Laparoscopic Resection Of Hepatocellular Carcinoma Research Articles

Minimally invasive surgery approaches in major liver resection for hepatocellular carcinoma

Over the past two decades, minimally invasive liver resection (MILR) has progressively become the standard for minor resection of hepatocellular carcinoma (HCC). In contrast, its implementation in major hepatectomy has been slower due to its higher technical complexity and morbidity. However, studies published in recent years have demonstrated that minimally invasive major hepatectomy (MIMH) is safe and feasible with less blood loss, fewer complications, earlier recovery, decreased hospital stay, and improved cosmetic outcomes compared with open surgery. This review examines the current status of MIMH, focusing on the respective strengths and weaknesses of the laparoscopic and robotic approaches, as well as assessing their cost-effectiveness and possible future directions. The earlier introduction of laparoscopic liver resection has led to its widespread utilization as a safe and accurate alternative to open hepatectomy. Of note is that the robotic approach has also been increasingly utilized, demonstrating better perioperative outcomes and decreased need for conversion to open hepatectomy vs. the laparoscopic approach. Advantages associated with the robotic approach include the three-dimensional large visual field and instrumental flexibility, allowing for improved bleeding control. Even though evidence has been slowly accumulating regarding long-term outcomes, most studies report no notable differences between open, robotic, and laparoscopic resection for HCC. Regarding cost-effectiveness, MIMH has been characterized by higher operating room and anesthesia costs, especially for robotic procedures that require highly expensive equipment. The increase in cost is often offset by the lower morbidity and, thus, shorter hospital stays associated with MIMH. Future developments, such as the implementation of artificial intelligence and augmented reality, may potentially maximize the safety and applicability of MIMH and, in time, lead to improved postoperative and oncological outcomes.

Microwave ablation versus laparoscopic resection for hepatocellular carcinoma in patients with clinically significant portal hypertension: a propensity score-matched study of postoperative liver decompensation.

The study of postoperative liver decompensation after microwave ablation (MWA) for hepatocellular carcinoma (HCC) in patients with clinically significant portal hypertension (CSPH) is still lacking. The purpose of the present study was to compare the postoperative liver decompensation after MWA and laparoscopic resection (LR) for HCC in patients with CSPH. The present retrospective study enrolled 222 HCC patients with CSPH who underwent MWA (n = 67) or LR (n = 155). Postoperative liver decompensation, complications, postoperative hospital stays, and overall survival were analyzed. Factors associated with postoperative liver decompensation were identified. After propensity score matching, the postoperative liver decompensation rate was significantly lower in the MWA group than that in the LR group (15.5% versus 32.8%, p = 0.030). The multivariable regression analysis identified that type of treatment (MWA vs. LR, odds ratio [OR] 0.44; 95% confidence interval [CI], 0.21-0.91; p = 0.026) and Child-Pugh B (OR, 2.86; 95% CI, 1.24-6.61; p = 0.014) were independent predictors for postoperative liver decompensation. The rate of complications for patients in the MWA group was significantly lower than that in the LR group (p < 0.001). And MWA showed shorter postoperative hospital stays than LR (3days vs. 6days, p < 0.001). Overall survival rate between the two groups was not significantly different (p = 0.163). Compared with laparoscopic resection, microwave ablation has a lower rate of postoperative liver decompensation and might be a better option for HCC patients with CSPH. Microwave ablation exhibited a lower incidence of postoperative liver decompensation in comparison to laparoscopic resection, thereby conferring greater advantages to hepatocellular carcinoma patients with clinically significant portal hypertension. •Postoperative liver decompensation rate after microwave ablation was lower than that of laparoscopic resection for hepatocellular carcinoma in patients with clinically significant portal hypertension. •Microwave ablation showed shorter postoperative hospital stays than laparoscopic resection. •Microwave ablation had fewer complications than laparoscopic resection.

The pre- and postoperative nomograms to predict the textbook outcomes of patients who underwent hepatectomy for hepatocellular carcinoma.

