Indications For Laparoscopic Liver Resection Research Articles

Surgical Techniques and Outcomes of Pure Laparoscopic Donor Right Posterior Sectionectomy for Living Donor Liver Transplantation.

Right posterior section (RPS) graft for living donor liver transplantation (LDLT) is an alternative graft in a live liver donor with insufficient remnant left lobe volume and portal vein anomaly.(1,2) In recent decades, laparoscopic liver resection (LLR) has been widely adopted by hepatobiliary surgeons, and the indication for LLR have expanded to donor hepatectomy.(3,4) Laparoscopic-approach donor surgery would be ideal for liver donation in healthy individuals, due to the fast return to normal life and satisfaction with the incisional scar. However, there have been no reports regarding laparoscopic donor hepatectomy for RPS graft. Herein, we report surgical outcomes and techniques of pure laparoscopic donor right posterior sectionectomy (PLDRPS) for LDLT. The institutional review boards of our center (number 2019-03-080) approved this study.

Safety assessment of laparoscopic liver resection: A project study of the Endoscopic Liver Surgery Study Group of Japan.

Laparoscopic liver resection (LLR) has been expanded rapidly and has been accepted worldwide; however, the safety assessment of LLR has not been fully conducted with a large-scale cohort. The aim of this study was to assess safety and identify clinical factors associated with postoperative major complications in LLR. This project study retrospectively collected the data of LLRs performed before October 2015 in Japan. Patient characteristics, details of LLRs, and surgical outcomes were analyzed. A total of 4122 patients from 66 institutions were enrolled. The main indications were hepatocellular carcinoma (HCC) and colorectal liver metastases. The majority of the procedures were performed for solitary tumor-located liver segment 2, 3, 5, and 6 and the partial resection and left-lateral sectionectomy occupied 77.3%. The rate of conversion, accidental events were 7.1% and 2.1%, respectively. Postoperative major complication occurred in 205 cases (5.0%), and 14 in-hospital deaths were found among HCC patients with chronically diseased liver. Occurrence of postoperative major complication was associated with operation time (≥360minutes), intraoperative blood loss (≥250mL), red blood cell transfusion (yes), and the difficulty score (≥6). The 30- and 90-day mortality was 0.14% and 0.41%, respectively. Laparoscopic liver resection was performed with an acceptable rate of conversion, accidental events, morbidity, and mortality. The indications for LLR should be cautiously judged considering tumor location, planned operative procedure, and liver function.

Extended Indications for Laparoscopic Parenchyma-Sparing Resection of Posterosuperior Liver Segments in Patients with Colorectal Metastases. PSM Analysis of Outcomes in Comparison with Open Hepatectomy

Background: Indications for laparoscopic liver resection (LLR) of posterosuperior segments (RSS) for colorectal liver metastases (CRLM) are commonly restricted to small, superficial lesions not adjacent to large vessels. There is no long-term survival comparative estimation after LRR and open liver resection (OLR). We aimed to compare outcomes after parenchyma-sparing LLR with extended indication and open liver resection (OLR) for CRLM located in PSS. Methods: Two Russian centers took part in the study. Patients with hemihepatectomy, extrahepatic tumors were excluded. Logistic regression was used for 1:1 propensity score matching (PSM). Results: PSS were resected in 77 patients. LLR were performed in 51 (66%) patients. Twenty pairs of patients were matched. Demographic and preoperative data are presented in the table. After matching, no differences were found in terms of blood loss, ICU and hospital stay, which were better for LLR group before PSM. No 90-day mortality was observed within both groups. After PSM, no difference was found in 5-year overall survival after LLR and OLR (78% and 63%, respectively) and 4-year disease-free survival (27% in both groups). Conclusions: Expanding indication for laparoscopic parenchyma-sparing resection of PSS for CRLM are justified in majority of patients if performed in high volume specialized centers expertized in laparoscopic liver surgery.OL01-03Demographic dataFactorsBefore matchingAfter matchingLLR (n=51)OLR (n=26)PLLR (n=20)OLR (n=20)PMedian size of largest metastatic tumor, mm40 (10-98)46 (15-100)0,38450 (15-98)44 (15-100)0,309Rate of metastases >50 mm, n (%)17 (33%)10 (39%)0,6569 (45%)7 (35%)0,519Proximity to the large hepatic vessels, n (%)12 (24%)8 (31%)0,4935 (25%)6 (30%)0,655Anatomical resection, n (%)22 (43%)9 (35%)0,4717 (35%)8 (40%)0,744Difficulty index, point7,0 (4,8-11,1)6,1 (2,9-10,7)0,0917,2 (4,8-11,8)6,4 (2,9-10,7)0,189Positive response to neoadjuvant chemo (RECIST), n (%)27 (53%)16 (62%)0,47313 (65%)12 (60%)0,744Positive response to adjuvant chemo (RECIST), n (%)36 (71%)18 (69%)0,90215 (75%)14 (70%)0,723 Open table in a new tab

