Laparoscopic Major Hepatectomies Research Articles

ThP5.2 - Comparison of perioperative outcomes of open (CUSA) versus laparoscopic (LOTUS) major hepatectomy – revisited. First evaluation of efficacy and safety of AEON stapler

Abstract Introduction In 2019, preliminary data matching 40 cases demonstrated improved outcomes of laparoscopic major liver resections using the BOWA-LOTUS liver blade (Devon, UK). An updated and expanded comparison between open and laparoscopic major hepatectomies is presented as well as evaluating of an endovascular stapler AEON™ (Lexington Medical, Massachusetts, USA). Methods January 2020 to June 2023 patients were identified from a prospectively maintained database. Propensity score matching analysis used R statistical tool in SPSS (IBM, New York, USA) to isolate matched open and laparoscopic cases. LOTUS ultrasonic energy device was used for parenchymal transection in laparoscopic cases and CUSA (Valleylab, Colorado, USA) in open procedures. AEON endovascular stapler was used from early 2021. Results 86 patients constitute the study population after applying propensity score matching analysis in a 1:1 ratio. The median (range) age in the matched sample was 63 (27-83) yrs. Hospital stay (mean 7.8 v 14.7 days; p=0.025) and blood transfusion requirement (0 v 4 units; p=0.035) were all significantly improved when comparing laparoscopic to open. Comparison of the AEON stapler with Endo-GIA (Medtronic, MN, USA) showed no significant difference in any outcome measure, although AEON demonstrated (non-significantly) a reduced trend in operating time comparing all cases (56 v 69 mins; p=0.300) and laparoscopic (56 v 71 min; p=0.295). Conclusion The LOTUS liver blade continues to be associated with acceptable outcomes in laparoscopic liver resections. The AEON endovascular stapler was equivalent to other staplers with a trend towards a shorter operating time in liver transectional surgery.

ASO Author Reflections: Impact of Tumor Size on the Difficulty of Laparoscopic Major Hepatectomies: A Step Towards a New and Improved Difficulty Score for Laparoscopic Hepatectomies.

ASO Author Reflections: Impact of Tumor Size on the Difficulty of Laparoscopic Major Hepatectomies: A Step Towards a New and Improved Difficulty Score for Laparoscopic Hepatectomies.

Impact of Tumor Size on the Difficulty of Laparoscopic Major Hepatectomies: An International Multicenter Study.

Although tumor size (TS) is known to affect surgical outcomes in laparoscopic liver resection (LLR), its impact on laparoscopic major hepatectomy (L-MH) is not well studied. The objectives of this study were to investigate the impact of TS on the perioperative outcomes of L-MH and to elucidate the optimal TS cutoff for stratifying the difficulty of L-MH. This was a post-hoc analysis of 3008 patients who underwent L-MH at 48 international centers. A total 1396 patients met study criteria and were included. The impact of TS cutoffs was investigated by stratifying TS at each 10-mm interval. The optimal cutoffs were determined taking into consideration the number of endpoints which showed a statistically significant split around the cut-points of interest and the magnitude of relative risk after correction for multiple risk factors. We identified 2 optimal TS cutoffs, 50mm and 100mm, which segregated L-MH into 3 groups. An increasing TS across these 3 groups (≤ 50mm, 51-100mm, > 100mm), was significantly associated with a higher open conversion rate (11.2%, 14.7%, 23.0%, P < 0.001), longer operating time (median, 340 min, 346min, 365min, P = 0.025), increased blood loss (median, 300ml, ml, 400ml, P = 0.002) and higher rate of intraoperative blood transfusion (13.1%, 15.9%, 27.6%, P < 0.001). Postoperative outcomes such as overall morbidity, major morbidity, and length of stay were comparable across the three groups. Increasing TS was associated with poorer intraoperative but not postoperative outcomes after L-MH. We determined 2 TS cutoffs (50mm and 10mm) which could optimally stratify the surgical difficulty of L-MH.

