Laparoscopic major hepatectomy: a systematic literature review and comparison of 3 techniques. Ann Surg. 2013;257:205-213. [PMID: 23263192 DOI: 10.1097/sla.0b013e31827da7fe]

Short-term outcomes of laparoscopic extended hepatectomy versus major hepatectomy: a single-center experience

INTRODUCTION

Laparoscopic major hepatectomy (LMH) remains restricted to a few specialized centers and poses a challenge to surgeons performing laparoscopic resections. Laparoscopic extended resections are even more complex and rarely conducted.

METHODS

From a single-institution database, we compared the short-term outcomes of patients who underwent major and extended laparoscopic resections, stratifying the entire retrospective cohort into four groups: right hepatectomy, left hepatectomy, right extended hepatectomy, and left extended hepatectomy. Patient demographics, tumor characteristics, operative variables, and especially postoperative outcomes were evaluated.

RESULTS

250 patients underwent major and extended laparoscopic liver resections, including 160 right, 31 right extended, 36 left, and 23 left extended laparoscopic hepatectomies. The most common indication for resection was colorectal liver metastases (64%). Laparoscopic extended hepatectomy (LEH) showed significantly longer operative time, more blood loss, need for Pringle maneuver, conversion to open surgery, higher rates of liver failure, postoperative ascites, and intra-abdominal hemorrhage, R1 margins and length of stay when compared with the LMH group. Mortality rates were similar between groups. Multivariate analysis revealed intraoperative blood transfusion (OR = 5.1[CI-95%: 1.15-6.79]; p = 0.02) as an independent predictor for major complications.

CONCLUSIONS

LEH showed to be feasible, however with higher blood loss and significantly associated to major complications.

A meta-analysis between robotic hepatectomy and conventional open hepatectomy

Current meta-analysis was performed to compare robotic hepatectomy (RH) with conventional open hepatectomy (OH) in terms of peri-operative and postoperative outcomes. PubMed, EMBASE, and the Cochrane Library were all searched up for comparative studies between RH and OH. RevMan5.3 software and Stata 13.0 software were used for statistical analysis. Nineteen studies with 1747 patients who received RH and 23,633 patients who received OH were included. Pooled results indicated that patients who received RH were generally younger than those received OH (P < 0.00001). Moreover, RH was associated with longer operative time (P = 0.0002), less intraoperative hemorrhage (P < 0.0001), lower incidence of intraoperative transfusion (P = 0.003), lower incidence of postoperative any morbidity (P < 0.00001), postoperative major morbidity (P = 0.0001), mortalities with 90 days after surgery (P < 0.0001), and shorter length of postoperative hospital stay (P < 0.00001). Comparable total hospital costs were acquired between RH and OH groups (P = 0.46). However, even at the premise of comparable R0 rate (P = 0.86), RH was associated with smaller resected tumor size (P < 0.00001). Major hepatectomy (P = 0.02) and right posterior hepatectomy (P = 0.0003) were less frequently performed in RH group. Finally, we concluded that RH was superior to OH in terms of peri-operative and postoperative outcomes. RH could lead to less intraoperative hemorrhage, less postoperative complications and an enhanced postoperative recovery. However, major hepatectomy and right posterior hepatectomy were still less frequently performed via robotic approach. Future more powerful well-designed studies are required for further exploration.

Hepatectomy After Conversion Therapy with Hepatic Arterial Infusion Chemotherapy, Tyrosine Kinase Inhibitors and Anti-PD-1 Antibodies for Initially Unresectable Hepatocellular Carcinoma

Background

Most patients with hepatocellular carcinoma (HCC) are not candidates for liver resection. We investigated the clinicopathological characteristics and prognosis of patients with initially unresectable HCC who underwent hepatectomy after conversion therapy with hepatic arterial infusion chemotherapy (HAIC), tyrosine kinase inhibitors (TKIs), and anti-PD-1 antibodies.

Materials and Methods

Patients with initially unresectable HCC who received HAIC combined with TKIs and anti-PD-1 antibodies followed by hepatectomy between December 2020 and December 2022, were retrospectively analyzed. Patient characteristics, tumor characteristics, treatment efficacy, perioperative characteristics, pathological characteristics, and survival outcomes were summarized and analyzed.

Results

67 patients were enrolled in this study. Patients were treated with 3 sessions (range:2-6 sessions) of combination therapy and were performed with hepatectomy in 4 months (range:1.4-17.8 months) after the initiation of the combination therapy. The median size of tumor shrinkage was 4.7 cm (range:0.9-11.7 cm). A pathological complete response (pCR) was achieved in 34.3% of the patients (n = 23). The median recurrence-free survival (RFS) was 19.3 months and the median overall survival (OS) was 28.7 months. Patients who achieved pCR had a better RFS (P = 0.004) and those without microscopic vascular invasion (MVI) had a better prognosis (RFS, P = 0.011; OS, P = 0.023). Multivariable logistic analysis revealed that the tumor number was associated with pCR.

Conclusion

Hepatectomy after conversion therapy with HAIC, TKIs, and anti-PD-1 antibodies is a feasible treatment strategy for patients with unresectable HCC. This treatment strategy is associated with a promising prognosis.

Validity of the Institut Mutualiste Montsouris classification system for robotic liver resection

BACKGROUND

The Institut Mutualiste Montsouris (IMM) classification system is one of several widely accepted difficulty scoring systems for laparoscopic liver resections. Nothing is yet known about the applicability of this system for robotic liver resections.

METHODS

We conducted a retrospective review of 359 patients undergoing robotic hepatectomies between 2016 and 2022. Resections were classified into low, intermediate, and high difficulty level. Data were analyzed utilizing ANOVA of repeated measures, 3 x 2 contingency tables, and area under the receiving operating characteristic (AUROC) curves. Data are presented as median (mean ± SD).

RESULTS

Of the 359 patients, 117 were classified as low-difficulty level, 92 as intermediate, and 150 as high. The IMM system correlates well with tumor size (p = 0.002). The IMM system was a strong predictor of intraoperative outcomes including operative duration (p<0.001) and estimated blood loss (EBL) (p<0.001). The IMM system also showed a strong calibration for predicting an open conversion (AUC=0.705) and intraoperative complications (AUC=0.79). In contrast, the IMM system was a poor predictor of postoperative complications, mortality, and readmission.

CONCLUSION

The IMM system provides a strong correlation with intraoperative, but not postoperative outcomes. A dedicated difficulty scoring system should be developed for robotic hepatectomy.

Robotic versus laparoscopic liver resection in posterosuperior region: a retrospective study of consecutive cases

BACKGROUND

Minimally invasive liver resection of the posterosuperior region is considered a challenging procedure due to poor exposure and difficult bleeding control. A robotic approach is supposed to be advantageous in posterosuperior segmentectomy. Its benefits over laparoscopic liver resection (LLR) remain undetermined. This study compared robotic liver resection (RLR) and LLR in the posterosuperior region performed by a single surgeon.

MATERIALS AND METHODS

We retrospectively analyzed consecutive RLR and LLR performed by a single surgeon between December 2020 and March 2022. Patient characteristics and perioperative variables were compared. A 1:1 propensity score matched (PSM) analysis was performed between both groups.

