Application of temporary inflow control of the Glissonean pedicle method provides a safe and easy technique for totally laparoscopic hemihepatectomy by Glissonean approach

Indocyanine green fluorescence image-guided laparoscopic anatomical S2/3 resection using the TICGL technique

BACKGROUND

Segment 2/3 (S2/3) resection, which can preserve more residual liver parenchyma, is a feasible alternative to left lateral sectionectomy. However, it is still challenging to perform anatomical S2/3 resection safely and precisely, especially laparoscopically. This study was designed to evaluate the safety and accuracy of the temporary inflow control of the Glissonean pedicle (TICGL) technique combined with indocyanine green (ICG) fluorescence imaging in laparoscopic anatomical S2/3 resection.

PATIENTS AND METHODS

A total of 12 patients recruited at Zhujiang Hospital of Southern Medical University from June 2021 to August 2022 were included in the study. All patients underwent ICG fluorescence imaging guided laparoscopic anatomical S2/3 resection. The TICGL technique was used to control the blood inflow of the target segment. The total time used to control the hepatic inflow of the target segment, the time of hemostasis, the amount of intraoperative blood loss, predicted resected liver volume (PRLV) and actual resected liver volume (ARLV) were used to evaluate the simplicity, safety, and accuracy of the TICGL technique combined ICG fluorescent imaging in guiding laparoscopic anatomical S2/3 resection.

RESULTS

Of the 12 included patients, 7 underwent S2 resection and 5 underwent S3 resection. The operation time was 76.92 ± 11.95 min, the intraoperative blood loss was 15.42 ± 5.82 ml, and the time of hepatic blood inflow control was 7.42 ± 2.43 min. There was a strong correlation between PRLV and ARLV (r = 0.903, P < 0.05).

CONCLUSION

The combination of the TICGL technique with ICG negative staining fluorescence imaging is a feasible approach for laparoscopic anatomical S2/3 resection.

Is the anterior approach suitable for laparoscopic right hemihepatectomy in patients with large HCC (5-10 cm)? A propensity score analysis

BACKGROUND

Right hemihepatectomy via the anterior approach was initially employed to improve the survival of patients with large hepatocellular carcinoma (HCC). To date, the safety and feasibility of laparoscopic right hemihepatectomy via the anterior approach (ALRH) for patients with large HCC remains unclear; thus, we compared short-term and long-term outcomes between ALRH and open right hemihepatectomy via the anterior approach (AORH).

METHODS

161 patients with HCC who met the inclusion and exclusion criteria in our department were enrolled in this study between January 2015 and August 2018. Perioperative and oncological outcomes were compared using propensity score matching analysis (PSM).

RESULTS

There were 45 patients in the ALRH group and 116 patients in the AORH group. After 1:3 PSM, 40 ALRH patients and 95 AORH patients were well matched. The intraoperative time was longer in the ALRH group than in the AORH group after PSM (median, 297.5 vs. 205 min, P < 0.001). However, ALRH led to less intraoperative blood loss than AORH after PSM (median, 265 vs. 350 ml, P = 0.049). The rates of overall complications (12.5% vs. 30.5%, P = 0.028) in the ALRH group were significantly lower than those in the AORH group after PSM. Moreover, the survival outcomes were equivalent between the two groups with regard to 1-, 3-, and 5-year overall survival rates (P = 0.698) and disease-free survival rates (P = 0.510).

CONCLUSION

ALRH could be safe and feasible for some patients with large HCCs (5-10 cm) when performed by experienced surgeons, and it had superior perioperative outcomes and equivalent oncological outcomes to AORH.

Realization of improved outcomes following liver resection in hepatocellular carcinoma patients aged 75 years and older

Purpose

Little is known about liver resection (LR) in hepatocellular carcinoma (HCC) patients older than 75 years of age. This study aimed to compare the postoperative and long-term outcomes of hepatectomy in this patient population according to operation period.

Methods

This study included 130 elderly patients who underwent LR for solitary treatment-naïve HCC between November 1998 and March 2020. Group 1 included patients who underwent LR before 2016 (n = 68) and group 2 included those who underwent LR during or after 2016 (n = 62).