Impact of body mass index on perioperative outcomes of laparoscopic major hepatectomies

BackgroundData on the effect of body mass index on laparoscopic liver resections are conflicting. We performed this study to investigate the association between body mass index and postoperative outcomes after laparoscopic major hepatectomies. MethodsThis is a retrospective review of 4,348 laparoscopic major hepatectomies at 58 centers between 2005 and 2021, of which 3,383 met the study inclusion criteria. Concomitant major operations, vascular resections, and previous liver resections were excluded. Associations between body mass index and perioperative outcomes were analyzed using restricted cubic splines. Modeled effect sizes were visually rendered and summarized. ResultsA total of 1,810 patients (53.5%) had normal weight, whereas 1,057 (31.2%) were overweight and 392 (11.6%) were obese. One hundred and twenty-four patients (3.6%) were underweight. Most perioperative outcomes showed a linear worsening trend with increasing body mass index. There was a statistically significant increase in open conversion rate (16.3%, 10.8%, 9.2%, and 5.6%, P < .001), longer operation time (320 vs 305 vs 300 and 266 minutes, P < .001), increasing blood loss (300 vs 300 vs 295 vs 250 mL, P = .022), and higher postoperative morbidity (33.4% vs 26.3% vs 25.0% vs 25.0%, P = .009) in obese, overweight, normal weight, and underweight patients, respectively (P < .001). However, postoperative major morbidity demonstrated a “U”-shaped association with body mass index, whereby the highest major morbidity rates were observed in underweight and obese patients. ConclusionLaparoscopic major hepatectomy was associated with poorer outcomes with increasing body mass index for most perioperative outcome measures.

Propensity-score Matched and Coarsened-exact Matched Analysis Comparing Robotic and Laparoscopic Major Hepatectomies: An International Multicenter Study of 4822

Propensity-score Matched and Coarsened-exact Matched Analysis Comparing Robotic and Laparoscopic Major Hepatectomies: An International Multicenter Study of 4822

Robotic versus laparoscopic major hepatectomy for hepatocellular carcinoma: short-term outcomes from a single institution

BackgroundCurrently, an increasing number of robotic major hepatectomies for hepatocellular carcinoma (HCC) are being performed. Despite the advantages of robotic surgery over laparoscopic procedures, studies comparing robotic with laparoscopic major hepatectomy in terms of short-term results remain scarce. This study was performed to compare robotic major hepatectomy and laparoscopic major hepatectomy in terms of their intraoperative and postoperative results.MethodsData regarding demographics and intraoperative and postoperative results of 131 patients undergoing robotic or laparoscopic major hepatectomy between January 2017 and March 2022 were retrieved from their medical records and compared between the two types of surgery.ResultsBetween January 2017 and March 2022, 44 robotic major hepatectomies and 87 laparoscopic major hepatectomies were performed at the Department of Hepatobiliary and Pancreatic Surgery, Shenzhen People’s Hospital. Patients undergoing robotic major hepatectomy were not significantly different from those undergoing laparoscopic major hepatectomy in terms of age (P = 0.397), sex (P = 0.624), body mass index (BMI) (P = 0.118), alpha-fetoprotein (AFP) (P = 0.09), tumor size (P = 0.176), cirrhosis (P = 0.384), fatty liver (P = 0.162), preoperative antiviral treatment (P = 0.934), hepatitis B virus (HBV) DNA (P = 0.646) and operation type (P = 0.054). Robotic major hepatectomy was associated with a longer operation time (median: 255.5 versus 206.8 min; P < 0.001) and less estimated blood loss (median: 118.9 versus 197.0 ml; P = 0.002) than laparoscopic major hepatectomy. However, robotic major hepatectomy was not significantly different from laparoscopic major hepatectomy regarding length of postoperative hospital stay (P = 0.849), open conversion (P = 0.077), ICU stay (P = 0.866), postoperative massive abdominal bleeding (P = 1.00), portal vein thrombosis (P = 1.00), abdominal infection (P = 1.00), pulmonary infection (P = 1.00), pulmonary embolism (P = 1.00), cardiac complications (P = 1.00), liver failure (P = 1.00), kidney failure (P = 1.00), biliary leak (P = 1.00), positive resection margin (P = 1.00), 30-day mortality (P = 1.00) and 90-day mortality (P = 1.00).ConclusionsRobotic major hepatectomy was as effective as laparoscopic surgery in terms of intraoperative and postoperative results but took longer and could more efficiently control intraoperative blood loss.

