Laparoscopic versus open left lateral segmentectomy

International multicenter propensity score matched study on laparoscopic versus open left lateral sectionectomy

BACKGROUND

Despite a lack of high-level evidence, current guidelines recommend laparoscopic left lateral sectionectomy (LLLS) as the routine approach over open LLS (OLLS). Randomized studies and propensity score matched studies on LLLS vs OLLS for all indications, including malignancy, are lacking.

METHODS

This international multicenter propensity score matched retrospective cohort study included consecutive patients undergoing LLLS or OLLS in six centers from three European countries (January 2000-December 2016). Propensity scores were calculated based on nine preoperative variables and LLLS and OLLS were matched in a 1:1 ratio. Short-term operative outcomes were compared using paired tests.

RESULTS

A total of 560 patients were included. Out of 200 LLLS, 139 could be matched to 139 OLLS. After matching, baseline characteristics were well balanced. LLLS was associated with shorter operative time (144 (110-200) vs 199 (138-283) minutes, P < 0.001), less blood loss (100 (50-300) vs 350 (100-750) mL, P = 0.005) and a 3-day shorter postoperative hospital stay (4 (3-7) vs 7 (5-9) days, P < 0.001).

CONCLUSION

This international multicenter propensity score matched study confirms the superiority of LLLS over OLLS based on shorter postoperative hospital stay, operative time, and less blood loss thus validating current guideline advice.

Laparoscopic vs. open left lateral sectionectomy: An update meta-analysis of randomized and non-randomized controlled trials

BACKGROUND

Left lateral sectionectomy (LLS) is thought to be the anatomical liver resection most suitable for the laparoscopic approach. Despite increasing popularity, comparative analysis of laparoscopic and open LLS are mostly limited to retrospective, underpowered studies with small sample size. Recent population-based studies and prospective trials have generated new data; however, this new body of knowledge has not been submitted systematic reviews or meta-analyses and high quality evidence regarding the actual benefits of minimally invasive LLS is lacking.

METHODS

Systematic review of studies published until December 31st, 2017 and indexed in Medline, EMBASE, Cochrane Library Central and Scielo/LILACS databases. Randomized controlled trials and observational studies comparing perioperative results of laparoscopic and open LLS were included. Studies with patients submitted to LLS for living donation were excluded. Treatment outcomes, including conversion rates, estimated blood loss, transfusion rates, operative time, length of in-hospital stay, morbidity and mortality rates, were evaluated.

RESULTS

The primary search yielded 2838 articles, 23 of which (21 observational studies and 2 randomized controlled trials; 3415 patients) were included in the meta-analysis. Overall conversion rate was 7.4%. Patients submitted to laparoscopic LLS had less blood loss (mean difference, MD = -119.81 ml, 95% CI = -127.90, -111.72, P < .00001, I² = 32%, N = 618), lower transfusion rates (4.1% vs. 10.1%; risk difference, RD = - 0.06, 95% CI = - 0.08, - 0.05, P < .00001, I² = 13%, N = 2968) and shorter length of in-hospital stay (MD = - 2.02 days, 95% CI = - 2.15, - 1.89, P < .00001, I² = 77%, N = 3160) compared to those undergoing open surgery. Marginally decreased overall complication (21.4% vs. 27.5%; RD = - 0.03, 95% CI = - 0.06, 0.00, P = .05, I² = 0%, N = 3268) and perioperative mortality (0.3% vs. 1.5%; RD = - 0.01, 95% CI = - 0.02, - 0.00, P = .01, I² = 0%; N = 3332) rates were also observed. Operative time and biliary, cardiac or pulmonary complication rates did not differ significantly between groups.

CONCLUSION

Current evidence supports the safety and feasibility of laparoscopic LLS. The laparoscopic approach is associated with reduced blood loss, lower transfusion rates and shorter length of in-hospital stay and should be considered the gold-standard for LLS.

Laparoscopic hand-assisted liver resection for tumours in the left lateral section

Context:

The role of the laparoscopic left lateral sectionectomy (LLLS) is debatable, and Level-1 data are lacking.

Aims:

The aim of the study is to evaluate the feasibility and safety of this approach.

Settings and Design:

This was a retrospective study.

Subjects and Methods:

From 2007 to 2014, patients undergoing LLLS were identified from two institutions.

Statistical Analysis Used:

Continuous variables were compared between groups with Student's t-test or Mann–Whitney test, as appropriate by type of distribution. Categorical variables were compared with Chi-square or Fisher's exact test, depending on the number of observations.

Results:

Thirty-eight patients were included in the study. The mean age was 63.5 + 13 years (range, 31–89), and the mean number of tumours was 1.7 + 1.5. Eleven (29%) patients underwent LLS combined with an additional liver resection (combined resections group). The mean duration of the operation and the mean estimated blood loss were significantly decreased in the LLS group compared to the combined resection group (101 + 71 min vs. 208 + 98 min and 216 + 217 ml vs. 450 + 223 ml; P < 0.05 for both, respectively). The major complications rate was 8% and no mortality occurred.

