Isolated laparoscopic resection of the hepatic caudate lobe: surgical technique and a report of 2 cases

Laparoscopic caudate lobe resections: How I do it: tips and pitfalls (with video)

BACKGROUND

The caudate lobe (S1) of the liver, due to its deep central position, presents a formidable challenge for laparoscopic resection. Historical skepticism about laparoscopic approaches has been overshadowed by advancements in technology and technique, with recent studies showing comparable outcomes to open surgery.

METHODS

This paper introduces the "Easy First" technique and the Sextet strategies for laparoscopic hepatic caudate lobectomy. The strategies include meticulous preoperative planning, optimal trocar placement, and team positioning, tailored to the anatomical complexities of the caudate lobe.

RESULTS

With a 0% conversion and mortality rate, our series demonstrates the safety of the "Easy First" technique. The Sextet strategies have been instrumental in navigating the technical challenges, emphasizing the importance of patient selection and surgeon expertise.

CONCLUSION

The "Easy First" technique, with its structured approach and the Sextet strategies, offers a replicable method for laparoscopic caudate lobectomy. It underscores the need for stringent patient selection, advanced technical skill, and high-volume center expertise to ensure procedural success and patient safety.

A comprehensive study and extensive review of the Caudate lobe: The last piece of "Jigsaw" puzzle

Many liver surgeons have updated their understanding of the liver in recent years because of detailed studies on the liver anatomy and the rapid advances in laparoscopic liver surgery. Despite newer approaches, concepts and methods, research on the caudate lobe continues to be based on case reports and several persistent challenges concerning caudate lobe surgery that are worth discussing. Based on the literature and the author's experience, this study considers and addresses the challenges associated with caudate lobectomy encountered by most liver surgeons. We searched PubMed for relevant articles in English for 'caudate lobe', 'cholangiocellular carcinoma', 'laparoscopic caudate resection', 'right-side boundary of the caudate lobe' and 'assessment of hepatic functional reserve' published up to May 2022. This study reviewed the anatomical history of the caudate lobe, focusing on the challenges associated with caudate lobe-related surgical resection. Due to the unique anatomical position of the caudate lobe, surgical strategy for caudate lobe resection is particularly important, and the technical requirements for hepatobiliary surgeons are also extremely strict. Therefore, understanding the anatomical history of the caudate lobe and discussing the challenges associated with caudate lobectomy is essential.

Laparoscopic resection of focal nodular hyperplasia in the hepatic caudate lobe

OBJECTIVE

To investigate the safety and feasibility of laparoscopic resection of focal nodular hyperplasia (FNH) in the hepatic caudate lobe.

METHODS

The clinical data of eight patients who underwent laparoscopic hepatic caudate lobe FNH resection at the Department of Hepatobiliary Surgery, Southwest Hospital, First Affiliated Hospital of Army Medical University, were retrospectively analyzed.

RESULTS

The laparoscopic procedures were successful in all eight patients, and no patients required conversion to open surgery. Five patients underwent partial caudate lobe resection, one patient underwent caudate lobe resection, and two patients underwent combined left hemihepatectomy with caudate lobe resection. Tumor resection was performed using the left approach in five cases, the right approach in one case, the middle hepatic fissure approach in one case, and the left and right combined approach in one case. The operation time ranged from 120 to 360 min, with a mean of 225 min. The intraoperative blood loss ranged from 50 to 600 ml, with a mean of 235 ml. No postoperative bleeding, bile leakage or abdominal infection occurred.

CONCLUSIONS

Laparoscopic resection of hepatic caudate lobe FNH was safe and feasible in appropriate patients. Skilled laparoscopic hepatectomy techniques, adequate preoperative evaluation, appropriate choice of surgical approach and the control of intraoperative bleeding are critical to perform this surgery.

Is laparoscopic surgery a preferred option for benign conditions in the caudate lobe of the liver?

BACKGROUND/AIM

Laparoscopic hepatectomy has become a common management strategy for liver tumors owing to its less invasive nature and enhanced visual perspective. Yet, its use in the caudate lobe poses challenges. This study evaluates the experiences of patients who underwent laparoscopic hepatectomy for hepatic tumors in the caudate lobe and aims to propose strategies for performing such procedures.

METHODS

We retrospectively analyzed the clinical data of twelve patients who underwent laparoscopic hepatic caudate lobe resection at the Department of Hepatopancreatobiliary Surgery, Second Affiliated Hospital of Kunming Medical University.

RESULTS

All twelve laparoscopic procedures were successful, with none requiring conversion to open surgery. The surgical methods varied: five cases involved simple resection of the Spiegel lobe, one case involved total caudate lobe resection, three cases involved paravena cava lobe resection, and three cases involved resection of the caudate process. The operation time ranged from 49 to 319 min (mean, 219 min). Intraoperative blood loss ranged from 20 to 500 ml, averaging 194 ml. No patients needed blood transfusions during or after the operation, and there were no instances of postoperative bleeding, bile leakage, or abdominal infection.

CONCLUSION

Given adequate control of hepatic inflow, sufficient exposure to the surgical field, and an appropriate approach, laparoscopic hepatectomy in the caudate lobe could potentially become a standard surgical technique.

Laparoscopic versus open surgery for hepatic caudate lobectomy: a retrospective study

BACKGROUND

This study was designed to investigate the feasibility and safety of laparoscopic hepatic caudate lobectomy (LHCL) for treating liver tumor by comparing with the open hepatic caudate lobectomy (OHCL).

METHODS

In the LHCL group, we included 24 patients with liver tumor received LHCL in Qilu Hospital of the Shandong University from January 2014 to January 2019. Meanwhile, 24 matched liver tumor patients underwent OHCL in our hospital served as control. Then we compared the patient characteristics, intraoperative parameters, and postoperative outcomes between LHCL group and OHCL group.

RESULTS

There were no significant differences in gender, age, degree of cirrhosis, tumor size, preoperative liver function, Child-Pugh grading, proportion of liver cirrhosis, and tumor size between LHCL group and OHCL group (P > 0.05). No death was reported in both groups. The length of incision in LHCL group was significantly lower than that in OHCL group (4.22 ± 1.14 cm vs. 22.46 ± 4.40 cm, P < 0.001). The intraoperative blood loss in LHCL group was significantly lower than that of OHCL group (116.82 ± 71.61 ml vs. 371.74 ± 579.35 ml, P = 0.047). The total operation time, Pringle maneuver occlusion time, and blocking rate in LHCL group showed no statistical difference compared with those of the OHCL group (P > 0.05). The VAS scores at postoperative 24 and 48 h showed no statistical differences between LHCL group and OHCL group (P > 0.05). Compared with the OHCL group, significant decrease was noticed in the proportion of patients with severe pain 48 h after surgery (0 vs. 4.25 ± 0.46, P < 0.001) and dezocine consumption (90.45 ± 45.77 mg vs. 131.6 ± 81.30 mg, P = 0.0448) in the LHCL group.

CONCLUSION

LHCL is effective and feasible for treating liver tumor, which is featured by reducing intraoperative blood loss and serious pain.