Impact of Three-Dimensional (3D) Visualization on Laparoscopic Hepatectomy for Hepatocellular Carcinoma.

The impact of three-dimensional (3D) visualization on laparoscopic hepatectomy for hepatocellular carcinoma is largely unknown. A retrospective review with propensity-score matched analysis of 3D and two-dimensional (2D) laparoscopic hepatectomy performed in a tertiary hepatobiliary surgery center. Since the availability of 3D laparoscopy, the proportion of laparoscopic major hepatectomies has significantly expanded (1.7% vs. 24.0%, p<0.0001) and the percentage of difficult resections among patients who underwent laparoscopic hepatectomy has also increased (12.6% vs. 40.0%, p=0.0001). A total of 305 patients (92 in the 3D group and 213 in the 2D group) underwent laparoscopic hepatectomy between 2002 and 2019. The 3D group had better liver function, larger tumors at more difficult locations, more major resections, and more difficult surgeries. After propensity score matching, 144 patients were analyzed (72 in both the 3D and 2D groups). Patients were comparable in terms of liver status, tumor status, and complexity of liver surgery. Operative time (218 vs. 218 mins, p=0.50) and blood loss (0.2 vs. 0.2L, p=0.49) were comparable between the two groups, however overall complications were higher in the 2D group (1.4 vs. 11.1%, p=0.03). Patients who underwent 3D laparoscopic major hepatectomy had a shorter hospital stay than their comparable counterparts operated through an open approach (7 vs. 6 days, p=0.003). 3D visualization enhanced the feasibility of laparoscopic major hepatectomy and difficult laparoscopic liver resection. 3D resection was potentially associated with fewer operative morbidities and the 3D laparoscopic approach did not jeopardize the outcome of major hepatectomy.

Is laparoscopic major hepatectomy feasible and safe in Swiss cantonal hospitals?

The number of laparoscopic liver resections is increasing worldwide, including in Switzerland. However, laparoscopy is mostly used for minor resections. Little is known about indications for and outcomes of major liver resections performed laparoscopically. The aim of this study was to compare the clinical outcome of open and laparoscopic major liver resection cohorts in two Swiss centres. Patients undergoing open or laparoscopic major hepatectomy (>3 segments) in two cantonal hospitals from January 2015 to December 2019 were analysed. All disease types except perihilar cholangiocarcinomas, rare malignancies and resections with biliary reconstruction were included. The primary outcome was the number of complications incurred. Operation time, blood loss, hospital stay and 90-day mortality were secondary outcomes investigated. A separate analysis was performed for colorectal liver metastases, the most common indication. Potential risk factors for major complications were evaluated in a multivariate analysis. A total of 88 patients were identified. Among those, 34 patients underwent laparoscopic major hepatectomy (LAPH) and 54 patients open major hepatectomy (OH). The two groups did not differ in demographics. The most common indication was malignancy (LAPH 94% vs OH 98%), mainly colorectal liver metastases (LAPH 53% vs OH 59%). There was no significant difference in major complications (21% vs 15%, p = 0.565). Median operation time (LAPH 433 minutes, interquartile range [IQR 351-482 vs OH 397 minutes, IQR 296-446; p = 0.222), blood loss (325 ml, IQR 200-575 vs 475 ml, IQR 300-800; p = 0.150) and hospital stay (9 days, IQR 8-14 vs 11 days, IQR 9-14; p = 0.441) were comparable between the two cohorts. There was no significant difference in 90-day mortality (3% vs 7%, p = 0.881). The laparoscopic technique was not identified as a risk factor for major complications in a multivariate analysis. This first report from Switzerland evaluating outcomes of laparoscopic major hepatectomies showed no difference in complications and clinical non-inferiority compared with open major hepatectomy.