Conclusions:

In a subset of carefully selected cases, LLLS may provide the benefits of laparoscopy. This does not appear to compromise perioperative morbidity rates. We believe that this approach may serve as a training platform for surgical trainees.

Laparoscopic left lateral sectionectomy: A three-port method

Background

Laparoscopic liver resection has become popular recent years. Laparoscopic left lateral sectionectomy (LLS) is now a standard operation with sufficient safety and feasibility. To improve the benefits of minimally invasive surgery, we invented and have been performing a reduced port LLS procedure using 3 ports since 2009.

Materials and Methods

All patients who underwent LLS at Toranomon Hospital (Tokyo, Japan) were included, except for patients with a previous history of upper abdominal surgery or those who had undergone the simultaneous resection of another organ. An essential point of this procedure was the extracorporeal traction of the divided round ligament using a ligature. As a result, the operator was able to perform the parenchymal transection within a good operative field.

Results

Twelve patients were enrolled in the study. All the patients had a Child-Pugh classification of Class A. The median indocyanine green retention rate at 15 min was 9.5%. Compared with previously reported results for conventional LLS, the median operation time (82.5 min), blood loss (0 mL) and rate of blood transfusion (0%) were lower for the 3-port LLS procedure. The rates of complications (9%) and a positive surgical margin (0%) were similar to those reported for the conventional approach.

Conclusion

Three-port LLS appears to be a safe and feasible procedure.

Meta-analysis of laparoscopic versus open liver resection for colorectal liver metastases

Background

To compare surgical and oncological outcomes of laparoscopic versus open liver resection for colorectal liver metastases.

Results

A total of 14 retrospective studies with 1679 colorectal liver metastases patients were analyzed: 683 patients treated with laparoscopic liver resection and 996 patients with open liver resection. With respect to surgical outcomes, laparoscopic compared with open liver resection was associated with lower blood loss (MD, -216.7, 95% CI, -309.4 to -124.1; P < 0.00001), less requiring blood transfusion (OR, 0.36; 95% CI, 0.23 to 0.55; P < 0.00001), lower postoperative complication morbidity (OR, 0.61; 95% CI, 0.47 to 0.80; P = 0.003), and shorter hospitalization time (MD, -3.85, 95% CI, -5.00 to -2.71; P < 0.00001). However, operation time and postoperative mortality were no significant difference between the two approaches. With respect to oncological outcomes, laparoscopic liver resection group was prone to lower recurrence rate (OR, 0.78; 95% CI, 0.61−0.99; P = 0.04), but surgical margins R0, overall survival and disease-free survival were no significant difference.

Materials and Methods

We performed a systematic search in MEDLINE, EMBASE, and CENTRAL for all relevant studies. All statistical analysis was performed using Review Manager version 5.3. Dichotomous data were calculated by odds ratio (OR) and continuous data were calculated by mean difference (MD) with 95% confidence intervals (CI).

Conclusions

Laparoscopic and open liver resection for colorectal liver metastases have the same effect on oncological outcomes, but laparoscopic liver resection achieves better surgical outcomes.

Laparoscopic left lateral hepatic sectionectomy was expected to be the standard for the treatment of left hepatic lobe lesions: A meta-analysis

BACKGROUND

Laparoscopic left lateral hepatic sectionectomy (LLLHS) has been widely accepted because of the benefits of minimally invasive surgery. We aimed to assess the benefits and drawbacks of left lateral sectionectomy (of segments II/III) compared with laparoscopic and open approaches.

METHODS

Relevant literature was searched using the PubMed, Embase, Cochrane, and Ovid Medline databases. We calculated odds ratios or mean differences with 95% confidence intervals (CIs) for fixed-effects and random-effects models.

RESULTS

The meta-analysis included 14 trials involving 685 patients. There were no statistically significant differences between LLLHS and open LLHS (OLLHS) regarding analgesia (P = .31), pedicle clamping (P = .70), operative time (P = .54), hospital expenses (P = .64), postoperative alanine aminotransferase levels (P = .57), resection margin (95% CI -3.02-4.28; P = .73), or tumor recurrence (95% CI 0.51-3.05; P = .62). However, the LLLHS group showed significantly better results regarding blood transfusion (95% CI 0.14-0.73; P = .007), blood loss (95% CI -140.95 to -67.23; P <.001), total morbidity (95% CI 0.24-0.56; P <.01), and hospital stay (95% CI -3.84 to -2.31; P <.001) than the OLLHS group.

CONCLUSION

LLLHS has an advantage in the hospital stay, blood loss, and total morbidity. It is an ideal method for LLHS surgery.

Randomized clinical trial of open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery after surgery programme (ORANGE II study)

BACKGROUND

Laparoscopic left lateral sectionectomy (LLLS) has been associated with shorter hospital stay and reduced overall morbidity compared with open left lateral sectionectomy (OLLS). Strong evidence has not, however, been provided.

