Single incision laparoscopic hepatectomy: Advances in laparoscopic liver surgery

Single incision laparoscopic surgery for hepatocellular carcinoma

Single incision laparoscopic liver resection (SILLR) is the most recent development in the laparoscopic approach to the liver. SILLR for hepatocellular carcinoma (HCC) has developed much more slowly than multiport LLR. So far, 195 patients completed SILLR for HCC. In this paper, we reviewed all published papers about SILLR for HCC and discussed the feasibility of the SILLR, peri and postoperative findings, tricks of patient selection and whether SILLR compromise the oncological principles.

Trends in Minimally Invasive Approaches for Liver Resections-A Systematic Review

BACKGROUND

SILS (single incision laparoscopic surgery) and NOTES (natural orifice transluminal endoscopic surgery) are considered breakthroughs in minimally invasive surgery, the first consisting in the surgeon working via a single entrance site and the second via a natural orifice (e.g., oral cavity).

METHODS

Since 2000 until 2022, the original articles published in the online databases were analyzed. Eligible studies included information about the current therapy of patients with liver surgical pathology and how the two new techniques improve the surgical approach.

RESULTS

A total of 798 studies were identified. By applying the exclusion criteria, nine studies remained to be included in the review. Two out of nine studies examined the NOTES approach in liver surgery, whereas the other seven focused on the SILS technique. The age of the patients ranged between 24 and 83 years. Liver resections for hepatocellular carcinoma or colorectal metastases were undertaken and biliary or hydatid cysts were removed. The mean procedure time was 95 to 205 min and the average diameter of the lesions was 5 cm.

CONCLUSIONS

When practiced by multidisciplinary teams, transvaginal liver resection is feasible and safe. The goals of SILS and NOTES are to be less intrusive, more easily tolerated and aesthetic.

Single-incision laparoscopic surgery to treat hepatopancreatobiliary cancer: A technical review

Single-incision laparoscopic surgery (SILS), or laparoendoscopic single-site surgery, was launched to minimize incisional traumatic effects in the 1990s. Minor SILS, such as cholecystectomies, have been gaining in popularity over the past few decades. Its application in complicated hepatopancreatobiliary (HPB) surgeries, however, has made slow progress due to instrumental and technical limitations, costs, and safety concerns. While minimally invasive abdominal surgery is pushing the boundaries, advanced laparoscopic HPB surgeries have been shown to be comparable to open operations in terms of patient and oncologic safety, including hepatectomies, distal pancreatectomies (DP), and pancreaticoduodenectomies (PD). In contrast, advanced SILS for HPB malignancy has only been reported in a few small case series. Most of the procedures involved minor liver resections and DP; major hepatectomies were rarely described. Single-incision laparoscopic PD has not yet been reported. We herein review the published SILS for HPB cancer in the literature and our three-year experience focusing on the technical aspects.

Standardized single-incision plus one-port laparoscopic left lateral sectionectomy: a safe alternative to the conventional procedure

Purpose

Laparoscopic left lateral sectionectomy (LLLS) is a feasible and safe procedure with a relatively smooth learning curve. However, single-incision LLLS requires extensive surgical experience and advanced techniques. The aim of this study is to report the standardized single-incision plus one-port LLLS (reduced port LLLS, RPLLLS) technique and evaluate its safety, feasibility, and effectiveness for junior surgeons.

Methods

Between January 2008 and November 2020, the clinical records of 49 patients who underwent LLLS, divided into the conventional LLLS (n = 37) and the RPLLLS group (n = 12), were retrospectively reviewed. The patient characteristics, pathologic results, and operative outcomes were evaluated.

Results

A history of previous abdominal surgery in the RPLLLS group was significantly high (56.8% vs. 91.7%, p = 0.552). Notably, junior surgeons performed 62.2% of the conventional LLLSs and 58.4% of the standardized RPLLLSs. There were no significant differences between the two groups in terms of median operative time (121.0 vs. 113.5, p = 0.387), median blood loss (13.0 vs. 8.5, p = 0.518), median length of hospital stays (7.0 vs. 7.0, p = 0.408), and morbidity rate (2.7% vs. 0%, p = 0.565), respectively.