An increasing number of studies have confirmed that non-textbook outcomes (non-TO) are a risk factor for the long-term outcome of malignant tumors. It is particularly important to identify the predictive factors of non-TO to improve the quality of surgical treatment. We attempted to construct two nomograms for preoperative and postoperative prediction of non-TO after laparoscopic hepatectomy for hepatocellular carcinoma (HCC). Patients who underwent curative-intent hepatectomy for HCC between 2014 and 2021 at two Chinese hospitals were analyzed. Using univariate and multivariate analyses, the independent predictors of non-TO were identified. The prediction accuracy is accurately measured by the receiver operating characteristic (ROC) curve and calibration curve. ROC curves for the preoperative and postoperative models, Child-Pugh grade, BCLC staging, and 8th TNM staging were compared relative to predictive accuracy for non-TO. Among 515 patients, 286 patients (55.5%) did not achieve TO in the entire cohort. Seven and eight independent risk factors were included in the preoperative and postoperative predictive models by multivariate logistic regression analysis, respectively. The areas under the ROC curves for the postoperative and preoperative models, Child-Pugh grade, BCLC staging, and 8th TNM staging in predicting non-TO were 0.762, 0.698, 0.579, 0.569, and 0.567, respectively. Our proposed preoperative and postoperative nomogram models were able to identify patients at high risk of non-TO following laparoscopic resection of HCC, which may guide clinicians to make individualized surgical decisions, improve postoperative survival, and plan adjuvant therapy against recurrence.

Impact of body mass index in elderly patients treated with laparoscopic liver resection for hepatocellular carcinoma.

The impact of obesity on surgical outcomes in elderly patients candidate for liver surgery is still debated. To evaluate the impact of high body mass index (BMI) on perioperative and oncological outcome in elderly patients (> 70 years old) treated with laparoscopic liver resection for hepatocellular carcinoma (HCC). Retrospective multicenter study including 224 elderly patients (> 70 years old) operated by laparoscopy for HCC (196 with a BMI < 30 and 28 with BMI ≥ 30), observed from January 2009 to January 2019. After propensity score matching, patients in two groups presented comparable results, in terms of operative time (median range: 200 min vs 205 min, P = 0.7 respectively in non-obese and obese patients), complications rate (22% vs 26%, P = 1.0), length of hospital stay (median range: 4.5 d vs 6.0 d, P = 0.1). There are no significant differences in terms of short- and long-term postoperative results. The present study showed that BMI did not impact perioperative and oncologic outcomes in elderly patients treated by laparoscopic resection for HCC.

The Impact of Bmi in Elderly Patients Treated with Laparoscopic Liver Resection for Hepatocellular Carcinoma

Introduction: The aim of our work was to assess the impact of high BMI on perioperative and oncological outcome in elderly patients (> 70 years old) treated with laparoscopic liver resection for hepatocellular carcinoma (HCC). Method: Retrospective multicenter study including 224 elderly patients (> 70 years old) operated by laparoscopy for HCC (196 with a BMI <30 and 28 with BMI> 30), observed from January 2009 to January 2019. Results: The operating time (200 vs. 220, p = 0.7), the transfusion rate (16% vs. 3%, p = 0.09) and the length of hospitalization (6 vs. 5.5, p = 0.2) are similar in the two groups. Patients with a BMI> 30 have a significantly higher complication rate (47% vs 25%, p = 0.02), but only related to the percentage of surgical site infections (SSI). There are no significant differences in terms of short and long term postoperative results. Conclusions: Despite a higher rate of SSI in obese patients, BMI does not appear to have an impact on perioperative and oncologic outcomes in elderly patients treated by laparoscopic resection for HCC.

