Total Transthoracic Approach Facilitates Laparoscopic Hepatic Resection in Patients with Significant Prior Abdominal Surgery

Subsegmental approaches to S7: anatomic laparoscopic transdiaphragmatic and nonanatomic robotic transthoracic

BACKGROUND

Minimally invasive liver surgery of postero-superior segments (S4a, S7, S8) remains a challenge. The caudal view, an increased distance between trocars and the operative field, and the liver fulcrum limiting the view, contribute to the difficulty [1, 2]. We and other groups have previously reported the use of intercostal trocars to access subdiaphragmatic tumors (transdiaphragmatic approach) [3-5], only few reports on a laparoscopic total transthoracic approach, none (to our knowledge) dynamic manuscripts of a total transthoracic robotic approach, and none (to our knowledge) that use preoperative port site and anatomic modelling exist. Further, we developed a total transthoracic (thoracoscopic) approach to avoid a hostile abdomen, while bringing viewing axis and instruments close to the target [6-10]. In this context, this report details the advantages of a laparoscopic vs. robotic transthoracic approach. According to institutional protocol, reports of individual cases in print or video format do not require institutional review board approval.

PATIENT

A 68-year-old male on peritoneal dialysis with left colon adenocarcinoma and a single synchronous liver metastasis in S6-7 close to the root of the right hepatic vein underwent a laparoscopic transdiaphragmatic metastasectomy. Two years later, the patient developed a recurrent 1.5 cm liver metastasis in S7, which lend itself to a robotic transthoracic approach.

TECHNIQUE

Following 3-D modelling and virtual port placement planning, the first metastasectomy was performed laparoscopically using a transdiaphragmatic approach. The recurrence was managed transthoracically due to more apical, subdiaphragmatic location. For this operation, a robotic approach was optimal as robotic wrist articulation facilitates manipulation via the limited intercostal space. This was particularly helpful during the diaphragmatic reconstruction.

CONCLUSIONS

Total transthoracic liver surgery is certainly an advanced procedure requiring superior MIS liver skills. Recommendations for starting with a total transthoracic approach are not unlike from starting a standard, none-transthoracic liver surgery. Early on in the experience we recommend advanced liver MIS skills, and single, small, subdiaphragmatic tumors away from major vessels. Nonetheless, when these recommendations are followed a total transthoracic approach may be safer and result in less access trauma, than traversing a hostile abdomen to reach the posterior-superior liver. Both laparoscopic and robotic transthoracic approaches can facilitate the resection of subdiaphragmatic tumors, especially in patients with hostile abdomens. While the laparoscopic approach has advantages due to a broader spectrum of available surgical tools (flexible tip camera, parenchymal dissection, and energy devices), the robotic wrist articulation facilitates manipulation via the restricted intercostal space.

All the Routes for Laparoscopic Liver Segment VIII Resection: A Comprehensive Review of Surgical Techniques

Liver surgery is highly demanding for anatomical, physiological and technical reasons, and minimally invasive approaches have been implemented at a slower rate. Today, laparoscopic liver resection is a standard of care in many occasions, yet specific operations remain particularly challenging and generally performed in open surgery. In particular, SVIII resection may be considered one of the most difficult due to anatomical characteristics including its sub-diaphragmatic position, the deep-lying Glissonean pedicle and the close contact with the inferior vena cava and right and middle hepatic veins. Many techniques have risen to overcome technical difficulties, and today laparoscopic SVIII resection has been demonstrated to be feasible. This review provides a complete picture of current approaches, focusing on all techniques reported so far with critical appraisal of each, discussing and explaining benefits and pitfalls.

A Systematic Review of Minimally Invasive Trans-thoracic Liver Resection to Examine Intervention Description, Governance, and Outcome Reporting of an Innovative Technique

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.

