Laparoscopic liver resection: personal experience with 107 cases

Red blood cell transfusion in liver resection

BACKGROUND

Several modalities exist for the management of hepatic neoplasms. Resection, the most effective approach, carries significant risk of hemorrhage. Blood loss may be corrected with red blood cell transfusion (RBCT) in the short term, but may ultimately contribute to negative outcomes.

PURPOSE

Using available literature, we seek to define the frequency and risk factors of blood loss and transfusion following hepatectomy. The impact of blood loss and RBCT on short- and long-term outcomes is explored with an emphasis on peri-operative methods to reduce hemorrhage and transfusion.

RESULTS

Following hepatic surgery, 25.2-56.8% of patients receive RBCT. Patients who receive RBCT are at increased risk of surgical morbidity in a dose-dependent manner. The relationship between blood transfusion and surgical mortality is less apparent. RBCT might also impact long-term oncologic outcomes including disease recurrence and overall survival. Risk factors for bleeding and blood transfusion include hemoglobin concentration < 12.5 g/dL, thrombocytopenia, pre-operative biliary drainage, presence of background liver disease (such as cirrhosis), coronary artery disease, male gender, tumor characteristics (type, size, location, presence of vascular involvement), extent of hepatectomy, concomitant extrahepatic organ resection, and operative time. Strategies to mitigate blood loss or transfusion include pre-operative (iron, erythropoietin), intra-operative (vascular occlusion, parenchymal transection techniques, hemostatic agents, antifibrinolytics, low central pressure, hemodilution, autologous blood recycling), and post-operative (normothermia, correction of coagulopathy, optimization of nutrition, restrictive transfusion strategy) methods.

CONCLUSION

Blood loss during hepatectomy is common and several risk factors can be identified pre-operatively. Blood loss and RBCT during hepatectomy is associated with post-operative morbidity and mortality. Disease-free recurrence, disease-specific survival, and overall survival may be associated with blood loss and RBCT during hepatectomy. Attention to pre-operative, intra-operative, and post-operative strategies to reduce blood loss and RBCT is necessary.

OPEN, LAPAROSCOPIC, AND ROBOTIC-ASSISTED HEPATECTOMY IN RESECTION OF LIVER TUMORS: A NON-SYSTEMATIC REVIEW

Introduction:

Several factors have made hepatectomy an increasingly safe surgery and new drugs allowed surgical treatment for patients who initially were not candidates for resection. Lesions often require resection, which can be performed by open, laparoscopic, or robotic assisted hepatectomy.

Aim:

Compare the surgical techniques in open, laparoscopic, and robotic assisted hepatectomy for resection of liver tumors.

Methods:

Literature review based on scientific papers published on Lilacs/Pubmed/Scielo in the last 17 years regarding the indications of these techniques for liver tumor resections and on papers comparing such techniques.

Results:

The comparative study shows the benefits of laparoscopic surgery over open surgery, such as smaller incisions, less postoperative pain, shorter recovery time, smaller immune and metabolic response, and quicker restoration of oral ingestion as well as lower morbidity rates. However, the need for a specialized surgical team and the reduction in handling area still remain as disadvantages in the laparoscopic technique. It is yet not clear whether robotic assistance presents considerable benefits over the laparoscopic technique considering that high acquisition and maintenance costs are limiting factors.

Conclusion:

Despite all challenges, laparoscopic hepatectomy presents many benefits over open surgery. The robotic assisted technique is still in evolution as many centers in the world perform hepatic resections with the platforms but only after a thorough patient selection. Thus, laparoscopy stands as the best option, unless there is some contraindication to the procedure.

CRITICAL EVALUATION OF LONG-TERM RESULTS OF MALIGNANT HEPATIC TUMORS TREATED BY MEANS CURATIVE LAPAROSCOPIC HEPATECTOMY

BACKGROUND

Laparoscopic hepatectomy has presented great importance for treating malignant hepatic lesions.

AIM

To evaluate its impact in relation to overall survival or disease free of the patients operated due different hepatic malignant tumors.

METHODS

Thirty-four laparoscopic hepatectomies were performed in 31 patients with malignant neoplasm. Patients were distributed as: Group 1 - colorectal metastases (n=14); Group 2 - hepatocellular carcinoma (n=8); and Group 3 - non-colorectal metastases and intrahepatic cholangiocarcinoma (n=9). The conversion rate, morbidity, mortality and tumor recurrence were also evaluated.

RESULTS

Conversion to open surgery was 6%; morbidity 22%; postoperative mortality 3%. There was tumor recurrence in 11 cases. Medians of overall survival and disease free survival were respectively 60 and 46 m; however, there was no difference among studied groups (p>0,05).

CONCLUSION

Long-term outcomes of laparoscopic hepatectomy for treating hepatic malignant tumors are satisfactory. There is no statistical difference in relation of both overall and disease free survival among different groups of hepatic neoplasms.

IMMEDIATE COMPLICATIONS AFTER 88 HEPATECTOMIES - BRAZILIAN CONSECUTIVE SERIES

Background:

Hepatectomies have been increasingly recommended and performed in Brazil; they present great differences related to immediate complications.

Aim:

Assessing the immediate postoperative complications in a series of 88 open liver resections.

Method:

Prospective database of patients subjected to consecutive hepatectomies over nine years. The post-hepatectomy complications were categorized according to the Clavien-Dindo classification; complications presenting grade equal to or greater than 3 were considered major complications. Hepatic resections involving three or more resected liver segments were considered major hepatectomies.

