Single incision laparoscopic surgery for hepatocellular carcinoma.

Introduction: Laparoscopic liver resection is a challenging procedure, yet it is increasingly applied in the treatment of hepatocellular carcinoma (HCC), including our center. Our aim is to evaluate the impact of laparoscopic hepatectomy for hepatocellular carcinoma regarding the long-term outcomes. Patients and Methods: A combined retrospective-prospective cohort study of 41 HCC patients who underwent laparoscopic hepatectomy at the Organ Transplantation Center, Viet Duc University Hospital from January 2019 to December 2023. Results: Liver resection for tumors >5 cm accounted for 24.4%, with 63.4% of cases classified as high difficulty (Ban Daisuke score). The mean operative time was 192 minutes, and the intraoperative blood transfusion rate was 18.9%. The mean disease-free survival was 44.5 ± 3.19 months, with 1-, 2-, 3-, and 4-year rates of 94.4%, 87.2%, 70.6%, and 70.6%, respectively. The mean overall survival was 50.0 ± 2.30 months, with corresponding rates of 96.7%, 92.9%, 86.8%, and 86.8%. Preoperative AFP 0.5 cm were favorable prognostic factors. Conclusions: Laparoscopic hepatectomy is a safe and effective treatment option for hepatocellular carcinoma offering significant survival benefits. Keywords: Laparoscopic hepatectomy, Difficulty Scoring System, Hepatocellular carcinoma. References GLOBOCAN 2020. Cancer fact sheet: Vietnam fact sheet. Accessed April 29, 2023. https://gco.iarc.fr/today/data/factsheets/populations/704-viet-nam-fact-sheets.pdf Balzan S, Belghiti J, Farges O, et al. The “50-50 Criteria” on Postoperative Day 5 An Accurate Predictor of Liver Failure and Death After Hepatectomy. Annals of Surgery. 2005;242(6):824-829. doi:10.1097/01.sla.0000189131.90876.9e Dindo D, Demartines N, Clavien PA. Classification of Surgical Complications. Annals of Surgery. 2004;240(2):205-213. doi:10.1097/01.sla.0000133083.54934.ae Johnson PJ, Berhane S, Kagebayashi C, et al. Assessment of Liver Function in Patients With Hepatocellular Carcinoma: A New Evidence-Based Approach—The ALBI Grade. Journal of Clinical Oncology. 2015;33(6):550-558. doi:10.1200/jco.2014.57.9151 Ban D, Tanabe M, Ito H, et al. A novel difficulty scoring system for laparoscopic liver resection. J Hepatobiliary Pancreat Sci. 2014;21(10):745-753. doi:10.1002/jhbp.166 Tran Cong Duy Long. Evaluation of the Role of Laparoscopic Liver Resection in the Treatment of Hepatocellular Carcinoma. Doctoral Thesis in Medicine. University of Medicine and Pharmacy at Ho Chi Minh City; 2016. Nguyen Dinh Hieu, Nguyen Quang Nghia, Pham Van Binh. Result of laparoscopic liver resection for hepatocellular carcinoma in Nghe An oncology hospital. VMJ. 2024;536(1B). doi:10.51298/vmj.v536i1B.8822 Yoon YI, Kim KH, Cho HD, et al. Long-term perioperative outcomes of pure laparoscopic liver resection versus open liver resection for hepatocellular carcinoma: a retrospective study. Surg Endosc. 2019;34(2):796-805. doi:10.1007/s00464-019-06831-w Yamamoto M, Kobayashi T, Oshita A, et al. Laparoscopic versus open limited liver resection for hepatocellular carcinoma with liver cirrhosis: a propensity score matching study with the Hiroshima Surgical study group of Clinical Oncology (HiSCO). Surg Endosc. 2020;34(11):5055-5061. doi:10.1007/s00464-019-07302-y Ghielmetti M, Ramser M, Oertli D. Laparoscopic liver resection: a single-centre experience. Swiss Med Wkly. 2021;151:w20391. doi:10.4414/smw.2021.20391 Ruzzenente A, Bagante F, Poletto E, et al. A machine learning analysis of difficulty scoring systems for laparoscopic liver surgery. Surg Endosc. 2022;36(12):8869-8880. doi:10.1007/s00464-022-09322-7 Tsai KY, Chen HA, Wang WY, Huang MT. Long-term and short-term surgical outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma: might laparoscopic approach be better in early HCC? Surg Endosc. 2019;33(4):1131-1139. doi:10.1007/s00464-018-6372-0 Soubrane O, Goumard C, Laurent A, et al. Laparoscopic resection of hepatocellular carcinoma: a French survey in 351 patients. HPB. 2014;16(4):357-365. doi:10.1111/hpb.12142 Cheng CH, Lai Y, Hung HC, et al. Recurrence Patterns After Hepatectomy With Very Narrow Resection Margins for Hepatocellular Carcinoma. Front Surg. 2022;9:926728. doi:10.3389/fsurg.2022.926728. Download file PDF