Conclusion

This standardized RPLLLS is a feasible and safe alternative to conventional LLLS and may become the ideal training procedure for both junior surgeons and surgeons aiming to learn more complex procedures.

Is Single-Incision Laparoscopic Liver Surgery Safe and Efficient for the Treatment of Malignant Hepatic Tumors? A Systematic Review

PURPOSE

The objective of this review was to evaluate the safety and efficiency of single-incision laparoscopic liver surgery (SILLS) for malignant liver lesions.

METHODS

A retrospective review of the Medline database was performed, including studies published up to February 2019.

RESULTS

Overall, 69 patients (50 males) with a median age of 61 years (range, 31-90) from 16 studies underwent SILLS for malignant liver disease and were included in this review. The majority of patients underwent resection for hepatocellular carcinoma (n = 52, 75 %), followed by metastatic disease (n = 15, 22 %). The hepatic lesions were located in anterolateral liver segments in 62 patients (90 %) and in posterosuperior liver segments in 7 patients (10 %). Sixty-five patients (94 %) underwent minor liver resection. The median blood loss was 200 mL (range 0-2500), while 4 patients that underwent single-port resection were converted to either conventional laparoscopy or open resections. Two cases were reported to be associated with postoperative complications in the single-port group (1 [1.7 %] grade Dindo-Clavien I-II, 1 [1.7 %] grade Dindo-Clavien III-IV), while no complications were noted in the multiport group. All patients successfully underwent R0 resection.

CONCLUSIONS

SILLS seems to be a safe and efficient treatment modality for malignant liver disease when performed by experienced surgeons in carefully selected patients. More studies are needed to better identify which patients may benefit from such an operative approach.

The Shift from Multiport to Single Port Increases the Amount of Bleeding in Laparoscopic Major Hepatectomy

Background: Bleeding is a negative outcome predictor in liver surgery. Reduction in the abdominal wall trauma in major hepatectomy is challenging but might offer possible benefits for the patient. This study was conducted to assess hemostasis techniques in single-port major hepatectomies (SP-MajH) as compared to multiport major hepatectomies (MP-MajH). Methods: The non-randomized study comprised 34 SP-MajH in selected patients; 14 MP-MajH served as the control group. Intraoperative blood loss and number of blood units transfused served as the primary endpoints. Secondary endpoints were complications and oncologic five-year outcome. Results: All resections were completed without converting to open surgery. Time for hepatectomy did not differ between SP-MajH and MP-MajH. Blood loss and number of patients with blood loss > 25 mL were significantly larger in MP-MajH (p = 0.001). In contrast, bleeding control was more difficult in SP-MajH, resulting in more transfusions (p = 0.008). One intestinal laceration (SP-MajH) accounted for the only intraoperative complication; 90-day mortality was zero. Postoperative complications were noted in total in 20.6% and 21.4% of patients for SP-MajH and MP-MajH, respectively. No incisional hernia occurred. During a median oncologic follow-up at 61 and 56 months (SP-MajH and MP-MajH), no local tumor recurrence was observed. Conclusions: SP-MajH requires sophisticated techniques to ensure operative safety. Substantial blood loss requiring transfusion is more likely to occur in SP-MajH than in MP-MajH.

Clinical advantages of single port laparoscopic hepatectomy

AIM

To evaluate the clinical advantages of single-port laparoscopic hepatectomy (SPLH) compare to multi-port laparoscopic hepatectomy (MPLH).

METHODS

We retrospectively reviewed the medical records of 246 patients who underwent laparoscopic liver resection between January 2008 and December 2015 at our hospital. We divided the surgical technique into two groups; SPLH and MPLH. We performed laparoscopic liver resection for both benign and malignant disease. Major hepatectomy such as right and left hepatectomy was also done with sufficient disease-free margin. The operative time, the volume of blood loss, transfusion rate, and the conversion rate to MPLH or open surgery was evaluated. The post-operative parameters included the meal start date after operation, the number of postoperative days spent in the hospital, and surgical complications was also evaluated.