Video case report of laparoscopic resection of hepatocellular carcinoma following liver transplantation

Video case report of laparoscopic resection of hepatocellular carcinoma following liver transplantation

Laparoscopic resection of hepatocellular carcinoma following liver transplantation: a video case report

Laparoscopy in the setting of cirrhosis has been described as having favorable outcomes compared to open in terms of collateral preservation, diminished manipulation, less fluid requirement, re-duced blood loss and transfusion rates leading to better short-term outcomes. Hepatocellular carcinoma (HCC) following liver transplantation (OLT) is frequent considering recurrence and de-novo lesions and the role of laparoscopy in this setting is unclear. In this setting, a minimally invasive approach could be indicated but should be considered with caution for the possibility of finding strong adhesions limiting the working space and because of the impossibility of performing the Pringle maneuver in case of bleeding. To the best of our knowledge, there are currently no reports of such an approach among the literature. We hereby present the video case report of a patient undergoing laparoscopic liver resection (LLR) following the diagnosis of a HCC in the liver “graft”. A 65-year-old male presented to our department for routine follow-up; He received OLT in May 2008 for liver cirrhosis HCV related and HCC. A CT scan showed a 40 mm lesion that was diag-nosed as an HCC (LIRADS classification 5). The patient was scheduled for a LLR. A 4-trocar technique was carried out using high energy device and bipolar forceps. No nasogastric tube was placed. The patient was put on clear liquids diet on postoperative day (POD) 1. On the second POD solid food intake was allowed. The drainage was removed in 3rd POD and the patient was discharged home without complications. Laparoscopic resection of HCC following liver transplantation is safe and feasible and should be considered as a first approach possibly improving outcomes.

Postlaparoscopic hepatic resection of hepatocellular carcinoma: Port‐site metastasis

Hepatocellular carcinoma (HCC), the most common primary liver cancer, occurs in 90 per cent of the cases in patients with chronic liver disease. Pure laparoscopic liver resection is a less invasive procedure than conventional liver resection for hepatic lesions. Port‐site metastasis of HCC is rare. We present a case of port‐site metastasis postlaparoscopic resection of HCC. The patient had laparoscopic nonanatomical resection for HCC 3 cm in diameter at segment III. Eleven months postoperative, the patient presented to our Department of Hepato‐Pancreatico‐Biliary with an anterior abdominal wall hard lump where the laparoscopic port had been used for the extraction of HCC and was associated with an elevated α‐fetoprotein level. Triphasic computed tomography scan showed HCC. Local excision was performed, and histopathology confirmed HCC. We recommend that examination of port sites after laparoscopic resection of HCC be included in the follow‐up protocol.

Laparoscopic resection of hepatocellular carcinoma in patients with and without cirrhosis: the Brisbane experience

Laparoscopic resection of hepatocellular carcinoma in patients with and without cirrhosis: the Brisbane experience

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: comparison between Middle Eastern and Western experience.

Laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) is increasing in this era of minimal invasive liver surgery. LLR for HCC is currently known to be a safer procedure than it was before because of technical advances and improvement in postoperative patient management and remains the first-line treatment for HCC in compensated cirrhosis in many centers. We have the chance of analyzing the paper about the comparison between Middle Eastern and Western experience for LLR as treatment of HCC.

Laparoscopic resection for hepatocellular carcinoma: eastern and western experiences.

Laparoscopic resection for hepatocellular carcinoma: eastern and western experiences.

Laparoscopic resection for hepatocellular carcinoma: comparison between Middle Eastern and Western experience.