The introduction of laparoscopic procedures is one of the milestones of surgical innovation over the past few decades. The advantages of minimally invasive approach have been gradually accepted owing to its less postoperative pain, reduced morbidity and faster recovery. Also, since the introduction of laparoscopic approach of liver surgery in 1955 (1), the benefit of the procedure had long been questioned but expected. The article by Piardi et al., entitled “Laparoscopic resection for hepatocellular carcinoma: comparison between Middle Eastern and Western experience” sought to compare the safety and feasibility of laparoscopic versus open liver resection for hepatocellular carcinoma between Middle Eastern and Western surgeons. To this end, 24 original studies with more than 15 patients were analyzed, while studies from both groups documented similar intraoperative and immediate postoperative outcomes. It is well documented that a positive histologic margin was associated with a higher incidence of postoperative HCC recurrence (2), and the long-term oncological result aroused debates for laparoscopic approach because of the difficult assessment and possible compromise of resection margin. Though some case series supported that the laparoscopic liver resection may be a safe and feasible approach (3,4), the risk of inadequate tumor resection of the procedure for malignancies still makes others hesitate. Among the discussions, good resection margins for laparoscopic hepatectomies were reported in the matched-pair comparative study conducted by Tranchart et al. (5), which suggested that with the appropriate preoperative choice of resection, the rate of the positive margin after laparoscopic resection could be similar or even lower than those after open hepatectomy. Furthermore, Piardi et al. documented that excellent outcomes could be obtained in the setting of underlying cirrhosis in both Middle Eastern and Western, and also confirmed that the laparoscopic liver resection for hepatocelluar carcinoma benefits to less blood loss, less transfusion requirement, and a shorter hospital stay. Besides, the fear of increasing the risk of trocar-site deposits may no longer be the consideration since no recurrence from trocar-sites was documented in the studied articles. Selection criteria for indications of laparoscopic liver resection in hepatocellular cancer may be varied among institutes. The surgical limit continued to expand (6,7), though once said the best candidate for laparoscopy were solitary lesions that were less than 5 cm, located in the anterior segments, and at a distance from transection, the hepatic hilum, and the vena cava (8). In fact, when planning a liver surgery for malignant disease, not only the safe margin but also the volume and functional reserve of the remnant liver are crucial. Apparently, compensated cirrhosis is a surgical contraindication since most hepatocellular carcinomas developed within chronic hepatitis or cirrhosis. Surgeons still face a big challenge dealing with these non-compensated cirrhotic patients. Interestingly, the article pointed out that studies from the Western tended to have uniform selection criteria in tumor size and location as well as the severity of the underlying disease. On the opposite, studies from Middle Eastern were reported with less clear criteria, which implied that Middle Eastern ones tended to use laparoscopic approach more aggressively. The indications for laparoscopic liver resection are expanding because of a wider acceptance of laparoscopic applications and improvement of the instrumentation and technology. In our experience of laparoscopic liver resection in hepatocellular carcinoma, the indications are expanding but require additional training, both in liver surgery and laparoscopic surgery. Furthermore, robotic assisted platforms are drawing focus and are gradually replacing some traditional laparoscopic applications.

Laparoscopic resection for hepatocellular carcinoma: eastern and western experiences.