RESULTS

Of the 246 patients, 155 patients underwent SPLH and 91 patients underwent MPLH. Conversion rate was 22.6% in SPLH and 19.8% in MPLH (P = 0.358). We performed major hepatectomy, which was defined as resection of more than 2 sections, in 13.5% of patients in the SPLH group and in 13.3% of patients in the MPLH group (P = 0.962). Mean operative time was 136.9 ± 89.2 min in the SPLH group and 231.2 ± 149.7 min in the MPLH group (P < 0.001). The amount of blood loss was 385.1 ± 409.3 mL in the SPLH group and 559.9 ± 624.9 mL in the MPLH group (P = 0.016). The safety resection margin did not show a significant difference (0.84 ± 0.84 cm in SPLH vs 1.04 ± 1.22 cm in MPLH, P = 0.704). Enteral feeding was started earlier in the SPLH group (1.06 ± 0.27 d after operation) than in the MPLH group (1.63 ± 1.27 d) (P < 0.001). The mean hospital stay after operation was non-significantly shorter in the SPLH group than in the MPLH group (7.82 ± 2.79 d vs 7.97 ± 3.69 d, P = 0.744). The complication rate was not significantly different (P = 0.397) and there was no major perioperative complication or mortality case in both groups.

CONCLUSION

Single-port laparoscopic liver surgery seems to be a feasible approach for various kinds of liver diseases.

The Role of the Single Incision Laparoscopic Approach in Liver and Pancreatic Resectional Surgery

Introduction. Single incision laparoscopic surgery (SILS) has gained increasing support over the last few years. The aim of this narrative review is to analyse the published evidence on the use and potential benefits of SILS in hepatic and pancreatic resectional surgery for benign and malignant pathology. Methods. Pubmed and Embase databases were searched using the search terms “single incision laparoscopic”, “single port laparoscopic”, “liver surgery”, and “pancreas surgery”. Results. Twenty relevant manuscripts for liver and 9 for pancreatic SILS resections were identified. With regard to liver surgery, despite the lack of comparative studies with other minimal invasive techniques, outcomes have been acceptable when certain limitations are taken into account. For pancreatic resections, when compared to the conventional laparoscopic approach, SILS produced comparable results with regard to intra- and postoperative parameters, including length of hospitalisation and complications. Similarly, the results were comparable to robotic pancreatectomies, with the exception of the longer operative time reported with the robotic approach. Discussion. Despite the limitations, the published evidence supports that SILS is safe and feasible for liver and pancreatic resections when performed by experienced teams in the tertiary setting. However, no substantial benefit has been identified yet, especially compared to other minimal invasive techniques.

Effectiveness and safety of single-port versus multi-port laparoscopic surgery for treating liver diseases: a meta-analysis

OBJECTIVE

To compare the effectiveness and safety of single-port versus multi-port laparoscopic surgery for treating liver diseases.

METHODS

Several databases were systematically searched for randomized controlled trials, cohort studies, and case-control studies on the use of single-port versus multi-port laparoscopic surgery to treat liver diseases from their inception until March 24, 2016. The primary outcomes were the operative time, volume of intraoperative blood loss, rate of postoperative complications, median length of postoperative stay, recovery time of gastrointestinal function, volume of postoperative drainage, and postoperative drainage time. The study-specific effect sizes and their 95 % confidence interval were all combined to calculate the pooled value by using a random-effects model.

RESULTS

A total of nine studies were included, which involved 277 patients. The total and subgroup data were combined by meta-analysis. This meta-analysis showed that single-port and multi-port laparoscopic liver surgery for treating liver diseases did not differ in terms of operative time (P = 0.48), rate of postoperative complications (P = 0.56), median length of postoperative stay (P = 0.80), and recovery time of gastrointestinal function (P = 0.54). For liver diseases, the single-port group exhibited a lower volume of intraoperative blood loss than that presented by the multi-port group (P = 0.0006). In the hepatic resection subgroup, a lower volume of intraoperative blood loss was noted in the single-port group (P < 0.0001). By contrast, in the hepatic cyst subgroup, the single-port group showed a higher volume of intraoperative blood loss (P = 0.02) but a shorter median length of postoperative stay (P = 0.02). The findings of the potential subgroup analysis in these outcomes were consistent with the total data.