METHODS

In this multicentre double-blind RCT, patients (aged 18-80 years with a BMI of 18-35 kg/m2 and ASA fitness grade of III or below) requiring left lateral sectionectomy (LLS) were assigned randomly to OLLS or LLLS within an enhanced recovery after surgery (ERAS) programme. All randomized patients, ward physicians and nurses were blinded to the procedure undertaken. A parallel prospective registry (open non-randomized (ONR) versus laparoscopic non-randomized (LNR)) was used to monitor patients who were not enrolled for randomization because of doctor or patient preference. The primary endpoint was time to functional recovery. Secondary endpoints were length of hospital stay (LOS), readmission rate, overall morbidity, composite endpoint of liver surgery-specific morbidity, mortality, and reasons for delay in discharge after functional recovery.

RESULTS

Between January 2010 and July 2014, patients were recruited at ten centres. Of these, 24 patients were randomized at eight centres, and 67 patients from eight centres were included in the prospective registry. Owing to slow accrual, the trial was stopped on the advice of an independent Data and Safety Monitoring Board in the Netherlands. No significant difference in median (i.q.r.) time to functional recovery was observed between laparoscopic and open surgery in the randomized or non-randomized groups: 3 (3-5) days for OLLS versus 3 (3-3) days for LLLS; and 3 (3-3) days for ONR versus 3 (3-4) days for LNR. There were no significant differences with regard to LOS, morbidity, reoperation, readmission and mortality rates.

CONCLUSION

This RCT comparing open and laparoscopic LLS in an ERAS setting was not able to reach a conclusion on time to functional recovery, because it was stopped prematurely owing to slow accrual. Registration number: NCT00874224 ( https://www.clinicaltrials.gov).

Laparoscopic left lateral sectionectomy: a population-based study

BACKGROUND

Laparoscopic left lateral sectionectomy (LLS) has now become standard practice. However, published series are small and retrospective. The aim was to compare at a national level the use and short-term outcome of laparoscopic and open LLS.

METHODS

National hospital discharge databases were screened to identify all adult patients who had undergone elective LLS in France between 2007 and 2012. Outcome measurements included blood transfusion, severe morbidity, mortality and length of hospital stay. The independent influence of the laparoscopic approach on these outcomes was tested overall and after stratifying for the indication (benign condition, primary malignancy, liver metastasis).

RESULTS

Over the 6-year study period, 2198 patients underwent LLS, accounting for 6.9% of all elective liver resections. Some 28.5% of LLS procedures were performed laparoscopically. Among hospitals in which LLS was carried out, 33.2% of procedures were done laparoscopically (median 2 laparoscopic LLS resections per year). The laparoscopic approach was independently associated with a shorter length of hospital stay irrespective of the indication, and a lower transfusion rate in patients with benign condition or primary malignancy.

CONCLUSION

LLS is seldom performed and the laparoscopic approach has not been adopted widely. The potential benefit of laparoscopic LLS varies according to the indication.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Laparoscopic Liver Resection for Tumors in the Left Lateral Liver Section

Background:

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

Methods:

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

Results:

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

Conclusions:

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

Laparoscopic hepatectomy versus open hepatectomy for colorectal cancer liver metastases: comparative study with propensity score matching

BACKGROUND

The objective of this study was to compare the results of laparoscopic hepatectomy with those of open hepatectomy for colorectal cancer liver metastases (CCLM) using a propensity score matching (PSM) in two university hospital settings.

METHODS

A patient in the laparoscopic approach (LA) surgery group was randomly matched with another patient in the open approach (OA) group using a 1:1 allocated ratio with the nearest estimated propensity score. No patients of the LA group were excluded for the matching. Matching criteria included age, gender, body mass index (BMI), American society anesthesiologists score, potential co-morbidities, hepatopathies, synchronous or metachronous lesions, size and number of CCLM, preoperative chemotherapy, minor or major liver resections. Intraoperative, postoperative data, and survival were compared in both groups.

RESULTS

From January 2012 to January 2015, a total of 242 hepatectomies were consecutively performed, of which 119 for CCLM, namely 101 in the OA group (84.9%) and 18 in the LA group (15.1%). The conversion rate was 5.6% (n=1). The mortality rate was 1% in the OA group and 0% in the LA group. Prior to PSM, there was a statistically significant difference favorable to the LA group regarding operative time, blood loss, length of hospital stay and the rate of medical complications. After PSM, there was no difference regarding operative time or length of hospital stay. However, there was a trend towards less blood loss (P=0.066) and fewer medical complications (44.4% vs.16.7%, P=0.07). The R0 resection rate was 94.4% (n=17) in the two groups. In addition, there was no difference regarding overall survival (P=0.358) and recurrence-free survival [HR =0.99 (0.1-12.7); P=0.99].

CONCLUSIONS

Laparoscopic liver resections for CCLM seem to yield short- and long-term results, which are similar to open hepatectomies, and could well be considered an alternative to open surgery and become the gold standard in carefully selected patients.

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

OBJECTIVE

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

SUMMARY BACKGROUND DATA

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The safety and efficacy of approaches to liver resection: a meta-analysis

Background:

The aim of this study is to compare the safety and efficacy of conventional laparotomy with those of robotic and laparoscopic approaches to hepatectomy.