Surgical outcomes of 118 complex laparoscopic liver resections: a single- center experience.

Indications for laparoscopic liver resection (LLR) are continuously expanding. The Japanese Society of Hepato-Biliary-Pancreatic Surgery defines highly difficult hepatectomy as a procedure involving one or more sections (except for left lateral sectionectomy) or anatomical segmentectomy. This study aimed to assess the outcomes of complex LLR procedures and compare their technical difficulties, about which only a little is known to date. We performed a retrospective review of the operative outcomes of 118 consecutive patients who underwent pure laparoscopic complex hepatectomy. The surgical outcomes, including operative times, blood loss amounts, and postoperative morbidity rates, were compared among complex LLR procedures. The overall median operative time was 280minutes, and the median intraoperative blood loss was 86mL. Two patients required conversion to open laparotomy (1.7%). The postoperative major morbidity rate was 11.0% Posterosuperior segmentectomy, right hemihepatectomy, and anterior sectionectomy required the longest operative times. Anterior and posterior sectionectomy resulted in the highest blood loss, and right hemihepatectomy and anterior sectionectomy resulted in the most complications. The surgical difficulties associated with complex LLR procedures vary. It is critical to recognize the specific risks and cautionary points to ensure patient safety and provide proper systemic training to surgeons.

Novel patient risk factors and validation of a difficulty scoring system in laparoscopic repeat hepatectomy

The indications for laparoscopic liver resection have expanded; however, the safety and benefits of laparoscopic repeat hepatectomy (LRH) remain unclear. We retrospectively reviewed data from 137 patients who underwent partial hepatectomy or left lateral sectionectomy without thoracotomy. We compared patients’ clinical factors using a difficulty scoring system for LRH. We defined factors associated with blood loss volumes in the 75th percentile or above as risk factors for bleeding in open repeat hepatectomy, and determined whether these factors were useful for LRH risk assessment. Open repeat hepatectomy and LRH was performed in 96 and 41 patients, respectively. Four of 41 (9.8%) patients undergoing LRH were converted to laparotomy. Blood loss volume was significantly greater in the intermediate-risk group than in the low-risk group (P = 0.046). Multivariate analysis revealed that the presence of tumours located adjacent and caudal or dorsal to the primary tumour site was an independent risk factor for bleeding in LRH (odds ratio 3.21, 95% confidence interval 1.16–8.88, P = 0.024). Our study validated the usefulness of a difficulty scoring system, identified patient factors that predicted the difficulty of LRH, and presented a novel difficulty scoring system for LRH based on an existing difficulty scoring system.

Indications for laparoscopic liver resection of mass-forming intrahepatic cholangiocarcinoma.

We investigated the indications for laparoscopic liver resection (LLR) of mass-forming intrahepatic cholangiocarcinoma (MF-ICC), including the need for lymph node dissection for improved postoperative prognosis. This study involved 36 patients who underwent surgery for solitary peripheral MF-ICC. Fifteen patients underwent LLR, and 21 underwent open liver resection (OLR). Surgical outcomes and prognostic factors were investigated to determine the indications for LLR. No significant differences were observed in perioperative outcomes between patients who underwent LLR and OLR. A significantly worse disease-free survival (DFS) rate was observed in patients who preoperatively had a tumor diameter ≥3 cm, vascular invasion on diagnostic imaging, and elevated serum carbohydrate antigen (CA) 19-9 and carcinoembryonic antigen (CEA) levels. A significantly worse overall survival (OS) rate was observed in patients with a tumor diameter ≥3 cm, vascular invasion on diagnostic imaging, and elevated serum CA19-9 levels. Therefore, a tumor diameter ≥3 cm, vascular invasion on diagnostic imaging, and elevated serum CA19-9 and CEA levels were determined to be preoperative prognostic factors. DFS and OS rates were significantly better in patients without these factors. Moreover, in six patients without these factors who underwent LLR, neither lymph node metastasis nor postoperative recurrence was observed. A tumor diameter ≥3 cm, vascular invasion on diagnostic imaging, and elevated serum CA19-9 and CEA levels are preoperative prognostic factors for peripheral MF-ICC. LLR is indicated for patients without these factors.