CONCLUSION

Compared with multi-port laparoscopic surgery, the single-port method showed comparable effectiveness and safety for the treatment of liver diseases in terms of current evidence.

Application of stapling devices in liver surgery: Current status and future prospects

The liver is a vascular-rich solid organ. Safe and effective dissection of the vessels and liver parenchyma, and control of intraoperative bleeding are the main concerns when performing liver resection. Several studies have confirmed that intraoperative blood loss and postoperative transfusion are predictors of postoperative morbidity and mortality in liver surgery. Various methods and instruments have been developed during hepatectomy. Stapling devices are crucial for safe and rapid anastomosis. They are used to divide hepatic veins and portal branches, and to transect liver parenchyma in open liver resection. In recent years, laparoscopic liver surgery has developed rapidly, and is now preferred by many surgeons. Stapling devices have also been gradually introduced in laparoscopic liver surgery, from dividing vascular and biliary structures to parenchymal transection. This may be because staplers make manipulation more simple, rapid and safe. Even in single incision laparoscopic surgery, which is recognized as a new minimally invasive technique, staplers are also utilized, especially in left lateral hepatectomy. For safe application of stapling devices in liver surgery, more related designs and modifications, such as application of a suitable laparoscopic articulating liver tissue crushing device, a staple line reinforcement technique with the absorbable polymer membrane or radiofrequency ablation assistance, are still needed. More randomized studies are needed to demonstrate the benefits and find broader indications for the use of stapling devices, to help expand their application in liver surgery.

Single port laparoscopic liver surgery: A minireview

Nowadays, the trend is to perform surgeries with "scarless" incisions. In light of this, the single-port laparoscopic surgery (SPLS) technique is rapidly becoming widespread due to its lack of invasiveness and its cosmetic advantages, as the only entry point is usually hidden in the umbilicus. The interest in "scarless" liver resections did not grow as rapidly as the interest in other scarless surgeries. Hepatopancreatobiliary surgeons are reluctant to operate a malignant lesion through a narrow incision with limited exposure. There are concerns over adverse oncological outcomes for single-port laparoscopic liver resections (SPL-LR) for hepatocellular carcinoma or metastatic colorectal cancer. In addition, getting familiar with using the operating instruments through a narrow incision with limited exposure is very challenging. In this article, we reviewed the published literature to describe history, indications, contraindications, ideal patients for new beginners, technical difficulty, advantages, disadvantages, oncological concern and the future of SPL-LR.

Transumbilical videolaparoscopic (single site) liver biopsy with laparoscopy equipment

INTRODUCTION

Liver diseases have a high incidence in the whole world. In order to diagnose, stage and follow these diseases it is often necessary the execution of liver biopsy. There are many possible ways to perform the procedure and the rise of transumbilical endoscopic surgery (TUES) brings to the medical practice an additional good option.

MATERIALS AND METHODS

The study is prospective, nonrandomised and cohort type. It involves 42 patients who underwent liver biopsy through TUES using conventional video laparoscopic material.

RESULTS

Among the patients 18 (42.86%) underwent isolated liver biopsy and 24 (57.14%) to liver biopsy associated with umbilical hernia repair. Within those, 27 (64.28%) were male and 15 (35.71%) female. The average body mass index (BMI) was of 27.26 kg/m(2), 10 were in the normal BMI range, 24 (57.14%) were in the overweight range, 6 (14.28%) had class I obesity and 2 (4.76%) had class II obesity. In none of the cases the procedure was converted to regular video laparoscopy, all the patients were discharged in the day after the procedure and reported a satisfactory aesthetic result.

CONCLUSIONS

The study shows that liver biopsy using TUES has applicability and good results, including in obese patients that would have a contraindication to other methods.