Laparoscopic caudate lobectomy for large hepatoblastoma in children: A case report

Hepatoblastoma originating in the caudate lobe (segment 1) is extremely rare. Complete resection of the caudate lobe, without sacrificing other parts of the liver, remains a surgical challenge. We present our experience with laparoscopic complete resection of caudate lobe hepatoblastoma for a 7-years-old girl, with a history of hepatitis B.

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Giant hepatoblastoma is located in segment 1 of a 7-year-old child.

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Complete resection of segment 1 by laparoscopic surgery without using intraoperative endoscopic ultrasonography.

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During the follow-up postoperative, AFP level has returned to normal with no sign of recurrence.

Safety and Efficacy of Laparoscopic Caudate Lobectomy: A Systematic Review

Resection of the caudate lobe of the liver is considered a highly challenging type of liver resection due to the region’s intimacy with critical vascular structures and deep anatomic location inside the abdominal cavity. Laparoscopic resection of the caudate lobe is considered one of the most challenging laparoscopic liver procedures. The objective of our systematic review was to evaluate the safety, technical feasibility and main outcomes of laparoscopic caudate lobectomy LCL. A systematic review of the literature was undertaken for studies published until September 2021. A total of 20 studies comprising 221 patients were included. Of these subjects, 36% were women, whereas the vast majority of resections (66%) were performed for malignant tumors. Tumor size varied significantly between 2 and 160 mm in the largest diameter. The mean operative time was 210 min (range 60–740 min), and estimated blood loss was 173.6 mL (range 50–3600 mL). The median hospital length of stay LOS was 6.5 days (range 2–15 days). Seven cases of conversion to open were reported. The vast majority of patients (93.7%) underwent complete resection (R0) of their tumors. Thirty-six out of 221 patients developed postoperative complications, with 5.8% of all patients developing a major complication (Clavien–Dindo classification ≥ III).No perioperative deaths were reported by the included studies. LCL seems to be a safe and feasible alternative to open caudate lobectomy OCL in selected patients when undertaken in high-volume centers by experienced surgeons.

Laparoscopic Caudal Approach of the Inferior Vena Cava for Isolated Segment 1 Liver Resection

INTRODUCTION

Isolated laparoscopic resection of the hepatic caudate lobe (segment 1) is a very challenging procedure. Very few references are available on this technique, and the aim of this paper is to show the main technical aspects of laparoscopic caudal approach for segment 1.

MATERIAL AND METHODS

The subject was a 64-year-old woman with a past medical history of surgically treated breast cancer (pT1N0M0, with positive hormonal receptors). Adjuvant treatment was administered as well as radiotherapy and hormone therapy (tamoxifen). After 12 months of follow-up, an 18-mm single liver metastasis was detected in segment 1, suggestive of metastatic disease. A complementary study was conducted with magnetic resonance imaging, computed tomography and positron emission tomography, and no other lesions were identified.

RESULTS

Isolated laparoscopic resection of segment 1 of the liver was performed with a caudal approach of the inferior vena cava. All the steps are extensively described. The surgery time was 120 min, and blood loss was less than 100 ml. No postoperative complications were registered. The patient was discharged on the third postoperative day.

CONCLUSION

Isolated laparoscopic resection of the hepatic caudate lobe with a caudal approach of the inferior vena cava is a safe technique in selected patients and should be performed in centres with experience in liver surgery and advanced laparoscopy, because of its high complexity.

Robotic Isolated Caudate Lobectomy for Solitary Colorectal Liver Metastasis

BACKGROUND

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

Safety and feasibility for laparoscopic versus open caudate lobe resection: a meta-analysis

BACKGROUND

Laparoscopic hepatectomy has been used widely due to its advantages as a minimally invasive surgery. However, multicenter, large-scale, population-based laparoscopic caudate lobe resection (LCLR) versus open caudate lobe resection (OCLR) has rarely been reported. We assessed the feasibility and safety of LCLR compared with OCLR using meta-analysis.

METHODS

Relevant literature was retrieved using PubMed, Embase, Cochrane, Ovid Medline, Web of Science, CNKI, and WanFang Med databases up to July 30th, 2020. Multiple parameters of feasibility and safety were compared between the treatment groups. Quality of studies was assessed with the Newcastle-Ottawa Scale (NOS). The data were analyzed by Review Manager 5.3. Results are expressed as odds ratio (OD) or mean difference (MD) with 95% confidence interval (95% CI) for fixed- and random-effects models.

RESULTS

Seven studies with 237 patients were included in this meta-analysis. Compared with OCLR, the LCLR group had a lower intraoperative blood loss (MD - 180.84; 95% CI - 225.61 to - 136.07; P < 0.0001), shorter postoperative hospital stays (MD - 4.38; 95% CI - 7.07 to - 1.7; P = 0.001), shorter operative time (MD - 50.24; 95% CI - 78.57 to - 21.92; P = 0.0005), and lower rates in intraoperative blood transfusion (OR 0.12; P = 0.01). However, there were no statistically significant differences between LCLR and OCLR regarding hospital expenses (MD 0.92; P = 0.12), pedicle clamping (OR 1.57; P = 0.32), postoperative complications (OR 0.58; P = 0.15), bile leak (P = 0.88), ascites (P = 0.34), and incisional infection (P = 0.36).

CONCLUSIONS

LCLR has multiple advantages over OCLR, especially intraoperative blood loss and hospital stays. LCLR is a very useful technology and feasible choice in patients with caudate lobe lesions.

Propensity score matching analysis for outcomes of laparoscopic versus open caudate lobectomy

BACKGROUND

To date, laparoscopic caudate lobectomy (LCB) remains a challenge, and evidence about its value is rare. Therefore, this study was performed to assess the benefits of LCB for patients with tumours located in the caudate lobe compared with open caudate lobectomy (OCB).

METHODS

From October 2015 to June 2019, 102 patients meeting the inclusion and exclusion criteria were eligible for this study. The patients were divided into LCB and OCB groups. Short-term outcomes between the groups were compared with propensity score matching (PSM).

RESULTS

LCB was performed in 31 of the 102 included patients. After PSM, 30 patients with well-balanced baseline levels were enrolled in each group. Intraoperative blood loss in the LCB group was less than that in the OCB group (median, 100 versus 200 mL, P = 0.017), even though it did not reach a statistically significant difference after PSM (median, 100 versus 187.5 mL, P = 0.085). Moreover, although post-operative overall complications were similar in the two groups, a tendency of lower rates of respiratory infection in the LCB group than the OCB group was observed (0% versus 12.7%, P = 0.054 before PSM; 0% versus 16.7%, P = 0.063 after PSM). There was no early mortality in either group. LCB had a shorter post-operative hospital stay than OCB (median, 5 versus 6 days, P < 0.001). However, the hospitalization cost was higher in the LCB group than in the OCB group (P < 0.001).

CONCLUSION

LCB is safe and feasible in selected patients when performed by experienced surgeons.