Innovative Strategies and Recent Advances in Liver Surgery

Hepatocellular carcinoma (HCC) is still a leading indication of Surgical resection of a portion of the liver. Laparoscopic and robotic liver resections are some of the techniques that are becoming increasingly common. Although RLR is more dextrous and precise, its benefits over LLR remain controversial because of the variation in the methodology of studies and patient selection. This meta-analysis compared perioperative outcomes between robotic and laparoscopic liver resection in HCC, focusing on operative time, hospital stay, morbidity, mortality, transfusion needs, and bile leak rates. The quality of evidence was assessed using the GRADE approach. A systematic search of PubMed, Scopus, and Cochrane identified 520 records. Five multicenter propensity score-matched cohort studies involving 3,616 patients (Robotic: 3,283; Laparoscopic: 333) met the inclusion criteria. Data on perioperative outcomes were pooled, and the Newcastle-Ottawa Scale (NOS) was used to evaluate the methodological quality of the studies. Compared with laparoscopic resection, robotic liver resection had a longer operative time (MD: -35.15min, 95% CI: -64.90 to - 5.39; p = 0.02; I² = 38%). However, there were no significant differences in blood transfusion rates (RR: 1.50, 95% CI: 0.41-5.47; p = 0.54), bile leaks (RR: 2.11, 95% CI: 0.59-7.52; p = 0.25), hospital stays (MD: -0.19 days, 95% CI: -2.42 to 2.05; p = 0.87; I² = 95%), or conversion to open surgery (RR: 1.22, 95% CI: 0.42-3.59; p = 0.71). RLR showed higher 30-day morbidity (RR: 1.59, 95% CI: 1.04-2.42; p = 0.03), while 90-day mortality did not differ significantly between the two approaches (RR: 4.33, 95% CI: 0.84-22.41; p = 0.08). RLR yields comparable results to LLR in HCC, with no differences in mortality or conversion rates but longer operative times and slightly higher short-term morbidity. Evidence quality was low to very low, emphasizing the need for well-designed randomized trials to inform surgical choices.

Background Laparoscopic liver resection (LLR) has been progressively developed along the past two decades. Liver surgery was one of the last frontiers reached by minimally invasive surgery. Surgical technique and equipment evolved to overcome technical limitations, making laparoscopic liver resections (LLR) safe and feasible. Surgeons developed skills in a stepwise approach, beginning with low complexity operations for benign diseases and reaching high-complexity surgeries for malignant cases and living donor organ harvesting. Objective s: The aim of the study is to compare short term results of laparoscopic versus open hepatectomy regarding to intra operative details and post-operative management and complications for achieving a safe hepatic resection for treatment of HCC in cirrhotic patients. Patients and Methods In this prospective study, a comparison between laparoscopic resection and open resection was done to compare short-term results between laparoscopic and open liver resection. This study was conducted on 30 patients with hepatocellular carcinoma. 15 patients (50%) were treated by laparoscopic liver resection (Group A) while the other 15 patients (50%) were treated by open liver resection (Group B). Results Regarding the demographic data, the presence of past history of medical condition and the preoperative laboratory results, no statistical significance was found. The mean operative time has statistically significant difference between the 2 groups, with decreased operative time in the laparoscopic group (P < 0.001). The mean blood loss has no statistically significant difference relations between the 2 groups, (P = 0.866) with conversion rate of (13.3%) happened in two cases. Conclusion Laparoscopic liver resection is a safe and feasible treatment option for HCC in cirrhotic patient needing minor resection at laparoscopic segments (II, III, IVa,V,VI). Laparoscopic liver resection for HCC has superior short- term and comparable oncological outcomes to open liver resection. LLR should be performed for carefully selected patients and by an expert surgical team.