RESULTS

The analysis included 48 RLR and 57 LLR procedures in the posterosuperior region. After PSM analysis, 41 cases of both groups were retained. In pre-PSM cohort, the operative time in the RLR group was significantly shorter than in the LLR group (160 vs. 208 min, P = 0.001), especially in radical resection of malignant tumors (176 vs. 231 min, P = 0.004). The total Pringle maneuver duration was also markedly shorter (40 vs. 51 min, P = 0.047), and the estimated blood loss in the RLR group was lower (92 vs. 150 mL, P = 0.005). The postoperative hospital stay (POHS) in the RLR group was significantly shorter (5.4 vs. 7.5 days, P = 0.048). In PSM cohort, operative time in the RLR group was also significantly shorter (163 vs. 193 min, P = 0.036), and the estimated blood loss was lower (92 vs. 144 mL, P = 0.024). However, the total Pringle maneuver duration and POHS showed no significant difference. The complications were similar between two groups in both pre-PSM and PSM cohorts.

CONCLUSION

RLR in the posterosuperior region was as safe and feasible as LLR. RLR was associated with reduced operative time and blood loss than LLR.

Laparoscopic and Robot-Assisted Hepatic Surgery: An Historical Review

Hepatic surgery is a rapidly expanding component of abdominal surgery and is performed for a wide range of indications. The introduction of laparoscopic cholecystectomy in 1987 was a major change in abdominal surgery. Laparoscopic surgery was widely and rapidly adopted throughout the world for cholecystectomy initially and then applied to a variety of other procedures. Laparoscopic surgery became regularly applied to hepatic surgery, including segmental and major resections as well as organ donation. Many operations progressed from open surgery to laparoscopy to robot-assisted surgery, including colon resection, pancreatectomy, splenectomy thyroidectomy, adrenalectomy, prostatectomy, gastrectomy, and others. It is difficult to prove a data-based benefit using robot-assisted surgery, although laparoscopic and robot-assisted surgery of the liver are not inferior regarding major outcomes. When laparoscopic surgery initially became popular, many had concerns about its use to treat malignancies. Robot-assisted surgery is being used to treat a variety of benign and malignant conditions, and studies have shown no deterioration in outcomes. Robot-assisted surgery for the treatment of malignancies has become accepted and is now being used at more centers. The outcomes after robot-assisted surgery depend on its use at specialized centers, the surgeon's personal experience backed up by extensive training and maintenance of international registries. Robot-assisted hepatic surgery has been shown to be associated with slightly less intraoperative blood loss and shorter hospital lengths of stay compared to open surgery. Oncologic outcomes have been maintained, and some studies show higher rates of R0 resections. Patients who need surgery for liver lesions should identify a surgeon they trust and should not be concerned with the specific operative approach used. The growth of robot-assisted surgery of the liver has occurred in a stepwise approach which is very different from the frenzy that was seen with the introduction of laparoscopic cholecystectomy. This approach allowed the identification of areas for improvement, many of which are at the nexus of engineering and medicine. Further improvements in robot-assisted surgery depend on the combined efforts of engineers and surgeons.

Recent Advances in Local Thermal Ablation Therapy for Hepatocellular Carcinoma

Image-guided local thermal ablation (LTA) plays an important role in the treatment of hepatocellular carcinoma (HCC), especially in patients with HCC who are not suitable for hepatectomy. Radiofrequency ablation (RFA) and microwave ablation (MWA) are the most widely used LTA clinically. Radiofrequency ablation can achieve the best result; that is, a similar therapeutic effect as hepatectomy if the tumor ≤3 cm, while MWA can effectively ablate tumors ≤5 cm. Local thermal ablation has an advantage over liver resection in terms of minimally invasive surgery and can achieve a comparable prognosis and efficacy to liver resection. For borderline liver function, selecting LTA as the first-line therapy may bring more benefits to patients with cirrhosis background. In addition, a combination of multiple therapies for HCC is a good choice, such as LTA combined with transcatheter arterial chemoembolization (TACE), which can achieve a better prognosis than single therapy for larger tumors. For patients who are awaiting liver transplantation, LTA is a good choice. The main problem of LTA needed to be solved is to prevent the local tumor recurrence after ablation in patients with HCC.

Recent Advances in Local Thermal Ablation Therapy for Hepatocellular Carcinoma

Image-guided local thermal ablation (LTA) plays an important role in the treatment of hepatocellular carcinoma (HCC), especially in patients with HCC who are not suitable for hepatectomy. Radiofrequency ablation (RFA) and microwave ablation (MWA) are the most widely used LTA clinically. Radiofrequency ablation can achieve the best result; that is, a similar therapeutic effect as hepatectomy if the tumor ≤3 cm, while MWA can effectively ablate tumors ≤5 cm. Local thermal ablation has an advantage over liver resection in terms of minimally invasive surgery and can achieve a comparable prognosis and efficacy to liver resection. For borderline liver function, selecting LTA as the first-line therapy may bring more benefits to patients with cirrhosis background. In addition, a combination of multiple therapies for HCC is a good choice, such as LTA combined with transcatheter arterial chemoembolization (TACE), which can achieve a better prognosis than single therapy for larger tumors. For patients who are awaiting liver transplantation, LTA is a good choice. The main problem of LTA needed to be solved is to prevent the local tumor recurrence after ablation in patients with HCC.

Shorter operation time and improved surgical outcomes in laparoscopic donor right hepatectomy compared with open donor right hepatectomy

BACKGROUND

Pure laparoscopic donor right hepatectomy is a complex procedure, and the safety and feasibility of this operation remain unclear. This study aimed to evaluate the clinical outcomes and learning curve of this operation performed by a single surgeon.

METHODS

We retrospectively reviewed the initial 100 donors who underwent pure laparoscopic donor right hepatectomy or open donor right hepatectomy by a single surgeon from December 2012 to May 2019. Endpoints analyzed included intraoperative results, postoperative complications, and learning curve, which was evaluated using the cumulative sum method based on the operation time. We divided the pure laparoscopic donor right hepatectomy group into initial and recent groups based on the time point of overcoming the learning curve.

RESULTS

The operative time was significantly shorter in the recent pure laparoscopic donor right hepatectomy group (n = 57; 181.0 ± 35.7 min) than in the open donor right hepatectomy (n = 50; 203.0 ± 37.3 min) and initial pure laparoscopic donor right hepatectomy (n = 43; 282.2 ± 59.2 min) groups (P < .001). Moreover, the length of hospital stay in the recent pure laparoscopic donor right hepatectomy group was significantly reduced compared to that in the open donor right hepatectomy group (7.7 ± 1.2 vs 5.8 ± 1.4; P < .001). The complication rate was reduced from 10% in the open donor right hepatectomy group and 8% in the initial pure laparoscopic donor right hepatectomy group to 2% in the recent pure laparoscopic donor right hepatectomy group.

CONCLUSION

As technology advances, the surgical outcomes of pure laparoscopic donor right hepatectomy are comparable and the operation time of pure laparoscopic donor right hepatectomy is superior to those of open donor hepatectomy.

Rethinking the Barcelona clinic liver cancer guidelines: Intermediate stage and Child-Pugh B patients are suitable for surgery?

According to Barcelona Clinic Liver Cancer recommendations, intermediate stage hepatocellular carcinomas (stage B) are excluded from liver resection and are referred to palliative treatment. Moreover, Child-Pugh B patients are not usually candidates for liver resection. However, many hepatobiliary centers in the world manage patients with intermediate stage hepatocellular carcinoma or Child-Pugh B cirrhosis with liver resection, maintaining that hepatic resection is not contraindicated in selected patients with non–early-stage hepatocellular carcinoma and without normal liver function. Several studies demonstrate that resection provides the best survival benefit for selected patients in very early/early and even in intermediate stages of Barcelona Clinic Liver Cancer classification, and this treatment gives good results in the setting of multinodular, large tumors in patients with portal hypertension and/or Child-Pugh B cirrhosis. In this review we explore this controversial topic, and we show through the literature analysis how liver resection may improve the short- and long-term survival rate of carefully selected Barcelona Clinic Liver Cancer B and Child-Pugh B hepatocellular carcinoma patients. However, other large clinical studies are needed to clarify which patients with intermediate stage hepatocellular carcinoma are most likely to benefit from liver resection.

