Randomized clinical trial of open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery after surgery programme (ORANGE II study).

RCT of open versus laparoscopic left lateral hepatic sectionectomy within an enhanced recovery after surgery programme (ORANGE II study)

Laparoscopic vs. open left lateral sectionectomy: an update systematic review and meta-analysis of randomized and non-randomized controlled trials

Laparoscopic left lateral sectionectomy: a population-based study

BackgroundThe use of lLaparoscopic liver resection in terms of time to functional recovery, length of hospital stay (LOS), long-term abdominal wall hernias, costs and quality of life (QOL) has never been studied in a randomised controlled trial. Therefore, this is the subject of the international multicentre randomised controlled ORANGE II trial.MethodsPatients eligible for left lateral sectionectomy (LLS) of the liver will be recruited and randomised at the outpatient clinic. All randomised patients will undergo surgery in the setting of an ERAS programme. The experimental design produces two randomised arms (open and laparoscopic LLS) and a prospective registry. The prospective registry will be based on patients that cannot be randomised because of the explicit treatment preference of the patient or surgeon, or because of ineligibility (not meeting the in- and exclusion criteria) for randomisation in this trial. Therefore, all non-randomised patients undergoing LLS will be approached to participate in the prospective registry, thereby allowing acquisition of an uninterrupted prospective series of patients. The primary endpoint of the ORANGE II trial is time to functional recovery. Secondary endpoints are postoperative LOS, percentage readmission, (liver-specific) morbidity, QOL, body image and cosmetic result, hospital and societal costs over 1 year, and long-term incidence of incisional hernias. It will be assumed that in patients undergoing laparoscopic LLS, length of hospital stay can be reduced by two days. A sample size of 55 patients in each randomisation arm has been calculated to detect a 2-day reduction in LOS (90% power and α = 0.05 (two-tailed)).The ORANGE II trial is a multicenter randomised controlled trial that will provide evidence on the merits of laparoscopic surgery in patients undergoing LLS within an enhanced recovery ERAS programme.Trial registrationClinicalTrials.gov NCT00874224.

Left lateral sectionectomy for donor hepatectomy is a well-established alternative to deceased donor pediatric liver transplantation. However, very little is available on the laparoscopic approach (laparoscopic left lateral sectionectomy [L-LLS]). With the aim to assess safety, reproducibility under proctorship, and outcomes following living donor liver transplantation in children, a comparative single-center series using propensity score matching (PSM) to evaluate open left lateral sectionectomy (O-LLS) versus L-LLS was carried out in a relatively short time period in a high-volume pediatric transplant center. A retrospective, observational, single-center, PSM study was conducted on 220 consecutive living donor hepatectomies from January 2011 to April 2017. The variables considered for PSM were as follows: year of operation, recipient age, indication for transplant, recipient weight, donor sex, donor age, and donor body mass index. After matching, 72 O-LLSs were fit to be compared with 72 L-LLSs. Operative time and warm ischemia time were significantly longer in L-LLSs, whereas blood loss and overall donor complication rates were significantly lower. Postoperative day 1 and 4 pain scores were significantly less in the L-LLS group (P = 0.015 and 0.003, respectively). The length of hospital stay was significantly shorter in L-LLS (4.6 versus 4.1 days; P = 0.014). Overall donor biliary complications were 9 (12.5%) and 1 (1.4%) for O-LLS and L-LLS (P = 0.022), respectively. Vascular complications occurred in 3 (4.2%) children without graft loss in the laparoscopic group. The 1-, 3-, and 5-year overall patient survival rates were 98.5%, 90.9%, and 90.9% in the O-LLS group and in the L-LLS group 94.3%, 92.7%, and 86.8% (P = 0.28). In conclusion, L-LLS for donor hepatectomy is a safe and reproducible technique yielding better donor perioperative outcomes with respect to the conventional approach with similar recipient outcomes.

Laparoscopic hepatectomy is progressively gaining popularity. However, it is still unclear whether the laparoscopic approach offers cost advantages compared with the open approach, especially when major hepatectomies are required. Data providing useful insights into the costs of the laparoscopic approach for clinicians and hospitals are needed. The aim of this study is to assess the financial implications of the laparoscopic approach for two standardized minor and major hepatectomies: left lateral sectionectomy and right hepatectomy. A cost comparison analysis of patients undergoing laparoscopic right hepatectomy (LRH) and laparoscopic left lateral sectionectomy (LLLS) versus the open counterparts was performed. Data considered for the comparison analysis were operative costs (theatre cost, consumables and surgeon/anaesthetic labour cost), postoperative costs (hospital stay, complication management and readmissions) and overall costs. A total of 149 patients were included: 38 patients underwent LRH and 46 open right hepatectomy (ORH); 46 patients underwent LLLS and 19 open left lateral sectionectomy (OLLS). For LRH the mean operative, postoperative and overall costs were £10,181, £4,037 and £14,218; for ORH the mean operative, postoperative and overall costs were £6,483 (p < 0.0001), £10,304 (p < 0.0001) and £16,787 (p = 0.886). Regarding LLLS, the mean operative, postoperative and overall costs were £5,460, £2,599 and £8,059; for OLLS the mean operative, postoperative and overall costs were £5,841 (p = 0.874), £5,796 (p < 0.0001) and £11,637 (p = 0.0001). Our data support the cost advantage of the laparoscopic approach for left lateral sectionectomy and the cost neutrality for right hepatectomy.

