of conversion included hypertension (OR 1.91; 95% CI 1.12-3.26) and right lobectomy (OR 20.23; 95% CI 3.74-109.35).

CONCLUSION

Patients with hypertension and those undergoing right lobectomy had a higher risk of conversion to open procedure. Conversion resulted in higher morbidity and longer length of stay compared to MIS patients, but outcomes were similar to planned open procedures.

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.

Early experience with robot-assisted laparoscopic hepatobiliary and pancreatic surgery in Singapore: single-institution experience with 20 consecutive patients

INTRODUCTION

Experience with robot-assisted laparoscopic (RAL) hepatobiliary and pancreatic (HPB) surgery remains limited worldwide. In this study, we report our early experience with RAL HPB surgery in Singapore.

METHODS

A retrospective review of the first 20 consecutive patients who underwent RAL HPB surgery at a single institution over a 34-month period from February 2013 to November 2015 was conducted. The 20 cases were performed by three principal surgeons, of which 17 (85.0%) were performed by a single surgeon.

RESULTS

The median age of patients was 56 (range 22-75) years and median tumour size was 4.0 (range 1.2-7.5) cm. The surgeries performed included left-sided pancreatectomies (n = 10), hepatectomies (n = 7), triple bypass with bile duct exploration for obstructing pancreatic head cancer with choledocholithiasis (n = 1), cholecystectomy for Mirizzi's syndrome (n = 1) and gastric resection for gastrointestinal stromal tumour (n = 1). The median operation time was 445 (range 80-825) minutes and median blood loss was 350 (range 0-1,200) mL. There was only 1 (5%) open conversion. There were 2 (10.0%) major morbidities (> Grade II on the Clavien-Dindo classification) and no 30-day/in-hospital mortalities. There was no reoperation for postoperative complications. The median postoperative stay was 5.5 (range 3-22) days.

CONCLUSION

Our initial experience confirms the feasibility and safety of RAL HPB surgery.

Laparoscopic versus robotic surgery for hepatocellular carcinoma: the first 46 consecutive cases

BACKGROUND

Hepatocellular carcinoma has a growing incidence worldwide, and represents a leading cause of death in patients with cirrhosis. Nowadays, minimally invasive approaches are spreading in every field of surgery and in liver surgery as well.

MATERIALS AND METHODS

We retrospectively reviewed demographics, clinical, and pathologic characteristics and short-term outcomes of patients who had undergone minimally invasive resections for hepatocellular carcinoma at our institution between June 2012 and May 2016.

RESULTS

No significant differences in demographics and comorbidities were found between patients in the laparoscopic (n = 24) and robotic (n = 22) groups, except for the rates of cirrhotic patients (91.7% and 68.2%, respectively, P = 0.046). Perioperative data analysis showed that the operative time (mean, 211 and 318 min, respectively, P < 0.001) was the only parameter in favor of laparoscopy. Conversely, robotic-assisted resections were related to less Clavien I-II postoperative complications (22 cases versus 13 cases; P = 0.03). As regards resection margins, the two groups were similar with no statistically significant differences in rates of disease-free resection margins.

CONCLUSIONS

A modern hepatobiliary center should offer both open and minimally invasive approaches to liver disease to provide the best care for each patient, according to the individual comorbidities, risk factors, and personal quality of life expectations. Our results show that the robotic approach is a reliable tool for accurate oncologic surgery, comparable to the laparoscopic approach. Robotic surgery also allows the surgeon to safely approach liver segments that are difficult to resect in laparoscopy, namely segments I-VII-VIII.

Laparoscopic Liver Resection of Right Posterior Segments for Hepatocellular Carcinoma on Cirrhosis

BACKGROUND

Laparoscopic liver resection (LLR) is now widely adopted for the treatment of liver malignancies. Liver resection with laparoscopic approach was first adopted for tumors located in the peripheral portion of the anterolateral segments of the liver, but recent experiences in literature modified the attitude toward that approach. We herein report our technique and outcomes of LLR for hepatocellular carcinoma (HCC) located in the right-posterior segments of the liver (VI and VII).