Robotic isolated partial and complete hepatic caudate lobectomy: A single institution experience

BACKGROUND

Current reports on robotic hepatic caudate lobectomy are limited to Spiegel lobectomy. This study aimed to compare the safety and feasibility of robotic isolated partial and complete hepatic caudate lobectomy.

METHODS

Clinical data of 32 patients who underwent robotic resection of the hepatic caudate lobe in our department from May 2016 to January 2020 were retrospectively analyzed. The patients were divided into three groups according to the lobectomy location: left dorsal segment lobectomy (Spiegel lobectomy), right dorsal segment lobectomy (caudate process or paracaval portion lobectomy), and complete caudate lobectomy. General information and perioperative results of the three groups were compared and analyzed.

RESULTS

Among the 32 patients, none had conversion to laparotomy, three received intraoperative blood transfusion (9.38%), and none had complications of Clavien-Dindo grade III or higher or died in the perioperative period. Among them, 17 patients (53.13%) underwent Spiegel lobectomy, 7 (21.88%) underwent caudate process or paracaval portion lobectomy, and 8 (25.00%) underwent complete caudate lobectomy. The operative time and blood loss in the left dorsal segment lobectomy group were significantly better than those in the right dorsal segment lobectomy and complete caudate lobectomy groups (operative time: P = 0.010 and P = 0.005; blood loss: P = 0.005 and P = 0.017, respectively). The postoperative hospital stay in the left dorsal segment lobectomy group was significantly shorter than that in the complete caudate lobectomy group (P = 0.003); however, there was no difference in the postoperative hospital stay between the left dorsal segment lobectomy group and right dorsal segment lobectomy group (P = 0.240).

CONCLUSIONS

Robotic isolated partial and complete caudate lobectomy is safe and feasible. Spiegel lobectomy is relatively straightforward and suitable for beginners.

Robotic anatomic isolated complete caudate lobectomy: Left-side approach and techniques

BACKGROUND

To demonstrate the surgical procedures and techniques of the robotic anatomical isolated complete caudate lobectomy.

METHODS

A retrospective analysis was performed on the demographic, operative, postoperative outcomes of seven patients who underwent robotic anatomical isolated complete caudate lobectomy at our department from January 2018 to November 2019. Mobilization of the left lateral and Spiegel lobe, dissection of the short hepatic veins and liver parenchyma transection from the dorsal plane of middle and right hepatic vein were crucial procedures for the robotic left-side approach. Anatomic complete caudate lobectomy was defined as total removal of the caudate lobe, in which the dorsal middle and right hepatic vein, the inferior vena cava and its right side were fully exposed on the raw surface.

RESULTS

All patients successfully underwent the robotic anatomical isolated caudate lobectomy with a left-side approach without conversion to laparotomy, and without Clavien-Dindo Grade III or higher complications. The average tumor diameter was 65.00 ± 10.61 mm, the average operation time was 212.00 ± 74.53 min, the median bleeding loss was 100 mL, and the average postoperative hospital stay was 8.71 ± 4.89 d, respectively. There were four patients with primary hepatocellular carcinoma, one with tumor recurrence five months after surgery and three patients were free of recurrence. All patients survived at the last follow-up.

CONCLUSION

Robotic anatomical isolated complete caudate lobectomy with a left-sided approach is safe and feasible for selected patients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A multicenter cohort analysis of laparoscopic hepatic caudate lobe resection

INTRODUCTION

Laparoscopic resection of the hepatic caudate lobe (LRCL) requires a high level of expertise due to its challenging anatomical area. Only case reports, case series, and single-center cohort studies have been published. The aim of this study was to assess the safety and feasibility of this laparoscopic procedure.

METHODS

A multicenter retrospective cohort study including all patients who underwent LRCL in 4 high-volume hepatobiliary units between January 2000 and May 2018 was performed. Perioperative, postoperative, and survival outcomes were assessed. Postoperative morbidity was stratified according to the Clavien-Dindo classification with severe complications defined by grade III or more. The Kaplan-Meier method was used for survival analysis.

RESULTS

A total of 32 patients were included, including 22 (68.8%) with colorectal liver metastasis (CRLM), one (3.1%) with cholangiocarcinoma, four (12.5%) with other malignancies, and five (15.6%) with symptomatic benign lesions. Simultaneous colorectal and/or additional liver resection was performed in 20 (62.5%) patients. The median (IQR) operative time was 155 (121-280) minutes, blood loss was 100 (50-275) ml, conversion rate was 9.4% (n = 3), severe complications were observed in 2 patients (6.3%), and median (range) length of hospital stay was 3 [1-39] days. No 90-day postoperative mortality was noticed. The median (IQR) follow-up for the CRLM group was 14 [10-23] months. Five-year overall survival rate was 82% in this subgroup. Small interinstitutional differences were observed without major impact on surgical outcomes.

CONCLUSION

LRCL is safe and feasible when performed in high-volume centers. Profound anatomical knowledge, advanced laparoscopic skills, and mastering intraoperative ultrasound are essential. No major interinstitutional differences were ascertained.

Laparoscopic caudate lobectomy: a multicenter, propensity score-matched report of safety, feasibility, and early outcomes

BACKGROUND

Caudate lobectomy via laparoscopic surgery has rarely been described. This multicenter, propensity score-matched study was performed to assess the safety and efficacy of laparoscopic caudate lobectomy (LCL).

METHODS

A multicenter retrospective study was performed including all patients who underwent LCL and open caudate lobectomy (OCL) in four institutions from January 2013 to December 2018. In total, 131 patients were included in this study and divided into LCL (n = 19) and OCL (n = 112) groups. LCLs were matched to OCLs (1:2) using a propensity score matching (PSM) based on nine preoperative variables, including patient demographics and tumor characteristics. The pathological results, perioperative and postoperative parameters, and short-term outcomes were compared between the two groups.

RESULTS

After PSM, there were 18 and 36 patients in the LCL and OCL groups, respectively. Baseline characteristics were comparable after matching. LCL was associated with less blood (100 vs. 300 ml, respectively; P < 0.001) and a shorter postoperative stay (6.0 vs 8.0 days, respectively; P = 0.003). Most patients' resection margins were > 10 mm in the LCL group (P = 0.021), and all patients with malignancy in both groups achieved R0 resection. In terms of early postoperative outcomes, the overall morbidity rate was identical in each group (11.1% vs. 11.1%, respectively; P = 1.000). No mortality occurred in either group.

CONCLUSIONS

Laparoscopy is a feasible choice for resection of tumors located in the caudate lobe with acceptable perioperative results.

Laparoscopic liver resection of the Spiegel lobe by a left-sided approach preserving an accessory left hepatic artery

BACKGROUND

Caudate lobe of the liver can be divided in three portions: Spiegel lobe, paracaval portion and caudate process [1]. The anatomy of the caudate lobe and its proximity to major vascular structures makes this operation a difficult resection, especially for laparoscopic liver surgery [2]. For that reason the Iwate criteria proposed to classify this surgery at the "2nd International Consensus Conference on Laparoscopic Liver Resection" as intermediate or advanced difficulty depending on the type of resection, and the size of the tumor [3]. For tumors located in the Spiegel lobe, the left side approach is preferred [4].