Robot‐assisted versus conventional laparoscopic major hepatectomies: Systematic review with meta‐analysis

Major hepatectomy is still regarded as a technically demanding procedure for which minimally invasive surgery remains limited to selected cases in experienced centres and robotic platforms may provide some advantages over conventional laparoscopy in this setting. We aimed to combine and meta-analyse the available literature upon this topic. The PubMed, MEDLINE and Web of Science databases were appraised to find all available studies comparing robotic and laparoscopic major hepatectomies. According to a pre-established pattern preoperative settings, operative and postoperative outcomes were assessed. The meta-analysis was performed by using the Revman 5.3 software. A total of 485 patients from eight studies were included in the analysis. Robotic major hepatectomies showed a significantly lower conversion rate and estimated blood loss as compared to laparoscopic ones. Laparoscopic major hepatectomies patients experienced significant shorter postoperative hospitalisation. Robotic surgery appears as competent as conventional laparoscopy to perform major hepatectomies, with possible advantages on conversion rate and perioperative blood loss, despite slightly prolonged postoperative hospitalisation.

The Dorsal Approach to Laparoscopic Major Hepatectomy

Introduction: This new technique, a modification of the caudal approach of Soubrane, involves a posterior to anterior transection of the liver for laparoscopic major hepatectomies. It was conceived to enable a standardised technique, and to broaden the indications for laparoscopic resection particularly for larger tumours and with anatomical variations of the porta. Methods: As the initial step for a right hemihepatectomy the retrohepatic tunnel of Belghiti is developed and the caudate process divided as far superiorly as possible. Liver parenchyma is dissected away from the posterior aspect of the right hepatic inflow from medial to lateral, enabling safe stapling. Development of the retrohepatic tunnel and division of the posterior parenchyma is continued as the leading edge of the parenchymal transection, maintaining good surgical orientation especially for tumours close to the midline or cava. Similar concepts apply for a left hemihepatectomy, with dissection beginning in the in the Arantius groove. Results: 31 major resections (23 right +/- extended, 8 left +/- extended) have utilised this technique. 2 required conversion, and 1 required transfusion. R0 resection was achieved in 29 cases. Median hospital stay was 6 days. With this technique conversion rate has decreased from 29% to 6% (P = 0.032) and selection of a laparoscopic approach for major resections increased from 24% to 60% (P < 0.001). Conclusion: The dorsal approach to laparoscopic major hepatectomy is a novel technical variation that enables a safe, standardised technique and an expanded set of indications for a laparoscopic approach.

Laparoscopic Major Hepatectomy: Do Not Underestimate the Impact of Specimen Extraction Site.

In laparoscopic major hepatectomy, analysis of outcomes according to specimen extraction site remains poorly described. The aim was to compare postoperative outcomes according to specimen extraction site. From 2000 to 2017, all laparoscopic major hepatectomies were reviewed and postoperative outcomes were analyzed according to specimen extraction site: subcostal (Group 1), midline (Group 2), or suprapubic (Group 3) incision. Among 163 patients, 15 (9.2%) belonged to Group 1, 49 (30.1%) in Group 2, and 99 (60.7%) in Group 3. The proportion of right-sided, left-sided, or central hepatectomies, mortality, and overall and severe complications were comparable between groups. Group 1 had larger tumors (61 vs. 38 vs. 47mm; P = 0.014), higher operative time (338 vs. 282 vs. 260min; P < 0.008), higher adjacent organ resection rate (46.6 vs. 16.3 vs. 7.1%; P < 0.001), and tended to increase pulmonary complications (40.0 vs. 12.2 vs. 18.2%; P = 0.064). In Group 2, a previous midline incision scar was more frequently used for specimen extraction site (65.3 vs. 26.6 and 30.3%, Group 1 and 3; P < 0.001). Postoperative incisional hernia was observed in 16.4% (n = 23) and was more frequent in Group 2 (26.6 vs. 6.6% and 10.1%, Group 1 and Group 3; P = 0.030). Finally, Group 2 (HR 2.63, 95% CI 1.41-3.53; P = 0.032) was the only independent predictive factor of postoperative incisional hernia. While using a previous incision makes sense, the increased risk of postoperative incisional hernia after midline incision promotes the suprapubic incision.

Pure laparoscopic versus open hemihepatectomy: a critical assessment and realistic expectations - a propensity score-based analysis of right and left hemihepatectomies from nine European tertiary referral centers.

