2nd International Consensus Conference Research Articles

Laparoscopic liver resection of the spiegel lobe by a lef-sidad approach preserving an accessory left hepatic artery

Presenter: Víctor Molina | Hospital de la Santa Creu i Sant Pau Background: Caudate lobe of the liver can be divided in three portions: Spiegel lobe, para-caval portion and caudate process . The anatomy of the caudate lobe and its proximity to major vascular structures makes this operation a difficult resection, especially for laparoscopic liver surgery. For that reason the Iwate criteria proposed to classify this surgery at the “2nd International Consensus Conference on Laparoscopic Liver Resection” as intermediate or advanced difficulty depending on the type of resection, and the size of the tumor . For tumors located in the Spiegel lobe, the left side approach is preferred Methods: We present a 69-year-old woman with liver metastasis from previously resected sternal condrosarcoma. A Spiegel lobe resection with left side approach preserving an accessory left hepatic artery was performed. Results: The patient was positioned in supine position. Six ports were used, 4 of 12mm and 2 of 5mm. We started the surgery with the left lateral segment mobilization. The gastrohepatic ligament was opened to expose the caudate lobe. In this case we only opened part of the ligament to preserve the accessory left hepatic artery. We continued retracting to the right the hepatic hilium with tissue band used as the external Pringle tourniquet to expose de caudate process and the right side of the Spiegel lobe. The transection of the liver was started with Thunderbeat and ultrasonic dissector. The portal branches to the Spiegel lobe were dissected and controlled with clips. We continued with the blunt dissection of the Spiegel lobe from the inferior vena cava. The fibrous ligament of the Spigel lobe to the crus of the diaphragm was cut and the retrocaudate vessels to the inferior vena cava were individualized and ligated with clips. Finally, we opened the gastrohepatic ligament behind the artery, pulled up the caudate lobe, and finished the liver transection. A closed aspirative drainage was left in place. The specimen was removed from an enlargement of the left subcostal 12mm port. The operative time was 180 min and the total Pringle time was 30 min. Patient was discharged at the 4 postoperative day and there were no postoperative complications. Conclusion: Laparoscopic liver resection of the caudate lobe for condrosarcoma liver metastasis is feasible and safe. Left approach seems the best option for Spiegel lobe resections even in patients with accessory left hepatic artery.

Validation of index-based IWATE criteria as an improved difficulty scoring system for laparoscopic liver resection

The original difficulty scoring system was revised after discussion at the 2nd International Consensus Conference on Laparoscopic Liver Resection held in Morioka (Iwate Prefecture) in Japan and renamed the IWATE criteria (a 4-level classification system involving 6 preoperative factors). We used Japanese and French cohorts to validate the IWATE criteria by evaluating their association with the procedure-based difficulty classification proposed by the Institut Mutualiste Montsouris. Patients who had undergone laparoscopic liver resection at multiple Japanese multi-institutions or the Institut Mutualiste Montsouris were assigned to the multiple Japanese multi-institution (n = 1,867) or Institut Mutualiste Montsouris cohort (n = 433). We analyzed clinical characteristics and outcomes according to the 4-level IWATE criteria difficulties (low, intermediate, advanced, and expert) and evaluated their association with 11 laparoscopic liver resection procedures in the Institut Mutualiste Montsouris classification (low, intermediate, and high levels). We found significant differences in age, surgical indications, and the 4-level IWATE criteria difficulties between the cohorts (all, P < .001). Operation time and blood loss were significantly different among the 4-level difficulties in both cohorts (all, P < .001). The rates of conversion, postoperative complications, liver failure, and in-hospital deaths also increased significantly with increasing difficulty (all, P < .001). The IWATE criteria classified the three low-level Institut Mutualiste Montsouris procedures in the low-to-intermediate levels, the two intermediate-level procedures in the intermediate-to-advanced levels, and the six high-level procedures in the advanced-to-expert levels. We observed associations between the IWATE criteria and intraoperative and postoperative outcomes in the Japanese multi-institution and Institut Mutualiste Montsouris cohorts and thus validated the IWATE system.

The challenge in determining difficulty of laparoscopic liver resection: are we there yet?

Laparoscopic liver resection (LLR) has evolved and improved over the years with a corresponding expansion of its indications. In 2014, after the 2nd International Consensus Conference on LLR in Morioka, Japan, it was concluded that LLR can be the standard of care for minor resections and is in the exploration phase for major resections. With increasing evidence supporting its safety and benefits, along with the expansion of accepted indications, the popularity of LLR has grown with an exponential increase in the number of surgeons adopting LLR worldwide (1-6).

Second international consensus guidelines for breast cancer in young women (BCY2)

The 2nd International Consensus Conference for Breast Cancer in Young Women (BCY2) took place in November 2014, in Dublin, Ireland organized by the European School of Oncology (ESO). Consensus recommendations for the management of breast cancer in young women (BCYW) were updated from BCY1 with incorporation of new evidence to inform the guidelines, and areas of research priorities were identified. This manuscript summarizes these international consensus recommendations, which are also endorsed by the European Society of Breast Specialists (EUSOMA).

What is the best technique in parenchymal transection in laparoscopic liver resection? Comprehensive review for the clinical question on the 2nd International Consensus Conference on Laparoscopic Liver Resection.