Results:

Eighty-four patients were subjected to 88 hepatectomies, mostly were minor liver resections (50 cases, 56.8%). Most patients had malignant diseases (63 cases; 71.6%). The mean hospitalization time was 10.9 days (4-43). Overall morbidity and mortality rates were 37.5% and 6.8%, respectively. The two most common immediate general complications were intra-peritoneal collections (12.5%) and pleural effusion (12.5%). Bleeding, biliary fistula and liver failure were identified in 6.8%, 4.5% and 1.1% of the cases, respectively, among the hepatectomy-specific complications.

Conclusion:

The patients operated in the second half of the series showed better results, which were apparently influenced by the increased surgical expertise, by the modification of the hepatic parenchyma section method and by the increased organ preservation.

Pure Laparoscopic Versus Open Liver Resection in Treatment of Hepatolithiasis Within the Left Lobes: A Randomized Trial Study

OBJECTIVE

The application of laparoscopic technology to liver surgery has been developing rapidly, yet very few studies have been conducted to compare the outcomes between open and laparoscopic liver resections. So little is known about their advantages and disadvantages. The aim of this prospective randomized study was to compare the outcomes between laparoscopic and open liver resection in treatment of hepatolithiasis within the left lateral lobes.

PATIENTS AND METHODS

Between January 2010 and May 2013, 98 patients with hepatolithiasis within the left lateral lobes diagnosed by preoperative computed tomography and magnetic resonance cholangiopancreatography were randomized into open group and laparoscopic group. Each group had 49 patients. We compared the operation time, the amount of bleeding, the length of their stay in hospital, and complications.

RESULTS

Of the laparoscopic group, 2 patients were converted to open surgery. No fatal complication occurred in either the open group or the laparoscopic group. There was no statistically significant difference in the complications between the 2 groups (4.08% vs. 6.12%, P=0.64), but the operating time, the amount of bleeding, and the length of stay in hospital were significantly shorter in the laparoscopic group than in the open group (P<0.05).

CONCLUSIONS

Laparoscopic liver resection displays similar safety and feasibility for hepatolithiasis within the left lateral lobes, and they were also similar with respect to the overall complications, but the laparoscopic group has an advantage in the operating time, the amount of bleeding, and the length of their staying in hospital. It is, however, agreed between the authors of this paper that further studies with larger number of patients and longer follow-up observations are necessary to make a definitive conclusion.

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.

Anatomical basis for the intrahepatic glissonian approach during hepatectomies

Background

Anatomical liver resections are based on some basic technical principles such as vascular control, ischemic area delineation to be resected and maximum parenchymal preservation. These aspects are achieved by the intrahepatic glissonian approach, which consists in accessing the pedicles of hepatic segments within the hepatic parenchyma. Small incisions on well-defined anatomical landmarks are performed to approach the pedicles, making dissection of the hilar plate unnecessary.

Aim

Analyze parameters in liver anatomy related to intrahepatic surgical technique to glissonians pedicles, to set the normal anatomy related to the procedure and thereby facilitate the attainment of this technique.

Methods

Anatomical parameters related to the intrahepatic glissonian approach were studied in 37 cadavers. Measurements were performed with precision instruments. Data were expressed as mean±standard deviation. The subjects were divided into groups according to gender and liver weight and groups were compared statistically.

Results

Twenty-five cadavers were male and 12 female. No statistically significant difference was observed in virtually all parameters when groups were compared. This demonstrates the consistency of the anatomical parameters related to the intrahepatic glissonian approach.

Conclusion

The results obtained in this study made possible major technical advances in the realization of open and laparoscopic hepatectomies with intrahepatic glissonian approach, and can help surgeons to perform liver resections by this method.

Totally laparoscopic liver resection: new Brazilian experience

Background

Despite the increasing number of laparoscopic hepatectomy, there is little published experience.

Aim

To evaluate the results of a series of hepatectomy completely done with laparoscopic approach.

Methods

This is a retrospective study of 61 laparoscopic liver resections. Were studied conversion to open technique; mean age; gender, mortality; complications; type of hepatectomy; surgical techniques applied; and simultaneous operations.

Results

The conversion to open technique was necessary in one case (1.6%). The mean age was 54.7 years (17-84), 34 were men. Three patients (4.9%) had complications. One died postoperatively (mortality 1.6%) and no deaths occurred intraoperatively. The most frequent type was right hepatectomy (37.7%), followed by bisegmentectomy (segments II-III and VI-VII). Were not used hemi-Pringle maneuvers or assisted technic. Six patients (8.1%) underwent simultaneous procedures (hepatectomy and colectomy).

Conclusion

Laparoscopic hepatectomy is feasible procedure and can be considered the gold standard for various conditions requiring liver resections for both benign to malignant diseases.

Intrahepatic glissonian approach for single-port laparoscopic liver resection

BACKGROUND

Minimal access surgery is moving toward reduced size and fewer ports. The aim of this article is to describe our experience with the intrahepatic Glissonian approach for single-port laparoscopic left lateral sectionectomy.

SUBJECTS AND METHODS

We have performed this procedure on 8 consecutive patients. A transumbilical incision is performed, and a single-incision platform is introduced. The operation begins with ultrasound examination of the liver. Intrahepatic Glissonian access of the portal pedicle from segments 2 and 3 is performed, and the pedicle is divided with a stapler. The liver is transected, and the left hepatic vein is divided with a stapler. A surgical specimen is retrieved through the single umbilical incision. No drains are left in place.

RESULTS

The median operative time was 68 minutes, and there was minimal bleeding. The median hospital stay was 1 day. Six patients were operated on for liver adenoma. There was no morbidity or mortality. During follow-up (median, 12 months), no patient developed incisional hernia. The cosmetic appearance of the incision was excellent in all cases.

CONCLUSIONS

Single-port laparoscopic left lateral sectionectomy is feasible and can be safely performed in specialized centers.