A stronger evidence level is needed to confirm the benefits and limits of laparoscopic hemihepatectomies. Laparoscopic and open hemihepatectomies from nine European referral centers were compared after propensity score matching (right and left hemihepatectomies separately, and benign and malignant diseases sub-analyses). Five hundred and forty-five laparoscopic hemihepatectomies were compared with 545 open. Laparoscopy was associated with reduced blood loss (P < 0.001), postoperative stay (P<0.001) and minor morbidity (P = 0.002), supported by a lower Comprehensive Complication Index (CCI) (P = 0.035). Laparoscopic right hemihepatectomies were associated with lower ascites (P = 0.016), bile leak (P = 0.001) and wound infections (P = 0.009). Laparoscopic left hemihepatectomies exhibited a lower incidence of bile leak and cardiovascular complications (P = 0.024; P = 0.041), lower minor and major morbidity (P = 0.003; P = 0.044) and reduced CCI (P = 0.002). Laparoscopic major hepatectomies (LMH) for benign disease were associated with lower blood loss (P = 0.001) and bile leaks (P = 0.037) and shorter total stay (P < 0.001). LMH for malignancy were associated with lower blood loss (P < 0.001) and minor morbidity (P = 0.027) supported by a lower CCI (P = 0.021) and shorter stay (P < 0.001). This multicenter study confirms some associated advantages of laparoscopic left and right hemihepatectomies in malignant and benign conditions highlighting the need for realistic expectations of the minimally invasive approach based on the resected hemiliver and the patients treated.

Comparison of Outcomes Between Open Major Hepatectomy Using CUSA and Laparoscopic Major Hepatectomy Using "Lotus" Liver Blade. A Propensity Score Matched Analysis.

Introduction: Evolution in laparoscopic liver surgery during the past two decades is an indisputable fact. According to the second international consensus conference for laparoscopic liver resection held in Morioka, Japan in 2014 major resections are still regarded as innovative procedures in the exploration phase. On this basis, our study aims to explore the efficacy and safety of laparoscopic vs. open major liver resection and therefore increase the existing evidence on major laparoscopic liver surgery.Methods: All consecutive patients who underwent major liver resection, open and laparoscopic from January 2016 to May 2018 were identified from our prospectively maintained database. Propensity score matching analysis was performed using R statistical tool in SPSS to isolate matched open and laparoscopic cases which were compared for intraoperative and postoperative short-term outcomes. Lotus ultrasonic energy device was used for parenchymal transection in laparoscopic cases vs. CUSA in open procedures.Results: Propensity score matching analysis was performed on 82 consecutive patients (61 open and 21 laparoscopic major hepatectomies) resulting in 40 matched patients, 20 in each group. The mean total duration of surgery and duration of parenchymal transection were slightly longer in the laparoscopic group (p = 0.419, p = 0.348). There was no difference in the intraoperative and postoperative transfusion rates. Patients after laparoscopic surgery were discharged 2 days earlier on average (p = 0.310). No difference was observed in complication rates and mortality.Conclusion: Our data did not reveal inferiority of the laparoscopic major hepatectomy vs. the open approach in any parameter compared. The use of the Lotus ultrasonic energy device appeared to be efficient and safe for parenchymal transection in the laparoscopic procedures.

Laparoscopic Versus Open Major Hepatectomy: Analysis of Clinical Outcomes and Cost Effectiveness in a High-Volume Center

BackgroundConsidering the increasing evidence on the feasibility of laparoscopic major hepatectomies (LMH), their clinical outcomes and associated costs were herein evaluated compared to open (OMH). MethodsMajor contributors of perioperative expenses were considered. With respect to the occurrence of conversion, a primary intention-to-treat analysis including conversions in the LMH group (ITT-A) was performed. An additional per-protocol analysis excluding conversions (PP-A) was undertaken, with calculation of additional costs of conversion analysis. ResultsOne hundred forty-five LMH and 61 OMH were included (14.5% conversion rate). At the ITT-A, LMH showed lower blood loss (p < 0.001) and morbidity (global p 0.037, moderate p 0.037), shorter hospital stay (p 0.035), and a lower need for intra- and postoperative red blood cells transfusions (p < 0.001), investigations (p 0.004), and antibiotics (p 0.002). The higher intraoperative expenses (+ 32.1%, p < 0.001) were offset by postoperative savings (− 27.2%, p 0.030), resulting in a global cost-neutrality of LMH (− 7.2%, p 0.807). At the PP-A, completed LMH showed also lower severe complications (p 0.042), interventional procedures (p 0.027), and readmission rates (p 0.031), and postoperative savings increased to − 71.3% (p 0.003) resulting in a 29.9% cost advantage of completed LMH (p 0.020). However, the mean additional cost of conversion was significant. ConclusionsCompleted LMH exhibit a high potential treatment effect compared to OMH and are associated to significant cost savings. Despite some of these benefits may be jeopardized by conversion, a program of LMH can still provide considerable clinical benefits without cost disadvantage and appears worth to be implemented in high-volume centers.