ABSTRACTPurpose: Laparoscopic liver resection is safe, feasible and associated with less blood loss, shorter hospital stays and fewer postoperative complications in the working age patients with malignant liver tumors. However, it is still unclear if the elderly patients with malignant liver tumors would also benefit from that approach as the younger patients. So, the aim of the study was to compare the clinical outcomes of laparoscopic versus open liver resection for malignant liver tumors in elderly patients. Materials and Methods: Between March 2009 and July 2016, all elderly patients (≥70 years old) who underwent laparoscopic (n = 40) and open (n = 202) liver resection for malignant liver tumors were included. A one to one propensity score matching analysis was performed, based on 6 covariates, to decrease the selection bias. Results: There was no significant difference between the laparoscopic and open liver resection groups regarding the patient characteristics and tumor features. The operative time was comparable between both groups (Laparoscopic group 259 min vs Open group 308 min, p = .86), while patients who underwent laparoscopic liver resection had lower intraoperative blood loss (30 ml vs 517 ml, p < .0001), shorter hospital stays (10 days vs 23 days, p < .0001), and less overall morbidity (15% vs 38%, p = .04). The one-, three-, and five-year survival for patients with hepatocellular carcinoma was comparable between both groups (Laparoscopic group 96%, 74%, 47%, vs Open group 94%, 71%, 48%, p = .82), whereas The one-, three-, and five-year recurrence-free survival for patients with hepatocellular carcinoma was significantly higher in the laparoscopic group (88%, 60%, 60% vs 54%, 25%, 19%, p = .019). Conclusions: Laparoscopic approach for minor liver resection in elderly patients is safe and feasible with less blood loss, a shorter hospital stay, less postoperative complications and a better oncological outcome.

Background: Laparoscopic liver resection has been gaining momentum, and it has become an accepted practice after the two international consensus conferences where experts worked up guidelines to standardize this approach and improve its safety. However, most laparoscopic hepatectomies were performed in patients with liver metastases. The concurrent presence of liver cirrhosis with hepatocellular carcinoma (HCC) poses a great challenge to clinicians trying to establish a routine use of laparoscopic liver resection for HCC. Summary: The first Asia Pacific consensus meeting on laparoscopic liver resection for HCC was held in July 2016 in Hong Kong. A group of expert liver surgeons with experience in both open and laparoscopic hepatectomy for HCC convened to formulate recommendations on the role and perspective of laparoscopic liver resection for primary liver cancer. The recommendations consolidate the most recent evidence pertaining to laparoscopic hepatectomy together with the latest thinking of practicing clinicians involved in laparoscopic hepatectomy, and give detailed guidance on how to deploy the treatment effectively for patients in need. Key Message: The panel of experts gathered evidence and produced recommendations providing guidance on the safe practice of laparoscopic hepatectomy for patients with HCC and cirrhosis. The inherent advantage of the laparoscopic approach may result in less blood loss if the procedure is performed in experienced centers. The laparoscopic approach to minor hepatectomy, particularly left lateral sectionectomy, is a preferred practice for HCC at experienced centers. Laparoscopic major liver resection for HCC remains a technically challenging operation, and it should be carried out in centers of excellence. There is emerging evidence that laparoscopic liver resection produces a better oncological outcome for HCC when compared with radiofrequency ablation, particularly when the lesions are peripherally located. Augmented features in laparoscopic liver resection, including indocyanine green fluorescence, 3D laparoscopy, and robot, will become important tools of surgical treatment in the near future. A combination of all of these features will enhance the experience of the surgeons, which may translate into better surgical outcomes. This is the first consensus workforce on laparoscopic liver resection for HCC, which is a unique condition that occurs in the Asia Pacific region.

ObjectiveTo compare between laparoscopic and open liver resection for liver tumors.BackgroundLaparoscopic surgery has become a standard in many elective procedures, but it is still gaining popularity in liver surgery. The safety of laparoscopic liver resection is still under study.Materials and methodsThis study was prospectively conducted from October 2012 to December 2014 on 30 patients presenting with hepatic tumors (benign and malignant) to the outpatient clinic of both Menoufia University Hospitals and El-Salam Oncology Center. Patients were divided randomly into two groups: group A, which includes 15 patients operated upon by laparoscopic technique; and group B, which includes 15 patients operated upon by open technique.ResultsOperating time was significantly longer in the laparoscopy group: it was 131.54 ± 15.61 versus 118.04 ± 19.41 min. Blood loss was highly significant in laparoscopic resections. Mean hospital stay was highly significant shortly after laparoscopy 6.20 ± 1.10 versus 8.81 ± 1.50 days. Patients who underwent laparoscopic procedure resumed oral intake earlier than the open group. The overall complication rate was significantly lower in the laparoscopic group than the open group.ConclusionLaparoscopic liver resection improved surgical and postsurgical outcome for open liver resection regarding less operative blood loss, postoperative pain, postoperative complications, and hospital stay.