Operative Time, Age, and Serum Albumin Predict Surgical Morbidity After Laparoscopic Liver Surgery

Background. Laparoscopic liver resection (LLR) has emerged as a considerable alternative to conventional liver surgery. However, the increasing complexity of liver resection raises the incidence of postoperative complications. The aim of this study was to identify risk factors for postoperative morbidity in a monocentric cohort of patients undergoing LLR. Methods. All consecutive patients who underwent LLR between 2015 and 2019 at our institution were analyzed for associations between complications with demographics and clinical and operative characteristics by multivariable logistic regression analyses. Results. Our cohort comprised 156 patients who underwent LLR with a mean age of 60.0 ± 14.4 years. General complications and major perioperative morbidity were observed in 19.9% and 9.6% of the patients, respectively. Multivariable analysis identified age>65 years (HR = 2.56; P = .028) and operation time>180 minutes (HR = 4.44; P = .001) as significant predictors of general complications (Clavien ≥1), while albumin<4.3 g/dl (HR = 3.66; P = .033) and also operative time (HR = 23.72; P = .003) were identified as predictors of major postoperative morbidity (Clavien ≥3). Conclusion. Surgical morbidity is based on patient- (age and preoperative albumin) and procedure-related (operative time) characteristics. Careful patient selection is key to improve postoperative outcomes after LLR.

Correlation Between Type of Retrieval Incision and Postoperative Outcomes in Laparoscopic Liver Surgery: A Critical Assessment

Background: At the end of a laparoscopic major hepatectomy, an incision wide enough for specimen retrieval is required. Classically, Pfannenstiel (PF) incision is the type of access favored as service incision in laparoscopy. However, in specific settings the use of a midline (ML) incision can be favorable, with doubtful impaction on the outcomes of a purely laparoscopic operation. The aim of this study was to investigate on clinical outcomes after laparoscopic hemihepatectomies using PF/ML incisions in comparison with open. Methods: The institutional clinical database of the Hepatobiliary Division at San Raffaele Hospital (Milan, Italy) was retrospectively reviewed identifying cases of laparoscopic and open hemihepatectomies. Three analyses were performed: whole laparoscopic versus open; ML versus open; PF versus ML. Clinical outcomes such as intraoperative blood loss, operative time, postoperative morbidity, motility resumption, perceived pain, and length of stay (LOS) were used for comparisons. Results: Laparoscopy was confirmed to be superior to open approach also in the present series in terms of lower blood loss (300 versus 400 mL, P = .041), fewer complications (14.2% versus 25.9%, P = .024), shorter hospitalization (5 versus 7 days, P = .033), and enhanced recovery in terms of better pain control (P = .035) and mobility resumption (P = .047). Similar outcomes were observed comparing ML alone with open (estimated blood loss 300 mL versus 400 mL, P = .039; complications 13.1% versus 25.9%, P = .037; LOS 5 days versus 7 days, P = .04; lower pain perception, P = .048 and faster mobility resumption, P = .046). No significant differences were observed in postoperative outcomes of PF versus ML. Conclusions: Suprapubic and ML incisions at the end of a pure laparoscopic case lead to comparable outcomes between each other. The adoption of ML incision for specimen retrieval does not affect outcomes of minimal invasiveness.

Laparoscopic right posterior anatomic liver resections with Glissonean pedicle-first and venous craniocaudal approach

BACKGROUND

Laparoscopic segment 7 segmentectomy and segment 6-7 bisegmentectomy are challenging resections because of the posterior position and the lack of landmarks. The anatomy of the right posterior Glissonean pedicle and the caudal view of laparoscopy make such resections suitable for the Glissonean pedicle-first approach.

METHODS

The study population included all consecutive patients treated with laparoscopic liver resection from August 2019 to February 2020. The approach is based on the ultrasonographic identification of the right posterior or segmental pedicle from the dorsal side of the liver after complete mobilization. The pedicle of interest is isolated through mini-hepatotomy and clamped. The segment anatomy is defined by ischemia. The transection starts from the ventral side, close to the right hepatic vein that is exposed and followed craniocaudally.

RESULTS

Ten patients underwent anatomical laparoscopic resection of right posterolateral segments. There were 7 colorectal liver metastases, 2 hepatocellular carcinoma, and 1 biliary cysto-adenoma. Five patients underwent Sg7 resection, one patient underwent a Sg7 subsegmentectomy, and 4 underwent Sg6-7 bisegmentectomy. The Glissonean pedicle-first approach was feasible in eight patients. The craniocaudal approach to the RHV was feasible in six patients, not indicated in three cases and was abandoned in one patient for technical difficulty. There was no operative morbidity or mortality. Median post-operative hospital stay was 5 days.

CONCLUSIONS

The Glissonean pedicle-first approach is safe and effective for laparoscopic anatomic resections of the right posterior sector. The craniocaudal approach to right hepatic vein from the ventral side is a convenient procedure to follow the segmental anatomy deep in the parenchyma.

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.

Impact of Surgeon Volume on Outcomes and Expenditure Among Medicare Beneficiaries Undergoing Liver Resection: the Effect of Minimally Invasive Surgery

BACKGROUND

Although the role of annual surgeon volume on perioperative outcomes after liver resection (LR) has been investigated, there is a paucity of data regarding the impact of surgeon volume on outcomes of minimally invasive LR (MILR) versus open LR (OLR).

METHODS

Patients undergoing LR between 2013 and 2015 were identified in the Medicare inpatient Standard Analytic Files. Patients were classified into three groups based on surgeons' annual caseload: low (≤ 2 cases), medium (3-5 cases), or high (≥ 6 cases). Short-term outcomes and expenditures of LR, stratified by surgeon volume and minimally invasive surgery (MIS), were examined.

RESULTS

Among 3403 surgeons performing LR on 7169 patients, approximately 90% of surgeons performed less than 5 liver resections per year for Medicare patients. Only 7.1% of patients underwent MILR (n = 506). After adjustment, the likelihood of experiencing a complication and death within 90 days decreased with increasing surgeon volume. Outcomes of open and MILR among low- or high-volume surgeon groups, including rates of complications, 30- and 90-day readmission and mortality were similar. However, the difference of average total episode payment between open and MIS was higher in the high-volume surgeon group (low volume: $2929 vs. medium volume: $2333 vs. high volume: $7055).

CONCLUSION

Annual surgeon volume was an important predictor of outcomes following LR. MILR had comparable results to open LR among both the low- and high-volume surgeons.

Laparoscopic liver resection: indications, limitations, and economic aspects

Background

Minimally invasive techniques have increasingly found their way into liver surgery in recent years. A multitude of mostly retrospective analyses suggests several advantages of laparoscopic over open liver surgery. Due to the speed and variety of simultaneous technical and strategic developments, it is difficult to maintain an overview of the current status and perspectives in laparoscopic liver surgery.

Purpose

This review highlights up-to-date aspects in laparoscopic liver surgery. We discuss established indications with regard to their development over time as well as continuing limitations of applied techniques. We give an assessment based on the current literature and according to our own center experiences, not least with regard to a highly topical cost discussion.