Laparoscopic versus open major hepatectomies: analysis of surgical outcomes and cost effectiveness in a high-volume centre

Background: We compared the clinical and financial outcomes of laparoscopic major hepatectomies (LMH) with open procedures (OMH). Methods: Intra, post and total expenses were considered. Intention-to-treat (ITT) and per-protocol (PP) analysis were undertaken, considering converted patients either in the LMH or OMH group. Results: Patients receiving major hepatectomy (May2014-Dec2016) were identified (132, 80LMH vs. 52OMH). 21 LMH were converted (26.2%), with the commonest reason being oncologic concerns (n=9, 42.8%). At the ITT analysis LMH showed longer operative time (p=0.03), but lower blood loss (p<0.001), transfusions (p=0.01), hospital stay (p=0.006) and morbidity (p=0.03). LMH had less investigations (p=0.004) and interventions (p=0.03). The higher intraoperative costs of LMH (p<0.001) were balanced by lower postoperative expenses (p=0.03), resulting in a total cost neutrality if compared to open (p=0.60). The PP analysis did not confirm longer operative time for LMH (p=0.44), while blood loss/transfusion (p<0.001, p=0.002), morbidity/investigations (p=0.01, p=0.001) and length of stay (p=0.002) were still lower and with increased significance. Higher intraoperative costs for LMH were confirmed (p<0.001), but lower postoperative expenses were exacerbated (p=0.004), now resulting in inferior global costs (p=0.02). Conclusion: Completed LMH provide significant advantages and cost savings compared to OMH. Despite some of these may be jeopardized by conversion, a program of LMH appears worth in a high-volume centre.

Laparoscopic versus open major hepatectomies: analysis of surgical outcomes and cost effectiveness in a high-volume centre

Laparoscopic versus open major hepatectomies: analysis of surgical outcomes and cost effectiveness in a high-volume centre

The “Dorsal” approach to laparoscopic major hepatectomy enables expanded indications for laparoscopic liver resection

Introduction: This new technique, a modification of the caudal approach of Soubrane, involves a posterior to anterior transection of the liver for laparoscopic major hepatectomies. It was conceived to enable a standardised technique, and to broaden the indications for laparoscopic resection particularly for larger tumours and with anatomical variations of the porta. Methods: As the initial step for a right hemihepatectomy the retrohepatic tunnel of Belghiti is developed and the caudate process divided as far superiorly as possible. Liver parenchyma is dissected away from the posterior aspect of the right hepatic inflow from medial to lateral, enabling safe stapling. Development of the retrohepatic tunnel and division of the posterior parenchyma is continued as the leading edge of the parenchymal transection, maintaining good surgical orientation especially for tumours close to the midline or cava. Similar concepts apply for a left hemihepatectomy, with dissection beginning in the in the Arantius groove. Results: 8 cases (6 right hemihepatectomy, 1 extended right hepatectomy, 1 extended left hepatectomy) have utilised this technique. I required conversion to a hybrid approach, and 1 case required transfusion. R0 resection was achieved in all cases. Average length of stay was 5 days. Comparison to 50 consecutive previous laparoscopic major hepatectomies demonstrates larger tumours and fewer conversions with the dorsal approach. Schematic and case videos will be presented. Conclusion: The dorsal approach to laparoscopic major hepatectomy is a novel technical variation that enables a safe, standardised technique and an expanded set of indications for a laparoscopic approach.

Training robotic hepatectomy: the Hong Kong experience and perspective.