Results

The proportion of major LR, anatomical LR, and laparoscopic LR (LLR) in group 1 was significantly lower than those in group 2. Also, the median operation time, amount of blood loss, hospitalization length, rates of intraoperative blood transfusion, and complications in group 2 were less than those in group 1. In the subgroup analysis of group 1, high proteins induced by vitamin K absence or antagonist-II, long hospitalization, and LLR were closely associated with mortality. In the subgroup analysis of group 2, however, none of the factors increased mortality. Nevertheless, the presence of tumor grade 3 or 4 and the incidence of microvascular invasion were higher in group 1 than in group 2, and the disease-free survival and overall survival were better in group 2 than in group 1 because of minimized blood loss and quicker recovery period by increased surgical techniques and anatomical approach, and LLR.

Conclusion

LR in elderly HCC patients has been frequently performed recently, and the outcomes have improved significantly compared to the past.

A randomized controlled trial to compare the efficacy of regenerated and non-regenerated oxidized cellulose gauze for the secondary treatment of local bleeding in patients undergoing hepatic resection

Purpose

Oxidized cellulose is available in many forms, but manufactured using either a regenerated or non-regenerated process. In this study, we evaluated the effects of 2 different hemostatic agents for the treatment of local bleeding in patients undergoing hepatic resection.

Methods

This was a monocentric, parallel-group, randomized, and controlled clinical trial to compare oxidized regenerated cellulose gauze (ORCG) with oxidized non-regenerated cellulose gauze (ONRCG) in patients undergoing hepatectomy. The primary endpoint was the time to hemostasis at the target bleeding site. The secondary endpoints were the postoperative drainage volume on the first 2 days after surgery and the hospital stay.

Results

There was no significant difference between the ORCG and ONRCG groups in time to hemostasis from column analysis (238.8 ± 121.6 seconds vs. 193.7 ± 85.3 seconds, P = 0.068), and there were no differences in the rates of hemostatic success between the 2 groups at 120 seconds (18.4% vs. 24.3%; odds ratio [OR], 0.703; 95% confidence interval [CI], 0.231–2.136) and 300 seconds (71.1% vs. 89.2%; OR, 0.298; 95% CI, 0.085–1.041). However, the ONRCG group was superior to the ORCG group in hemostasis according to the survival analysis (log-rank test, P = 0.044). Moreover, there were also no significant differences between the 2 groups in postoperative drainage volume on the first 2 days (P = 0.436, P = 0.381) and hospital stay (P = 0.537, P = 0.200).

Conclusion

ONRCG was not inferior to ORCG as a hemostatic agent in patients undergoing liver resection.

"Liver parenchyma dissecting-first" method facilitates the Glissonean pedicle approach in anatomical laparoscopic hepatolobectomy

Background

Anatomical laparoscopic hepatolobectomy (ALH) is a difficult and challenging operation, and avoiding massive hemorrhage during parenchyma transection remains one of its major concern. Glissonean pedicle approach (GPA) has achieved great success in open liver surgery due to its simplicity and reproducibility, but it is difficult to apply in ALH for the limited vision and motion. We thus aimed to introduce a modified method to facilitate the GPA in ALH.

Methods

In this retrospective study, in 15 patients who underwent ALH (at least 2 couinaud segments), the liver parenchyma was dissected at first (LPDF) adequately under intermittent total inflow control to reveal the Glissonean pedicle (GP) sufficiently for safe and precise transection. The technical details of LPDF for different types of hepatolobectomy and a modified laparoscopic Pringle maneuver are described, and the surgical outcomes are reviewed.

Results

LPDF was applied in all patients, and intraoperative blood transfusion was not needed. LPDF facilitated GPA in ALH without any severe morbidity or mortality.

Conclusions

LPDF is a safe and effective technique, it reduces the difficulties in inflow occlusion in GPA and can promote the application of ALH. Further clinical control trails are needed to validate the superiority of LPDF compared with GPA in ALH.

Elderly Hepatocellular Carcinoma Patients: Open or Laparoscopic Approach?