A few studies have reported only short-term outcomes of various robotic and laparoscopic liver resection types; however, published data in left lateral sectionectomy (LLS) have been limited. The aim of this study was to compare the long- and short-term outcomes of robotic and laparoscopic LLS. We retrospectively compared demographic and perioperative data as well as postoperative outcomes of robotic (n=12) and laparoscopic (n=31) LLS performed between May 2007 and July 2013. Resection indications included malignant tumors (n=31) and benign lesions (n=12) including intrahepatic duct (IHD) stones (n=9). There were no significant differences in perioperative outcomes of estimated blood loss, major complications, or lengths of stay, but operating time was longer in robotic than in laparoscopic LLS (391 vs. 196min, respectively) and the operation time for IHD stones did not differ between groups (435 vs. 405min, respectively; p=0.190). Disease-free (p=0.463) and overall (p=0.484) survival of patients with malignancy did not differ between groups. The 2- and 5-year disease-free survival rates were 63.2 and 36.5%, respectively. However, robotic LLS costs were significantly higher than laparoscopic LLS costs ($8183 vs. $5190, respectively; p=0.009). Robotic LLS was comparable to laparoscopic LLS in surgical outcomes and oncologic integrity during the learning curve. Although robotic LLS was more expensive and time intensive, it might be a good option for difficult indications such as IHD stones.

Backgrounds/AimsAnatomical resection has superior oncologic outcomes over non-anatomical resection in hepatocellular carcinoma, and left lateral sectionectomy is the simplest and easiest perform anatomical resection procedure among liver resections. The purpose of this study was to find out the safety and feasibility of pure laparoscopic left lateral sectionectomy (PLLLS) for hepatocellular carcinoma.MethodsPatients who underwent left lateral sectionectomy at a tertiary referral hospital, from August 2007 to April 2019 were enrolled in this retrospective study. After matching the 1 : 3 propensity score, 17 open and 51 pure laparoscopic cases were selected out of 102 cases of total left lateral resection for hepatocellular carcinoma. The group was analyzed in terms of patient demographics, preoperative data, and postoperative outcomes.ResultsDuring the study period, there was no open conversion case. The mean operative time and complication were not statistically significant different between the two groups. There was no statistically significant difference in disease-free survival and overall survival had no statistical between the two groups. There were no mortality cases, and postoperative hospital stay was significantly shorter in the PLLLS group than in the open left lateral sectionectomy (OLLS) group.ConclusionsThe oncologic outcomes and complication rate were the same in the PLLLS and OLLS groups. However, the hospital stay was shorter in the PLLLS group than in the OLLS group. The present study findings demonstrate that the PLLLS is a safe and feasible procedure for hepatocellular carcinoma.

Minimally Invasive Liver Resection: Robotic Versus Laparoscopic Left Lateral Sectionectomy

Laparoscopic living donor liver procurement for transplantation has increased in popularity over the past decade. The purpose of this study was to compare the laparoscopic and open approaches in living donor left lateral sectionectomy (LLS) and to assess the safety and feasibility of this laparoscopic approach. A total of 103 living donor LLSs were performed at our center from May 2016 to December 2017. Of these, 35 were completely laparoscopic procedures, which represented the subject of this study. An additional 68 open living donor LLSs performed during the same period were studied as a comparison group. To overcome selection bias, LLS donors were balanced on a 1:1 ratio (laparoscopic [n=35]: open [n=35]) according to covariates with similar values. The PSM was based on the operation date, recipient age, diagnosis, recipient weight, and donor age. There were significant differences between the laparoscopic and open LLS groups (P<0.001) in terms of blood loss (96.8±16.5 vs 155.8±17.8mL) as well as the duration of hospital stay (4±0.4 vs 6.9±0.5days). Laparoscopic LLS is a feasible and efficacious in the setting of a developed program with advanced laparoscopic expertise.

Compared to the open method of left lateral sectionectomy, the laparoscopic method has demonstrated shorter hospital stay with less bleeding and complications and is becoming the gold standard procedure. We report our experience with 15 Iaparoscopic left lateral sectionectomies performed during PLDLTs from May 2008. From May 2008 to April 2010, there were 15 cases where laparoscopic left lateral sectionectomy was performed for donor hepatectomy. All cases were performed by a sin-gle surgeon. The mean size of the actual graft was 248.8±52.8mL (range 150-350). The mean operation time was 331.3+63.1 minutes (range 220-480),the mean blood loss was 410.0+71.2mL (range 250-500) and the mean warm ischemic time was 5.8+1.6 minutes (range 4-10). The mean time to oral intake was 2.0±0.3 days (range 1-3) and the mean hospital stay was 7.1+0.8 days (range 6-10). There were no complications or deaths among donors postoperative-ly. We believe it is a safe and reproducible procedure and an especially useful procedure for young mother donors who desire small wounds and rapid recovery.

