Anatomical Liver Resection Research Articles

Novel Liver Parenchymal Transection Technique Using Saline-linked Monopolar Cautery Scissors (SLiC-Scissors) in Robotic Liver Resection.

IntroductionAlthough there are a number of benefits to using robotics in liver surgery over conventional open and laparoscopic approaches, liver parenchymal transection is still the most difficult aspect of robotic liver resection (RLR) due to the limitations of the currently available robotic instruments and the lack of a standardized method.MethodsWe present a novel method for transecting the liver parenchyma during RLR employing saline-linked monopolar cautery (SLiC) scissors (SLiC-Scissors method). Between September 2021 and April 2022, 10 RLRs were performed utilizing the SLiC-Scissors method for both anatomical and non-anatomical liver resections. We assessed the short-term results, as well as the safety and practicality of our robotic liver parenchymal transection technique.ResultsSix of the 10 patients had malignant liver tumors, and four of them had liver metastases from colorectal cancer. Except for S1, the target lesions were present everywhere, and their median size was 25 mm (14-43 mm). The median amount of intraoperative bleeding was 5 mL (5-30 mL), and the median operative and console times were 223 and 134 min, respectively. There were no conversions to open liver resections. The median length of the postoperative stay was seven (4-13) days, and there were no serious postoperative complications or mortality.ConclusionsThe SLiC-Scissors method is a safe and practical procedure for liver parenchymal transection in RLR. In order to standardize and broadly implement RLR into normal patient treatment, this unique approach enables an advanced, locally controlled preparation of intrahepatic vessels and bile ducts.

A Case Report of Fibrolamellar Hepatocellular Carcinoma in a Young Adult

Among the four histopathological variants of hepatocellular carcinoma, Fibrolamellar hepatocellular carcinoma (FLHCC) is a rare variant of hepatocellular carcinoma (HCC). It occurs in less than 1 % cases of hepatocellular carcinoma with distinct features as compared to classical HCC. It differs from typical HCC in terms of epidemiology, etiology, clinical presentation and prognosis. In this case report we are going to present a case of fibrolamellar variety of HCC in a 20-year young male with no history of previous liver disease and no characteristics features on Computed Tomography (CT) scan when compared with typical HCC. After discussing in multidisciplinary meeting, he underwent non anatomical liver resection which remained uneventful. Histopathology of the biopsy sample revealed FLHCC. No neoadjuvant therapy was given. Patient was kept on 1 year follow-up and no recurrence or metastasis occurred.

A comprehensive framework of the right posterior section for tailored anatomical liver resection based on three-dimensional simulation system.

BackgroundThe anatomical right posterior sectionectomy (ARPS) is a technically challenging procedure. We aimed to develop and validate a novel framework of the right posterior section for a safe and tailored anatomical liver resection (ALR) based on a three-dimensional (3D) simulation system.Methods3D hepatectomy simulations of healthy participants who underwent contrast-enhanced computed tomography of the upper abdomen were retrospectively reviewed to develop the framework according to the relationship between the simulated plane determined by the right posterior portal pedicle (RPP) and the course of the right hepatic vein (RHV) trunk. The framework was validated in the practice of ARPS for hepatocellular carcinoma (HCC) prospectively.ResultsScans from 336 eligible participants were assessed. The framework was summarized into four types: normal, caudal-redundant, cranial-deficient, and combined types, accounting for 43.4% (146/336), 25.3% (85/336), 18.5% (62/336), and 12.8% (43/336) respectively. The caudal-redundant type was associated with the variable portal branches of the RPP or segment 6 branch across the ventral side of RHV. The mean aberrant volume proportion in type IIa was significantly greater than that in type IIb (P<0.001), which were 7.0%±3.5% and 4.4%±1.8% respectively. The cranial-deficient type was associated with the aberrant segment 7 portal pedicle originating from the right portal trunk or the dorsal portal branch of segment 8 crossing over to the RHV. The median aberrant volume proportion in type IIIa was significantly greater than that in type IIIb (P<0.001), which were 10.9% (8.5–13.3%) and 4.0% (3.0–6.1%), respectively. The combined type represented a combination of the caudal-redundant type and the cranial-deficient type. The framework provided instructions on tailored ARPS in 6 patients with HCC by maximizing lesion removal and functional liver remnant with favorable perioperative outcomes.ConclusionsPrecise preoperative planning with an individualized surgical approach based on our framework allows safe anatomical liver resections for cases with lesions in the right posterior section.