It remains unclear whether the short-term benefits and long-term outcomes of laparoscopic liver resection (LLR) accrue to elderly patients with medical comorbidities. The aim of the present study was to compare the outcomes between LLR and open liver resection (OLR) in elderly patients (≥65 years) with solitary, treatment-naïve solitary hepatocellular carcinoma (HCC). From January 2013 to August 2017, 256 elderly patients with solitary treatment-naive HCC underwent liver resection. All patients were Child–Pugh class A and older than 65 years. The OLR and LLR groups contained 160 and 96 patients, respectively. The median tumor size in the OLR group was significantly larger than that in the LLR group (3.9 vs. 2.6 cm), but the tumor size did not differ between the two groups after matching. The median operation time, blood loss, transfusion rate, and postoperative complications in the OLR group did not differ from those in the LLR group, but the operation time in the LLR group was longer than that in the OLR group after matching. The median hospitalization in the LLR group was significantly shorter than that in the OLR group. Disease-free survival (DFS) in the LLR group was better than that in the OLR group before and after matching, but the difference was not significant. Patient survival (PS) in the LLR group was similar to that in the OLR group. LLR is feasible and safe for elderly patients with solitary, treatment-naïve HCC. The short- and long-term benefits of LLR are evident in geriatric oncological liver surgery patients.

Laparoscopic Right Hemihepatectomy Using the Glissonean Approach: Detachment of the Hilar Plate (with Video)

BACKGROUND

The Glissonean approach is a fundamental technique for anatomical liver resection using both open and laparoscopic surgery. After detachment of the hilar plate from the liver parenchyma, the right Glissonean pedicle can be easily approached. This study describes the technical details and surgical outcomes of laparoscopic right hemihepatectomy using the Glissonean approach through the detachment of the hilar plate.

METHODS

The key procedures of our technique were as follows: Step (1) Incision of the peritoneum between segment 4 and the superior surface of the hilar plate, Step (2) Division of the posterior extremity of the cystic plate, Step (3) Incision of the peritoneum between the caudate process and the inferior surface of the hilar plate, Step (4) Clamping of the right Glissonean pedicle after partial detachment of the hilar plate, Step (5) Transection of the right Glissonean pedicle during the parenchymal transection.

RESULTS

Between May 2013 and December 2019, 13 patients underwent laparoscopic right hemihepatectomy using the Glissonean approach. The median operation time was 280 min (range 200-410 min), and the median blood loss was 310 ml (range 120-600 ml). The median postoperative hospital stay was 8 days (range 7-25 days). There were no biliary complications.

CONCLUSION

The detachment of the hilar plate was a feasible and effective technique in laparoscopic right hemihepatectomy using the Glissonean approach. Our standardized technique prevents biliary complications by meticulous dissection of potential injury sites related to the hilar plate.

Learning curve of laparoscopic living donor right hepatectomy

Background

The feasibility and learning curve of laparoscopic living donor right hepatectomy was assessed.

Methods

Donors who underwent right hepatectomy performed by a single surgeon were reviewed. Comparisons between open and laparoscopy regarding operative outcomes, including number of bile duct openings in the graft, were performed using propensity score matching.

Results

From 2014 to 2018, 103 and 96 donors underwent laparoscopic and open living donor right hepatectomy respectively, of whom 64 donors from each group were matched. Mean(s.d.) duration of operation (252·2(41·9) versus 304·4(66·5) min; P &lt; 0·001) and median duration of hospital stay (8 versus 10 days; P = 0·002) were shorter in the laparoscopy group. There was no difference in complication rates of donors (P = 0·298) or recipients (P = 0·394) between the two groups. Total time for laparoscopy decreased linearly (R2 = 0·407, β = –0·914, P = 0·001), with the decrease starting after approximately 50 procedures when cases were divided into four quartiles (2nd versus 3rd quartile, P = 0·001; 3rd versus 4th quartile, P = 0·023). Although grafts with bile duct openings were more abundant in the laparoscopy group (P = 0·022), no difference was found in the last two quartiles (P = 0·207).

Conclusion

Laparoscopic living donor right hepatectomy is feasible and an experience of approximately 50 cases may surpass the learning curve.

Does liver cirrhosis have an impact on the results of different hepatic inflow occlusion methods in laparoscopic liver resection? a propensity score analysis

BACKGROUND

Few studies have analyzed the impact of liver cirrhosis on different hepatic inflow occlusion methods in laparoscopic liver resection (LLR). Intermittent Pringle (IP) was compared to continuous hemihepatic vascular inflow occlusion (CHVIO) in LLR in patients with or without cirrhosis.

METHODS

Patients who underwent LLR at the West China Hospital of Sichuan University form January 2015 to October 2017 were grouped according to occlusion methods and severity of cirrhosis. A matched propensity score analysis was performed.