To assess the feasibility and safety of laparoscopic liver resections. The use of the laparoscopic approach for liver resections has remained limited for technical reasons. Progress in laparoscopic procedures and the development of dedicated technology have made it possible to consider laparoscopic resection in selected patients. A prospective study of laparoscopic liver resections was undertaken in patients with preoperative diagnoses including benign lesion, hepatocellular carcinoma with compensated cirrhosis, and metastasis of noncolorectal origin. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6), and the tumor had to be 5 cm or smaller. Surgical technique included CO2 pneumoperitoneum and liver transection with a harmonic scalpel, with or without portal triad clamping or hepatic vein control. Portal pedicles and large hepatic veins were stapled. Resected specimens were placed in a bag and removed through a separate incision, without fragmentation. From May 1996 to December 1999, 30 of 159 (19%) liver resections were included. There were 18 benign lesions and 12 malignant tumors, including 8 hepatocellular carcinomas in cirrhotic patients. Mean tumor size was 4.25 cm. There were two conversions to laparotomy (6.6%). The resections included 1 left hepatectomy, 8 bisegmentectomies (2 and 3), 9 segmentectomies, and 11 atypical resections. Mean blood loss was 300 mL. Mean surgical time was 214 minutes. There were no deaths. Complications occurred in six patients (20%). Only one cirrhotic patient developed postoperative ascites. No port-site metastases were observed in patients with malignant disease. Laparoscopic resections are feasible and safe in selected patients with left-sided and right-peripheral lesions requiring limited resection. Young patients with benign disease clearly benefit from avoiding a major abdominal incision, and cirrhotic patients may have a reduced complication rate.

Laparoscopic repeat liver resection after open liver resection is safe and feasible compared with laparoscopic primary liver resection: a comparative study from a single center

The purpose of this study is the evaluation of the surgical and oncological results of laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) by comparing laparoscopic and open liver resection (OLR) in the treatment of this disease. Retrospective analysis of laparoscopic and OLR for HCC (<5 cm) performed over a 4-year period was conducted. The LLR was done by a single surgeon. The study was performed on patients who received liver resection for HCC between July 2007 and August 2011 in our institution. Propensity-based matched analyses were used to account for operative method selection biases. During the 4 years, 1,050 patients with HCC received an operation. Among them patients who never received TACE or RFA before surgery and had HCC (<5 cm) were selected for this study. 174 patients had OLR, and 58 patients underwent LLR. Patients who received LLR had lower operative time, transfusion rate, complication rate, and shorter hospital days. There were significant differences in hospital mortality and morbidity between the two groups. Dietary recovery was relatively fast in the group of LLR. Overall and disease-free survival rates during the 4 years were also not significantly different between the two groups. LLR is a developing and safe technique in a select group of patients including those with malignancies, and use of this procedure is associated with short hospital stays, a rapid return to a normal diet, full mobility, and minimal morbidity, with acceptable oncological parameters. It may be an optimal method of hepatectomy in HCC (<5 cm). Further, long-term follow-up should be acquired for adequate evaluation for survival.