Laparoscopic liver resection with simultaneous diaphragm resection

Background

Liver resection or ablation remains the only curative treatment for patients with colorectal metastases. Simultaneous resection of tumors in the liver with invasion to the diaphragm is challenging and controversial. Therefore, we wanted to assess the safety of simultaneous laparoscopic liver and diaphragm resection (SLLDR) in a large single center.

Methods

Patients who underwent primary laparoscopic liver resection (LLR) for colorectal liver metastases at Oslo University Hospital between 2008 and 2019 were included in this study. Patients who underwent SLLDR (group 1) were compared to patients who underwent LLR only (group 2). Perioperative and oncologic outcomes were analyzed.

Results

A total of 467 patients were identified, of whom 12 patients needed a simultaneous diaphragm resection (group 1) while 455 underwent laparoscopic liver surgery alone (group 2). The conversion rate was 16.7% in group 1 and 2.4% in group 2 (P=0.040). In 10 of 12 (83.3%) cases the diaphragm resection was performed en bloc with the liver tumor. There was no significant difference in operative time, blood loss, resection margins, hospital stay or postoperative complications. One patient died within 30 postoperative days (0.2%) in group 2 and none in group 1. Overall survival was not statistically different between the groups.

Conclusions

In selected patients, SLLDR can be performed safely with good surgical and oncological outcomes.

A novel exposure maneuver in laparoscopic right hepatectomy

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.

Use of Transthoracic Transdiaphragmatic Approach Assisted with Radiofrequency Ablation for Thoracoscopic Hepatectomy of Hepatic Tumor Located in Segment VIII

BACKGROUND

Resection of segment VIII remains challenging despite the widespread laparoscopic hepatectomies in past decades,^1,2 especially for patients with cirrhosis. In this case, we combined radiofrequency ablation (RFA) with transthoracic approach, which was a novel approach for laparoscopic-guided hepatectomy of segment VIII in a cirrhotic patient.

PATIENT

A 42-year-old male patient with a body mass index of 22.0 kg/m² suffered from HBV-related cirrhosis was admitted to our institution. The preoperative MRI showed a 1.3 cm liver mass located in segment VIII. The preoperative AFP is 192 ng/ml. The patient was considered to have hepatectomy using transthoracic transdiaphragmatic approach with the assist of RFA.

TECHNIQUE

The patient was placed in a left lateral position with artificial pneumothorax in the right lung and left side ventilation. Three trocars were placed into the right thoracic space. Transdiaphragmatic intraoperative ultrasonography (IOUS) was performed to confirm the size and location of the lesion. In order to decrease the blood loss during parenchymal dissection and to reach tumor-free margins, the RFA was performed around the tumor before hepatectomy. After that the resection was carried out along the ablative margin. After the specimen was removed, the diaphragm was sutured and a closed thoracic drainage tube was placed. The operative time was 210 min with an estimated blood loss of 50 mL. The postoperative course was uneventful. Antibiotics was used in the first 24 h post-operation to prevent thoracic infection. Drainage tube was pulled out on the fourth day post-operation when we observed the daily fluid volume was less than 100 ml for 2 days and X-ray showed no gases and effusion in chest cavity. The pathology confirmed the diagnosis of hepatocellular carcinoma and the surgical margin was negative. The patient was discharged on the 8th day after surgery.

DISCUSSION

Lesions in the postero-superior segments still be challenging as we know.³ Previous studies showed that the procedure's results, such as the blood loss and operative time, were similar between thoracoscopic hepatectomy and laparoscopic hepatectomy, even the former was better.^2,4 Thus, for the superficial lesions in the postero-superior segments, and not more than 3 cm in diameter, thoracoscopic hepatectomy is recommended. Furthermore, a patient with a hostile abdomen who has a lesion in S7 or S8, transthoracic approach may be particularly helpful. However, functional lung is required due to the unilateral ventilation. Besides, anatomic resections are difficult to perform from the top.⁵ In this case, we used RFA before liver resection, and the tumor cells were destroyed to ensure the negative margin of the cut, and the bleeding blood vessels were also closed. This method can make a significant reduction of blood loss in the patients with cirrhosis compared with conventional hepatectomy (whether through thoracoscopic⁶ or laparoscopic⁷ approach).