The continuing evolution of technique and devices used in laparoscopic liver resection (LLR) has allowed successful application of this minimally invasive surgery for the treatment of liver disease. However, the type of instruments by energy sources and technique used vary among each institution. We reviewed the literature to seek the best technique for parenchymal transection, which was proposed as one of the important clinical question in the 2nd International Consensus Conference on LLR held on October 2014. While publications have described transection techniques used in LLR from 1991 to June 2014, it is difficult to specify the best technique and device for laparoscopic hepatic parenchymal transection, owing to a lack of randomized trials with only a small number of comparative studies. However, it is clear that instruments should be used in combination with others based on their functions and the depth of liver resection. Most authors have reported using staplers to secure and divide major vessels. Preparation for prevention of unexpected hemorrhaging particularly in liver cirrhosis, the Pringle's maneuver and prompt technique for hemostasis should be performed. We conclude that hepatobiliary surgeons should select techniques based on their familiarity with a concrete understanding of instruments and individualize to the procedure of LLR.

Bleeding control during laparoscopic liver resection: a review of literature.

Despite the established advantages of laparoscopy, bleeding control during laparoscopic liver resection (LLR) is a liver-specific improvement. The 2nd International Consensus Conference on Laparoscopic Liver Resection was held in October 2014 at Morioka, Japan. One of the most capital questions was: What is essential in bleeding control during LLR? In order to correctly address this question, we conducted a comprehensive review of the literature. Essential points based on personal experience of the expert panel are also discussed. A total of 54 publications were identified. Based on this analysis, the working group built these recommendations: (1) a pneumoperitoneum of 10-14 mmHg should be used as it allows a good control of the bleeding without significant modifications of hemodynamics; (2) a low central venous pressure (<5 mmHg) should be used; (3) laparoscopy facilitates inflow and outflow control; and (4) surgeons should be experienced with the use of all surgical devices for liver transection and should master laparoscopic suture before starting LLR. Precoagulation with radiofrequency can be useful, particularly in cases of atypical resection. These recommendations are mostly based on experts' opinions and on B or C quality of evidence grade studies. More prospective data are required to confirm these results.

Laparoscopic hepatectomy is theoretically better than open hepatectomy: preparing for the 2nd International Consensus Conference on Laparoscopic Liver Resection.

Six years have passed since the first International Consensus Conference on Laparoscopic Liver Resection was held. This comparatively new surgical technique has evolved since then and is rapidly being adopted worldwide. We compared the theoretical differences between open and laparoscopic liver resection, using right hepatectomy as an example. We also searched the Cochrane Library using the keyword "laparoscopic liver resection." The papers retrieved through the search were reviewed, categorized, and applied to the clinical questions that will be discussed at the 2nd Consensus Conference. The laparoscopic hepatectomy procedure is more difficult to master than the open hepatectomy procedure because of the movement restrictions imposed upon us when we operate from outside the body cavity. However, good visibility of the operative field around the liver, which is located beneath the costal arch, and the magnifying provide for neat transection of the hepatic parenchyma. Another theoretical advantage is that pneumoperitoneum pressure reduces hemorrhage from the hepatic vein. The literature search turned up 67 papers, 23 of which we excluded, leaving only 44. Two randomized controlled trials (RCTs) are underway, but their results are yet to be published. Most of the studies (n = 15) concerned short-term results, with some addressing long-term results (n = 7), cost (n = 6), energy devices (n = 4), and so on. Laparoscopic hepatectomy is theoretically superior to open hepatectomy in terms of good visibility of the operative field due to the magnifying effect and reduced hemorrhage from the hepatic vein due to pneumoperitoneum pressure. However, there is as yet no evidence from previous studies to back this up in terms of short-term and long-term results. The 2nd International Consensus Conference on Laparoscopic Liver Resection will arrive at a consensus on the basis of the best available evidence, with video presentations focusing on surgical techniques and the publication of guidelines for the standardization of procedures based on the experience of experts.

International Survey on Technical Aspects of Laparoscopic Liver resection: a web‐based study on the global diffusion of laparoscopic liver surgery prior to the 2nd International Consensus Conference on Laparoscopic Liver Resection in Iwate, Japan

The technique of laparoscopic liver resection (LLR) has been greatly improved since the first international consensus conference. Our aim was to evaluate the worldwide spread of LLR prior to the 2nd International Consensus Conference on Laparoscopic Liver Resection in Iwate, Japan (4-6 October 2014). The International Survey on Technical Aspects of Laparoscopic Liver resection was designed to assess dissemination of LLR, indications, and the surgical techniques. The anonymous questionnaire was e-mailed to liver surgeons worldwide. A total of 448 liver surgeons responded to the survey. The peak age range of surgeons performing LLR was 41-50 years. Japan had by far the largest number of respondents (n = 223), followed by the US (n = 38) and France (n = 20). In Japan, the majority of surgeons performing LLR belonged to community hospitals, where LLR has been increasingly used since its implementation in 2009 or later, comprising up to 40% of all liver resection cases. In contrast, in North America and Europe, LLR was mostly performed at academic medical centers. LLR has undergone global dissemination after the first international consensus conference in 2008. Japan has experienced unparalleled, explosive diffusion characterized by the adoption of LLR at middle-tier, regional institutions.