METHODS

We present a 69-year-old woman with liver metastasis from previously resected sternal condrosarcoma on 30/05/2017. A unique recurrence in the caudate lobe was found on computed tomography and magnetic resonance imaging on April 2019.

RESULTS

A Spiegel lobe resection with left side approach preserving an accessory left hepatic artery was performed. A resection of the artery was planned if the preservation was not possible. The operative time was 180 min and the total Pringle time was 30 min. Patient was discharged at the 4 postoperative day and there were no postoperative complications CONCLUSIONS: Laparoscopic liver resection of the caudate lobe for condrosarcoma liver metastasis is feasible and safe. Left approach seems the best option for Spiegel lobe resections even in patients with accessory left hepatic artery.

Feasibility of laparoscopic isolated caudate lobe resection for rare hepatic mesenchymal neoplasms

BACKGROUND

Mesenchymal tumors such as perivascular epithelioid cell neoplasm (PEComa) and inflammatory pseudotumor-like follicular dendritic cell sarcoma (IPT-like FDC sarcoma) are relatively uncommon in the liver and are particularly rare in the caudate lobe. The clinical manifestations and available imaging tests lack specificity for hepatic mesenchymal tumors. To the best of our knowledge, no caudate PEComa or IPT-like FDC sarcoma has been completely resected by laparoscopy. The standard laparoscopic technique, surgical approaches, and tumor margins for potentially malignant or malignant caudate mesenchymal tumors are still being explored.

AIM

To assess both the safety and feasibility of laparoscopic resection for rare caudate mesenchymal neoplasms.

METHODS

Eleven patients who underwent isolated caudate lobe resection from 2003 to 2017 were identified from a prospective database. Three consecutive patients with rare caudate mesenchymal tumors underwent laparoscopic resection. Patient demographic data, intraoperative parameters, and postoperative outcomes were assessed and compared with the open surgery group.

RESULTS

All procedures for the three resection patients with caudate mesenchymal tumors were completed using a total laparoscopic technique by two different approaches. The average operative time was 226 min, and the estimated blood loss was 133 mL. The average length of postoperative hospital stay was 6.3 ± 0.3 d for the laparoscopy group and 15.5 ± 2.3 d for the open surgery group (P < 0.05). There were no perioperative complications or patient deaths in this series.

CONCLUSION

Laparoscopic isolated caudate lobe resection for rare mesenchymal neoplasms is a feasible and curative surgical option in selected patients.

Comparison of clinical outcomes of laparoscopic versus open surgery for recurrent hepatocellular carcinoma: a meta-analysis

BACKGROUND

The purpose of this study is to compare the clinical outcomes of laparoscopic liver resection versus open liver resection for recurrent hepatocellular carcinoma (RHCC).

METHODS

Published studies which investigated laparoscopic versus open liver resection for RHCC were identified, and meta-analysis was used for statistical analysis.

RESULTS

Six studies were analyzed by meta-analysis method, and cumulative 335 cases were included in this study. Laparoscopic liver resection was performed in 145 cases, and open liver resection was performed in 190 cases. Meta-analysis showed that there was no difference in operative time and 90-day mortality between the laparoscopic group and the open group (p = 0.06 and p = 0.06 respectively); Nevertheless, compared with the open group, the laparoscopic group resulted in significantly lower rate of in-hospital complication (p < 0.0001), much less blood loss (p < 0.0001) and shorter postoperative hospital stay (p = 0.002).

CONCLUSION

Laparoscopic liver resection for RHCC offers a benefit of lower in-hospital complication rate, less blood loss, shorter postoperative hospital stay, while similar operative time and 90-day mortality as the open liver resection. Laparoscopic liver resection is feasible with satisfactory postoperative outcomes and can be a safe alternative treatment strategy to open procedure for RHCC.

Prognoses and Clinicopathological Characteristics for Hepatocellular Carcinoma Originating from the Caudate Lobe After Surgery

BACKGROUND

The aim was to evaluate the prognoses and clinicopathological characteristics of solitary hepatocellular carcinoma (HCC) originating from the caudate lobe (HCC-CL).

METHODS

We analyzed 584 patients with a solitary tumor <10 cm from January 1990 to November 2014. Patients were classified into a caudate lobe group (CL; n = 39) and a non-caudate lobe group (NCL; n = 545). We investigated the prognoses and clinicopathological characteristics of solitary HCC-CL. We compared the surgical procedures performed in these cases.

RESULTS

HCC-CL had a similar rate of portal venous invasion (PVI) as HCC-NCL (21% vs. 19%); however, the frequency of tumor thrombus at the first branch of the portal vein (PV) or extension to the trunk or the opposite side of the PV was significantly higher in HCC-CL (8% vs. 2%). HCC-CL had similar OS rates compared to HCC-NCL; however, HCC-CL showed significantly poorer RFS. Although there were no significant differences among the three surgical procedures, blood loss and complication rates tended to be higher in cases who underwent an isolated caudate lobectomy. Tumor size ≥5 cm, PVI, and liver fibrosis or cirrhosis (LF or LC) were independent unfavorable factors for both OS and RFS. PIVKA-II ≥120 mAU/ml was an independent unfavorable factor for RFS.

CONCLUSION

HCC-CL presented a poorer RFS rate. Patients with a tumor size ≥5 cm, PIVKA-II ≥120 mAU/ml, portal venous invasion, and LF or LC should be diligently followed up as these cases have a high risk of recurrence.

Laparoscopic Anatomic Spiegel Lobectomy With the Extrahepatic Glissonean Approach

BACKGROUND

Laparoscopic Spiegel lobectomy is difficult due to its deep location and being surrounded by gross vessels. Extrahepatic Glissonean pedicle transection method has been proposed by Takasaki during open liver resections. This approach can be successfully performed during laparoscopic anatomic hepatectomy. Here we describe pure laparoscopic Spiegel lobectomy using the extrahepatic Glissonean approach.

METHODS

The patient was a 25-year-old male with a background of hepatitis B. A 1.5 cm×1.7 cm mass was detected in liver Spiegel lobe and highly suspected to be an hepatocellular carcinoma. The liver function was normal (Child-pugh 5), and alpha-fetoprotein was within the normal ranges. Laparoscopic Spiegel lobectomy using extrahepatic Glissonean approach was proposed. The hilar plate was partly detached from liver parenchyma, and 2 Glissonean pedicles of the Spiegel lobe were dissected, clamped and divided. Liver parenchymal transection was performed using the harmonic scalpel.

RESULTS

The operation time was 196 minutes without Pringle's maneuver. Estimated blood loss was <50 mL, and no blood transfusion was required. The patient recovered well and was discharged on postoperative day 6. There was no complication. Pathologic findings support the diagnosis of hepatocellular carcinoma.

CONCLUSIONS

Laparoscopic Spiegel lobectomy using the extrahepatic Glissonean approach is safe and feasible.