Database:

Independent reviewers conducted a systematic review of publications in PubMed and Embase, with searches limited to comparative articles of laparoscopic hepatectomy with either conventional or robotic liver approaches. Outcomes included total operative time, estimated blood loss, length of hospitalization, resection margins, postoperative complications, perioperative mortality rates, and cost measures. Outcome comparisons were calculated using random-effects models to pool estimates of mean net differences or of the relative risk between group outcomes. Forty-nine articles, representing 3702 patients, comprise this analysis: 1901 (51.35%) underwent a laparoscopic approach, 1741 (47.03%) underwent an open approach, and 60 (1.62%) underwent a robotic approach. There was no difference in total operative times, surgical margins, or perioperative mortality rates among groups. Across all outcome measures, laparoscopic and robotic approaches showed no difference. As compared with the minimally invasive groups, patients undergoing laparotomy had a greater estimated blood loss (pooled mean net change, 152.0 mL; 95% confidence interval, 103.3–200.8 mL), a longer length of hospital stay (pooled mean difference, 2.22 days; 95% confidence interval, 1.78–2.66 days), and a higher total complication rate (odds ratio, 0.5; 95% confidence interval, 0.42–0.57).

Conclusion:

Minimally invasive approaches to liver resection are as safe as conventional laparotomy, affording less estimated blood loss, shorter lengths of hospitalization, lower perioperative complication rates, and equitable oncologic integrity and postoperative mortality rates. There was no proven advantage of robotic approaches compared with laparoscopic approaches.

Laparoscopic hepatectomy: indications and results from 18 resectable cases

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pure laparoscopic left lateral sectionectomy in living donors: from innovation to development in France

OBJECTIVE

In this study, we report the results obtained from 70 living donors in France.

BACKGROUND

Left lateral sectionectomy for pediatric live donor liver transplantation is a well-standardized surgical procedure. Our team introduced the laparoscopic approach to live donation in 2002, and the reproducibility and safety of this method was discussed in 2006.

METHODS

Between March 2001 and October 2012, a total of 70 donors underwent a liver procurement. Sixty-seven donors (95.7%) underwent a left lateral sectionectomy, and 3 underwent a left hepatectomy without middle hepatic vein procurement. All data were prospectively recorded in a database.

RESULTS

Of the 70 donors, 66 (94%) liver grafts were procured by laparoscopy, whereas 4 (6%) patients required conversion into an open technique. Seventeen donors experienced complications, leading to an overall complication rate of 24.2%. Eleven donors (16%) had grade 1 complications, according to the Clavien system. Five donors (7.1%) presented grade 2 complications, and 1 donor (1.4%) had a grade 3 complication. No death occurred. Overall, patient and graft survival rates for pediatric recipients were 95% and 92% at 1 year, 95% and 88% at 3 years, and 95% and 84% at 5 years, respectively.

CONCLUSIONS

The laparoscopic retrieval of the left lateral section for live donor liver transplantation is safe and reproducible and has transitioned from an innovative surgery to a development phase in France.

An update on laparoscopic liver resection: The French Hepato-Bilio-Pancreatic Surgery Association statement

Laparoscopic liver resection has been recognized as a safe and efficient approach since the Louisville Conference in 2008, but its use still remains confined to experienced teams in specialized centers, and may lack some standardization. The 2013 Session of French Association for Hepatobiliary and Pancreatic Surgery (ACHBT) specifically focused on laparoscopic liver surgery and the particular aspects and issues arising since the 2008 conference. Our objective is to provide an update and summarize the current French position on laparoscopic liver surgery. An overview of the current practice of laparoscopic liver resections in France since 2008 is presented. The issues surrounding standardization for left lateral sectionectomy and right hepatectomy, hybrid and hand-assisted techniques are raised and discussed. Finally, future technologies and technical perspectives are outlined.

Open versus laparoscopic liver resection for colorectal liver metastases (the Oslo-CoMet Study): study protocol for a randomized controlled trial

BACKGROUND

Laparoscopic liver resection is used in specialized centers all over the world. However, laparoscopic liver resection has never been compared with open liver resection in a prospective, randomized trial.

METHODS/DESIGN

The Oslo-CoMet Study is a randomized trial into laparoscopic versus open liver resection for the surgical management of hepatic colorectal metastases. The primary outcome is 30-day perioperative morbidity. Secondary outcomes include 5-year survival (overall, disease-free and recurrence-free), resection margins, recurrence pattern, postoperative pain, health-related quality of life, and evaluation of the inflammatory response. A cost-utility analysis of replacing open surgery with laparoscopic surgery will also be performed. The study includes all resections for colorectal liver metastases, except formal hemihepatectomies, resections where reconstruction of vessels/bile ducts is necessary and resections that need to be combined with ablation. All patients will participate in an enhanced recovery after surgery program. A biobank of liver and tumor tissue will be established and molecular analysis will be performed.

DISCUSSION

After 35 months of recruitment, 200 patients have been included in the trial. Molecular and immunology data are being analyzed. Results for primary and secondary outcome measures will be presented following the conclusion of the study (late 2015). The Oslo-CoMet Study will provide the first level 1 evidence on the benefits of laparoscopic liver resection for colorectal liver metastases.