Trans-arterial positive ICG staining-guided laparoscopic liver watershed resection for hepatocellular carcinoma.

IntroductionAnatomical liver resection is the optimal treatment for patients with resectable hepatocellular carcinoma (HCC). Laparoscopic Couinaud liver segment resection could be performed easily as liver segments could be stained by ultrasound-guided indocyanine green (ICG) injection into the corresponding segment portal vein. Several smaller liver anatomical units (liver watersheds) have been identified (such as S8v, S8d, S4a, and S4b). However, since portal veins of liver watersheds are too thin to be identified under ultrasound, the boundaries of these liver watersheds could not be stained intraoperatively, making laparoscopic resection of these liver watersheds demanding. Digital subtraction angiography (DSA) could identify arteries of liver watersheds with a diameter of less than 2 mm. Yet, its usage for liver watershed staining has not been explored so far.PurposeThe aim of this study is to explore the possibility of positive liver watershed staining via trans-arterial ICG injection under DSA examination for navigating laparoscopic watershed-oriented hepatic resection.MethodsWe describe, in a step-by-step approach, the application of trans-arterial ICG injection to stain aimed liver watershed during laparoscopic anatomical hepatectomy. The efficiency and safety of the technique are illustrated and discussed in comparison with the laparoscopic anatomical liver resection via ultrasound-guided liver segment staining.ResultsEight of 10 HCC patients received successful trans-arterial liver watershed staining. The success rate of the trans-artery staining approach was 80%, higher than that of the ultrasound-guided portal vein staining approach (60%). Longer surgical duration was found in patients who underwent the trans-artery staining approach (305.3 ± 23.2 min vs. 268.4 ± 34.7 min in patients who underwent the ultrasound-guided portal vein staining approach, p = 0.004). No significant difference was found in major morbidity, reoperation rate, hospital stay duration, and 30-day and 90-day mortality between the 2 groups.ConclusionsTrans-arterial ICG staining is safe and feasible for staining the aimed liver watershed, navigating watershed-oriented hepatic resection under fluorescence laparoscopy for surgeons.

Multivariate analysis of the effect of two liver resection methods on the survival outcome of patients with intrahepatic cholangiocarcinoma

Objective: To investigate the effect of anatomical hepatectomy and non-anatomic hepatectomy in the treatment of elderly patients with intrahepatic cholangiocarcinoma (IHCC) and their impact on survival outcomes. Methods: In this study, a retrospective method was used to select elderly patients with IHCC who were surgically treated in Shangqiu First People's Hospital from April 2014 to April 2018, and were divided into anatomic resection group and non-anatomical resection group according to the surgical methods they received.The factors affecting the survival outcome of IHCC in the two liver resection methods were analyzed and compared, as well as the effects of liver cirrhosis rate, TNM stage, ascites rate, lymph node metastasis rate, and vascular invasion rate on survival. Results: A total of 181 cases were included in this study, including 87 cases in the anatomical resection group, with 54 males and 33 females, aged (71.4±5.2) years old;There were 94 cases in the non-anatomical resection group, including 49 males and 45 females, aged (70.8±4.8) years.The 3-year survival rate of the anatomical resection group was 41.4% (36/87), which was higher than that of the non-anatomical resection group (25.5% (24/94), the difference was statistically significant (P<0.05);The median survival time of the anatomic resection group was longer than that of the non-anatomical resection group, and the difference was statistically significant P<0.05;The patient's TNM stage was stage III [OR (95%CI): 2.168 (1.245-3.776)], lymph node metastasis [1.664 (1.087-2.545)], and vascular invasion [1.883 (1.167-3.038)] was an independent risk factor for death 3 years after surgery (P<0.05), The patient's anatomical liver resection was a protective factor for the 3-year follow-up survival (P<0.05). Conclusion: The postoperative survival of elderly patients with IHCC is affected by many factors, but anatomic liver resection is beneficial to prolong the survival time of patients.