Conclusions

While in the beginning mainly benign tumors were laparoscopically operated on, liver metastasis and hepatocellular carcinoma are now among the most frequent indications. Technical limitations remain and should be evaluated with the overall aim not to endanger quality standards in open surgery. Financial aspects cannot be neglected with the necessity of cost-covering reimbursement.

ERAS in minimally invasive hepatectomy

Open hepatectomy is associated with significant post-operative morbidity and mortality profile. The use of minimally invasive approach for hepatectomy can reduce the post-operative complication profile and total length of hospital stay. Enhanced recovery after surgery (ERAS) programs involve evidence-based multimodal care pathways designed to achieve early recovery for patients undergoing major surgery. This review will discuss the published evidence, challenges and future directions for ERAS in minimally invasive hepatectomy.

Outcomes of Minimally Invasive Versus Open Major Hepatic Resection

Introduction: Minimally invasive major hepatic resection (MIMHR) is increasingly being performed in tertiary centers using either hand-assisted laparoscopic surgery (HALS) or totally laparoscopic surgery (TLS). The outcomes data of MIMHR are scarce, especially in comparison to open major hepatic resection (OMHR). Our aim was to compare 90-day outcomes in major hepatic resections when minimally invasive approaches are attempted. Methods and Procedures: At our institution, minimally invasive liver resection was formally introduced in January 2007, initially using the HALS approach. Since then, the use of TLS approach has increased. We collected data on all patients who underwent major liver resection between January 2007 and December 2017 at our institution. In an intention to treat fashion, we then compared MIMHR to OMHR. Results: From January 2007 to December 2017, 669 patients underwent liver resection. Of these, 203 patients (30%) underwent major hepatic resection and MIMHR and OMHR were performed in 68 (33%) and 135 (67%) patients, respectively. The rate of conversion from minimally invasive to open was 30.9%. Overall, there were no significant differences in 90-day mortality (2.9% versus 1.5%; P = .499) or major complications (14.7% versus 14.8%; P = .985). MIMHR was associated with a shorter average postoperative hospital stay (6.2 days versus 7.9 days; P = .0110) and shorter average ICU stay (0.66 days versus 0.90 days; P = .0299) compared with OMHR. Conclusions: The minimally invasive approach to major liver resection is a safe and reasonable alternative to an open approach when performed by a surgeon experienced with the relevant surgical techniques. MIMHR may be associated with similar outcomes and a shorter postoperative hospital stay with no increase in 90-day postoperative complications to OMHR.

Initial Report: A Novel Intraoperative Navigation System for Laparoscopic Liver Resection Using Real-Time Virtual Sonography

Recent progress in navigation has revealed problems involving non-rigid registration for hepatic surgery. With the increasing popularity of laparoscopic liver surgery, a new laparoscopic navigation system is necessary. This study involved an in-vitro demonstration of a 3-dimensional printer model and in vivo demonstration in four patients. For the in vitro examination, a position detecting unit attached at 33 cm and 13 cm distance conditions from the tip of the electrocautery was examined eight times at the marked points on the liver surface eight times respectively. The differences between the simulation and the authentic dissecting plane were conventionally investigated in vivo. In vitro, the errors of the 33 cm and 13 cm distance model were7.8 ± 3.5 mm (mean ± SD), and 3.3 ± 1.0 mm, respectively. The mean differences of the dissection plane were within 10 mm. The potentiality and safety of the novel navigation system was confirmed, although further investigation is recommended.

Laparoscopic versus open hemihepatectomy: a 1:1 matched analysis

Background

Laparoscopic liver resection has increased rapidly and procedure has almost extended to all the types of liver resection. Major liver resections, such as hemihepatectomies, were still innovative procedures in the exploration phase and continued cautious introduction of major laparoscopic liver resections was recommended by experts. The study aims to evaluate the safety of laparoscopic hemihepatectomy (LH) by the comparing with open hemihepatectomy (OH).

Methods

Patients who underwent hemihepatectomy in Sir Run Run Shaw Hospital from January 2012 to December 2017 were reviewed. A 1:1 matched study was performed between LH group and OH group. Patients who fail to be matched were excluded. Perioperative outcomes, complications and cost were compared between LH group and OH group.

Results

One hundred and thirty-eight exact matches for all matching variables were found between LH patients and OH patients. The length of postoperative hospital stay of LH group was significant shorter than the OH group (P=0.031). Intraoperative blood loss (P=0.005) and transfusion rate (P=0.001) in the LH group were significantly lower than the OH group. There was no mortality in either group. Twenty-six patients in LH group and 31 patients in OH group had complications and all of them recovered uneventfully after immediate treatments. The hospital expense of LH group was significantly higher than OH group (P<0.001).

Conclusions

These results lead us to believe that LH is a safe procedure and it could be performed routinely in experienced laparoscopic centers.

The Extrahepatic Glissonian Versus Hilar Dissection Approach for Laparoscopic Formal Right and Left Hepatectomies in Patients with Hepatocellular Carcinoma

BACKGROUND

Few studies have been performed to evaluate the value of the Glissonian approach (GA) for laparoscopic formal hemihepatectomy. The purpose of this study was to compare the outcomes of extrahepatic GA with those of the conventional hilar dissection approach for laparoscopic formal right and left hepatectomies in patients with hepatocellular carcinoma (HCC).

METHODS

Between January 2015 and October 2017, a total of 95 HCC patients who underwent pure laparoscopic formal hemihepatectomies, of whom 49 underwent the GA, were included in this study. After a 1:1 propensity score matching, 42 laparoscopic GA hepatectomies were compared to 42 conventional approach (CA) hepatectomies. We have analyzed perioperative and oncologic outcomes of the two different operative approaches for HCC treatments.

RESULTS

The GA did not increase the postoperative overall complication rates (P = 0.415) or the mean comprehensive complication index (P = 0.414) when compared with the CA. However, the operative time was significantly shorter (P = 0.006), and intraoperative blood loss was significantly lower (P < 0.001) in the GA group than in the CA group. There were no significant differences between the GA and CA groups regarding 3-year overall survival rate (P = 0.765) or 3-year disease-free survival rate (P = 0.622).

CONCLUSIONS

Pure laparoscopic extrahepatic GA hemihepatectomy is safe and feasible, and it was associated with similar complication rates and equivalent 3-year survival outcomes compared to the conventional approach in selected patients with HCC.

Laparoscopic Liver Resection: Experience of 436 Cases in One Center

BACKGROUND

To report experience of laparoscopic liver resection (LLR) in one center.

METHODS

We retrospectively reviewed 436 consecutive LLRs in 411 patients between December 2010 and December 2016. On the basis of the 2008 Louisville Statement, we divided the 436 cases into two groups: Simple Group (n = 203) and Difficult Group (n = 233).

RESULTS

The indications were HCC (n = 194), colorectal cancer liver metastasis (n = 156), benign tumors (n = 62), hepatolithiasis (n = 2), and other malignant lesions (n = 22). The median tumor size was 24 mm (range 3 to 130). Procedures of LLR included wedge resection (n = 230), one segmentectomy (n = 8), two segmentectomies (n = 12), left lateral sectionectomy (n = 75), right hepatectomy (n = 52), left hepatectomy (n = 31), extended right hepatectomy (n = 2), extended left hepatectomy (n = 5), central bisectionectomy (n = 3), right posterior sectionectomy (n = 12), and right anterior sectionectomy (n = 6). The median operative time was 228 min (range 9-843) and median blood loss was 150 ml (range 2-3500). Twenty-five cases required blood transfusion (5.7%). Conversion to open surgery was required in six cases (1.4%). The mean length of stay was 6.4 ± 2.9 days. Overall complication rate was 9.4% and major complication rate was 5%. One patient died of liver failure on the thirtieth postoperative day after a right hepatectomy. We had higher median blood loss (200 vs. 100 ml; p < 0.001), higher transfusion rate (8.2 vs. 2.9%; p = 0.020), longer median operative time (297 vs. 164 min; p < 0.001), higher conversion rate (2.6 vs. 0%; p = 0.021), higher complication rate (14.2 vs. 3.9%; p < 0.001), and longer mean postoperative hospital stay (6.8 ± 2.9 vs. 5.9 ± 3.0 days; p < 0.001) in the Difficult Group.

