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Pure abdominal laparoscopic approach versus thoraco-abdominal laparoscopic approach: What is the best technique for liver resection in segment 7 and segment 8? An answer from the Institut Mutualiste Montsouris experience with short- and long-term outcome evaluation. Surgery 2023; 173:1176-1183. [PMID: 36669939 DOI: 10.1016/j.surg.2022.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/03/2022] [Accepted: 12/06/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Lesions in segments 7 and 8 are a challenge during standard laparoscopic liver resection. The addition of transthoracic trocars could be useful in the standard abdominal approach for laparoscopic liver resection. We report our experience with a thoraco-abdominal laparoscopic combined approach for liver resection with the aim of comparing short- and long-term outcomes. METHODS We reviewed 1,003 laparoscopic liver resections in a prospectively maintained, single-institution database. We compared patient outcomes intraoperatively and postoperatively. We analyzed the long-term outcomes of the colorectal liver metastasis subgroup. Propensity score matching 1:1 was performed based on the following variables: age, American Society of Anesthesiologists, body mass index, previous abdominal surgery, multiple or single liver resection, lesion >50 mm or <50 mm, presence of solitary or multiple lesions, T stage, and N stage. RESULTS The standard abdominal approach was used in 110 laparoscopic liver resections, and the thoraco-abdominal laparoscopic combined approach was used in 62 laparoscopic liver resections. The thoraco-abdominal laparoscopic combined approach was associated with better intraoperative results (less blood loss and no need for conversion to open surgery). The R1s rate for segmentectomy 7 and 8 was lower in the thoraco-abdominal laparoscopic combined approach in the entire group and in the colorectal liver metastasis subgroup. In the colorectal liver metastasis subgroup, the 3- and 5-year overall survival was 90% and 80% in the thoraco-abdominal laparoscopic combined approach group and 76% and 52% in the standard abdominal approach group, respectively (P = .02). In univariate and multivariate analysis, the thoraco-abdominal laparoscopic combined approach was a significant factor that positively affected disease-free survival and overall survival. CONCLUSION The thoraco-abdominal laparoscopic combined approach in laparoscopic liver resection in segments 7 and 8 is safe and feasible, and it has demonstrated better oncologic outcomes than the pure abdominal approach, especially in segmentectomy.
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Wang MX, Xiang JF, Chen SK, Xiao LK. The safety and feasibility of laparoscopic right posterior sectionectomy vs. open approach: A systematic review and meta-analysis. Front Surg 2022; 9:1019117. [PMID: 36325043 PMCID: PMC9618829 DOI: 10.3389/fsurg.2022.1019117] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 09/21/2022] [Indexed: 11/07/2022] Open
Abstract
Background Laparoscopic right posterior sectionectomy (LRPS) is one of the most technically challenging and potentially hazardous procedures in laparoscopic liver resection. Although some available literature works demonstrated the safety and feasibility of LRPS, these data are limited to reports from a single institution and a small sample size without support from evidence-based medicine. So, we performed a meta-analysis to assess further the safety and feasibility of LRPS by comparing it with open right posterior sectionectomy (ORPS). Methods MEDLINE, Embase, and Cochrane Library were systematically searched for eligible studies comparing LRPS and open approaches. Random and fixed-effects models were used to calculate outcome measures. Results Four studies involving a total of 541 patients were identified for inclusion: 250 in the LRPS group and 291 in the ORPS group. The postoperative complication and margin were not statistically different between the two groups (OR: 0.49, 95% CI: 0.18 to 1.35, P = 0.17) (MD: 0.05, 95% CI: −0.47 to 0.57, P = 0.86), respectively. LRPS had a significantly longer operative time and shorter hospital stay (MD: 140.32, 95% CI: 16.73 to 263.91, P = 0.03) (MD: −1.64, 95% CI: −2.56 to −0.72, P = 0.0005) respectively. Conclusion Data from currently available literature suggest that LRPS performed by an experienced surgeon is a safe and feasible procedure in selected patients and is associated with a reduction in the hospital stay.