Extra‐hepatic Glissonean approach allows safe segmental liver resection in patients with cirrhosis with hepatocellular carcinoma

AbstractAimThis study aims to report our experience with the extra‐hepatic Glissonean approach (EHGA) in liver resection in patients with cirrhosis.Patients and MethodsFrom a prospectively maintained database in Al‐Rajhi Liver Hospital, Assiut University, Egypt, all patients with cirrhosis with hepatocellular carcinoma (HCC) who had open liver resections of two or more segments from January 2014 to December 2016 were identified. As many as 49 patients received resection via the classical pedicle dissection technique (PDT) and 38 by EHGA.ResultsThere was no difference in age, sex, American Society of Anesthesiologists grade, aetiology of liver disease, alpha‐fetoprotein, tumour number, size, Child‐Turcotte‐Pugh or Model for End‐stage Liver Disease scores between groups. Patients in the EHGA group had shorter operative time (214 ± 54 vs. 249 ± 44 minutes in PDT; P = .001), lesser blood loss (647 ± 140 ml vs. 741 ± 192 ml, respectively; P = .010), wider safety margin (14 ± 3.5 mm vs. 11.5 ± 5.8 mm, respectively; P = .029), lesser decompensation (18.4% vs. 40.8%, respectively; P = .026) and shorter hospital stay (8, range 3‐26 vs. 9, range 4‐36 days, respectively; P = .015). There was no 30‐day mortalities in the EHGA group compared with two in the PDT group. There were no differences between groups in 1‐ and 3‐year overall and recurrence‐free survival rates.ConclusionsEHGA is a rapid, safe and oncologically sound approach for segmental anatomical liver resections of HCC in patients with cirrhosis.

State of the art of anatomic liver resection

State of the art of anatomic liver resection

Laparoscopic anatomic liver resection in the era of fluorescence imaging systems

Laparoscopic anatomic liver resection in the era of fluorescence imaging systems

Atypical anatomic liver resection in patients with small future liver remnant

Atypical anatomic liver resection in patients with small future liver remnant

Indocyanine green fluorescence staining based on the "hepatic pedicle first" approach during laparoscopic anatomic liver resection.

Indocyanine green (ICG) fluorescence staining is one of the most challenging procedures for laparoscopic anatomic liver resection (LALR). Here, we introduce a novel method based on the "hepatic pedicle first" approach that can improve the success rate of positive staining. The target hepatic pedicle (even for the subsegment) was dissected through the first porta until it became visible. Five milliliters of 0.025mg/ml ICG was injected after the target hepatic pedicle (extra-Glissonian approach) or portal vein/hepatic artery (intra-Glissonian approach) was punctured successfully using scalp acupuncture under direct vision. Then, the Glissonian pedicle or vessel was clamped immediately to prevent the intrahepatic diffusion of ICG. During the operation, a fluorescence imaging model was used repeatedly to confirm the segmental boundary. Finally, 24 patients underwent LALR with the "hepatic pedicle first" approach for ICG fluorescence-positive staining. In 5 patients, ICG-positive staining failed, representing a 79.17% success rate. The average staining time was 25.92min ± 14.64min. There were no complications associated with vessel puncture (bile leakage,hemorrhage,and thrombosis). The "hepatic pedicle first" approach is a feasible, convenient, and safe method for ICG-positive staining, with a high success rate.

Laparoscopic anatomical versus non-anatomical liver resection for hepatocellular carcinoma located in the posterosuperior segments of the liver: A propensity score matched analysis

Laparoscopic anatomical versus non-anatomical liver resection for hepatocellular carcinoma located in the posterosuperior segments of the liver: A propensity score matched analysis

The current state of the issues of diagnosis and surgical treatment of liver echinococcosis (literature review)

The article presents a review of literature data in order to study current problems in the diagnosis and surgical treatment of liver echinococcosis. At the present stage of technological progress, it is possible to study the genetic, anatomical and pathophysiological aspects of echinococcosis. The article highlights the advantages and disadvantages of surgical operations performed in patients with echinococcal liver damage. Methods and results of surgical treatment in various clinics are considered. The main surgical directions in the treatment of parasitic liver damage have been determined. These are more radical anatomical and extensive liver resections and minimally invasive, including laparoscopic and robotic techniques. Each of the methods used has its own niche of application and its own limitations. An opinion is expressed about the prospects for the development of minimally invasive methods of surgical treatment. The authors note the actual absence of a unified standardized tactics of surgical treatment at the moment. It is noted that the literature contains only fragmentary data on the possibility of combining minimally invasive and classical methods of surgical treatment. Despite the introduction of new methods of treatment, the percentage of complications and mortality are still high. Thus, the lack of uniform diagnostic standards and principles for determining surgical tactics testifies to the urgency of the problem of treating parasitic liver damage and determines the search for new solutions in order to improve the results of surgical treatment of this pathology.