The introduction of robotic surgical systems has revolutionized the practice of minimal invasive surgery (MIS). Although little data regarding robotic hepatectomies have been reported, it appears to be similar to conventional laparoscopic approach in terms of blood loss, morbidity rate, mortality rate and hospital stay at least. The application of robotic system in liver surgery was not well evaluated yet, particularly learning curve. Studies were identified by searching MEDLINE and PubMed databases for articles from January 2001 to May 2016 using the keywords "laparoscopic hepatectomy", "robotic hepatectomy", and "learning curve". With the limited data in robotic hepatectomy, the learning curve model of robotic hepatectomy needs to base on the experience of conventional laparoscopic hepatectomy. Based on the learning curve study experience for laparoscopic hepatectomies, the minimal number laparoscopic minor and major hepatectomies to overcome learning curve are 22-64 cases, and 45-75 cases, respectively. Left lateral sectionectomy technique is more standardized, and it is a good start for training of MIS liver surgery. However, the training program required for the robotic liver surgeons still highly depends on the surgeons' experience of previous open and laparoscopic liver surgery, the surgeons' previous experience of other robotic surgeries, the experience of the surgical team including the assistant surgeons and nursing staffs, and the complexity of the diseases. We discourage performance of robotic hepatectomy in the occasional patient by a team that is not well prepared and is not embedded in a specialized center. Knowledge and practical skills are both required in MIS liver surgery and cannot be replaced by newer tools, including the most advanced robotic system.

Early experience with totally laparoscopic major hepatectomies: single institution experience with 31 consecutive cases.

Totally laparoscopic major hepatectomy (LMH) is a technically challenging procedure with limited studies mainly from high-volume expert centers reported. In this study, we report our initial experience with totally LMH. A retrospective review of a prospective database of 340 consecutive patients who underwent laparoscopic liver resection at a single institution was conducted. Thirty-one consecutive patients who underwent attempted totally LMH between March 2011 to December 2016 were identified. Major hepatectomies were defined as resection of ≥3 contiguous segments which included only right/left hepatectomies, extended hepatectomies or central hepatectomies. The procedures included 11 right hepatectomies, one extended right hepatectomy, nine left hepatectomies (two including middle hepatic vein), two extended left hepatectomies, two left hepatectomies with caudate lobe and six central hepatectomies. The median tumor size was 40 (range, 12-100) mm and the median operation time was 435 (range, 245-585) min. Median blood loss was 500 (range, 100-1900) mls and 10 (32.3%) patients required blood transfusion. There were three (9.7%) open conversions of which two occurred during the first five cases. There was one (3.2%) major (>grade 2) morbidity and there were no 30-day/in-hospital mortalities or reoperations. The median postoperative stay was 5 (range, 3-14) days. Our initial experience confirms the feasibility and safety of LMH. There was an increase in the number and proportion of LMH performed at our institution over time.

Laparoscopic hepatectomy significantly shortens the time to postoperative chemotherapy in patients undergoing major hepatectomies

BackgroundThe benefit of adjuvant chemotherapy occurs with early initiation, but is commonly delayed due to postoperative complications. Minimally invasive surgery is proven to significantly reduce complications and hospital length of stay. This study compares open versus laparoscopic liver resection in patients requiring adjuvant chemotherapy. Methods120 consecutive patients with metastatic colorectal liver cancer who underwent liver resection between 2007 through 2012 were reviewed from an IRB prospective database. Results44 laparoscopic cases were compared to 76 open cases having equivalent resections. Laparoscopic liver resection patients had lower blood loss (276 ml) than patients with open resection (614 ml). Patients with laparoscopy had shorter length of hospital stay (5 days) than patients with open resection (9 days). Patients with laparoscopic resection had a shorter time of chemotherapy initiation postoperatively (24 days v 39 days). Overall complication rates were higher, but statistically insignificant in patients with open resection. ConclusionsOur data showed that the shorter LOS with laparoscopic major hepatectomies allows earlier initiation of chemotherapy compared to the open group, without jeopardizing surgical margins or extent of resection. SummaryOver the past decade multiple authors have established that, despite occasional longer operating times, laparoscopic liver surgery is associated with reduced blood loss, reduced postoperative morbidity and shorter hospital stay. The purpose of this analysis was to determine if the advantages of a minimally invasive approach correspond to shorter initiation of adjuvant chemotherapy versus an open approach.