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Affiliation(s)
- Meng-Xiao Wang
- Department of General Surgery, Chongqing General Hospital, Chongqing, China
| | - Ji-Feng Xiang
- Department of Hepatopancreatobiliary Surgery, Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China
| | - Sheng-Kai Chen
- Department of Hepatopancreatobiliary Surgery, Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China
| | - Lin-Kang Xiao
- Department of Hepatopancreatobiliary Surgery, Institute of Hepatopancreatobiliary Surgery, Chongqing General Hospital, Chongqing, China,Correspondence: Lin-Kang Xiao
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Pathak S, Main BG, Blencowe NS, Rees JRE, Robertson HF, Abbadi RAG, Blazeby JM. A Systematic Review of Minimally Invasive Trans-thoracic Liver Resection to Examine Intervention Description, Governance, and Outcome Reporting of an Innovative Technique. Ann Surg 2021; 273:882-889. [PMID: 32511126 DOI: 10.1097/sla.0000000000003748] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION The number of laparoscopic liver resections undertaken has increased. However, lesions located postero-superiorly are difficult to access. This may be overcome by the novel use of trans-thoracic port(s). Methods for the safe and transparent introduction of new and modified surgical procedures are limited and a summary of these issues, for minimally invasive trans-thoracic liver resections (MITTLR), is lacking. This study aims to understand and summarize technique description, governance procedures, and reporting of outcomes for MITTLR. METHODS A systematic literature search to identify primary studies of all designs describing MITTLR was undertaken. How patients were selected for the new technique was examined. The technical components of MITTLR were identified and summarized to understand technique development over time. Governance arrangements (eg, Institutional Review Board approval) and steps taken to mitigate harm were recorded. Finally, specific outcomes reported across studies were documented. RESULTS Of 2067 screened articles, 16 were included reporting data from 145 patients and 6 countries. Selection criteria for patients was explicitly stated in 2 papers. No studies fully described the technique. Five papers reported ethical approval and 3 gave details of patient consent. No study reported on steps taken to mitigate harm.Technical outcomes were commonly reported, for example, blood loss (15/16 studies), operative time (15/16), and margin status (11/16). Information on patient-reported outcomes and costs were lacking. CONCLUSIONS Technical details and governance procedures were poorly described. Outcomes focussed on short term details alone. Transparency is needed for reporting the introduction of new surgical techniques to allow their safe dissemination.
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Affiliation(s)
- Samir Pathak
- Bristol Center for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
- NIHR Bristol Biomedical Research Center, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Barry G Main
- Bristol Center for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
- NIHR Bristol Biomedical Research Center, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Natalie S Blencowe
- Bristol Center for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
- NIHR Bristol Biomedical Research Center, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Jonathan R E Rees
- Bristol Center for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Harry F Robertson
- Bristol Center for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
| | | | - Jane M Blazeby
- Bristol Center for Surgical Research, Population Health Sciences, Bristol Medical School, Bristol, UK
- NIHR Bristol Biomedical Research Center, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Shen Z, Zhang Q, Sun Z, Jiang Y, Yan S. A novel exposure maneuver in laparoscopic right hepatectomy. J Surg Oncol 2019; 120:1386-1390. [PMID: 31691288 DOI: 10.1002/jso.25754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 10/27/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND AND OBJECTIVES Laparoscopic access to the posterosuperior and lateral parts of the right liver is difficult for blocked and deep surgical situations. We invented a novel water bag device (WBD) to improve the exposure of the right liver. METHODS Eighteen consecutive patients with lesions isolated to the posterosuperior or lateral right liver were included in our research. They underwent laparoscopic right hepatectomy with the help of the device and were compared with previous similar laparoscopic cases of our operating surgeon. RESULTS The device was successfully employed without related complications and provided enhanced and stable surgical exposure. All patients were operated on without the need for blood transfusions or laparotomy conversion. The median operation time and estimated blood loss were 227 minutes (range, 114-568) and 88 mL (range, 25-250), respectively. In all cases, tumor-free surgical margins were confirmed and no major complications were observed. The results were better than those in previous similar laparoscopic cases. CONCLUSIONS The WBD is safe and effective for laparoscopic exposure when lesions are located in the posterosuperior and lateral parts of the right liver. With the help of the device, laparoscopic right liver resection is easier to perform instead of undergoing open hepatectomy.