TRIAL REGISTRATION

The trial was registered in ClinicalTrals.gov (NCT01516710) on 19 January 2012.

Laparoscopic versus Open Liver Resection: Differences in Intraoperative and Early Postoperative Outcome among Cirrhotic Patients with Hepatocellular Carcinoma-A Retrospective Observational Study

Introduction. Laparoscopic liver resection is considered risky in cirrhotic patients, even if minor surgical trauma of laparoscopy could be useful to prevent deterioration of a compromised liver function. This study aimed to identify the differences in terms of perioperative complications and early outcome in cirrhotic patients undergoing minor hepatic resection for hepatocellular carcinoma with open or laparoscopic technique. Methods. In this retrospective study, 156 cirrhotic patients undergoing liver resection for hepatocellular carcinoma were divided into two groups according to type of surgical approach: laparoscopy (LS group: 23 patients) or laparotomy (LT group: 133 patients). Perioperative data, mortality, and length of hospital stay were recorded. Results. Groups were matched for type of resection, median number of nodules, and median diameter of largest lesions. Groups were also homogeneous for preoperative liver and renal function tests. Intraoperative haemoglobin decrease and transfusions of red blood cells and fresh frozen plasma were significantly lower in LS group. MELD score lasted stable after laparoscopic resection, while it increased in laparotomic group. Postoperative liver and renal failure and mortality were all lower in LS group. Conclusions. Lower morbidity and mortality, maintenance of liver function, and shorter hospital stay suggest the safety and benefit of laparoscopic approach.

Laparoscopic left lateral sectionectomy as a training procedure for surgeons learning laparoscopic hepatectomy

BACKGROUND

Laparoscopic liver resection remains limited to a relatively small number of institutions because of insufficient hepatic and laparoscopic surgical experience and few training opportunities. The aim of this study was to assess the feasibility and safety of an improved laparoscopic left lateral sectionectomy technique as a training procedure for new surgeons.

METHODS

Twenty-four laparoscopic left lateral sectionectomies (LLLSs) were retrospectively reviewed. Patients were divided into 3 groups with 8 patients in each: those undergoing surgery by expert surgeons prior to 2008 (Group A); those undergoing surgery by expert surgeons after 2008, when a standardized LLLS technique was adopted (Group B); and those undergoing LLLS by junior surgeons being trained (Group C).

RESULTS

The median operative time was significantly shorter for Group B (103 min; range, 99-109 min) and C (107 min; range, 85-135 min) patients than for Group A (153 min; range, 95-210 min) patients. There were no significant differences in blood loss or hospital stay. In Groups B and C, no conversions to open laparotomy or complications occurred.

CONCLUSION

The standardized LLLS procedure was both safe and feasible as a technique for training surgeons in laparoscopic hepatectomy.

Laparoscopic left lateral resection is the gold standard for benign liver lesions: a case-control study

INTRODUCTION

A left lateral section is the first choice for a laparoscopic anatomic liver resection. The objective of this case-control study was to assess the surgical outcome after a laparoscopic left lateral resection for benign liver lesions compared with the open approach.

METHODS

From January 2004 to April 2011, 31 laparoscopic left lateral resections were matched with 31 open left lateral resections by selection based on pathology of the lesion, size of the lesion, American Society of Anesthesiologists (ASA) grade, body mass index (BMI), age and gender of the patient.

RESULTS

Duration of the operation (laparoscopic: 182 ± 71 versus open: 244 ± 105 min; P = 0.04), blood loss (223 ± 281 versus 455 ± 593 ml; P = 0.03), duration of hospital stay (4.1 ± 1.7 versus 8.1 ± 4.4 days; P < 0.001) and total cost of hospitalization (7475 ± 2679 versus 11504 ± 7776 Euros; P < 0.001) were significantly lower in the laparoscopic group.

CONCLUSIONS

This matched case-control study demonstrated procedural safety, excellent post-operative outcomes and economic benefits for a laparoscopic liver resection. A laparoscopic left lateral liver sectionectomy is recommended as a gold standard for benign liver lesions.

Laparoscopic liver surgery: An overview of the literature and experiences of a single centre

In the past two decades there has been an enormous increase in laparoscopic liver surgery. There is a trend from limited to laparoscopic major resections and more centres are adopting laparoscopic liver surgery as a standard of care. Although no randomized clinical trials are published, different reports on minor and major hepatectomies and meta-analyses suggest (at least) equal outcomes and cost-effectiveness compared to open procedures.

[The surgical technique of laparoscopic right hemihepatectomy. Technical aspects and results]

INTRODUCTION

This study compared the technical aspects and results for two different techniques of total laparoscopic anatomical right hemihepatectomy.

PATIENTS AND METHODS

From September 2010 to February 2013 a total of 16 patients underwent total laparoscopic right hemihepatectomy at the University Hospital of Freiburg. Of the patients 8 received an intraglissonian approach (IGA) and the other 8 patients an extraglissonian approach (EGA). In the patients of the IGA group, vascular inflow control of the right liver was accomplished by dissection and dividing the right hepatic artery, the right portal vein and the right bile duct separately before parenchymal dissection. In contrast, vascular control for patients in the EGA group was performed by enclosure and transsection of the whole right pedicle using a vascular linear stapler.