MATERIALS AND METHODS

We retrospectively reviewed our prospectively maintained database, comparing peri- and postoperative outcomes of patients who underwent laparoscopic (13 patients) or open (51 patients) resections for HCC localized in the right-posterior segments between 2000 and 2014.

RESULTS

The two populations were homogeneous, showing no statistically significant differences in terms of gender, age, body mass index, and cirrhosis prevalence. Alpha-fetoprotein levels were higher in the open group (P = .04) and etiology of cirrhosis varied in a statistically significant manner (P = .01). The laparoscopic group showed an improved perioperative outcome with statistically significant less postoperative morbidity (P = .01) and less in-hospital stay (P = .0001). No differences were found in terms of blood loss or operative time, but any Pringle maneuver was needed (P = .04).

CONCLUSIONS

Patients affected by HCC localized in the right-posterior segments of the liver can be safely treated with laparoscopic approach. However, this kind of procedure can be challenging and should be performed in tertiary referral hospitals to provide the patient the best care, with the integration of different specialties.

Robotic liver surgery is the optimal approach as bridge to transplantation

The role of minimally invasive liver surgery as a bridge to transplantation is very promising but still underestimated. However, it should be noted that surgical approach for hepatocellular carcinomas (HCC) is not merely a technical or technological issue. Nowadays, the epidemiology of HCC is evolving due to the increasing role of non-alcoholic fatty-liver-disease, and the emerging concerns on direct-acting antivirals against hepatitis C virus in terms of HCC incidence. Therefore, a fully multidisciplinary study of the cirrhotic patient is currently more important than ever before, and the management of those patients should be reserved to tertiary referral hepatobiliary centers. In particular, minimally invasive approach to the liver showed several advantages compared to the classical open procedure, in terms of: (1) the small impact on abdominal wall; (2) the gentle manipulation on the liver; (3) the limited surgical trauma; and (4) the respect of venous shunts. Therefore, more direct indications should be outlined also in the Barcelona Clinic Liver Cancer model. We believe that treatment of HCC in cirrhotic patients should be reserved to tertiary referral hepatobiliary centers, that should offer patient-tailored approaches to the liver disease, in order to provide the best care for each case, according to the individual comorbidities, risk factors, and personal quality of life expectations.

Evolution of laparoscopic liver resection at Singapore General Hospital: a nine-year experience of 195 consecutive resections

INTRODUCTION

We aimed to analyse the changing trends, safety and outcomes associated with the adoption of laparoscopic liver resection (LLR) at a single centre.

METHODS

A retrospective review of patients who underwent LLR from 2006 to 2014 at our institution was performed. To explore the evolution of LLR, the study was divided into three equal consecutive time periods (Period 1: 2006-2008, Period 2: 2009-2011, and Period 3: 2012-2014).

RESULTS

Among 195 patients who underwent LLR, 24 (12.3%) required open conversions, 68 (34.9%) had resection of tumours in the difficult posterosuperior segments and 12 (6.2%) underwent major (≥ 3 segments) hepatectomies. Median operation time was 210 (range 40-620) minutes and median postoperative stay was 4 (range 1-26) days. Major postoperative morbidity (> Grade II) occurred in 11 (5.6%) patients and 90-day/in-hospital mortality was 1 (0.5%). During the study, the number of LLRs performed showed an increasing trend (Period 1: n = 22; Period 2: n = 19; Period 3: n = 154). Other statistically significant trends were: (a) increase in malignant neoplasms resected; (b) increase in resections of difficult posterosuperior segments; (c) longer median operation time; and (d) decrease in open conversion rates.

CONCLUSION

Over the study period, the number of LLRs increased rapidly. LLR was increasingly performed for malignant neoplasms and lesions located in the difficult posterosuperior segments, resulting in longer operation times. However, open conversion rates decreased, and there was no change in postoperative morbidity and other perioperative outcomes.