Objective To evaluate the feasibility and efficacy of laparoscopic liver resection (LLR) in elderly patients with hepatocellular carcinoma (HCC). Methods Twenty-nine elderly patients undergoing laparoscopic liver resection (LLR) and 58 elderly patients receiving open liver resection (OLR) for HCC were included from January 2013 to December 2015 in our department of Fujian Medical University.Two groups were 1∶2 matched for gender, tumor numbers, and operative procedure.Besides, general clinical data, intraoperative data, postoperative recovery, and postoperative survival were compared. Results The postoperative hospital stay was shorter in the LLR group[(9.1±3.8) days]than in the OLR group[(11.8±5.1) days](t=-2.66, P<0.05). The incidence of portal triad clamping was lower in the LLR group than in the OLR group (34.5% vs.60.3%, χ2=5.18, P<0.05). The removal time of abdominal drainage tube was earlier in the LLR group (4.18 ± 1.94)days than in the OLR group (5.4±2.1)days (t=-2.48, P<0.05). The overall survival (OS) showed no difference (37.08 months vs.38.72 months, t=0.72, P=0.789). The disease-free survival (DFS) showed no difference (29.00 months vs.27.49 months, t=0.53, P=0.467). Conclusions LLR in elderly patients with HCC can achieve the same long-term outcome as the conventional open hepatectomy, and LLR has better short-term outcomes with obvious advantages of minimal invasion. Key words: Laparoscopes; Hepatectomy; Hepatocellular carcinoma

: Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver and the third leading cause of cancer-related deaths worldwide. Liver resection has been widely accepted as the mainstay of HCC treatment, leading to long-term survival in well-selected patients. Over the last two decades, laparoscopic liver resection (LLR) has developed worldwide parallel to technological advancements and increased experience of liver surgeons. Several meta-analyses revealed that LLR for HCC has yielded better short-term outcomes without compromising long-term outcomes, compared to open liver resection (OLR). During treatment of HCC patients with chronic liver disease or liver cirrhosis, LLR decreases blood loss and postoperative complications including refractory ascites, leading to a shorter hospital stay. In the treatment of recurrent HCC, LLR makes subsequent procedures easier by minimizing adhesion formation. The procedure of laparoscopic major liver resection (major LLR) is yet to be standardized and is still in exploration stage according to the Morioka international conference, 2014. Laparoscopic parenchyma-sparing anatomical liver resection (Lap-PSAR) is a novel surgical strategy to resect all malignant tissues while preserving enough liver parenchyma to prevent postoperative liver failure. In conclusion, LLR has many advantages for the treatment of HCC patients and generally results in better short-term outcomes. Further investigations are needed to standardize the procedures of major LLR and Lap-PSAR.

Laparoscopic surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver, above all for patients with hepatocellular carcinoma (HCC) and cirrhosis. This approach mainly includes diagnostic procedures and interstitial therapies. However, we believe there is room for laparoscopic liver resections in well-selected cases. The aim of this study is to assess: (a) the risk of intraoperative bleeding and postoperative complications, (b) the safety and the respect of oncological criteria, and (c) the potential benefit of laparoscopic ultrasound in guiding liver resection. A prospective study of laparoscopic liver resections for hepatocellular carcinoma was undertaken in patients with compensated cirrhosis. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6), and the tumor had to be 5 cm or smaller. Tumor location and its transection margins were defined by laparoscopic ultrasound. From January 1997, 22 out of 250 patients with HCC (9%) underwent laparoscopic liver resections. The mean patient age was 61.4 years (range, 50-79 years). In three patients, conversion to laparotomy was necessary. The laparoscopic resections included five bisegmentectoies (2 and 3), nine segmentectomies, two subsegmentectomies and three nonanatomical resections for extrahepatic growing lesions. The mean operative time, including laparoscopic ultrasonography, was 199 +/- 69 min (median, 220; range, 80-300). Perioperative blood loss was 183 +/- 72 ml (median, 160; range, 80-400 ml). There was no mortality. Postoperative complications occurred in two out of 19 patients: an abdominal wall hematoma occurred in one patient and a bleeding from a trocar access in the other patient requiring a laparoscopic re-exploration. Mean hospital stay of the whole series was 6.5 +/- 4.3 days (median, 5; range, 4-25), while the mean hospital stay of the 19 laparoscopic patients was 5.4 +/- 1 (median, 5; range, 4-8). Laparoscopic treatment should be considered in selected patients with HCC and liver cirrhosis in the left lobe or segments 5 and 6 of the liver. It is clear that certain types of laparoscopic resection are feasible and safe when carried out by adequately skilled surgeons with appropriate instruments.