RESULTS

Indications for right hemihepatectomy were benign tumors in 2 and malignancies in 14 cases. The average maximum tumor diameter was 5.5 cm (range 1.5-10.0 cm). Adequate tumor-free surgical margins (R0) were confirmed in all patients with malignancies. The perioperative mortality rate was 0 %, surgical complications according to Clavien's classification were grade I (n = 1 trocar site superficial wound infection), grade II (n = 2 cholangitis) and grade IIIb (n = 1 wound dehiscence after conversion to open procedure). The median operating time was 366 min (range 265-422 min) and 313 min (range 247-417 min) in the IGA and EGA groups, respectively. Conversion from laparoscopic to open minimal access procedure was necessary in three patients in the IGA group and two patients in the EGA group. Mean intraoperative blood loss was 644 ml (200-1000 ml) and 518 ml (200-1500 ml) in the IGA and EGA groups, respectively. Transfusion of two units of packed red blood cells was necessary for one patient in group EGA. No patient in either group needed a Pringle maneuver. Mean postoperative hospital stay was 11 days (range 7-23 days) and 13 days (range 7-31 days) in the IGA and EGA groups, respectively.

CONCLUSIONS

Total laparoscopic anatomical right hemihepatectomy is a feasible procedure. The extraglissonian technique can provide shorter operating times by correctly facilitating vascular control of the right liver.

Radical laparoscopic treatment for liver hydatidosis

BACKGROUND

There is no scientific evidence to show which surgical technique should be used in treating hydatidosis of the liver; nor is there consensus on whether laparoscopy should be used in hydatidosis, because of the risk of dissemination or anaphylaxis.

MATERIALS

We conducted a multicenter study of laparoscopic radical surgery for hydatidosis of the liver (LRSH). The main objectives of the study were to determine the feasibility of LRSH, to examine the associated morbidity, and to evaluate the associated recurrence rate.

MATERIALS AND METHODS

The present report is based on a retrospective multicenter study of patients with hydatid disease of the liver treated by LRSH. The study period was from January 2000 to April 2012.

RESULTS

There were 37 patients (46 % male) with 43 cysts. The median age was 53.1 years. Median cyst size was 5.8 cm. The most common location of the cyst was the left lateral sector (62 %). The median number of trocars used was 4. Protective scolicide-soaked swabs were used in 57 % of patients. We performed 24 total closed cystectomies, 12 left lateral sectionectomies, and 4 liver resections. The median operating time was 185 min and the mean blood loss was 184 mL. The conversion rate was 8 %. Morbidity was 16 % and mortality 0 %. The length of hospital stay was 4.8 days. No cyst recurrence was observed after a follow-up of 30.6 months.

CONCLUSIONS

Despite the limitations and biases of a retrospective multicenter study, we believe that LRSH is feasible in favorable segments but is technically demanding. The low morbidity and absence of recurrence suggest that LRSH should be performed whenever feasible.

Laparoscopic versus open liver resection for benign and malignant hepatic lesions in adults

BACKGROUND

Liver (hepatic) resection refers to removal of the whole liver, or one or more of its vascular segments. Elective liver resection is mainly performed for benign and malignant liver tumours. The operation can be performed as an open procedure or with a laparoscopic approach. With the advancement of laparoscopic skills and equipment, liver resection is selectively being carried out with this approach. A laparoscopic procedure is intended to be less severe, allowing for quicker healing, fewer complications, and a shorter hospital stay as the insult to the body is minimised. However, evidence about the efficacy of this approach when compared to an open procedure is still scattered. Current practice at different hepato-pancreato-biliary centres is based on the clinical judgement of experts in their field, which is highly insufficient in terms of evidence.

OBJECTIVES

To assess the benefits and harms of laparoscopic versus open liver resection for benign or malignant lesions on the liver in adult patients.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until February 2013. We also conducted searches of reference lists of relevant articles and reviews, conference proceedings, and ongoing trial databases.

SELECTION CRITERIA

We searched for randomised clinical trials of participants undergoing liver resection for benign or malignant lesions which reported on benefits and harms. We searched for quasi-randomised or observational studies for reports of harm.

DATA COLLECTION AND ANALYSIS

No data from randomised clinical trials could be collected.

MAIN RESULTS

Two authors performed study selection independently. We were not able to identify any randomised clinical trials that met the inclusion criteria of our review protocol. We identified two ongoing randomised clinical trials performed in Europe with data yet to be published. We retrieved a few observational studies (prospective and retrospective) with the searches for randomised clinical trials. They included a limited number of participants in whom laparoscopic and open liver resection was compared. Since these studies were non-randomised observational studies, the results for any adverse events are not included in the review as the risk of bias in such studies is high.

AUTHORS' CONCLUSIONS

No conclusions can be made at this time as no randomised clinical trials are available. In addition to the two ongoing randomised clinical trials for which results are expected to be published in the near future, well-designed, prospective, randomised clinical trials are needed in order to evaluate the benefits and harms of the laparoscopic procedure versus open liver resection.