Single-Port Laparoscopic Liver Resection: Largest Turkish Experience

Single-port laparoscopic surgery has the advantage of a hidden scar and reduced abdominal wall trauma. Although single-port laparoscopic surgery is widely performed for other organs, its application is very limited for liver resection. Here, we report our experience with nine patients who underwent single-port laparoscopic liver resection. Nine patients underwent single-port laparoscopic liver resection for the indications of hydatid cyst, hepatocellular carcinoma, and colorectal cancer liver metastasis. Nine patients were successfully treated with single-port laparoscopic surgery. The operative time was between 60 and 240 min. The only operative complication was bleeding up to 650 mL in a patient with cirrhosis. No postoperative complications occurred. All patients were discharged earlier than usual. Single-port laparoscopic liver surgery is a challenging surgery. Surgeon with the experience of laparoscopic liver surgery should perform the single-port laparoscopic liver surgery. It is technically feasible with a good outcome in well-selected patients. Initial cases must be benign lesions to avoid jeopardizing oncological safety.

Single incision laparoscopic liver resection (SILL) - a systematic review

Background: Today, minimally invasive liver resections for both benign and malignant tumors are routinely performed. Recently, some authors have described single incision laparoscopic liver resection (SILL) procedures. Since SILL is a relatively young branch of laparoscopy, we performed a systematic review of the current literature to collect data on feasibility, perioperative results and oncological outcome.

Methods: A literature research was performed on Medline for all studies that met the eligibility criteria. Titles and abstracts were screened by two authors independently. A study was included for review if consensus was obtained by discussion between the authors on the basis of predefined inclusion criteria. A thorough quality assessment of all included studies was performed. Data were analyzed and tabulated according to predefined outcome measures. Synthesis of the results was achieved by narrative review.

Results: A total of 15 eligible studies were identified among which there was one prospective cohort study and one randomized controlled trial comparing SILL to multi incision laparoscopic liver resection (MILL). The rest were retrospective case series with a maximum of 24 patients. All studies demonstrated convincing results with regards to feasibility, morbidity and mortality. The rate of wound complications and incisional hernia was low. The cosmetic results were good.

Conclusions: This is the first systematic review on SILL including prospective trials. The results of the existing studies reporting on SILL are favorable. However, a large body of scientific evidence on the field of SILL is missing, further randomized controlled studies are urgently needed.

BiClamp-Fracture Method in Pure Laparoscopic Hepatectomy: Verifying its Efficacy Irrespective of Liver Stiffness

BACKGROUND

Transecting cirrhotic liver in pure laparoscopic hepatectomy (PLH) is generally considered technically demanding. We have preferentially used BiClamp in PLH by fracturing liver parenchyma using this device. The aim of the current study was to retrospectively verify the efficacy of BiClamp-fracture method in transecting cirrhotic parenchyma.

METHODS

The medical records of 21 patients who underwent PLH using BiClamp-fracture method between April 2011 and September 2014 were examined. The patients were divided into the Nonstiff group (F0-F2, n=11) and the Stiff group (F3 and F4, n=10) and various surgical factors were compared between the groups.

RESULTS

The mean operation time, the mean intraoperative blood loss, and the mean postoperative hospital stay in the Stiff group were comparable with those in the Nonstiff group. There were no postoperative complications in both groups.

CONCLUSION

BiClamp-fracture method was effective in transecting liver parenchyma irrespective of liver stiffness in PLH.

Advances in reduced port laparoscopic liver resection

Reduced port surgery has been attracting attention in the field of minimally invasive surgery. Although the use of SILS is becoming widespread, technical difficulty has delayed its adoption for laparoscopic liver resection. Recently, advances in laparoscopic liver resection have been made in tandem with advances in surgical skill and devices. The main driver in conventional laparoscopic liver resection's evolution to become less surgically invasive seems to be single-incision laparoscopic liver resection (SILLR). To date, most reports on SILLR have been single case reports or case series. Only a few cohort studies on conventional laparoscopic surgery and SILLR have been conducted. Recent reports have described the use of SILLR for well-localized lesions and solitary tumors located in the anterolateral segments of the liver or left liver lobe, but its application remains limited to partial resection and left lateral sectionectomy. The feasibility and safety of SILLR have been demonstrated, but additional work is needed for standardization of the procedure.