Laparoscopic Liver Resection for Tumors in the Left Lateral Liver Section

Background:

The laparoscopic approach is increasingly adopted for liver resections today especially for lesions located in the left lateral liver section. This study was conducted to determine the impact of the introduction of laparoscopic liver resection (LLR) as a surgical option for suspected small- to medium-sized (<8 cm) tumors located in the left lateral section (LLS).

Methods:

This is a retrospective review of 156 consecutive patients who underwent LLR or open liver resection (OLR) of tumors located in the LLS. The study was divided into 2 consecutive periods (period 1, January 2003 through September 2006, and period 2, October 2006 through April 2014); LLR was available as a surgical option only in the latter period. Comparisons made were LLR versus OLR, LLR versus OLR (in period 2 only), and resections performed in period 1 versus period 2.

Results:

Forty-two patients underwent LLR with 4 conversions. LLR was significantly associated with a longer median operative time [167.5 minutes (range, 60–525) vs 105 minutes (range, 40–235); P < .001], decreased need for the Pringle maneuver [n = 1 (2%) vs 22 (19%); P = .008], and shorter postoperative stay [n = 4 (range, 1–10) days vs 5 days (range, 2–47); P < .001] compared with open resection. Comparison of the 42 patients who underwent LLR with the 64 contemporaneous patients who underwent OLR demonstrated similar outcomes. Again, LLR was associated with a significantly longer operation, decreased need for the Pringle maneuver, and shorter hospital stay.

Conclusions:

LLR can be safely adopted to treat lesions in the LLS. The procedure is associated with a shorter postoperative stay and a decreased need for the Pringle maneuver, but longer operative time compared with that required for OLR.

Clinical impact of laparoscopic hepatectomy: technical and oncological viewpoints

The objective of this study was to assess the clinical impact of laparoscopic hepatectomy from technical and oncological viewpoints through the consecutive 5-year experience of an expert team. The subjects consisted of 491 consecutive hepatectomies performed over the course of 5 years. A total of 190 hepatectomies (38.6 %) were performed laparoscopically, and the remaining 301 (61.4 %) were open hepatectomies. Chronological trends of operative procedures and their indications were evaluated, and patients with hepatocellular carcinoma (HCC) were analyzed from an oncological viewpoint. The proportion of laparoscopic hepatectomies performed increased significantly during the study period (from 17.6 to 49.5 %). According to chronological trends, right hepatectomy was standardized using consecutive steps after minor hepatectomy, left lateral sectionectomy, and left hepatectomy were standardized. The proportion of laparoscopic hepatectomies performed for HCC increased from 21.4 to 71.0 %. No significant difference was observed in the proportion of major hepatectomies performed for HCC between the open and laparoscopy groups (50.6 vs. 48.6 %, p = 0.8053), whereas that of anatomical segmentectomy for HCC was significantly lower in the laparoscopy group (28.7 vs. 11.1 %, p = 0.0064). All laparoscopic anatomical segmentectomies were of segments 5 and 6, and there was no segmentectomy of posterosuperior lesions. The present study shows the consecutive technical developmental processes for minor hepatectomy, left lateral sectionectomy, left hepatectomy, and right hepatectomy without compromising oncological principles. Laparoscopic anatomical segmentectomy for posterosuperior lesions may be the most technically demanding procedure, requiring individualized standardization.

Comparative Short-term Benefits of Laparoscopic Liver Resection: 9000 Cases and Climbing

OBJECTIVE

To perform a systematic review of worldwide literature on laparoscopic liver resections (LLR) and compare short-term outcomes against open liver resections (OLR) by meta-analyses.

SUMMARY BACKGROUND DATA

There are no updated pooled data since 2009 about the current status and short-term outcomes of LLR worldwide.

PATIENTS AND METHODS

All English language publications on LLR were screened. Descriptive worldwide data and short-term outcomes were obtained. Separate analyses were performed for minor-only and major-only resection series, and series in which minor/major resections were not differentiated. Apparent case duplications were excluded.