CONCLUSIONS

Laparoscopic liver resection is safe for selected patients in the Difficult Group. On the basis of the 2008 Louisville Statement, selection criteria of LLR are helpful to predict the difficulty of the operation and the postoperative outcomes of LLR.

Propensity Score-Matched Analysis of Pure Laparoscopic Versus Hand-Assisted/Hybrid Major Hepatectomy at Two Western Centers

BACKGROUND

Laparoscopic major hepatectomy is expanding, but little data exist comparing surgical approaches. The aim of this study was to test the hypothesis that pure laparoscopic liver resection (PLAP) has advantages over hand-assisted (HALS) or hybrid (HYB) resection for major hemi-hepatectomy at two western centers.

METHODS

Using propensity score matching, 65 cases of HALS + HYB (18 hand-assisted and 47 hybrid) were matched to 65 cases of PLAP. Baseline characteristics were well matched for gender, age, ASA score, Childs A cirrhosis, right/left hepatectomy, malignancy, tumor size, and type between the groups.

RESULTS

The HALS + HYB group had 27 right and 38 left major hepatectomies (n = 65) versus 29 right and 36 left (n = 65) in the PLAP group (p = NS). The median number of lesions resected was 1 in each group, with median size 5.6 cm (HALS + HYB) versus 6.0 cm (PLAP), (p = NS). The HALS + HYB group had shorter OR time (240 versus 330 min, p < 0.01), and less blood loss (EBL 150 ml vs. 300 ml, p < 0.01) versus the PLAP group, respectively. Median length of stay (LOS) was 4 days with HALS + HYB versus 5 days in the PLAP group (p = 0.02). There were no significant differences in use of the Pringle maneuver, transfusion rate, ICU stay, post-op morbidity, liver-specific complications, or R0 resection. Pain regimen/usage in each group is provided. There were no 30/90-day deaths in either group.

CONCLUSION

This is the first reported series of propensity score matching of HALS + HYB versus PLAP for major hepatectomy. The HALS + HYB group had non-inferior OR time, blood loss, and LOS versus the PLAP group, while the other perioperative parameters were comparable. We conclude that minimally invasive liver resection with either PLAP or HALS + HYB technique yields excellent results.

Resection of liver metastases from breast cancer: a multicentre analysis

BACKGROUND

Surgery is becoming more practical and effective than conservative treatment in improving the poor outcomes of patients with breast cancer liver metastasis (BCLM). However, there is no generally acknowledged set of standards for identifying BCLM candidates who will benefit from surgery.

METHODS

Between January 2011 and September 2018, 67 female BCLM patients who underwent partial hepatectomy were selected for analysis in the present study. Prognostic factors after hepatectomy were determined. Univariate and multivariate analyses were performed to identify predictors of overall survival (OS) and intrahepatic recurrence-free survival (IHRFS).

RESULTS

The 1-, 3- and 5-year OS of patients treated with surgery was 93.5%, 73.7% and 32.2%, respectively, with a median survival time of 57.59 months. The Pringle manoeuvre [hazard radio (HR) = 0.117, 95% CI0.015-0.942, p = 0.044] and an increased interval between breast surgery and BCLM diagnosis (HR0.178, 95% CI 0.037-0.869, p = 0.033) independently predicted improved overall survival for BCLM patients. The 1-, 2- and 3-year IHRFS of patients who underwent surgery was 62.8, 32.6% and 10.9%, respectively, with a median intrahepatic recurrence-free survival time of 13.47 months. Moderately differentiated tumours (HR  0.259, 95% CI 0.078-0.857, p = 0.027) and the development of liver metastasis more than 2 years after breast surgery (HR  0.270, 95% CI 0.108-0.675, p = 0.005) might be predictors of increased IHRFS.

CONCLUSIONS

An interval of more than 2 years between breast cancer surgery and liver metastasis seems to be an indication of liver surgery in BCLM patients. The Pringle manoeuvre and moderately differentiated tumours are potential predictors associated with OS and IHRFS, respectively, as benefits from liver resection. Studies with increased sample sizes are warranted to validate our results.

Early experience of laparoscopic liver resection: A single institution experience with 37 consecutive cases

Backgrounds/Aims

Laparoscopic liver resection (LLR) has evolved and broadened in scope. While open liver resections are currently being performed safely in our hospital, LLRs are being implemented in fewer cases. The aim of this study was to review our initial experience in LLR to assess early outcomes of the procedure.

Methods

A retrospective chart review was conducted for 37 patients who underwent laparoscopic liver resections for various indications between January 2014 and July 2017 by a single surgeon who had performed 161 open liver resections and 50 live donor hepatectomies during the same period.

Results

Of 37 laparoscopic liver resections performed, male to female ratio was 23 to 4. Their mean age was 61.4 years. There were 13 cases of wedge resections, 7 cases of left lateral sectionectomy, 9 cases of left hepatectomy, and 8 cases of right hepatectomy. Pathology included hepatocellular carcinoma (n=20), cholangiocarcinoma (n=3), intrahepatic duct stones (n=6), metastatic liver carcinoma (n=6), primary neuroendocrine tumor of liver (n=1), and huge hemangioma (n=1). The mean operation time was 174.7 minutes (range, 40–410 minutes). Mean blood loss was 200.5 ml (range, 10–2200 ml). There were no open-conversion cases. There were no intraoperative or postoperative complications except that a case of severe portal vein stenosis in the laparoscopic right hepatectomy occurred postoperatively. The patient underwent reoperation (portal vein resection and anastomosis, stenting). The mean hospital stay was 8.7 days (range, 2–44 days).

Conclusions

Even though our experience in laparoscopic liver resection is still developing, our results are comparable to those of other studies. Therefore, an experienced surgeon in performing open liver resection should be able to perform the laparoscopic liver resection safely.

Standardization of operative technique in minimally invasive right hepatectomy: improving cost-value relationship through value stream mapping in hepatobiliary surgery

BACKGROUND

With current emphasis on improving cost-quality relationship in medicine, it is imperative to evaluate cost-value relationships for surgical procedures. Previously the authors demonstrated comparable clinical outcomes for minimally invasive right hepatectomy (MIRH) and open right hepatectomy (ORH). MIRH had significantly higher intraoperative cost, though overall costs were similar.

METHODS

MIRH was decoded into its component critical steps using value stream mapping, analyzing each associated cost. MIRH technique was prospectively modified, targeting high cost steps and outcomes were re-examined. Records were reviewed for elective MIRH before (pre-MIRH n = 50), after (post MIRH n = 25) intervention and ORH (n = 98), between January 1, 2008 and November 30, 2016.

RESULTS

Average overall cost was significantly lower for post-standardization MIRH (post-MIRH $21 768, pre-MIRH $28 066, ORH $33 020; p < 0.001). Average intraoperative blood loss was reduced with MIRH (167, 292 and 509 mL p < 0.001). Operative times were shorter (147, 190 and 229 min p < 0.001) and LOS was reduced for MIRH (3, 4, 7 days p < 0.002).

