Is hand-assisted minimally invasive hepatectomy superior to the totally laparoscopic approach?

Abstract

Background: Minimally invasive liver resection has been proven safe and effective for the treatment of hepatic malignancy, but the optimal technique remains controversial. Description of technique: Hand-assisted laparoscopic surgery (HALS) begins with placement of an optical trocar allowing for initial diagnostic laparoscopy and intraoperative ultrasound. For left-sided lesions, a midline incision is created for handport placement and for right-sided lesions, a rarely-described far-right subcostal incision in the anterior axillary line is used (Fig. 1a). The latter incision is particularly beneficial as it provides access to cephalad and posterior lesions often difficult to resect in a laparoscopic fashion, and it does not impede laparoscopic vision (Fig. 1b). Results: In a retrospective review comparing 74 HALS cases to 24 totally laparoscopic (TL) cases (with Pfannenstiel extraction) in a similar cohort of patients undergoing hepatic resection for malignancy, factors including extent of resection, operative time, and blood loss were similar (Table 1). TL cases were more likely to convert to open (0% vs 8%, p = 0.012). The techniques had similar perioperative outcomes including complication rates and hernia occurrence. Oncologically, HALS had a lower margin positivity rate and 6 patients (8%) in the HALS group had additional lesions detected through palpation and removed that were not seen on intraoperative ultrasound. Conclusion: HALS is associated with increased ability to train fellows and improved vascular control compared to TL approaches. Given the oncologic superiority and equivalent patient experience demonstrated, HALS should be the preferred approach, particularly in teaching settings.EPTT-025Table 1 HALS vs. TL approachFactorTotalHALS (N = 74)TL (N = 24)P valueAge (years)58 (50–64)60 (52–67)56 (42–62)0.062Operative time (min)192 (150–240)196 (155–238)163 (121–242)0.093Major hepatectomy3 (3)3 (4)0 (0)0.316Diameter largest lesion (cm)2 (1–3)2 (1–4)2 (1–2)0.102Estimated blood loss (cc)100 (50–150)100 (50–150)75 (20–138)0.185Conversion to open2 (2)0 (0)2 (8)0.012Positive surgical margin8 (8)4 (6)4 (17)0.110Wound infection2 (2)2 (3)0 (0)0.416Major complication (Accordion grade ≥3)1 (1)0 (0)1 (4)0.078 Open table in a new tab