Anatomical liver resection along the intersegmental plane provides oncological advantages for primary liver malignancies and may reduce complications such as blood loss and postoperative bile leakage. In left lateral sectionectomy (LLS), the falciform ligament and umbilical fissure are conventionally regarded as landmarks; however, tertiary branches from the dorsal and cephalic sides of the portal umbilicus (P4dor) often annulate the left lateral region of the falciform ligament. We propose a novel LLS technique using an extrahepatic Glissonean approach combined with indocyanine green (ICG) fluorescence. To preliminarily investigate the P4dor territory, protocol-based dynamic computed tomography images of 128 patients scheduled for hepatobiliary and pancreatic surgery were analyzed. The safety and efficacy of the technique were assessed using robotic, laparoscopic, and open LLS. The Glissonean pedicles of segments 2 and 3 were isolated, P4dor boundaries delineated under ICG guidance, and the parenchyma transected along the demarcation line to preserve the P4dor region. P4dor was identified in 91.4% of cases, with a mean of 1.4 branches, an annular volume of 21.7 ml (2.1%), and a mean distance of 15.9 mm between the left border of the P4dor territory and the portal umbilicus. In all three surgical cases, the P4dor boundaries were clearly delineated and preserved. No postoperative complications occurred. This LLS technique is simple, feasible for minimally invasive surgery, and enables reproducible anatomical resection by clarifying the P4dor demarcation. It may also facilitate adequate margins in biliary tumors while preserving functional liver parenchyma.

Laparoscopy is nowadays considered as the standard approach for hepatic left lateral sectionectomy (LLS), but its value in the prevention of incisional hernia (IH) has not been demonstrated. Between 2012 and 2017, patients undergoing laparoscopic (LLLS) or open LLS (OLLS) in 8 centers were compared. Patients undergoing a simultaneous major abdominal procedure were excluded. The incidence of IH was assessed clinically and morphologically on computed tomography (CT) using inverse probability of treatment weighting (IPTW) and multivariable regression analysis. After IPTW, 84 LLLS were compared to 48 OLLS. Compared to OLLS, LLLS patients had reduced blood loss (100 [IQR: 50-200] ml vs. 150 [IQR: 50-415] ml, p = 0.023) and shorter median hospital stay (5 [IQR: 4-7] days vs. 7 [6-9] days, p < 0.001), but experienced similar rate of postoperative complications (mean comprehensive complication index: 12 ± 19 after OLLS versus 13 ± 20 after LLLS, p = 0.968). Long-term radiological screening was performed with a median follow-up of 27.4 (12.1-44.9) months. There was no difference between the two groups in terms of clinically relevant IH (10.7% [n = 9] after LLLS, 8.3% [n = 4] after OLLS, p = 0.768). The rate of IH detected on computed tomography was lower after LLLS than after OLLS (11.9% [n = 10] versus 29.2% [n = 14], p = 0.013). On multivariable analysis, the laparoscopic approach was the only independent factor influencing the risk of morphological IH (OR = 0.290 [95% CI: 0.094-0.891], p = 0.031). The 2 preferential sites for specimen extraction after LLLS were Pfannenstiel and midline incisions, with rates of IH across the extraction site of 2.3% [n = 1/44] and 23.8% [n = 5/21], respectively (p = 0.011). The laparoscopic approach for LLS decreases the risk of long-term IH as evidenced on morphological examinations, with limited clinical impact. Pfannenstiel's incision should be preferred to midline incision for specimen extraction after LLLS.

Enhanced Recovery After Lung Resection Surgery: Knowing What We Can Do… and Doing It

Laparoscopic liver resection has thus far not gained widespread acceptance among liver surgeons. Valid questions remain regarding the relative clinical superiority of the laparoscopic approach as well as whether laparoscopic hepatectomy carries any economic benefit compared with open liver surgery. The aim of this work is to compare the clinical and economic impact of laparoscopic versus open left lateral sectionectomy (LLS). Between May 2002 and July 2008, 44 laparoscopic LLS and 29 open LLS were included in the analysis. Deviation-based cost modeling (DBCM) was utilized to compare the combined clinical and economic impact of the open and laparoscopic approaches. The laparoscopic approach compared favorably with the open approach from both a clinical and economic standpoint. Not only was the median length of stay (LOS) shorter by 2 days in the laparoscopic group (3 versus 5 days, respectively, P = 0.001), but the laparoscopic cohort also benefited from a significant reduction in postoperative morbidity (P = 0.001). Because the groups differed significantly in age and ratio of benign to malignant disease, a subgroup analysis limited to patients with malignant disease was undertaken. The same reduction in LOS and postoperative morbidity was evident within the malignant subgroup undergoing laparoscopic LLS (P = 0.003). The economic impact of the laparoscopic approach was noteworthy, with the laparoscopic approach US$1,527-2,939 more cost efficient per patient compared with the open technique. Our study seems not only to corroborate the safety and clinical benefit of the laparoscopic approach but also suggests a fiscally important cost advantage for the minimally invasive approach.