CONCLUSIONS

Using a common quality improvement tool, the authors established a model for cost effective clinical care. These tools allow surgeons to overcome personal or traditional biases such as stapler choices, but most importantly eliminate non-value added interventions for patients.

A Comparison of Open and Minimally Invasive Surgery for Hepatic and Pancreatic Resections Among the Medicare Population

INTRODUCTION

Minimally invasive surgery (MIS) has become standard of care for many gastrointestinal surgical procedures. Despite possible clinical benefits, MIS may be underutilized in some populations. The aim of this study was to access the utilization of MIS among Medicare patients undergoing hepatopancreatic procedures and define clinical outcomes, as well as costs, of minimally invasive techniques compared with the conventional open approach.

METHODS

The Medicare Provider Analysis and Review (MEDPAR) Inpatient Files were reviewed to identify Medicare patients who underwent pancreatic and liver procedures between 2013 and 2015. Primary outcomes of the analysis included perioperative clinical outcomes such as rates of complications, index hospitalization length-of-stay (LOS), failure-to-rescue, rates, and causes of 90-day readmission, as well as 90-day mortality. Secondary outcomes were Medicare payments for index hospitalization and readmission. Multivariable logistic regression was used to investigate the impact of MIS on clinical outcomes and health expenditures.

RESULTS

A total of 13,716 (90.6%) patients underwent open resection, while MIS was performed in 1424 (9.4%) patients. LOS was shorter among patients undergoing MIS (mean 7.3 ± SD 7.3) versus open (mean 9.3 ± SD 9.1) surgery (p < 0.001). The incidence of perioperative complications was lower following MIS (open 25.5%, n = 3492 vs. MIS 17.2%, n = 245) (p < 0.001). Rates of failure-to-rescue were similar among patients undergoing an open versus MIS pancreatic procedure (open 19.4%, n = 271 vs. MIS 13.4%, n = 17) (p = 0.09). In contrast, 90-day readmission (open 31.1%, n = 1630 vs. MIS 24.1%, n = 201, p < 0.001), as well as 90-day mortality (open 7.7%, n = 404 vs. MIS 4.2%, n = 35, p < 0.001) were lower among patients undergoing pancreatic resections via an MIS approach. In contrast, failure-to-rescue and readmission, as well as mortality, were all comparable among patients undergoing a liver resection, regardless as to whether the operation was performed open or via an MIS approach (all p > 0.05). Mean total payments for open pancreatic surgery were on average $1421 higher in the open versus MIS pancreatic group (p = 0.01); in contrast, there was no difference in the overall payment for hepatic resection (p > 0.05).

CONCLUSION

The MIS approach was underutilized among patients undergoing liver and pancreatic procedures. MIS was associated with lower complication and readmission and shorter LOS, as well as comparable/slightly lower Medicare payments, compared with the open approach. The MIS approach should strongly be considered among older patients undergoing liver and pancreatic procedures.

Laparoscopic left lateral section procurement in living liver donors: A single center propensity score-matched study

BACKGROUND

Laparoscopic living donor liver procurement for transplantation has increased in popularity over the past decade. The purpose of this study was to compare the laparoscopic and open approaches in living donor left lateral sectionectomy (LLS) and to assess the safety and feasibility of this laparoscopic approach.

METHODS

A total of 103 living donor LLSs were performed at our center from May 2016 to December 2017. Of these, 35 were completely laparoscopic procedures, which represented the subject of this study. An additional 68 open living donor LLSs performed during the same period were studied as a comparison group. To overcome selection bias, LLS donors were balanced on a 1:1 ratio (laparoscopic [n = 35]: open [n = 35]) according to covariates with similar values. The PSM was based on the operation date, recipient age, diagnosis, recipient weight, and donor age.

RESULTS

There were significant differences between the laparoscopic and open LLS groups (P < 0.001) in terms of blood loss (96.8 ± 16.5 vs 155.8 ± 17.8 mL) as well as the duration of hospital stay (4 ± 0.4 vs 6.9 ± 0.5 days).

CONCLUSION

Laparoscopic LLS is a feasible and efficacious in the setting of a developed program with advanced laparoscopic expertise.

Laparoscopy-assisted versus open and pure laparoscopic approach for liver resection and living donor hepatectomy: a systematic review and meta-analysis

BACKGROUND

Laparoscopy-assisted (hybrid) liver surgery is considered a minimally invasive technique, however there are doubts regarding loss of the benefits of laparoscopy due to the use of an auxiliary incision. The aim of this study was to compare perioperative results of hybrid vs. open and hybrid vs. pure laparoscopic approach to liver resection for focal lesions and living donation.

METHODS

A systematic review was performed in Medline, EMBASE, Cochrane Library Central and LILACS databases. Perioperative outcomes were analyzed.

RESULTS

21 studies were included. Hybrid vs. open: operative time was lower in open group (mean difference [MD] = 34 min; 95%CI: 22-47; P < 0.001; N = 669). Hybrid technique was associated with a reduction in operative blood loss [MD = -43 ml; 95%CI: -74-(-13); P = 0.005, N = 1738]; shorter hospital stay [MD = -1.9 days; 95%CI: -3.2-(-0.5); P = 0.008; N = 833] and lower morbidity [risk difference (RD) = -0.05; 95%CI: -0.10-(-0.01); P = 0.010; N = 1359]. Hybrid vs. pure laparoscopic: There was no difference regarding blood loss, transfusion rate, hospital stay and morbimortality.

DISCUSSION

Hybrid technique had perioperative outcomes that were more in keeping with pure laparoscopic outcomes than open surgery. Hybrid liver surgery should be considered a minimally invasive approach.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Pure laparoscopic right hemihepatectomy using the caudodorsal side approach (with videos)

BACKGROUND

In our process of standardizing laparoscopic right hemihepatectomy (Lap-RH), we found several advantages of the laparoscopic caudate lobe first approach by using a unique laparoscopic caudodorsal view.

METHODS

Between April 2012 and October 2017, 21 patients underwent pure Lap-RH at our hospital. The mean patient age was 62 years (range 36-75 years), and there were more male than female patients (66.7%). Of 21 patients, 11 had hepatocellular carcinoma, eight had metastatic tumor, and the other two had focal nodular hyperplasia and refractory liver abscess. All 21 patients had Child-Pugh class A liver function. The surgical technique was recorded on video.

RESULTS

The mean operative time was 409 min (range 241-522 min), and the mean blood loss was 279 g (range 0-1,010 g). No procedure was converted to open surgery. With regard to postoperative complications, one patient had bile leakage from the stump of the main Glissonean branch and another patient had abscess formation in the subphrenic space. No postoperative bleeding, hepatic failure, and mortality occurred.

CONCLUSIONS

Our standardized procedure of Lap-RH using the unique laparoscopic caudodorsal view is not only feasible but also confers a true advantage of the laparoscopic approach.

The clinical and biological impacts of the implementation of fast-track perioperative programs in complex liver resections: A propensity score-based analysis between the open and laparoscopic approaches

BACKGROUND

The aim of this study was to evaluate the impact of the fast-track approach in patients undergoing complex liver procedures and to analyse factors that influence morbidity and functional recovery.

METHODS

Hepatic resections (2014-2016) were stratified according to difficulty score, obtaining a group of 215 complex resections (102 laparoscopic, 163 open). The laparoscopic group was matched by propensity score with open patients to obtain the minimally invasive liver surgery group (n = 102) and the open group (n = 102).

