Laparoscopic liver resection with simultaneous diaphragm resection

Laparoscopic surgical management of hepatocellular carcinoma patients with diaphragmatic involvement

BACKGROUND

Hepatocellular carcinoma (HCC) is a common malignancy of the digestive system with high morbidity and high mortality worldwide. Currently, surgical resection is considered the most effective treatment for HCC. Laparoscopic surgery is a major trend in contemporary minimally invasive surgery. However, is laparoscopic resection suitable for HCC patients with diaphragmatic involvement? If so, then what is the preferred resection method, and how safe and effective is this treatment? Are there any factors that require special attention?

METHODS

Clinical data of 17 patients who underwent laparoscopic surgery in the Second Affiliated Hospital, Third Military Medical University (Army Medical University) from January 2018 to February 2021 were retrospectively analyzed.

RESULTS

The mean age was 48.9 ± 14.0 years; mean operation time, 186.00 ± 18.3 min; median blood loss, 170.0 ml (140.8-207.5 ml); and median length of hospital stay, 8.0 days (7.0-9.5 days). There was no case of open conversion. Pathologic findings revealed all cases of HCC. Intraoperative frozen pathology and postoperative pathology showed free surgical margins. Six patients had pathologically confirmed diaphragmatic invasion (DI), and eleven was confirmed as having diaphragmatic fibrous adhesion (DFA) only. Post-operative complications included liver section effusion, pleural effusion, pneumonia and bile leak. All the complications responded well to conservative treatment. No other abnormality was noted during outpatient follow-up examination. Sixteen patients survived tumor-free; one patient with HCC developed intrahepatic metastasis 1 year after surgery, and this patient survived with tumor after treatment.

CONCLUSIONS

Our experience initially provides valuable support for the laparoscopic surgical treatment of HCC patients with diaphragmatic involvement.

Stapled Full-Thickness Diaphragm Resection: A Novel Approach to Diaphragmatic Resection in Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

Full-thickness diaphragm resection (FT-DR) during cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is sometimes required to achieve a complete cytoreduction. It is conventionally performed with electrocautery with primary repair or mesh repair. FT-DR using a linear cutting stapler is a novel technique that avoids entry to the chest cavity and minimizes the use of electrocautery on the diaphragm. We performed an institutional retrospective review of a prospectively maintained database of 145 patients who underwent CRS-HIPEC between 2013 and 2019. Patients were divided into the Conventional or Stapled group based on the FT-DR approach indicated in the operative report. Of the 145 patients who underwent CRS-HIPEC, 27 underwent FT-DR, with 63% (n = 17) in the Stapled group. There were no significant demographic or oncologic differences between the 2 groups. Patients in the Stapled group underwent tube thoracostomy (13.3% vs 60%; p = 0.008), were diagnosed with pneumonia (12% vs 50%; p = 0.04), required reintubation (6% vs 40%; p = 0.03), and required mechanical ventilation more than 48 hours (6% vs 50%; p = 0.02) less frequently than the Conventional group. There was no difference in pleural recurrence between the 2 groups (Conventional 20% vs Stapled 12%, p = 0.56). Stapled full-thickness diaphragm resection is a novel approach to achieving a complete cytoreduction that excludes the pleural cavity, minimizes diaphragm manipulation, and is associated with improved postoperative pulmonary outcomes in patients undergoing CRS-HIPEC.

The impact of multivisceral liver resection on short- and long-term outcomes of patients with colorectal liver metastasis: A systematic review and meta-analysis

The impact of Multivisceral Liver Resection (MLR) on the outcome of patients with Colorectal Liver Metastasis (CRLM) is unclear. The present systematic review aimed to compare patients with CRLM who underwent MLR versus standard hepatectomy regarding short- and long-term outcomes. MLR is a feasible procedure but has a higher risk of major complications. MLR did not negatively affect long-term survival, suggesting that an extended resection is an option for potentially curative treatment for selected patients with CRLM.

Laparoscopic liver resection with open partial resection of the thoracoabdominal wall for cancer along the transhepatic biliary drainage tract: A case report

Introduction and importance

Recently, laparoscopic liver resection has been established as a standard procedure for a certain group of hepatic resections; its indications and procedures have been expanding.

Case presentation

A 67-year-old woman was referred with a chief complaint of left subcostal pain. Eight years and nine months before, she underwent pancreatoduodenectomy for cancer of the ampulla of Vater after endoscopic retrograde biliary drainage for obstructive jaundice. A trans-anastomotic internal-external retrograde transhepatic biliary drainage (RTBD) catheter was placed intraoperatively. Based on radiological findings, intrahepatic cholangiocarcinoma, or local recurrence of cancer of the ampulla of Vater, invading the anterior thoracoabdominal wall, diaphragm, and pericardium, without distant metastasis, were considered. Laparoscopic lateral segmentectomy of the liver combined with open en bloc resection of the invaded portion of the anterior thoracoabdominal wall with costal cartilage, diaphragm, and pericardium was performed. The postoperative course was uneventful, and the patient was discharged 17 days post-surgery. The patient died of cancer recurrence 46 months later.

Clinical discussion

The cancer invaded along the RTBD tract. Although the mechanisms of carcinogenesis remain unclear, transhepatic biliary drainage is a risk factor for cancer invasion along the tract. Laparoscopic liver resection before open thoracoabdominal wall resection ensured clear delineation of the cancer margins invading the thoracoabdominal wall and minimized the defect of the thoracoabdominal wall.

Conclusion

Laparoscopic liver resection for hepatic cancer invading adjacent structures or organs would be feasible and useful in selected patients, even if resection of the invaded area is performed by open surgery.

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Cancer developed along the retrograde transhepatic biliary drainage tract after pancreatoduodenectomy.

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Laparoscopic liver resection and simultaneous open en bloc partial resection of the thoracoabdominal wall was performed.

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The patient’s 46-month survival post-operation was relatively long for recurrent cancer of the ampulla of Vater.

A safe and simple procedure for laparoscopic hepatectomy with combined diaphragmatic resection

Diaphragmatic resection may be required beneath the diaphragm in some patients with liver tumors. Laparoscopic diaphragmatic resection is technically difficult to secure in the surgical field and in suturing. We report a case of successful laparoscopic hepatectomy with diaphragmatic resection. A 48-year-old man who underwent laparoscopic partial hepatectomy for liver metastasis of rectal cancer 20 months ago underwent surgery because of a new hepatic lesion that invaded the diaphragm. The patient was placed in the left hemilateral decubitus position. The liver and diaphragm attachment areas were encircled using hanging tape. Liver resection preceded diaphragmatic resection with the hanging tape in place. Two snake retractors were used to secure the surgical field for the inflow of CO₂ into the pleural space after diaphragmatic resection. The defective part of the diaphragm was repaired using continuous or interrupted sutures. Both ends of the suture were tied with an absorbable suture clip without ligation. In laparoscopic liver resection with diaphragmatic resection, the range of diaphragmatic resection can be minimized by performing liver resection using the hanging method before diaphragmatic resection. The surgical field can be secured using snake retractors. Suturing with an absorbable suture clip is conveniently feasible.