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Affiliation(s)
- Zhenhua Shen
- Department of General Surgery, Huzhou Hospital, Zhejiang University School of Medicine, Huzhou Central Hospital, Huzhou, Zhejiang, China.,Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Qiyi Zhang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Zhongquan Sun
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yuancong Jiang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Sheng Yan
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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Morise Z, Wakabayashi G. First quarter century of laparoscopic liver resection. World J Gastroenterol 2017; 23:3581-3588. [PMID: 28611511 PMCID: PMC5449415 DOI: 10.3748/wjg.v23.i20.3581] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 03/04/2017] [Accepted: 04/21/2017] [Indexed: 02/06/2023] Open
Abstract
The beginnings of laparoscopic liver resection (LLR) were at the start of the 1990s, with the initial reports being published in 1991 and 1992. These were followed by reports of left lateral sectionectomy in 1996. In the years following, the procedures of LLR were expanded to hemi-hepatectomy, sectionectomy, segmentectomy and partial resection of posterosuperior segments, as well as the parenchymal preserving limited anatomical resection and modified anatomical (extended and/or combining limited) resection procedures. This expanded range of LLR procedures, mimicking the expansion of open liver resection in the past, was related to advances in both technology (instrumentation) and technical skill with conceptual changes. During this period of remarkable development, two international consensus conferences were held (2008 in Louisville, KY, United States, and 2014 in Morioka, Japan), providing up-to-date summarizations of the status and perspective of LLR. The advantages of LLR have become clear, and include reduced intraoperative bleeding, shorter hospital stay, and - especially for cirrhotic patients-lower incidence of complications (e.g., postoperative ascites and liver failure). In this paper, we review and discuss the developments of LLR in operative procedures (extent and style of liver resections) during the first quarter century since its inception, from the aspect of relationships with technological/technical developments with conceptual changes.
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Morise Z. Laparoscopic liver resection for posterosuperior tumors using caudal approach and postural changes: A new technical approach. World J Gastroenterol 2016; 22:10267-10274. [PMID: 28058008 PMCID: PMC5175240 DOI: 10.3748/wjg.v22.i47.10267] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 09/27/2016] [Accepted: 10/31/2016] [Indexed: 02/06/2023] Open
Abstract
Laparoscopic liver resection (LLR) for tumors in the posterosuperior liver [segment (S) 7 and deep S6] is a challenging clinical procedure. This area is located in the bottom of the small subphrenic space (rib cage), with the large and heavy right liver on it when the patient is in the supine position. Thus, LLR of this area is technically demanding because of the handling of the right liver which is necessary to obtain a fine surgical view, secure hemostasis and conduct the resection so as to achieve an appropriate surgical margin in the cage. Handling of the right liver may be performed by the hand-assisted approach, robotic liver resection or by using spacers, such as a sterile glove pouch. In addition, the operative field of posterosuperior resection is in the deep bottom area of the subphrenic cage, with the liver S6 obstructing the laparoscopic caudal view of lesions. The use of intercostal ports facilitates the direct lateral approach into the cage and to the target area, with the combination of mobilization of the liver. Postural changes during the LLR procedure have also been reported to facilitate the LLR for this area, such as left lateral positioning for posterior sectionectomy and semi-prone positioning for tumors in the posterosuperior segments. In our hospital, LLR procedures for posterosuperior tumors are performed via the caudal approach with postural changes. The left lateral position is used for posterior sectionectomy and the semi-prone position is used for S7 segmentectomy and partial resections of S7 and deep S6 without combined intercostal ports insertion. Although the movement of instruments is restricted in the caudal approach, compared to the lateral approach, port placement in the para-vertebra area makes the manipulation feasible and stable, with minimum damage to the environment around the liver.