RESULTS

Groups were similar in terms of patient and disease characteristics. The postoperative morbidity was 31.4% in the minimally invasive liver surgery and 38.2% in the open group (P = .05), and functional recovery was shorter in the minimally invasive liver surgery (respectively 4 versus 6 days, P = .041). The adherence to fast-track was high in both groups, with several items with higher penetrance in the minimally invasive liver surgery group. Among factors associated with morbidity and functional recovery, a laparoscopic approach and strict adherence to a fast-track protocol resulted in protective factors.

CONCLUSION

The combination of minimally invasive approaches and fast-track protocols allows a reduced rate of postoperative morbidity and satisfactory functional recovery even in the setting of complex liver resections. When the laparoscopic approach is not feasible, strict adherence to a fast-track program is associated with the achievement of adequate results and should be implemented.

Total laparoscopic partial hepatectomy versus open partial hepatectomy for primary left-sided hepatolithiasis: A propensity, long-term follow-up analysis at a single center

BACKGROUND

This trial was performed to compare short- and long-term outcomes after laparoscopic left-sided hepatectomy and open left-sided hepatectomy. Left-sided hepatectomy is a novel, minimally invasive operative technique for primary left-sided hepatolithiasis, but it has not been accepted widely due to the limited information about short- and long-term outcomes, effectiveness, and safety compared with the open approach.

METHODS

Patients who underwent left-sided hepatectomy between January 2007 and December 2016 were reviewed and grouped into the open left-sided hepatectomy and left-sided hepatectomy groups, according to propensity score matching in terms of age, sex, body mass index, liver function, location of stone, hepatitis serology, and comorbidity on a ratio of 1:1.

RESULTS

No significant differences were observed in the demographic characteristics of the 200 patients included in the study. For the left-sided hepatectomy group (100 patients) when compared to the open left-sided hepatectomy group (100 patients, the duration of hospital stay was less (10.3 vs 14.7 days, P< .001), the incidence of postoperative biliary fistulas (5% vs 14%, P = .003) and overall morbidity were less (25% vs 45%, P = .003), out of bed return to activity was expedited (2.0 vs 2.7 days, P< .001), and the rate of stone recurrence in the long-term follow-up was les (5.1% vs 17%, P = .003).

CONCLUSION

Left-sided hepatectomy was associated with significantly lesser rate of stone recurrence, a shorter hospital stay, decreased morbidity and clinical biliary fistula rate, and expedited postoperative recovery compared with open left-sided hepatectomy.

Dissemination of Minimally Invasive Liver Resection for Primary Malignancy: Reevaluating Effectiveness

BACKGROUND

Experiences at specialized hepatobiliary centers have demonstrated efficacy of minimally invasive liver resection, but concerns exist regarding whether these procedures would remain effective once disseminated to a broad range of clinical practices. We sought to present the first comparison of MILR and open liver resection (OLR) for primary liver malignancy from a nationally representative cancer registry.

METHODS

Cases of liver and intrahepatic bile duct cancer were identified from the National Cancer Data Base Participant Use File. Mixed effects logistic regression and stratified Cox proportional hazards regression were used for analysis. A propensity score matched cohort was used as an alternative form of analysis to evaluate the robustness of results.

RESULTS

A total of 3236 cases were analyzed from 2010 to 2011 with 2581 OLR (80%) and 655 MILR (20%). Of the variation in patient selection for MILR 28.5% was related to treatment at a specific treatment center; however, the proportion of MILR was similar among low-, medium-, and high-volume centers. Overall 90-day mortality was lower at high-volume centers (odds ratio [OR] 0.58; 95% confidence interval [CI] 0.40-0.85) compared with low-volume centers. MILR was similar to OLR in both 90-day mortality and overall survival (OR 0.9; 95% CI 0.62-1.10) and hazard ratio [HR] 0.88 (95% CI 0.72-1.07), regardless of treatment center volume.

CONCLUSIONS

MILR for primary liver malignancy is used across a variety of practice settings, with similar outcomes to OLR. While volume is associated with short-term outcomes of liver resection as a whole, this relationship is not explained by adoption of MILR at low-volume centers.

Laparoscopic liver hanging maneuver through the retrohepatic tunnel on the right side of the inferior vena cava combined with a simple vascular occlusion technique for laparoscopic right hemihepatectomy

Background

Laparoscopic hepatectomy has been performed in many hospitals, with the development of the laparoscopic operation technique. However, performing complex laparoscopic hepatectomy, such as right hemihepatectomy, is still a challenge. The aim of this study was to describe the application of a simple vascular occlusion technique and new liver hanging maneuver (LHM) in complex laparoscopic hepatectomy, which are both advocated by Chen Xiaoping for open hepatectomy.

Methods

The clinical data of 29 consecutive patients who underwent laparoscopic right hemihepatectomy (LRH) from October 2014 to October 2016 were retrospectively analyzed. During operation, the vascular occlusion technique without hilus dissection and LHM through the retrohepatic avascular tunnel on the right side of the inferior vena cava were used.

Result

All 29 operations were successfully performed laparoscopically, while adopting Chen’s methods. The study consisted of 23 patients with hepatocellular carcinoma, four patients with intrahepatic cholangiocarcinoma, and two patients with hepatic metastasis of colonic carcinoma. The tumor size was 12.4 ± 1.9 cm. The operation time of LRH was 190.3 ± 49.9 min. The intraoperative blood loss of LRH was 281.7 ± 117.8 mL; five patients required blood transfusion, and the amount of blood transfusion was 300.0 ± 89.4 mL. No case was converted to open surgery, and no death occurred. All resulted in R0 resections. The median free margin was 20.1 ± 10.8 mm. The time of postoperative oral diet intake was 2.10 ± 0.96 days. The complication rate was 17.2%. The average hospital stay after operation was 10.0 ± 2.9 days.

Conclusion

Complex hepatectomy is a bloodless procedure that can be performed under a laparoscope safely using Chen’s methods of vascular occlusion technique and LHM.

Predictors and implications of unplanned conversion during minimally invasive hepatectomy: an analysis of the ACS-NSQIP database

BACKGROUND

Minimally-invasive hepatectomy (MIH) is increasingly utilized; however, predictors and outcomes for patients requiring conversion to an open procedure have not been adequately studied.

METHODS

The 2014-15 ACS-NSQIP database was analyzed. Unplanned conversion was compared to successful MIH and elective open hepatectomy.

RESULTS

Among 6918 hepatectomies, 1062 (15.4%) underwent attempted MIH: 989 laparoscopic, 73 robotic. Conversion occurred in 203 (19.1%). Compared to successful MIH, patients requiring unplanned conversion experienced higher rates of complications (34.5% vs 14.6%, p<0.001), including bile leaks (7.4% vs 2.8%, p=0.002), organ space infection (6.4% vs 2.9%, p=0.016), UTI (4.9% vs 1.2%, p=0.002), perioperative bleeding (21.2% vs 6.1%, p<0.001), DVT (3.0% vs 0.8%, p=0.024), and sepsis (5.9% vs 1.9%, p=0.001). Conversion led to greater LOS (5 days vs 3 days, p<0.001) and 30-day mortality (3.0% vs 0.5%, p=0.005). Compared to elective open hepatectomy, conversion was associated with greater perioperative bleeding (21.2% vs 15.3%, p = 0.037). On multivariate analysis, major hepatectomy (OR 2.21, p<0.001), concurrent ablation (OR 1.79, p=0.020), and laparoscopic approach (vs. robotic) (OR 3.22, p=0.014) were associated with conversion.