Open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery ERAS® programme (ORANGE II-trial): study protocol for a randomised controlled trial

Background

The use of lLaparoscopic liver resection in terms of time to functional recovery, length of hospital stay (LOS), long-term abdominal wall hernias, costs and quality of life (QOL) has never been studied in a randomised controlled trial. Therefore, this is the subject of the international multicentre randomised controlled ORANGE II trial.

Methods

Patients eligible for left lateral sectionectomy (LLS) of the liver will be recruited and randomised at the outpatient clinic. All randomised patients will undergo surgery in the setting of an ERAS programme. The experimental design produces two randomised arms (open and laparoscopic LLS) and a prospective registry. The prospective registry will be based on patients that cannot be randomised because of the explicit treatment preference of the patient or surgeon, or because of ineligibility (not meeting the in- and exclusion criteria) for randomisation in this trial. Therefore, all non-randomised patients undergoing LLS will be approached to participate in the prospective registry, thereby allowing acquisition of an uninterrupted prospective series of patients. The primary endpoint of the ORANGE II trial is time to functional recovery. Secondary endpoints are postoperative LOS, percentage readmission, (liver-specific) morbidity, QOL, body image and cosmetic result, hospital and societal costs over 1 year, and long-term incidence of incisional hernias. It will be assumed that in patients undergoing laparoscopic LLS, length of hospital stay can be reduced by two days. A sample size of 55 patients in each randomisation arm has been calculated to detect a 2-day reduction in LOS (90% power and α = 0.05 (two-tailed)).

The ORANGE II trial is a multicenter randomised controlled trial that will provide evidence on the merits of laparoscopic surgery in patients undergoing LLS within an enhanced recovery ERAS programme.

Trial registration

ClinicalTrials.gov NCT00874224.

Laparoscopic or open liver resection? Let systematic review decide it

BACKGROUND

Laparoscopic liver resection is increasingly being used for the excision of benign and malignant hepatic lesions. The aim of this study was to perform meta-analysis on the compiled data from available observational studies.

METHODS

All the studies comparing laparoscopic versus open liver resections were searched on the available databases. Data were analyzed using Review Manager software version 5.0 (The Cochrane Collaboration, Software Update, Oxford, UK).

RESULTS

There was a total of 2,466 patients: 1,161 (47.1%) in the laparoscopic group and 1,305 (52.9%) in the open group. The laparoscopic group was associated with a reduced overall complication rate (odds ratio = .35; 95% confidence interval [CI], .28-.45; P < .001; heterogeneity (HG): P = .51), fewer positive resection margins for malignant tumor resections (odds ratio = .38; CI, .20-.76; P = .006; HG: P = .52) and a decrease in the number of patients requiring blood transfusion (odds ratio = .36; CI, .23-.74; P < .001; HG: P = .30).

CONCLUSIONS

Laparoscopic liver resection showed a reduced overall morbidity rate and favorable and comparable outcomes when compared with the open group. However, there is still a need for randomized controlled trials to compare laparoscopic versus open hepatic resection in benign and malignant lesions.

Clinical and economic comparison of laparoscopic to open liver resections using a 2-to-1 matched pair analysis: an institutional experience

BACKGROUND

Surgical resection of hepatic lesions is associated with intraoperative and postoperative morbidity and mortality. Our center has introduced a laparoscopic liver resection (LLR) program over the past 3 years. Our objective is to describe the initial clinical experience with LLR, including a detailed cost analysis.

STUDY DESIGN

We evaluated all LLRs from 2006 to 2010. Each was matched to 2 open cases for number of segments removed, patient age, and background liver histology. Model for End-Stage Liver Disease (MELD) and the Charlson comorbidity index were calculated retrospectively. Nonparametric statistical analysis was used to compare surgical and economic outcomes. Analyses were performed including and excluding converted cases.

RESULTS

Fifty-seven patients underwent attempted LLR. Demographic characteristics were similar between groups. Estimated blood loss was lower in the LLR vs the open liver resection (OLR) group, at 250 mL and 500 mL, respectively (p < 0.001). Median operating room times were 240 minutes and 270 minutes in the LLR and OLR groups, respectively (p = 0.14). Eight cases were converted to open (14%): 2 for bleeding, 2 for anatomic uncertainty, 1 for tumor size, 1 for margins, 1 for inability to localize the tumor, and 1 for adhesions. Median length of stay was lower for LLR at 5 days vs 6 days for OLR (p < 0.001). There was no difference in frequency of ICU admission, reoperation, 30-day emergency room visit, or 30-day readmission rates. Median overall cost for LLR was lower at $11,376 vs $12,523 for OLR (p = 0.077).

CONCLUSIONS

Our experience suggests that LLR confers the clinical advantages of reduced operating room time, estimated blood loss, and length of stay while decreasing overall cost. LLR, therefore, appears to be a clinically and fiscally advantageous approach in properly selected patients.