RESULTS

Among patients without cirrhosis, there were no significant differences in blood loss (238 ± 30 ml VS 265 ± 46 ml, P = 0.653), operative time (228 ± 9 min VS 265 ± 20 min, P = 0.437) or other postoperative results between the IP and CHVIO groups after propensity score matching. Among patients with cirrhosis, blood loss (279 ± 24 ml VS 396 ± 35 ml, P = 0.012) and operative time (237 ± 11 min VS 285 ± 24 min, P = 0.041) were significantly lower in the IP group, while postoperative liver function did not significantly differ between the two groups after propensity score matching.

CONCLUSIONS

In patients without cirrhosis, IP is as efficient and as safe as CHVIO in cirrhotic patients. IP offers the advantages of shorter operative time and less blood loss and does not result in worse postoperative liver function.

Impact of technical innovation on surgical outcome of laparoscopic major liver resection: 10 years' experience at a large-volume center

Purpose

Laparoscopic major liver resection (major LLR) remains a challenging procedure because of the technical difficulty. Several significant technical innovations have been applied in our center since 2012. They include routine application of bipolar electrocautery, initiation of temporary increase of intra-abdominal pressure during bleeding events from veins to balance the central venous pressure, and use of temporary inflow control of the Glissonean pedicle. This study evaluated the impact of these technique modifications in patients with major LLR.

Methods

Between January 2004 and February 2015, a total of 606 patients underwent LLR at Samsung Medical Center in Seoul, Korea. Major LLR was employed in 233 cases. All major LLR procedures were anatomical resections performed with a totally laparoscopic approach. We compared surgical parameters of right hepatectomy (RH), left hepatectomy (LH), and right posterior sectionectomy (RPS) before and after 2012.

Results

Open conversion rates of RH and LH and estimated blood loss in RPS significantly decreased after 2012. The postoperative complication rate of major LLR was 12.7% and was similar before and after 2012. Bile leakage was the most common complication (3.2%).

Conclusion

The modifications of surgical techniques resulted in good outcomes for laparoscopic major LLR. We recommend routine application of these techniques to improve outcomes, especially in patients requiring major liver resection.

Laparoscopic Versus Open Right Posterior Sectionectomy for Hepatocellular Carcinoma in a High-Volume Center: A Propensity Score Matched Analysis

BACKGROUND

While minimal invasive surgery is becoming popular in liver resection, right posterior sectionectomy (RPS) is still considered as a difficult procedure. We summarize the clinical data and investigate the feasibility of laparoscopic right posterior sectionectomy (LRPS) in hepatocellular carcinoma (HCC) by comparing its outcomes with those of open right posterior sectionectomy (ORPS).

METHODS

We retrospectively reviewed 191 patients who underwent RPS for HCC during January 2009 to August 2016 at Samsung Medical Center. After 1:2 propensity score matching, 53 patients in LRPS group were matched to 97 patients in ORPS group.

RESULTS

There was no statistical difference in preoperative data. While operation time was significantly longer in LRPS group (381.1 ± 118.7 vs. 234.4 ± 63.7 min, P < 0.001), transfusion rate (13.2 vs. 2.1%, P = 0.061) and complication rate (9.4 vs. 8.3%, P = 0.709) were not statistically different between groups. Clustered Cox proportional hazards regression analysis for matched paired data showed no difference in both disease-free survival (P = 0.607) and overall survival (P = 0.858).

CONCLUSIONS

In HCC, LRPS can be performed safely compared to ORPS, regarding the operative outcome, patient recovery, and oncological outcomes.

Outcomes of pure laparoscopic Glissonian pedicle approach hepatectomy for hepatocellular carcinoma: a propensity score matching analysis

BACKGROUND

Few studies had been performed to concern the outcomes of pure laparoscopic Glissonian pedicle approach hepatectomy (LGAH) for hepatocellular carcinoma (HCC). The aim of this study was to compare the outcomes of LGAH versus open Glissonian pedicle approach hepatectomy (OGAH) for HCC, especially in patients with cirrhosis.

METHODS

Hepatocellular carcinoma patients who underwent pure LGAH and OGAH between January 2015 and July 2017 in our institution were retrospectively enrolled in this study. Propensity score matching (PSM) of patients in a ratio of 1:1 was conducted to adjust the known confounders. The perioperative and oncological outcomes were compared between the two groups after PSM.