RESULTS

A set of 463 published manuscripts were reviewed. One hundred seventy-nine single-center series were identified that accounted for 9527 LLR cases worldwide. Minor-only, major-only, and combined major-minor series were 61, 18, and 100, respectively, including 32, 8, and 43 comparative series, respectively. Of the total 9527 LLR cases reported, 6190 (65%) were for malignancy and 3337 (35%) were for benign indications. There were 37 deaths reported (mortality rate = 0.4%). From the meta-analysis comparing case-matched LLR to OLR (N = 2900 cases), there was no increased mortality and significantly less complications, transfusions, blood loss, and hospital stay observed in LLR vs OLR.

CONCLUSIONS

This is the largest review of LLR available to date with over 9000 cases published. It confirms growing safety when performed in selected patients and by trained surgeons, and suggests that LLR may offer improved patient short-term outcomes compared with OLR. Improved levels of evidence, standardized reporting of outcomes, and assuring proper training are the next challenges of laparoscopic liver surgery.

Laparoscopic Right Hepatectomy by the Caudal Approach Versus Conventional Approach: A Comparative Study

BACKGROUND

Laparoscopic right hepatectomy (LRH) is increasingly performed for the treatment of many liver diseases. However, it remains a challenging procedure and is limited to highly specialized centers. Increasing the safety and efficacy of LRH is crucial. This study evaluated the safety and feasibility of the novel caudal approach (CDA) in LRH and in comparison with the conventional approach (CA).

METHODS

Of a total of 40 patients who underwent LRH between June 2007 and July 2015 at our center, 10 cases underwent the CDA, while 30 underwent the CA. Operative and postoperative outcomes were analyzed.

RESULTS

Clinical data and patient characteristics were comparable between the two groups. Only 1 patient required a laparoscopic-assisted procedure in the CDA group, while 14 patients were converted to laparotomy (n = 10) or laparoscopic-assisted procedures (n = 4) in the CA group, although the difference did not reach statistical significance (P = .060). However, the difference in conversion to laparotomy between the two groups was significant (P = .043). In addition, when considering 23 patients with malignancies, the median surgical margin was significantly greater in the CDA group (n = 6) (20 mm versus 10 mm; P = .023) than in the CA group (n = 17). Other operative and postoperative outcomes were similar between the two groups.

CONCLUSIONS

The CDA achieves safety and feasibility similar to that of the CA in LRH and requires relatively less conversion to laparotomy. In selected patients, the CDA offers an alternative option to the CA for LRH in experienced hands. Further studies with larger samples are warranted to evaluate the CDA.

Appraisal of Laparoscopic Liver Resection in the Treatment of Liver Metastasis with Special Reference to Outcome in Colorectal Malignancies

Treatment of metastatic liver disease is at the crossroads of an evolutionary transformation with more and more reports reiterating the benefits of resectional therapy in various cancers. A quest for application of laparoscopic approaches to the management of liver metastasis has arisen due to the projected benefits of less morbidity, early recovery, and equivalent oncological outcome in selected malignancies. However, the diverse and heterogenous data on indications, operative technique, and outcome evaluation make a comparative analysis of these studies difficult. This review is an appraisal of technique and outcome of minimally invasive liver resection as reported in the current literature with special reference to treatment of metastatic colorectal cancers.

Laparoscopic versus open major hepatectomy for hepatocellular carcinoma: a matched pair analysis

BACKGROUND

Laparoscopic major hepatectomy (LMH) for hepatocellular carcinoma (HCC) is currently perceived a complex and challenging laparoscopic procedure and is limited to a few expert teams. This study analyzed the short- and long-term outcomes of LMH for HCC compared with open hepatectomy.

METHODS

From January 2006 to May 2014, 38 patients underwent LMH for HCC (10 left and 28 right hepatectomy). They were matched and compared to 38 patients (10 left and 28 right hepatectomy) who underwent a conventional open approach. Short-term operative and postoperative outcomes as well as long-term outcomes, including disease-free survival and overall survival rates, were evaluated.