Laparoscopic anatomical liver resection under the concept of " precision medicine"

With the advancement and development of life science and technology, many problems in liver surgery have been solved, and the surgical procedures of liver surgery have been continuously developed and the indications for surgery have been continuously expanded. Benign and malignant lesions and even donor liver can be performed under laparoscopy. The indications for laparoscopic liver resection are expanding, from superficial liver resection to a wider range of anatomical resection. At the same time of technological advancement, along with the development of the humanistic spirit, liver resection is not only the removal of lesions, but the pursuit of rehabilitation, which is the best rehabilitation with minimal trauma . Laparoscopic liver resection has been greatly developed due to the spread of the concept of precise medicine . Key words: Laparoscopy; Hepatectomy

Short-Term Outcomes of Totally Laparoscopic Central Hepatectomy and Right Anterior Sectionectomy for Centrally Located Tumors: A Case-Matched Study with Propensity Score Matching.

Recent advances in technology and accumulation of surgical experience have expanded the indications for laparoscopic liver resection (LLR). However, compared to open liver resection (OLR), the feasibility of laparoscopic anatomical liver resection for centrally located tumor (CLT) has not been clearly established. The aim of our study was to assess the feasibility and safety of laparoscopic anatomical major liver resection for CLT. From April 2011 to March 2016, 20 cases of anatomical LLR and 86 cases of OLR for CLTs such as central hepatectomy (CH) and right anterior sectionectomy (RAS) were performed at a single institution. We performed one-to-one propensity score matching and analyzed short-term outcomes between the LLR (n=20) and OLR (n=20) groups. Among 20 cases in the LLR group, two cases underwent open conversion due to common bile duct injury and anatomical distortion, respectively. There were no statistically significant difference between the LLR and OLR groups regarding clamping time of the Pringle maneuver (p=0.502), blood loss (p=0.746), surgical margin (p=0.198), or length of hospital stay (p=0.110). However, surgical time was significantly longer in the LLR group than in the OLR group (388 vs 268min; p<0.001). There were no significant differences between the two groups with regard to morbidity rate or mean comprehensive complication index (p=0.716 and p=0.819, respectively). Total anatomical LLR can be performed safely in selected CLT patients by experienced surgeons. Laparoscopic CH or RAS appears feasible with non-inferior perioperative outcomes compared to OLR.

A novel model for prediction of pure laparoscopic liver resection surgical difficulty.

Extending the clinical indications for laparoscopic liver resection (LLR) should be carefully considered based on a surgeon's experience and skill. However, objective indexes to help surgeons assess the estimated difficulty of LLR are scarce. The aim of our study was to develop the first objective numerical rating scale to predict the surgical difficulty of various LLR procedures. We performed a retrospective review of the operative outcomes of 187 patients who underwent a pure LLR. First, the value of preoperative factors for predicting surgical time was evaluated by multivariate linear regression analyses, and a scoring system was constructed. Next, the integrity of our predictive linear model was evaluated against the documented operative outcomes for patients forming our study group. Four predictive factors were identified and scored based on the weighted contribution of each factor predicting surgical time: extent of resection (scored 0, 2, or 3); location of tumor (scored 0, 1, or 2); obesity (scored 0 or 1); and platelet count (scored 0 or 1). The scores were summed to classify surgical difficulty into three levels: low (total score ≤1); medium (total score 2-3); and high (total score ≥4). Operative outcomes, including surgical time, volume of blood loss, length of hospital stay, and rate of morbidity, were significantly different between the three surgical difficulty levels. Our novel model will be useful for surgeons to predict the difficulty of an LLR procedure relative to their own experience and skill.