Developments and perspectives of laparoscopic liver resection in the treatment of hepatocellular carcinoma

Laparoscopic liver resection (LLR) was introduced in the early 1990s, initially for partial resection of the anterolateral segments, from where it has expanded in a stepwise fashion. Movement restriction makes bleeding control demanding. Managing pneumoperitoneum pressure with inflow control can inhibit venous bleeding and create a dry surgical field for easier hemostasis. Since the lack of overview leads to disorientation, simulation and navigation with imaging studies have become important. Improved direct access to the liver inside the rib cage can be obtained in LLR, reducing destruction of the associated structures and decreasing the risk of refractory ascites and liver failure, especially in patients with a cirrhotic liver. Although LLR can be performed as bridging therapy to transplantation for severe cirrhosis, its impact on expanding the indications of liver resection (LR) and the consequent survival benefits must be evaluated. For repeat LR, LLR is advantageous by producing fewer adhesions and reducing the need for adhesiolysis. The laparoscopic approach facilitates better access in a small operative field between adhesions. Further evaluations are needed for repeat anatomical resection, since alterations of the anatomy and surrounding scars and adhesions of major vessels have a larger impact.

Laparoscopic caudate lobe resection for the treatment of hepatolithiasis

Background

To explore the safety and feasibility of laparoscopic caudate lobe (CL) resection for the treatment of hepatolithiasis.

Methods

A retrospective study of nine patients who received laparoscopic CL resection for treatment of hepatolithiasis in our hospital from January 2013 to April 2017. Of these cases, we studied the patients' demographic data, the operation time, blood loss, post-operative hospital stay, post-operative complications and prognosis.

Results

All the nine cases are performed successfully; the post-operative recovery was symptom free except for one case of post-operative bile leakage. Among them, there were six cases of CL resection in combination with other lobe, three cases of separate CL resection, and three cases of whole CL resection. The average operative time was 310 min (Range: 180-450 min), the average intraoperative blood loss was 530 ml (Range: 100-1000 ml), average post-operative hospital stay was 9 days (Range: 6-13 days), average total hospital stay was 10 days (Range: 9-19 days). Intraoperative calculi exhaustion rate was 66.7% (6/9), which at the end of treatment was 88.9% (8/9). No cases had calculi recurrence.

Conclusion

The application of laparoscopic CL resection is feasible and safe.

Laparoscopic liver resection: a review of current indications and surgical techniques

Laparoscopic liver resection (LLR) has been the most impressive development in the field of liver surgery in recent two decades. Technical innovations and experience accumulation have made LLR a safe and effective procedure with faster postoperative recovery. Despite the fast spreading of the procedure, details regarding the indications, oncological outcomes and technical essentials were still disputable. To address these issues, two international consensus conferences were hold to update the knowledge in this field. The statements of the both conferences were not conclusive and more high-quality researches are required. In this article, we reviewed the development and the current state of LLR. Indications, outcomes, surgical techniques and devices used in LLR were also discussed.

Surgical Technique and Clinical Analysis of Twelve Cases of Isolated Laparoscopic Resection of the Hepatic Caudate Lobe

Objective

To describe the surgical procedures of laparoscopic caudate lobectomy and analyze its clinical efficiency for treating cancer.

Methods

Twelve consecutive patients of hepatocellular carcinoma, hepatic hemangioma, and focal nodular hyperplasia who received laparoscopic caudate lobectomy in Qilu Hospital of Shandong University from January 2013 to January 2017 were included in this study. The clinical data, intraoperative parameters, and postoperative outcomes were assessed.

Results

All 12 patients received totally laparoscopic technique. The operative time was 140.8 ± 95.34 minutes. The average estimated blood loss was 97.92 ± 90.54 ml, and no blood transfusions were required. The mean duration of hospital stay was 9.17 ± 2.88 days. There was no perioperative complication or patient mortality in this series.

Conclusions

Laparoscopic caudate lobectomy is safe and feasible in the selected patients.

Systematic review of the feasibility and future of laparoscopic liver resection for difficult lesions

Laparoscopic liver resection (LLR) is now performed widely, but is difficult to accomplish in some anatomical locations, such as the posterosuperior segments (S7 and S8) and caudate lobe (S1). An international survey revealed that lesions in these locations are less frequently indicated for LLR than those in other segments. Recent reports from experienced centers document several case series and present technical tips for treating such lesions. The lateral approach using intercostal (transdiaphragmatic) trocars was reported to be useful for lesions in the posterosuperior segments with a semi- to full-decubitus position. The thoracoscopic approach was also reported to be useful for lesions just under the diaphragm dome, but the tumor location and patient selection should be considered carefully because pneumoperitoneum pressure and Pringle's maneuver cannot be applied. Several case series have described the feasibility of LLR for caudate lobe lesions, with similar operative outcomes to lesions in the posterosuperior segments, but this demands technical expertise. The caudal view of laparoscopy is advantageous for approaching the caudate lobe. We conducted a systematic review to clarify the feasibility of LLR for difficult lesions and discuss its current and future status.

First quarter century of laparoscopic liver resection

The beginnings of laparoscopic liver resection (LLR) were at the start of the 1990s, with the initial reports being published in 1991 and 1992. These were followed by reports of left lateral sectionectomy in 1996. In the years following, the procedures of LLR were expanded to hemi-hepatectomy, sectionectomy, segmentectomy and partial resection of posterosuperior segments, as well as the parenchymal preserving limited anatomical resection and modified anatomical (extended and/or combining limited) resection procedures. This expanded range of LLR procedures, mimicking the expansion of open liver resection in the past, was related to advances in both technology (instrumentation) and technical skill with conceptual changes. During this period of remarkable development, two international consensus conferences were held (2008 in Louisville, KY, United States, and 2014 in Morioka, Japan), providing up-to-date summarizations of the status and perspective of LLR. The advantages of LLR have become clear, and include reduced intraoperative bleeding, shorter hospital stay, and - especially for cirrhotic patients-lower incidence of complications (e.g., postoperative ascites and liver failure). In this paper, we review and discuss the developments of LLR in operative procedures (extent and style of liver resections) during the first quarter century since its inception, from the aspect of relationships with technological/technical developments with conceptual changes.

Laparoscopic Total Caudate Lobectomy for Hepatocellular Carcinoma

BACKGROUND

Caudate lobe is located in the deep dorsal area of the liver between the portal triad and the inferior vena cava (IVC). Torrential bleeding can occur from the IVC and short hepatic veins during dissection. Isolated total caudate lobe resection is still rare and technically demanding. We herein present a video on the technical aspect of laparoscopic total caudate lobectomy.

METHOD

A 61-year-old woman was admitted for recurrent hepatocellular carcinoma detected on imaging. She had history of multifocal hepatocellular carcinoma in July 2015 and underwent open cholecystectomy, segment 6 and segment 8 tumorectomy. Ten months later, the computed tomography scan and magnetic resonance imaging showed a 1 cm arterial enhancing lesion in segment I (S1) with no other foci of recurrence. Laparoscopic total caudate lobectomy was contemplated.