CONCLUSION

Analysis of this national database revealed unplanned conversion during MIH is associated with greater morbidity and mortality. MIH should be approached cautiously in patients requiring major hepatectomy.

Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a multimodal pathway developed to overcome the deleterious effect of perioperative stress after major surgery. In colorectal surgery, ERAS pathways reduced perioperative morbidity, hospital stay and costs. Similar concept should be applied for liver surgery. This study presents the specific ERAS Society recommendations for liver surgery based on the best available evidence and on expert consensus.

METHODS

A systematic review was performed on ERAS for liver surgery by searching EMBASE and Medline. Five independent reviewers selected relevant articles. Quality of randomized trials was assessed according to the Jadad score and CONSORT statement. The level of evidence for each item was determined using the GRADE system. The Delphi method was used to validate the final recommendations.

RESULTS

A total of 157 full texts were screened. Thirty-seven articles were included in the systematic review, and 16 of the 23 standard ERAS items were studied specifically for liver surgery. Consensus was reached among experts after 3 rounds. Prophylactic nasogastric intubation and prophylactic abdominal drainage should be omitted. The use of postoperative oral laxatives and minimally invasive surgery results in a quicker bowel recovery and shorter hospital stay. Goal-directed fluid therapy with maintenance of a low intraoperative central venous pressure induces faster recovery. Early oral intake and mobilization are recommended. There is no evidence to prefer epidural to other types of analgesia.

CONCLUSIONS

The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.

Critical appraisal of the impact of individual surgeon experience on the outcomes of laparoscopic liver resection in the modern era: collective experience of multiple surgeons at a single institution with 324 consecutive cases

BACKGROUND

Most studies analyzing the learning experience of laparoscopic liver resection (LLR) focused on the experience of one or two expert pioneering surgeons. This study aims to critically analyze the impact of individual surgeon experience on the outcomes of LLR based on the contemporary collective experiences of multiple surgeons at single institution.

METHODS

Retrospective review of 324 consecutive LLR from 2006 to 2016. The cases were performed by 10 surgeons over various time periods. Four surgeons had individual experience with <20 cases, four surgeons with 20-30 cases, and two surgeons with >90 cases. The cohort was divided into two groups: comparing a surgeon's experience between the first 20, 30, 40, and 50 cases with patients treated thereafter. Similarly, we performed subset analyses for anterolateral lesions, posterosuperior lesions, and major hepatectomies.

RESULTS

As individual surgeons gained increasing experience, this was significantly associated with older patients being operated, decreased hand-assistance, larger tumor size, increased liver resections, increased major resections, and increased resections of tumors located at the posterosuperior segments. This resulted in significantly longer operation time and increased use of Pringle maneuver but no difference in other outcomes. Analysis of LLR for tumors in the posterosuperior segments demonstrated that there was a significant decrease in conversion rates after a surgeon had experience with 20 LLR. For major hepatectomies, there was a significant decrease in morbidity, mortality, and length of stay after acquiring experience with 20 LLR.

CONCLUSION

LLR can be safely adopted today especially for lesions in the anterolateral segments. LLR for lesions in the difficult posterosuperior segments and major hepatectomies especially in cirrhosis should only be attempted by surgeons who have acquired a minimum experience with 20 LLR.

Hand-assisted Approach as a Model to Teach Complex Laparoscopic Hepatectomies: Preliminary Results

BACKGROUND

Currently, there are limited and scarce models to teach complex liver resections by laparoscopy. The aim of this study is to present a hand-assisted technique to teach complex laparoscopic hepatectomies for fellows in liver surgery.

MATERIALS AND METHODS

Laparoscopic hand-assisted approach for resections of liver lesions located in posterosuperior segments (7, 6/7, 7/8, 8) was performed by the trainees with guidance and intermittent intervention of a senior surgeon. Data as: (1) percentage of time that the senior surgeon takes the surgery as main surgeon, (2) need for the senior surgeon to finish the procedure, (3) necessity of conversion, (4) bleeding with hemodynamic instability, (5) need for transfusion, (6) oncological surgical margins, were evaluated.

RESULTS

In total, 12 cases of complex laparoscopic liver resections were performed by the trainee. All cases included deep lesions situated on liver segments 7 or 8. The senior surgeon intervention occurred in a mean of 20% of the total surgical time (range, 0% to 50%). A senior intervention >20% was necessary in 2 cases. There was no need for conversion or reoperation. Neither major bleeding nor complications resulted from the teaching program. All surgical margins were clear.

CONCLUSIONS

This preliminary report shows that hand-assistance is a safe way to teach complex liver resections without compromising patient safety or oncological results. More cases are still necessary to draw definitive conclusions about this teaching method.

Are Hybrid Liver Resections Truly Minimally Invasive? A Propensity Score Matching Analysis

BACKGROUND

Hybrid liver resection is considered a modality of minimally invasive surgery; however, there are doubts regarding loss of benefits of laparoscopy due to the use of an auxiliary incision. We compared perioperative results of patients undergoing hybrid × open and hybrid × pure laparoscopic resections.

METHODS

Consecutive patients undergoing liver resection between June 2008 and January 2016 were studied. Study groups were compared after propensity score matching (PSM).

RESULTS

Six hundred forty-four resections were included in the comparative analysis: 470 open, 120 pure laparoscopic, and 54 hybrids. After PSM, 54 patients were included in each group. Hybrid × open: hybrid technique had shorter operative time (319.5 ± 108.6 × 376.2 ± 155.8 minutes, P = .033), shorter hospital stay (6.0 ± 2.7 × 8.1 ± 5.6 days, P = .001), and lower morbidity (18.5% × 40.7%, P = .003). Hybrid × pure laparoscopic: hybrid group had lower conversion rate (0% × 13%, P = .013). There was no difference regarding estimated blood loss, transfusion rate, hospital stay, complications, or mortality.

CONCLUSIONS

Hybrid resection has better perioperative results than the open approach and is similar to pure laparoscopy. The hybrid technique should be considered a minimally invasive approach.

Early experience with totally laparoscopic major hepatectomies: single institution experience with 31 consecutive cases

BACKGROUND

Totally laparoscopic major hepatectomy (LMH) is a technically challenging procedure with limited studies mainly from high-volume expert centers reported. In this study, we report our initial experience with totally LMH.

METHODS

A retrospective review of a prospective database of 340 consecutive patients who underwent laparoscopic liver resection at a single institution was conducted. Thirty-one consecutive patients who underwent attempted totally LMH between March 2011 to December 2016 were identified. Major hepatectomies were defined as resection of ≥3 contiguous segments which included only right/left hepatectomies, extended hepatectomies or central hepatectomies.

RESULTS

The procedures included 11 right hepatectomies, one extended right hepatectomy, nine left hepatectomies (two including middle hepatic vein), two extended left hepatectomies, two left hepatectomies with caudate lobe and six central hepatectomies. The median tumor size was 40 (range, 12-100) mm and the median operation time was 435 (range, 245-585) min. Median blood loss was 500 (range, 100-1900) mls and 10 (32.3%) patients required blood transfusion. There were three (9.7%) open conversions of which two occurred during the first five cases. There was one (3.2%) major (>grade 2) morbidity and there were no 30-day/in-hospital mortalities or reoperations. The median postoperative stay was 5 (range, 3-14) days.

CONCLUSION

Our initial experience confirms the feasibility and safety of LMH. There was an increase in the number and proportion of LMH performed at our institution over time.