RESULTS

Patients were well matched for several preoperative factors. Overall complication rates were significantly higher for the open group. No significant difference was seen in 3-year overall survival between the open and laparoscopic groups (69.2 vs. 73.4 %; p = 0.951). A trend toward better 3-year disease-free survival after laparoscopy was observed (29.7 vs. 50.3 %; p = 0.219), even though the difference did not reach statistical significance. The same trend was seen in subgroup analyses of right and left hepatectomy.

CONCLUSIONS

This study shows the feasibility of LMH for HCC compared to open hepatectomy in regard to both short- and long-term outcomes. LMH offers many advantages commonly attributed to laparoscopy and is well suited for HCC with cirrhosis when performed by experienced surgeons.

Laparoscopic versus open major hepatectomy for hepatocellular carcinoma: a matched pair analysis

BACKGROUND

Laparoscopic major hepatectomy (LMH) for hepatocellular carcinoma (HCC) is currently perceived a complex and challenging laparoscopic procedure and is limited to a few expert teams. This study analyzed the short- and long-term outcomes of LMH for HCC compared with open hepatectomy.

METHODS

From January 2006 to May 2014, 38 patients underwent LMH for HCC (10 left and 28 right hepatectomy). They were matched and compared to 38 patients (10 left and 28 right hepatectomy) who underwent a conventional open approach. Short-term operative and postoperative outcomes as well as long-term outcomes, including disease-free survival and overall survival rates, were evaluated.

RESULTS

Patients were well matched for several preoperative factors. Overall complication rates were significantly higher for the open group. No significant difference was seen in 3-year overall survival between the open and laparoscopic groups (69.2 vs. 73.4 %; p = 0.951). A trend toward better 3-year disease-free survival after laparoscopy was observed (29.7 vs. 50.3 %; p = 0.219), even though the difference did not reach statistical significance. The same trend was seen in subgroup analyses of right and left hepatectomy.

CONCLUSIONS

This study shows the feasibility of LMH for HCC compared to open hepatectomy in regard to both short- and long-term outcomes. LMH offers many advantages commonly attributed to laparoscopy and is well suited for HCC with cirrhosis when performed by experienced surgeons.

Bleeding control during laparoscopic liver resection: a review of literature

Despite the established advantages of laparoscopy, bleeding control during laparoscopic liver resection (LLR) is a liver-specific improvement. The 2nd International Consensus Conference on Laparoscopic Liver Resection was held in October 2014 at Morioka, Japan. One of the most capital questions was: What is essential in bleeding control during LLR? In order to correctly address this question, we conducted a comprehensive review of the literature. Essential points based on personal experience of the expert panel are also discussed. A total of 54 publications were identified. Based on this analysis, the working group built these recommendations: (1) a pneumoperitoneum of 10-14 mmHg should be used as it allows a good control of the bleeding without significant modifications of hemodynamics; (2) a low central venous pressure (<5 mmHg) should be used; (3) laparoscopy facilitates inflow and outflow control; and (4) surgeons should be experienced with the use of all surgical devices for liver transection and should master laparoscopic suture before starting LLR. Precoagulation with radiofrequency can be useful, particularly in cases of atypical resection. These recommendations are mostly based on experts' opinions and on B or C quality of evidence grade studies. More prospective data are required to confirm these results.

Factors associated with and outcomes of open conversion after laparoscopic minor hepatectomy: initial experience at a single institution

BACKGROUND

Laparoscopic liver resection has been increasingly adopted worldwide as a result of the rapid advancement in surgical techniques and equipment. This study aims to determine the factors associated with and outcomes of open conversion after laparoscopic minor hepatectomy (LMH) based on a single center multi-surgeon experience.

METHODS

This is a retrospective review of the first 147 consecutive LMH performed between 2006 and April 2014 at a single institution. Data on patient demographics, pathology results, perioperative outcomes, and operative results were collected. Factors associated with open conversion were analyzed via univariate analysis and a P value <.05 was considered statistically significant.