RESULTS

The operative time was 270 minutes. The intraoperative blood loss was 200 mL and blood transfusion was not necessary. The patient was discharged on the fourth postoperative day without any complications.

CONCLUSION

This report showed the safety and feasibility of laparoscopic total caudate lobectomy. Nonetheless, it is a technically demanding procedure. It should be performed in carefully selected patients and by experienced hepatobiliary surgeons proficient in laparoscopic liver resection.

Surgical Techniques for Totally Laparoscopic Caudate Lobectomy

OBJECTIVES

The purpose of this study is to identify the safety and feasibility of laparoscopic caudate lobectomy.

BACKGROUND

Caudate lobectomy has been considered as technically difficult because of the deep location of the caudate lobe and its proximity to great vessels. Due to the technical difficulty, laparoscopic caudate lobectomy was not feasible in patients with malignancy in the caudate lobe.

METHODS

Six consecutive patients with caudate hepatic malignancy received laparoscopic caudate lobectomy at Samsung Medical Center from September 2007 to May 2014. Demographic data, intraoperative parameters, and postoperative outcomes were assessed.

RESULTS

All procedures for these 6 patients with caudate malignancy were completed with totally laparoscopic technique. Only 1 patient who had hepatocellular carcinoma in the Spiegel lobe underwent partial caudate lobectomy, and others underwent complete caudate lobectomy. The mean tumor size was 2.65 cm (range 0.9-5.1 cm). The mean operative time was 382 minutes (range 168-615 minutes) and none required transfusion. The mean duration of hospital stay was 8 days (range 6-13 days). There was no perioperative complication and patient mortality in this series. The resected margins of the specimens were tumor free (R0 resections, range 0.1-1.2 cm). The mean follow-up period was 56 months (range 12.9-93.7 months). No patient died during the follow-up period.

CONCLUSIONS

Our experience demonstrated that laparoscopic caudate lobectomy is safe and feasible in selected patients with malignancy in the caudate lobe.

Prospective, single-center cohort study analyzing the efficacy of complete laparoscopic resection on recurrent hepatocellular carcinoma

Background

Laparoscopic hepatectomy is increasingly being used to treat hepatocellular carcinoma (HCC). However, few studies have examined the treatment of recurrent HCC in patients who received a prior hepatectomy. The present prospective study compared the clinical efficacy of laparoscopic surgery with conventional open surgery in HCC patients with postoperative tumor recurrence.

Methods

We conducted a prospective study of 64 patients, all of whom had undergone open surgery once before, who were diagnosed with recurrent HCC between June 2014 and November 2014. The laparoscopic group (n = 31) underwent laparoscopic hepatectomy, and the control group (n = 33) underwent conventional open surgery. Operation time, intraoperative blood loss, surgical margins, postoperative pain scores, postoperative time until the patient could walk, anal exsufflation time, length of hospital stay, and inpatient costs were compared between the two groups. The patients were followed up for 1 year after surgery, and relapse-free survival was compared between the two groups.

Results

All surgeries were successfully completed. No conversion to open surgery occurred in the laparoscopic group, and no serious postoperative complications occurred in either group. No significant difference in inpatient costs was found between the laparoscopic group and the control group (P = 0.079), but significant differences between the two groups were observed for operation time (116.7 ± 37.5 vs. 148.2 ± 46.7 min, P = 0.031), intraoperative blood loss (117.5 ± 35.5 vs. 265.9 ± 70.3 mL, P = 0.012), postoperative time until the patient could walk (1.6 ± 0.6 vs. 2.2 ± 0.8 days, P < 0.05), anal exsufflation time (2.1 ± 0.3 vs. 2.8 ± 0.7 days, P = 0.041), visual analogue scale pain score (P < 0.05), postoperative hepatic function (P < 0.05), and length of hospital stay (4.5 ± 1.3 vs. 6.0 ± 1.2 days, P = 0.014). During the 1-year postoperative follow-up period, 6 patients in each group had recurrent HCC on the side of the initial operation, but no significant difference between groups was observed in the recurrence rate or relapse-free survival. In the laparoscopic group, operation time, postoperative time until the patient could walk, anal exsufflation time, and inpatient costs were not different (P > 0.05) between the patients with contralateral HCC recurrence (n = 18) and those with ipsilateral HCC recurrence (n = 13). However, intraoperative blood loss was significantly less (97.7 ± 14.0 vs. 186.3 ± 125.6 mL, P = 0.012) and the hospital stay was significantly shorter (4.2 ± 0.7 vs. 6.1 ± 1.7 days, P = 0.021) for the patients with contralateral recurrence than for those with ipsilateral recurrence.

Conclusions

For the patients who previously underwent conventional open surgical resection of HCC, complete laparoscopic resection was safe and effective for recurrent HCC and resulted in a shorter operation time, less intraoperative blood loss, and a faster postoperative recovery than conventional open surgery. Laparoscopic resection was especially advantageous for the patients with contralateral HCC recurrence.

Feasibility of laparoscopic liver resection for caudate lobe: technical strategy and comparative analysis with anteroinferior and posterosuperior segments

BACKGROUND

Although laparoscopic liver resection (LLR) is now considered a standard procedure in peripheral segments, there are few reports on laparoscopic segment 1 (Sg1) resection. The aim of this study was to assess both safety and feasibility of Sg1 LLR.

METHODS

From 2000 to 2014, all patients who underwent LLR were identified from a prospective database. Patients with resection of Sg1 (Sg1 group) were compared with those with resection of anteroinferior segments (AI group: segments 3, 4b, 5, 6) or posterosuperior segments (PS group: segments 4a, 7, 8), in terms of tumor characteristics, surgical treatment, and short-term outcomes.

RESULTS

There were 15, 151, and 67 patients in Sg1, AI, and PS groups. Tumor size and tumor number were similar between the three groups (p = 0.139, p = 0.102). Operative time was significantly shorter in Sg1 (150 min) and AI group (135 min) compared with PS group (180 min) (p = 0.021). Median blood loss was notably higher in PS group (140 ml) compared with Sg1 group (75 ml) and AI group (10 ml) (p = 0.001). No mortality was observed in all groups. Postoperative complication rate was 20.0 % with Sg1 group, 14.6 % with AI group, and 20.9 % with PS group (p = 0.060). The rate of major complication was significantly higher in Sg1 group (13.3 %) and PS group (11.9 %) compared with AI group (4.0 %) (p = 0.042). Resection margins were clear in all Sg1 and PS group patients, whereas two (1.3 %) patients in AI group had R1 margins (p = 0.586).

CONCLUSION

The laparoscopic approach of isolated resection located in the caudate lobe is a feasible and curative surgical option in selected patients.

A Left-Sided, Purely Laparoscopic Approach for Anatomic Caudate Hepatectomy: A Single-Center Experience

BACKGROUND

Laparoscopic caudate hepatectomy, which is a challenging procedure, has been reported sporadically. However, there is no standardized surgical technique, and the safety and feasibility of this procedure remain controversial.