Laparoscopic versus open anatomical liver resection for the centrally located tumor: Case-matched study with propensity score matching

Background: Recent advanced technology and an accumulation experience of surgeons have expanded the indications for laparoscopic liver resection (LLR). However, compared with open liver resection (OLR), laparoscopic anatomical liver resection for centrally located tumor (CLT) has not been well established in terms of feasibility. Methods: From September 2005 to April 2015, 136 consecutive anatomical major liver resections for the centrally located tumor were performed, including 12 cases of totally laparoscopic anatomical liver resections. We performed 1:2 match using propensity score matching between laparoscopic and open liver resection. Results: After propensity score matching, 12 and 24 patients were included in the LLR and OLR group, respectively. Surgical time was longer in the LLR (392, range 131 to 632 minutes) than the OLR (272, range 92 to 412 minutes) (P = 0.013), but the hospitalization was shorter (8.9, range 5 to 17 days versus 13, range 5 to 24 days, P = 0.006). The portal triad clamping time was shorter (15 versus 46 minutes, P = 0.105) and mean blood loss was less in LLR (417 versus 431 mL, P = 0.897) but the values were not statistically significant. The morbidity rates were 25% (3 of 12 cases) in the LLR group and 29.2% (7 of 24 cases) in the OLR group. There was no postoperative mortality in either group. Conclusion: Laparoscopic approach for CLT requiring central hepatectomy or right anterior sectionectomy seems feasible with non-inferior outcome perioperative compared to OLR. CLT may be performed safely by totally laparoscopic approach in experienced hands.

Laparoscopic liver resection: Experience based guidelines.

Laparoscopic liver resection (LLR) has been progressively developed along the past two decades. Despite initial skepticism, improved operative results made laparoscopic approach incorporated to surgical practice and operations increased in frequency and complexity. Evidence supporting LLR comes from case-series, comparative studies and meta-analysis. Despite lack of level 1 evidence, the body of literature is stronger and existing data confirms the safety, feasibility and benefits of laparoscopic approach when compared to open resection. Indications for LLR do not differ from those for open surgery. They include benign and malignant (both primary and metastatic) tumors and living donor liver harvesting. Currently, resection of lesions located on anterolateral segments and left lateral sectionectomy are performed systematically by laparoscopy in hepatobiliary specialized centers. Resection of lesions located on posterosuperior segments (1, 4a, 7, 8) and major liver resections were shown to be feasible but remain technically demanding procedures, which should be reserved to experienced surgeons. Hand-assisted and laparoscopy-assisted procedures appeared to increase the indications of minimally invasive liver surgery and are useful strategies applied to difficult and major resections. LLR proved to be safe for malignant lesions and offers some short-term advantages over open resection. Oncological results including resection margin status and long-term survival were not inferior to open resection. At present, surgical community expects high quality studies to base the already perceived better outcomes achieved by laparoscopy in major centers' practice. Continuous surgical training, as well as new technologies should augment the application of laparoscopic liver surgery. Future applicability of new technologies such as robot assistance and image-guided surgery is still under investigation.

The difficulty of laparoscopic liver resection.

Grading of difficulty is needed for laparoscopic liver resection (LLR). Indications for LLR are expanding worldwide from minor to major resections, particularly in institutions having surgeons with advanced skills. If the degrees of surgical difficulty were defined, it would serve as a useful guide when introducing LLR and stepping up to the more advanced LLR. As no previous study has addressed the degrees of difficulty of various LLR procedures, we devised a practical scoring system for this purpose. We extracted the following five factors from preoperative information to score difficulty levels: (1) tumor location, (2) extent of liver resection, (3) tumor size, (4) proximity to major vessels, and (5) liver function. This difficulty index is comprised of the cumulative score for the five individual factors. There has not yet been a standard definition of difficulty. Our proposed scoring system might be a practical means of assessing the difficulty of LLR procedures. However, this system must be prospectively validated.

Can we expand the indications for laparoscopic liver resection? A systematic review and meta-analysis of laparoscopic liver resection for patients with hepatocellular carcinoma and chronic liver disease.