RESULTS

LMH was performed for malignancy in 114 (77.6%) patients of which hepatocellular carcinoma (n = 82) and colorectal metastases (n = 16) were the most common pathologies. Forty-one (27.9%) patients had cirrhotic livers and 18 (15.7%) had fibrotic livers. Fifty patients (44%) had concomitant surgery in addition to LMH. Twenty (13.6%) procedures required open conversion and the most common reason was for bleeding (n = 12). Twenty-five patients (17%) experienced postoperative complications. Univariate analyses demonstrated that only individual surgeon volume (n ≤ 10 cases) [15 (24.2%) vs 5 (5.9%), P = .001] and institution volume (n ≤ 25 cases) [8 (32%) vs 12 (9.8%), P = .003] were factors associated with open conversion. Open conversion was significantly associated with increased intra-operative blood loss, increased intra-operative blood transfusion, increased postoperative morbidity, and longer postoperative stay.

CONCLUSIONS

Individual surgeon and institution volumes were important factors associated with open conversion after LMH. Open conversion after LMH resulted in poorer outcomes compared to procedures that were successfully completed laparoscopically.

Laparoscopic liver resection for living donation: Where do we stand?

In Western countries, living donor liver transplantation (LDLT) may represent a valuable alternative to deceased donor liver transplantation. Yet, after an initial peak of enthusiasm, reports of high rates of complications and of fatalities have led to a certain degree of reluctance towards this procedure especially in Western countries. As for living donor kidney transplantation, the laparoscopic approach could improve patient’s tolerance in order to rehabilitate this strategy and reverse the current trend. In this setting however, initial concerns regarding patient’s safety and graft integrity, need for acquiring surgical expertise in both laparoscopic liver surgery and living donor transplantation and lack of evidence supporting the benefits of laparoscopy have delayed the development of this approach. Similarly to what is performed in classical resectional liver surgery, initial experiences of laparoscopy have therefore begun with left lateral sectionectomy, which is performed for adult to child living donation. In this setting, the laparoscopic technique is now well standardized, is associated with decreased donor blood loss and hospital stays and provides graft of similar quality compared to the open approach. On the other hand laparoscopic major right or left hepatectomies for adult-adult LDLT currently lack standardization and various techniques such as the full laparoscopic approach, the hand assisted approach and the hybrid approach have been reported. Hence, even-though several reports highlight the feasibility of these procedures, the true benefits of laparoscopy over laparotomy remain to be fully assessed. This could be achieved through standardization of the procedures and creation of international registries especially in Eastern countries where LDLT keeps on flourishing.

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.

[Laparoscopic liver resection: lessons learned after 132 resections]

INTRODUCTION

After 20 years of experience in laparoscopic liver surgery there is still no clear definition of the best approach (totally laparoscopic [TLS] or hand-assisted [HAS]), the indications for surgery, position, instrumentation, immediate and long-term postoperative results, etc.

AIM

To report our experience in laparoscopic liver resections (LLRs).

PATIENTS AND METHOD

Over a period of 10 years we performed 132 LLRs in 129 patients: 112 malignant tumours (90 hepatic metastases; 22 primary malignant tumours) and 20 benign lesions (18 benign tumours; 2 hydatid cysts). Twenty-eight cases received TLS and 104 had HAS.

SURGICAL TECHNIQUE

6 right hepatectomies (2 as the second stage of a two-stage liver resection); 6 left hepatectomies; 9 resections of 3 segments; 42 resections of 2 segments; 64 resections of one segment; and 5 cases of local resections.

RESULTS

There was no perioperative mortality, and morbidity was 3%. With TLS the resection was completed in 23/28 cases, whereas with HAS it was completed in all 104 cases. Transfusion: 4,5%; operating time: 150min; and mean length of stay: 3,5 days. The 1-, 3- and 5-year survival rates for the primary malignant tumours were 100, 86 and 62%, and for colorectal metastases 92, 82 and 52%, respectively.

CONCLUSION

LLR via both TLS and HAS in selected cases are similar to the results of open surgery (similar 5-year morbidity, mortality and survival rates) but with the advantages of minimally invasive surgery.