MATERIALS AND METHODS

A left-sided, purely laparoscopic approach for anatomic caudate hepatectomy was used for 11 selected patients in our institution. The procedure and technique of laparoscopic caudate hepatectomy were described. Perioperative data of these patients were retrospectively reviewed.

RESULTS

The 11 cases included two subgroups: laparoscopic isolated caudate hepatectomy (n = 4) and laparoscopic combined caudate and left hemihepatectomy (n = 7). There were three major steps for anatomic caudate hepatectomy. Two conversions were required (18.2%). Two complications (Clavien Grades I and II) occurred but no deaths.

CONCLUSIONS

The left-sided, purely laparoscopic approach for anatomic caudate hepatectomy is safe and feasible in selected patients. This procedure can be performed by hepatobiliary surgeons with abundant experience in laparoscopic liver surgery.

Safety and feasibility of laparoscopic hepatectomy for hepatocellular carcinoma in the posterosuperior liver segments

BACKGROUND

Laparoscopic hepatectomy (LH) is mostly performed to treat solitary tumors in the anterolateral liver segments (II, III, IVb, V, and VI). Few reports are available on LH for the treatment of hepatocellular carcinoma (HCC) in the posterosuperior liver segments (I, IVa, VII, and VIII), especially in association with cirrhosis. The purpose of this study was to investigate the safety and feasibility of LH in this clinical setting.

METHODS

From January 2008 to January 2011, LH was conducted in 56 patients with HCC in the posterosuperior liver segments (PS group) and 70 patients with HCC in the anterolateral liver segments (AL group) who were admitted to Southwest Hospital of the Third Military Medical University, Chongqing, China. The clinical data and follow-up results in the two groups of patients were retrospectively analyzed.

RESULTS

No patient in either group died during the perioperative period. Statistically significant differences were found between the PS and AL groups in terms of the operation time (217.5 ± 63.7 vs 176.8 ± 48.4 min, P = 0.000), volume of blood loss (295.5 ± 186.8 vs 220.4 ± 164.2 ml, P = 0.001), conversion rate from laparoscopy to laparotomy (17.9 vs 7.1 %, P = 0.031), transfusion rate (16.1 vs 4.3 %, P = 0.025), cases of hepatic inflow occlusion (38/18 vs 28/42, P = 0.002), and duration of inflow occlusion (41.3 ± 16.3 vs 31.3 ± 12.2 min, P = 0.005). Parameters with no significant differences between the two groups of patients included tumor size (4.0 ± 1.5 vs 3.9 ± 1.7 cm, P = 0.894), resection margin (1.7 ± 0.7 vs 1.8 ± 0.6 cm, P = 0.102), postoperative complication rate (16.1 vs 17.1 %, P = 0.873), postoperative anal exhaust time (3.2 ± 0.6 vs 3.0 ± 0.6 days, P = 0.361), and postoperative hospital stay (10.5 ± 2.7 vs 10.0 ± 0.6 days, P = 0.102). The serum alanine transaminase (ALT) and aspartate aminotransferase (AST) levels on postoperative days 1 and 3 were significantly higher in the PS group than in the AL group. There were no significant differences in the postoperative levels of the serum total bilirubin, albumin, ALT, or AST levels on postoperative days 5 and 7. After 2-48 months of follow-up, no significant differences in the 1- and 3-year overall survival rates (92.9 vs 95.7 %, P = 0.487 and 76.0 vs 76.8 %, P = 0.878, respectively) or 1- and 3-year disease-free survival rates (85.7 vs 87.1 %, P = 0.797 and 57.6 vs 56.4 %, P = 0.806, respectively) were noted between the two groups.

CONCLUSIONS

LH is safe and feasible for selected patients with HCC in the posterosuperior segments of the liver.

How Far Can We Go with Laparoscopic Liver Resection for Hepatocellular Carcinoma? Laparoscopic Sectionectomy of the Liver Combined with the Resection of the Major Hepatic Vein Main Trunk

Although the reports of laparoscopic major liver resection are increasing, hepatocellular carcinomas (HCCs) close to the liver hilum and/or major hepatic veins are still considered contraindications. There is virtually no report of laparoscopic liver resection (LLR) for HCC which involves the main trunk of major hepatic veins. We present our method for the procedure. We experienced 6 cases: 3 right anterior, 2 left medial, and 1 right posterior extended sectionectomies with major hepatic vein resection; tumor sizes are within 40–75 (median: 60) mm. The operating time, intraoperative blood loss, and postoperative hospital stay are within 341–603 (median: 434) min, 100–750 (300) ml, and 8–44 (18) days. There was no mortality and 1 patient developed postoperative pleural effusion. For these procedures, we propose that the steps listed below are useful, taking advantages of the laparoscopy-specific view. (1) The Glissonian pedicle of the section is encircled and clamped. (2) Liver transection on the ischemic line is performed in the caudal to cranial direction. (3) During transection, the clamped Glissonian pedicle and the peripheral part of hepatic vein are divided. (4) The root of hepatic vein is divided in the good view from caudal and dorsal direction.

Totally laparoscopic caudate lobe resection: technical aspects and literature review

The particular anatomic location of the hepatic caudate lobe between the hilar plate and inferior vena cava means that it is still considered unsuitable for laparoscopic measures and a difficult site even for conventional surgery. Here we describe the first case to be reported in the literature of caudate lobe resection for a single metastasis from breast adenocarcinoma that was completed using an exclusively laparoscopic procedure and a simplified scheme involving the placement of 4 trocars, without any need for conversion or the Pringle maneuver. The patient was 31 years old with a history of radical right mastectomy and chemotherapy. The patient's postoperative course was uneventful and she was discharged 4 days after the surgery. Twelve months on, she is currently alive and disease free.

Laparoscopic liver resection for lesions adjacent to major vasculature: feasibility, safety and oncological efficiency

BACKGROUND AND OBJECTIVES

Laparoscopic liver resection for lesions adjacent to major vasculature can be challenging, and many would consider it a contraindication. Recently, however, laparoscopic liver surgeons have been pushing boundaries and approached some of these lesions laparoscopically. We assessed feasibility, safety and oncological efficiency of this laparoscopic approach for these lesions.

METHODS

This is a monocenter study (2003-2013) describing technique and outcomes of laparoscopic liver resection for lesions adjacent to major vasculature: <2 cm from the portal vein (main trunk and first division), hepatic arteries or inferior vena cava.

RESULTS

Thirty-seven patients underwent laparoscopic liver resection (LLR) for a lesion adjacent to major vasculature. Twenty-four (65%) resections were for malignant disease and 92% R0 resections. Conversion occurred in three patients (8%). Mean operative time was 313 min (standard deviation (SD) ± 101) and intraoperative blood loss 400 ml (IQR 213-700). Clavien-Dindo complications > II occurred in two cases (5%), with no mortality. Lesions at <1 cm were larger (7.2 cm (2.7-14) vs. 3 cm (2.5-5), p = 0.03) and operation time was longer (344 ± 94 vs. 262 ± 92 min, p = 0.01) than lesions at 1-2 cm from major vasculature.