Liver resection (LR) for patients with hepatocellular carcinoma (HCC) and chronic liver disease (CLD) poses a high risk of serious postoperative complications and multicentric metachronous lesions requiring repeated treatment. The efficacy of laparoscopic LR (LLR) for such patients has yet to be established. The objective of this study is to test the outcomes of LLR for HCC with the aim of considering potential expansion of the indications for LLR. We performed a systematic review of the pertinent English-language literature. Our search yielded four meta-analyses and 23 comparative studies of LLR for HCC. On the basis of the findings from these studies and our newly conducted meta-analysis, the possibility for expanding the indications for LLR to HCC was examined. The studies show that LLR (vs open) for HCC generally yields better short-term outcomes without compromising long-term outcomes, and that incidences of postoperative ascites and liver failure are decreased with LLR. Several studies show the benefits of LLR for patients with severe CLD and for repeat surgery. Reductions of postoperative ascites and liver failure are among the advantages of LLR. These characteristics of LLR may allow us to expand the indications of LLR to HCC with CLD.

Expanding the selection criteria of laparoscopic hepatectomy for hepatocellular carcinoma.

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.

Laparoscopic resection for hepatocellular carcinoma: eastern and western experiences.

Short-term Results of Laparoscopic versus Open Liver Resection for Liver Metastasis from Colorectal Cancer: A Comparative Study

Laparoscopic liver resection is currently performed in an increasing number of institutions as a minimally invasive treatment. However, no randomized controlled trials have compared laparoscopic and open liver resections. Twenty-three laparoscopic and 24 open liver resections for colorectal cancer liver metastases (CRCLM) were performed, and these data for both were retrospectively compared in the short-term results. The estimated blood loss was 99 ± 207 mL in the laparoscopic group and 397 ± 381 mL in the open group (P = 0.0018); blood loss was significantly higher in the open group. There were no differences in the surgical procedure, blood loss, transfusion rate, pathological margins, postoperative complications, 30-day mortality, duration of intravenous drip, or hospital stay. On postoperative courses, the values of total bilirubin, white blood cell count, and C-reactive protein were significantly lower in the laparoscopic group. The data of the present series suggest the lesser invasiveness and safety of laparoscopic liver resection even for patients with CRCLM, and they showed that postoperative laboratory tests were better after laparoscopy than after the traditional open approach with better short-term results. Tumor diameter less than 5 cm appears to be the appropriate indication for laparoscopic liver resection for CRCLM.

Pure laparoscopic hepatectomy in semiprone position for right hepatic major resection

BackgroundPure laparoscopic liver resection is technically difficult for tumors located in the dorsal anterior and posterior sectors. We have developed a maneuver to perform pure laparoscopic hepatectomy in the semiprone position which was developed for resecting tumors located in these areas.MethodsThe medical records have been reviewed retrospectively in 30 patients who underwent laparoscopic liver resection in the semiprone position for carcinoma in the dorsal anterior or posterior sectors of the right liver between 2008 and 2011.ResultsSeventeen liver tumors were primary liver tumors and 13 were colorectal metastases. Of the 30 patients, 11 (36.6 %) underwent major hepatectomy [right hemihepatectomy in 7 (23.3 %) and posterior sectionectomy in 4 (13.3 %)]. Anatomical minor resection, such as S6 or S7 segmentectomy, was performed in five patients (16.6 %). Five patients with liver metastasis underwent a simultaneous laparoscopic resection. There was no mortality, reoperation, or conversion to open procedures. There were no hepatectomy-related complications such as postoperative bleeding, bile leakage, or liver failure.ConclusionsPure laparoscopic hepatectomy in the semiprone position for tumors present in the dorsal anterior and posterior sectors is feasible and safe. This method expands the indications for laparoscopic liver resection for tumors.Electronic supplementary materialThe online version of this article (doi:10.1007/s00534-012-0558-y) contains supplementary material, which is available to authorized users.