Impact of laparoscopic liver resection on liver regeneration.

Liver regeneration after liver resection plays an important role in preventing posthepatectomy liver failure. In this study, we aimed to evaluate and compare the impact of laparoscopic liver resection (LLR) and open liver resection (OLR) on liver regeneration. Patients who underwent curative anatomical liver resection for hepatocellular carcinoma, cholangiocellular carcinoma, and colorectal liver metastases at our institution between January 2010 and December 2018 were included in this study. The patients were divided into the OLR and LLR groups. Preoperative liver volume (PLV), future remnant liver volume, resected liver volume (RLV), liver volume at 1month after the surgery, and liver volume at 6months after the surgery were calculated. The liver regeneration rate was defined as the increase in the rate of RLV, and the liver recovery rate was defined as the rate of return to the PLV. The study included 72 patients. Among them, 43 were included in the OLR group and 29 were included in the LLR group. No differences were observed in the baseline characteristics and surgical procedures between the two groups. Moreover, no significant difference was observed in the liver regeneration rate at 1month after the surgery (OLR vs. LLR: 68.9% vs. 69.0%, p = 0.875) and at 6months after the surgery (91.8% vs. 93.2%, p = 0.995). Furthermore, the liver recovery rates were not significantly different between the two groups at 1month after the surgery (90.3% vs. 90.6%, p = 0.893) and at 6months after the surgery (96.9% vs. 98.8%, p = 0.986). Liver regeneration after liver resection is not affected by the type of surgical procedure and both laparoscopic and open procedures yield similar regeneration and recovery rates.

Long-term surgical outcomes of Non alcoholic fatty liver disease associated hepatocellular carcinoma

BackgroundThe global burden of non-alcoholic fatty liver disease (NAFLD) and NAFLD-associated hepatocellular carcinoma (HCC) is steadily rising. We pursued to investigate the results after liver resection for NAFLD-HCC versus hepatitis B virus (HBV)-HCC exploiting Kaplan Meier method, log-rank test and uni/multivariate analysis with the logistic regression models”. MethodsPatients who underwent liver resection for HCC between January 2004 and December 2018 were included. The outcomes of NAFLD-associated HCC were analyzed. ResultsThe prevalence of NAFLD-associated HCC was 8.4%. A significant number of NAFLD patients had no cirrhosis (21 patients; 38.8%). Although NAFLD patients had a significantly better 5-year survival (P = 0.033), NAFLD was not significantly associated with overall survival in multivariate analysis (P = 0.287). However, survival after 5 years declined in NAFLD patients and was similar to HBV. NAFLD was protective against systemic recurrence compared with HBV (P = 0.018), and this was confirmed in multivariate analysis (P = 0.044). Five-year systemic recurrence (P = 0.044) was significantly lower in NAFLD patients and decreased with time from surgery. Multivariate analysis revealed that anatomical liver resection was independently associated with decreased recurrence in NAFLD patients (HR = 0.337; P = 0.033). ConclusionOverall survival is similar between NAFLD-associated HCC and HBV-associated HCC. Despite there being no significant difference between liver function tests, type of surgery performed, liver cirrhosis, size of tumor, number of tumors, pathological factors like satellite nodules and Edmonson Steiner staging, NAFLD-associated HCC shows lower systemic recurrence compared to HBV-associated HCC.

Right hemihepatectomy for ischemic liver necrosis after cholecystectomy

Injury of the extrahepatic bile duct system during cholecystectomy is a complex problem in biliary surgery. Combined injuries of the bile ducts and vessels in the hepatoduodenal ligament significantly complicate treatment and increase mortality. Efficient revascularization is possible in a specialized clinic during the initial hours following the injury. Anatomical liver resection is a rescue technique for the surgical elimination of such complications. Herein, we present a case of a patient who underwent right hemihepatectomy.