CONCLUSIONS

Lesions <2 cm from major hepatic vasculature do not represent an absolute contraindication for LLR when performed by experienced laparoscopic liver surgeons in selected patients.

Robot-assisted laparoscopic partial caudate lobe resection for hepatocellular carcinoma in cirrhotic liver

PURPOSE

To evaluate the technical feasibility and safety of robot-assisted laparoscopic partial caudate lobe resection using the robotic surgical system.

MATERIALS AND METHODS

This is a report of the use of robot-assisted laparoscopic partial caudate lobe resection on 2 patients with hepatocellular carcinoma.

RESULTS

Robot-assisted laparoscopic partial caudate lobe resection was completed successfully in these 2 patients. The operating time was 137 and 150 minutes, respectively. The blood loss was 137 and 150 mL, respectively. They were able to tolerate liquids on the second postoperative day. Both patients recovered from the operation. They were discharged 4 and 5 days after the operation, respectively. The resected margins of both specimens were tumor free (R0 resections).

CONCLUSIONS

Robot-assisted laparoscopic partial caudate lobe resection is a feasible and safe procedure. Our results demonstrate the advantages of robotic system on short-term outcomes and suggest the extended indication of minimally invasive hepatectomy even in the technically challenging anatomic area.

Laparoscopic caudate hepatectomy for cancer--an innovative approach to the no-man's land

BACKGROUND

Caudate hepatectomy remains a surgical challenge in spite of recent advances in laparoscopic technique. Hepatic tumor in the caudate lobe is usually deeply located in the center of the liver and close to the vena cava and hepatic hilum. Thus, lesion in this region was considered as a contraindication of laparoscopic hepatectomy. Only sporadic reports could be found in the literature. The aim of this study is to review the safety and feasibility of laparoscopic hepatectomy for lesions in the caudate lobe.

METHODS

Nine consecutive patients with caudate hepatic tumor received laparoscopic caudate hepatectomy in our institute from February 2006 to July 2010. One patient with hepatic adenoma was excluded from the analysis. Demographic data, intraoperative parameters, and postoperative outcomes of the remaining eight patients were assessed.

RESULTS

All procedure for these eight patients with caudate hepatic tumors (size 0.9-4.5 cm) were completed with totally laparoscopic technique except one in which additional left hepatectomy was also done. The average operative time was 254 min (range 210-345 min) and estimated blood loss was 202 ml (range 10-1,000 ml), and average length of postoperative hospital stay was 6.9 days (range 4-11 days). There was no perioperative complications and patient mortality in this series.

CONCLUSIONS

Our experience demonstrated that laparoscopic hepatectomy is a safe and feasible procedure for caudate hepatic tumors in selected patients.

Laparoscopic liver resection for centrally located tumors close to the hilum, major hepatic veins, or inferior vena cava

BACKGROUND

Despite the accumulation of favorable results from laparoscopic liver resection (LLR), centrally located tumors close to the hilum, major hepatic veins, or inferior vena cava (IVC) are still considered contraindications for LLR. We evaluated the feasibility and safety of LLR for centrally located tumors.

METHODS

Of the 182 patients who underwent LLR for benign or malignant tumors between September 2003 and June 2010, the clinical outcomes of 13 patients with tumors within 1 cm or less of the major vascular structures, including the hilum, major hepatic veins, and IVC, were retrospectively analyzed. The perioperative outcomes of the patients were compared with those of the 23 patients who underwent open liver resection for tumors with similar criteria in terms of location and size during the same period.

RESULTS

Anatomic liver resection, including left and right hepatectomy, central bisectionectomy, right anterior and posterior sectionectomy, and extended S4 segementectomy, was performed in 10 patients. The remaining 3 patients underwent subsegmentectomy for tumors located in the Spiegel lobe of the caudate. There was no open conversion or postoperative mortality. Compared with the open group, the laparoscopic group showed similar rates of intraoperative transfusion, postoperative complications, and operative time. However, the laparoscopic group spent less time in the hospital postoperatively and had shorter resection margins. After a median follow-up of 34.3 months, there were no statistically significant differences between the 2 groups in reference to the overall survival rates and the disease-free survival rates.

CONCLUSION

This study shows that LLR can be safely performed in selected patients with centrally located tumors close to the liver hilum, the major hepatic veins, or the IVC that were previously considered to be contraindications for LLR. Recent technical developments in the performance of laparoscopic major liver resection may have contributed to the successful application of LLR for centrally located tumors.

Auxiliary partial orthotopic liver transplantation for adult onset type II citrullinemia

Adult-onset type II citrullinemia (CTLN2) is a disorder caused by an inborn error of metabolism affecting the liver. CTLN2 is an autosomal recessive disorder characterized by recurrent encephalopathy with hyperammonemia due to highly elevated plasma levels of citrulline and ammonia, caused by a deficiency of argininosuccinate synthetase in the liver. A small number of patients have undergone liver transplantation with favorable results. In Korea, the limitations of the deceased donor pool have made living donor liver transplantation a common alternative treatment option. We report the case of a patient with type II citrullinemia who was treated successfully with auxiliary partial orthotopic liver transplantation (APOLT) from a living donor. This is the first description of an APOLT for a patient with adult onset type II citrullinemia in Korea.

Liver Surgery for Hepatocellular Carcinoma: Laparoscopic versus Open Approach

In this study, we try to compare the benefit of laparoscopic versus open operative procedures. Patients and Methods. One hundred and sixteen patients underwent laparoscopic liver resection (LR) and another 208 patients went for open liver resection (OR) for hepatocellular carcinoma (HCC). Patients' selection for open or laparoscopic approach was not randomized. Results. The CLIP score for LR and OR was 0.59 ± 0.75 and 0.86 ± 1.04, respectively, (P = .016). The operation time was 156.3 ± 308.2 and 190.9 ± 79.2 min for LR and OR groups, respectively. The necessity for blood transfusion was found in 8 patients (6.9%) and 106 patients (50.9%) for LR and OR groups. Patients resumed full diet on the 2nd and 3rd postoperative day, and the average length of hospital stay was 6 days and 12 days for LR and OR groups. The complication rate and mortality rate were 0% and 6.0%, 2.9% and 30.2% for LR and OR groups, respectively. The 1-yr, 3-yr, and 5-yr survival rate was 87.0%, 70.4%, 62.2% and 83.2%, 76.0%, 71.8% for LR and OR group, respectively, of non-significant difference. From these results, HCC patients accepted laparoscopic or open approach were of no significant differences between their survival rates.

[Value of laparoscopic liver resection]

Whereas in other fields of surgery minimally invasive techniques have replaced the open surgery approach, liver resection is still a domain of conventional surgery. However, it is internationally emerging that laparoscopic hepatic surgery will become more important by conceptional improvements. This article describes the technical aspects of laparoscopic liver resection, in particular the procedure with respect to the individual liver segments. The advantages and disadvantages of the minimally invasive technique and also the indications for laparoscopic liver resection will be discussed.