CONCLUSION

The novel approach for transthoracic hepatectomy was safe and feasible for lesions of segment VIII in selected patients with cirrhosis,⁸ which was associated with reduced blood loss and a safe surgical margin.

Minimally invasive management of the entire treatment sequence in patients with stage IV colorectal cancer: a propensity-score weighting analysis

BACKGROUND

In patients with stage IV colorectal cancer (CRC), minimally invasive surgery (MIS) may offer optimal oncologic outcome with low morbidity. However, the relative benefit of MIS compared to open surgery in patients requiring multistage resections has not been evaluated.

METHODS

Patients who underwent totally minimally invasive (TMI) or totally open (TO) resections of CRC primary and liver metastases (CLM) in 2009-2016 were analyzed. Inverse probability of weighted adjustment by propensity score was performed before analyzing risk factors for complications and survival.

RESULTS

The study included 43 TMI and 121 TO patients. Before and after adjustment, TMI patients had significantly less cumulated postoperative complications (41% vs. 59%, p = 0.001), blood loss (median 100 vs. 200 ml, p = 0.001) and shorter length of hospital stay (median 4.5 vs. 6.0 days, p < 0.001). Multivariate analysis identified TO approach vs. MIS (OR = 2.4, p < 0.001), major liver resection (OR = 4.4, p < 0.001), and multiple CLM (OR = 2.3, p = 0.001) as independent risk factors for complications. 5-year overall survival was comparable (81% vs 68%, p = 0.59).

CONCLUSION

In patients with CRC undergoing multistage surgical treatment, MIS resection contributes to optimal perioperative outcomes without compromise in oncologic outcomes.

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

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

Operative and short-term oncologic outcomes of laparoscopic versus open liver resection for colorectal liver metastases located in the posterosuperior liver: a propensity score matching analysis

BACKGROUND

Laparoscopic resection (LLR) of colorectal liver metastases (CRLM) located in the posterosuperior liver (segments 4a, 7, and 8) is challenging but has become more practical recently due to progress in operative techniques. We aimed to compare tumor-specific, perioperative, and short-term oncological outcomes after LLR and open liver resection (OLR) for CRLM.

METHODS

Patients who underwent curative resection of CRLM with at least 1 tumor in the posterosuperior liver during 2012-2015 were analyzed. Tumor-specific factors associated with the adoption of LLR were analyzed by logistic regression model. One-to-one propensity score matching was used to match baseline characteristics between patients with LLR and OLR.

RESULTS

The original cohort included 30 patients with LLR and 239 with OLR. Median follow-up time was 23.8 months. Logistic regression analysis showed that multiple, diameter ≥30 mm, deep location, and closeness to major vessels were associated with OLR. None of the 24 patients with none or one of these factors were converted from LLR to OLR. After matching, 29 patients with LLR and 29 with OLR were analyzed. The 2 groups had similar preoperative factors. The LLR and OLR groups did not differ with respect to operative time, intraoperative bleeding, incidence of blood transfusion, surgical margin positivity, incidence of postoperative complications, and unplanned readmission within 45 days. Median length of postoperative hospital stay was significantly shorter for LLR versus OLR (4 days [1-12] vs. 5 days [4-18]; p = 0.0003). Median recurrence-free survival was similar for patients who underwent LLR versus OLR (10.6 months for LLR vs. 13.4 months for OLR; p = 0.87).

CONCLUSIONS

Compared to OLR, LLR of posterosuperior CRLM is associated with significantly shorter postoperative hospital stay but otherwise similar perioperative and short-term oncological outcomes. Tumor-specific factors associated with safe and routine LLR approach despite challenging location are superficial, solitary, and small (<30 mm) CRLM not associated with major vessels.