"Anatomic" Liver Resection Performed by Approaching the Umblical Plate for Perihilar Cholangiocarcinoma (with Video)

Introduction: The Anatomic right hepatic trisectionectomy with caudate lobectomy for hilar cholangiocarinoma was reported in 2006. This technique need the umblical plate access. With extension of this technique, anatomic central bisectionectomy can be also performed for the Bismuth type 4 of perihilar cholaniocarcinoma (CCA). Methods: From 2010 to 2020, anatomic right trisectionectomy (N=8) and anatomic central bisectionectomy (N=3) was performed for the patients with the Bismuth type 4 of perihilar CCA. All anatomic liver resection was performed by approaching the umblical plate, in which the bile ducts of the left lateral section were divided at the left side of the umblical fissure following complete dissection of the umblical plate. Results: Liver resection was successfully performed, and there was no postoperative mortality. All patients were histologically diagnosed as having CCA. Among the patients who underwent anatomic right trisectionectomy, 5 patients received portal vein embolization (PVE) and 3 patients did not. R0 resection rate was 63%. 2 patients performed portal vein wedge resection. 3 patients died of cancer progression and 2 patients died of biliary sepsis. One patients survived without recurrence for 8 years. 4 patients are under follow-up without recurrence. The remaining one patient recurred after 28 months and is undergoing radiation therapy. There were only three patients had biliary leakage. Conclusions: Anatomic liver resection that is performed by approaching the umblical plate can be safely and effectively proformed even in perihilar CCA.

‘Inside-Out’ Transection: Simple and Safe Way of Laparoscopic Anatomical Liver Resection

Introduction: In open anatomical liver resection, liver parenchymal transection from the peripheral part to the hilum because of restricted surgical view. Confirmation of transection line as a demarcation line using dye-injection method or extrahepatic glissonian approach, Modification of disorientation during liver parenchymal transection by intraoperative ultrasonography are too complicated and technical-demanding procedures for laparoscopic approach. Theoretically considering the directions of branched Glissonian pedicles and hepatic veins, parenchymal transection should be done from the hilum to the the peripheral, in other words, ‘inside-out’. We recently perform laparoscopic anatomical ‘inside-out’ liver resection utilizing laparoscopic caudal view. Methods: Anatomical resection starts from parenchymal transection around the root of the corresponding Glissonian pedicle and a tip of CUSA is moved inside-out to the direction with low resistance between the glissonian pedicles, which leads to the right intersegmental plane. The direction of transection can also be corrected by visually checking the ramification of branched Glissonian pedicles that are clearly recognizable in laparoscopic view. The corresponding Glissonian pedicle is dissected on the way of paremchymal transection when surgical space is made for safe procesures. ‘Inside-out’ transection also prevents from bleeding from the root of branched hepatic veins and enables to keep a good surgical view and tension on the dissection point. Liver peripheral parenchyma is dissected in the end. The process of laparoscopic anatomical ‘inside-out’ liver resection is so simple because all procesures is completed on one direction way. Conclusions: Laparoscopic anatomical ‘inside-out’ liver resection is simple and safe utilizing the advantages of laparoscopic approach.

Anatomical and Non-Anatomical Liver Resection for Secondary Liver Tumors, a One-Year Experience

Introduction: The role of liver resection in secondary liver tumours, mainly caused by metastases colo-rectal cancer (MCRC) increases. The authors would like to share their experience in secondary liver tumour resections,using various energy devices,techniques,and results.

Anatomical Liver Resections for Intrahepatic Cholangiocarcinoma: Perioperative Results and Survival. Multicenter Study in Two University Hospitals in Latin America

Anatomical Liver Resections for Intrahepatic Cholangiocarcinoma: Perioperative Results and Survival. Multicenter Study in Two University Hospitals in Latin America

Laparoscopic and Robotic Volume Preserving Major Hepatectomy

Background: Transection along the right anterior fissure was proposed as a mechanism by which to open the third door of the liver for anatomical hepatectomy. nowadays, laparoscopic anatomical liver resection is gaining momentum with less blood loss and shorter postoperative hospital stay. In this study, we sought to evaluate the feasibility, safety and potential benefits of laparoscopic assisted volume preserving major hepatectomy.