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Yamashita S, Loyer E, Kang HC, Aloia TA, Chun YS, Mehran RJ, Eng C, Lee JE, Vauthey JN, Conrad C. Total Transthoracic Approach Facilitates Laparoscopic Hepatic Resection in Patients with Significant Prior Abdominal Surgery. Ann Surg Oncol 2016; 24:1376-1377. [PMID: 27878479 DOI: 10.1245/s10434-016-5685-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND While the oncologic safety of minimally invasive hepatectomy for colorectal liver metastases (CLM) has been demonstrated, lesions in the postero-superior segments may be challenging.1 - 3 For these lesions, a transthoracic approach may be particularly helpful, especially in patients with a hostile/reoperative abdomen or morbid obesity.4 , 5 PATIENT: A 43-year-old man with a body mass index of 36.0 who had undergone rectosigmoid resection for primary cancer 5 years ago recurred with a solitary liver metastasis in SVIII. He had previously undergone the following resections for metachronous CLM: (i) partial resections of SV/VIII and SII/III; (ii) ablation for SVII; and (iii) left hepatectomy, common bile duct resection, and choledochojejunostomy. Following four cycles of FOLFIRI/panitumumab with good response, the patient was considered for his fourth abdominal cancer intervention via a thoracoscopic approach. TECHNIQUE In a modified French position with left-lung ventilation, access to the right thoracic cavity was gained. Following thoracic adhesiolysis, transdiaphragmatic intraoperative ultrasonography (IOUS) was performed. To ensure optimal margins, IOUS-guided transthoracic hepatic resection with partial resection of the diaphragm was conducted. The diaphragm was reconstructed and a chest tube placed. Operative time was 247 min, with an estimated blood loss of 100 mL. Postoperative recovery was uneventful; pathology demonstrated no viable tumor, with the closest margin 5 mm from the necrotic area. CONCLUSION Transthoracic hepatic resection of SVIII can optimize the port-target axis while minimizing morbidity. A systematic approach that includes precise port positioning, non-traumatic intrathoracic adhesiolysis, and meticulous transdiaphragmatic IOUS-guided parenchymal transection can optimize outcomes.
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Affiliation(s)
- Suguru Yamashita
- Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Evelyne Loyer
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hyunseon C Kang
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thomas A Aloia
- Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yun Shin Chun
- Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Reza J Mehran
- Department of Thoracic and Cardiovascular Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cathy Eng
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey E Lee
- Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Claudius Conrad
- Department of Surgical Oncology, Hepato-Pancreato-Biliary Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Egger ME, Gottumukkala V, Wilks JA, Soliz J, Ilmer M, Vauthey JN, Conrad C. Anesthetic and operative considerations for laparoscopic liver resection. Surgery 2016; 161:1191-1202. [PMID: 27545995 DOI: 10.1016/j.surg.2016.07.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 07/06/2016] [Accepted: 07/09/2016] [Indexed: 02/06/2023]
Abstract
We enumerate the broad range of anesthetic considerations that affect the outcome of patients undergoing laparoscopic liver resection. Key elements for excellent outcomes after laparoscopic liver resection are careful patient selection and risk stratification, appropriate monitoring, techniques to reduce blood loss and transfusion, and active recovery management. Although some of these key elements are the same for open liver operation, there are specific anesthetic considerations of which both the surgical and anesthesia teams must be aware to achieve optimal patient outcomes after laparoscopic liver resection. While unique advantages of laparoscopic liver resection typically include decreased intraoperative bleeding, transfusion requirements, and a lower incidence of postoperative ascites, specific challenges include management of the complicated interplay between low-volume anesthesia and increased intraabdominal pressure due to pneumoperitoneum, with additional considerations regarding circulatory support to treat acute blood loss with need for emergent conversion in some cases. This article will address in detail the preoperative, intraoperative, and postoperative anesthetic considerations for patients undergoing laparoscopic liver resection that both the surgical and anesthesia team should be aware of to optimize outcomes.
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Affiliation(s)
- Michael E Egger
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vijaya Gottumukkala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jonathan A Wilks
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jose Soliz
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Matthias Ilmer
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jean Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Claudius Conrad
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX.
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