Short- and long-term outcomes after laparoscopic and open hepatic resection: systematic review and meta-analysis

BACKGROUND

Laparoscopic liver resection (LLR) is now considered a feasible alternative to open liver resection (OLR) in selected patients. Nevertheless studies comparing LLR and OLR are few and concerns remain about long-term oncological equivalence. The present study compares outcomes with LLR vs. OLR using meta-analytical methods.

METHODS

Electronic literature searches were conducted to identify studies comparing LLR and OLR. Short-term outcomes evaluated included operating time, blood loss, length of hospital stay, peri-operative morbidity and resection margin status. Longer-term outcomes included local and distant recurrence, and overall (OS) and disease-free survival (DFS). Meta-analyses were performed using the Mantel-Haenszel method and Cohen's d method, with results expressed as odds ratio (OR) or standardized mean difference (SMD), respectively, with 95% confidence intervals (CI).

RESULTS

Twenty-six studies met the inclusion criteria with a population of 1678 patients. LLR resulted in longer operating time, but reduced blood loss, portal clamp time, overall and liver-specific complications, ileus and length of stay. No difference was found between LLR and OLR for oncological outcomes.

DISCUSSION

LLR has short-term advantages and seemingly equivalent long-term outcomes and can be considered a feasible alternative to open surgery in experienced hands.

Laparoscopic left lateral liver resection should be a standard operation

BACKGROUND

Laparoscopic liver resection was first performed by Gagner in 1992. In the following years, laparoscopic left lateral liver resection rapidly gained the interest of hepatobiliary surgeons due to the easy accessibility of the left lateral segment. This study aimed to gather and analyze available data from the observational studies that have compared laparoscopic and open left lateral hepatic resections.

METHODS

All the studies comparing laparoscopic and open left lateral liver resections were searched on the available databases including Medline, Ovid, Embase, Pubmed, and the Cochrane database. The latest date for the search was 30 January 2010. All the articles were cross-references. The studies comparing left lateral liver resections were included in the metaanalysis. Data was analyzed using Review Manager software version 5.0.

RESULTS

After the literature search, a total of seven studies were included in the metaanalysis, which involved 245 patients: 134 in the laparoscopic group and 111 in the open group. The laparoscopic group was shown to have a lower overall complication rate (0.36; 95% CI, 0.20-0.68) and shorter operative time (48.07 min; 95% CI, 30.93-65.21 min) than the open group (p=0.001), which were not associated with heterogeneity between the studies (p=0.84 and 0.34, respectively). The hospital stay of the laparoscopic group was 4.52 days shorter (95% CI, -8.03 to -1.02) than that of the open group. This difference was significant (p=0.01) but associated with significant heterogeneity between the studies.

CONCLUSION

Although no randomized controlled trials have compared open and laparoscopic liver resection, this metaanalysis demonstrated that laparoscopic left lateral resection is a safe and feasible option associated with a reduced overall complication rate. The authors conclude that it should be performed routinely in liver centers.

Video. Single-incision laparoscopic left lateral segmentectomy of colorectal liver metastasis

Laparoscopic surgery via a single port is an evolving technique being applied to an increasing variety of operations [1]. Multiple series over the past 3 years have shown single-incision laparoscopic cholecystectomy to be feasible and safe [2]. The ergonomic difficulties of single-port laparoscopy include a loss of instrument triangulation and operation with camera and instruments in parallel. Many different modifications of techniques and equipment have been used to compensate. Single-port techniques have been applied by a few authors to laparoscopic nephrectomy [3], splenectomy [4], and obesity surgery [5, 6]. Laparoscopic liver resection is well established and shown to be safe in multiple series [7]. The laparoscopic approach is accepted as the gold standard for resection of segments 2 and 3 [8]. To the authors' knowledge, no reports of laparoscopic liver resection via a single port have been published. They report the use of their technique for single-incision laparoscopic left lateral segmentectomy in a patient with a solitary segment 2 colorectal liver metastasis. The authors maintained strict oncologic principles and adhered to their standard laparoscopic technique as far as possible. They used a TriPort (Advanced Surgical Concepts, Wicklow, Ireland) placed via a 12-mm incision at the umbilicus. Following diagnostic laparoscopy and intraoperative liver ultrasound, hepatic attachments were divided using electrocautery. Parenchymal transection and vascular control were achieved using an ultrasonic dissector and laparoscopic staplers. Standard straight laparoscopic instruments were used. A number of technical challenges were apparent. Movement of instruments was jerky at times, either because instruments were clashing with one another other or deflecting the camera. The multiport device can be stiff, requiring copious lubrication throughout surgery. Crossing hands facilitates internal triangulation of the operating instruments to allow retraction or to apply tension, for example, during the division of hepatic attachments. Control of minor hemorrhage is possible with judicious and patient application of pressure using small pieces of surgical gauze. An articulating laparoscopic stapler is useful to achieve the ideal angle of staple deployment during transection of vascular pedicles. The specimen was extracted by extending the umbilical incision. No complications occurred. The patient was able to resume an oral diet and full mobility free of opioid analgesia on the first postoperative day. The resection margin was clear. This video demonstrates that the authors' technique is feasible and oncologically safe for selected patients requiring liver resection.