RESULTS

Some 80 patients underwent pure LGAH and 134 had OGAH. After PSM, 67 patients in each group were well matched for analysis. Both the postoperative overall complication rates (13.4% vs. 29.9%, P = 0.021) and mean comprehensive complication index (2.63 vs. 7.40, P = 0.035) were significantly lower in the LGAH group than those in OGAH group. Although the operative time was longer in the LRH group (P < 0.001), the length of postoperative hospital stay was shorter in the LRH group (P = 0.024). Furthermore, both the 3-year overall survival rate (73.3% for LGAH vs. 77.8% for OGAH, P = 0.338) and 3-year disease-free survival rate (56.4% for LGAH vs. 62.5% for OGAH, P = 0.455) were not significantly different between the groups.

CONCLUSION

Pure laparoscopic Glissonian approach may be a better alternative to open Glissonian approach in selected HCC patients, which provided fewer complications, shorter postoperative hospital stay and comparable oncological outcomes.

Which approach is preferred in left hepatocellular carcinoma? Laparoscopic versus open hepatectomy using propensity score matching

Background

Laparoscopic liver resection has been reported as a safe and effective approach for the management of hepatocellular carcinoma (HCC). However, its perioperative and oncological outcomes have not been evaluated in left hepatectomy patients. The aim of the present study is to compare the outcomes of left hepatectomy through laparoscopic and open approaches in left HCC.

Methods

From December 2012 to October 2016, laparoscopic left hepatectomy (LLH) was performed in 40 patients and open left hepatectomy (OLH) was performed in 80 patients. All clinical data were analyzed retrospectively. Propensity score matching of patients in a 1:1 ratio was conducted based on tumor size and presence of microvascular invasion.

Results

Tumor size and presence of microvascular invasion were higher in the OLH group than the LLH group (P < 0.05). However, the operative time was longer in the LLH group than in the OLH group (266 min vs. 239 min; P = 0.005). The median postoperative hospital stay was significantly shorter in the LLH group than in the OLH group before and after matching (9 days vs. 13 days; P < 0.001). The incidence of complications in the LLH and OLH groups was 10.0 and 7.5%, respectively. The disease-free survival (DFS) and overall survival (OS) in the LLH group were not different from those in the OLH group after propensity score matching.

Conclusions

A laparoscopic approach is feasible and safe for left HCC. The oncologic outcome of LLH is comparable to that of OLH.

Portal vein aneurysm associated with arterioportal fistula after hepatic anterior segmentectomy: Thought-provoking complication after hepatectomy

Background

Few cases of postoperative arterioportal fistula (APF) have been documented. APF after hepatectomy is a very rare surgery-related complication.

Case presentation

A 62-year-old man was diagnosed with hepatocellular carcinoma in segments 5 and 8, respectively. Anterior segmentectomy was performed as a curative surgery. Each branch of the hepatic artery, portal vein, and biliary duct for the anterior segment was ligated together as the Glissonean bundle. The patient was discharged on postoperative day 14. Three months later, dynamic magnetic resonance imaging showed an arterioportal fistula and portal vein aneurysm. Surprisingly, the patient did not have subtle symptoms. Although a perfect angiographic evaluation could not be ensured, we performed angiography with subsequent interventional radiology to avoid sudden rupture. Arteriography was immediately performed to create a portogram via the APF from the stump of the anterior hepatic artery, and portography clearly revealed hepatofugal portal vein flow. Portography also showed that the stump of the anterior portal vein had developed a 40-mm-diameter portal vein aneurysm. Selective embolization of the anterior hepatic artery was accomplished in the whole length of the stump of the anterior hepatic artery, and abnormal blood flow through the APF was drastically reduced. The portal vein aneurysm disappeared, and portal flow was normalized. Dynamic computed tomography after embolization clearly demonstrated perfect interruption of the APF. The patient maintained good health thereafter.

Conclusions

Post-hepatectomy APFs are very rare, and some appear to be cryptogenic. Our thought-provoking case may help to provide a possible explanation of the causes of post-hepatectomy APF.

Useful maneuvers for precise laparoscopic liver resection

Laparoscopic liver resection has evolved over the past decade and nearly replaced open exploration. This procedure not only provides comparable oncological outcomes, but it also has improved recovery after surgery. Many of the challenges presented by limitations of instruments and techniques have been overcome through adaptations and new developments, and it is possible that the remaining obstacles will be overcome within a few years. Moreover, as surgeons continue to gain experience, their technical knowledge has supported further improvement in minimally invasive approaches. This review examines every important procedures in performing a precise laparoscopic liver resection.