Glissonian approach for laparoscopic mesohepatectomy

Experience with advanced techniques has increased the indications for laparoscopic liver resection. This video demonstrates technical aspects of a pure laparoscopic mesohepatectomy using intrahepatic Glissonian technique. To the best of our knowledge, this is the first case of anatomic laparoscopic mesohepatectomy using the Glissonian approach published in the English literature. A 62-year-old man with colorectal liver metastasis occupying central liver segments was referred for surgical treatment. The first step is the control of segment 4 pedicle. Using the round ligament as a guide, one incision is performed on its right margin and another is made at the bottom of segment 4. A vascular clamp is introduced through those incisions to occlude segment 4 Glissonian sheath. The next step is to control the right anterior pedicle. The first incision is made in front of the hilum and another is performed on the right edge of gallbladder bed. Laparoscopic clamp is introduced through these incisions and closed producing ischemic discoloration of segments 5 and 8. Vascular clamp is replaced by an endoscopic vascular stapling device and stapler is fired. Line of liver transection is marked along the liver surface following ischemic area. Liver transection is accomplished with bipolar vessel sealing device and endoscopic stapling device as appropriate. Specimen was extracted through a suprapubic incision. Liver raw surfaces were reviewed for bleeding and bile leaks. Operative time was 200min with minimum blood loss and no need for blood transfusion. Recovery was uneventful, and the patient was discharged on the fifth postoperative day. Histological examination revealed clear surgical margins. Mesohepatectomy can be safely performed laparoscopically in selected patients and by surgeons with expertise in both liver surgery and laparoscopic techniques. The use of the intrahepatic Glissonian approach may help to identify the exact limits of the mesohepatectomy to avoid ischemic injury of the remnant liver.

Stellenwert laparoskopischer Leberresektionen

Whereas in other fields of surgery minimally invasive techniques have replaced the open surgery approach, liver resection is still a domain of conventional surgery. However, it is internationally emerging that laparoscopic hepatic surgery will become more important by conceptional improvements. This article describes the technical aspects of laparoscopic liver resection, in particular the procedure with respect to the individual liver segments. The advantages and disadvantages of the minimally invasive technique and also the indications for laparoscopic liver resection will be discussed.

The International Position on Laparoscopic Liver Surgery

To summarize the current world position on laparoscopic liver surgery. Multiple series have reported on the safety and efficacy of laparoscopic liver surgery. Small and medium sized procedures have become commonplace in many centers, while major laparoscopic liver resections have been performed with efficacy and safety equaling open surgery in highly specialized centers. Although the field has begun to expand rapidly, no consensus meeting has been convened to discuss the evolving field of laparoscopic liver surgery. On November 7 to 8, 2008, 45 experts in hepatobiliary surgery were invited to participate in a consensus conference convened in Louisville, KY, US. In addition, over 300 attendees were present from 5 continents. The conference was divided into sessions, with 2 moderators assigned to each, so as to stimulate discussion and highlight controversies. The format of the meeting varied from formal presentation of experiential data to expert opinion debates. Written and video records of the presentations were produced. Specific areas of discussion included indications for surgery, patient selection, surgical techniques, complications, patient safety, and surgeon training. The consensus conference used the terms pure laparoscopy, hand-assisted laparoscopy, and the hybrid technique to define laparoscopic liver procedures. Currently acceptable indications for laparoscopic liver resection are patients with solitary lesions, 5 cm or less, located in liver segments 2 to 6. The laparoscopic approach to left lateral sectionectomy should be considered standard practice. Although all types of liver resection can be performed laparoscopically, major liver resections (eg, right or left hepatectomies) should be reserved for experienced surgeons facile with more advanced laparoscopic hepatic resections. Conversion should be performed for difficult resections requiring extended operating times, and for patient safety, and should be considered prudent surgical practice rather than failure. In emergent situations, efforts should be made to control bleeding before converting to a formal open approach. Utilization of a hand assist or hybrid technique may be faster, safer, and more efficacious. Indications for surgery for benign hepatic lesions should not be widened simply because the surgery can be done laparoscopically. Although data presented on colorectal metastases did not reveal an adverse effect of the laparoscopic approach on oncological outcomes in terms of margins or survival, adequacy of margins and ability to detect occult lesions are concerns. The pure laparoscopic technique of left lateral sectionectomy was used for adult to child donation while the hybrid approach has been the only one reported to date in the case of adult to adult right lobe donation. Laparoscopic liver surgery has not been tested by controlled trials for efficacy or safety. A prospective randomized trial appears to be logistically prohibitive; however, an international registry should be initiated to document the role and safety of laparoscopic liver resection. Laparoscopic liver surgery is a safe and effective approach to the management of surgical liver disease in the hands of trained surgeons with experience in hepatobiliary and laparoscopic surgery. National and international societies, as well as governing boards, should become involved in the goal of establishing training standards and credentialing, to ensure consistent standards and clinical outcomes.