Laparoscopic liver resection (LLR) is growing in popularity, but the short- and long-term outcome of patients undergoing LLR for hepatocellular carcinoma (HCC) has not yet been established. A literature search was performed using PubMed, Scopus, and Web of Science (WoS) from cited English and Chinese publications. Clinical and survival parameters were extracted. The search was last conducted in October 2013. After application of selective criteria, 24 remaining original studies with more than 15 patients were analyzed. In the Western experience, mean operative time was between 150 to 300 minutes, and mean blood loss ranged from 55 to 452 mL. Transfusion was required in all series, ranging from 2.8% to 50%. The conversion rate ranged from 5% to 19.4%. Three cases of death were reported. General morbidity rate ranged from 1.5% to 25%. Specific complications were divided into hemorrhage (2.4% to 25%), ascites (3.7% to 15.3%), and biliary collection (0.6% to 5%). Liver insufficiency was reported in two cases. Mean hospital stay ranged from 5.4 to 15 days. In all case-matched studies, LLR was statistically associated with a shorter hospital stay. The 5-year overall survival rate ranged from 55% to 70%. No trocar-site recurrence was observed. The recurrence rate ranged from 21.4% to 50%. Comparative studies did not demonstrate any significant difference in terms of recurrence between LLR and open liver resection (OLR). In the Middle Eastern experience, mean operative time ranged from 147 to 325 minutes, and mean blood loss ranged from 88 to 808 mL. Transfusion was required, ranging from 1.8% to 19.2%. The conversion rate ranged from 1.8% to 18.6%, and four series reported no conversion. There was no mortality. The main specific complication was ascites (1.7% to 26.6%). A biliary collection was reported in only two series (10.7% and 13.3%), and only one case of postoperative liver insufficiency was reported. Mean hospital stay ranged from 4 to 11.5 days. Statistically, three comparative studies reported a shorter postoperative hospital stay following LLR versus OLR. The 5-year overall survival rate ranged from 50% to 76.6%. Comparative studies did not demonstrate any significant difference in terms of overall survival and recurrence rate between LLR and OLR. No trocar-site recurrence was reported. The recurrence rate ranged from 26.9% to 45.5%, and two series reported no recurrence. Laparoscopic surgery should be considered an acceptable alternative for the treatment of HCC.

Laparoscopic resection of hepatocellular carcinoma: a French survey in 351 patients

ObjectivesCurrent clinical studies report the results of laparoscopic resection of hepatocellular carcinoma (HCC) obtained in small cohorts of patients. Because France was involved in the very early development of laparoscopic surgery, the present study was conducted in order to report the results of a large, multicentre experience. MethodsA total of 351 patients underwent laparoscopic liver resection for HCC during the period from 1998 to 2010 in nine French tertiary centres. Patient characteristics, postoperative mortality and morbidity, and longterm survival were retrospectively reviewed. ResultsOverall, 85% of the study patients had underlying liver disease. Types of resection included wedge resection (41%), left lateral sectionectomy (27%), segmentectomy (24%), and major hepatectomy (11%). Median operative time was 180min. Conversion to laparotomy occurred in 13% of surgeries and intraoperative blood transfusion was necessary in 5% of patients. The overall morbidity rate was 22%. The 30-day postoperative mortality rate was 2%. Negative resection (R0) margins were achieved in 92% of patients. Rates of overall and progression-free survival at 1, 3 and 5 years were 90.3%, 70.1% and 65.9%, and 85.2%, 55.9% and 40.4%, respectively. ConclusionsThis multicentre, large-cohort study confirms that laparoscopic liver resection for HCC is a safe and efficient approach to treatment and can be proposed as a first-line treatment in patients with resectable HCC.

Laparoscopic vs open approach to resection of hepatocellular carcinoma in patients with known cirrhosis: systematic review and meta-analysis.

To review the currently available literature comparing laparoscopic to open resection of hepatocellular carcinoma (HCC) in patients with known liver cirrhosis. A literature search of MEDLINE, EMBASE, and Cochrane databases was conducted. The search terms used included (laparoscopic OR laparoscopy) AND (hepatic or liver) AND (surgery or resection) AND "hepatocellular carcinoma" AND (cirrhosis or cirrhotic). Furthermore, to widen the search, we also used the "related articles" section. Studies reporting a comparison of outcomes and methods of open vs laparoscopic hepatic resection for HCC in patients with liver cirrhosis were included. Meta-analysis of results was performed using a random effects model to compute relative risk (RR) and for dichotomous variables and standard mean differences (SMD) for continuous variables. A total of 420 patients from 4 cohort studies were included in final analysis. Patients undergoing laparoscopic procedures had statistically less blood loss compared to the open cohort, SMD of -1.01 (95%CI: -1.23-0.79), P < 0.001, with a reduced risk of transfusion, RR = 0.19 (95%CI: 0.09-0.38), P < 0.001. A wider clearance at tumour resection margins was achieved following a laparoscopic approach, SMD of 0.34 (95%CI: 0.08-0.60), P = 0.011. No significant difference was noted between laparoscopic and open resection operative times, SMD of -0.15 (95%CI: 0.35-0.05), P = 0.142. The overall RR of suffering from postoperative morbidity is 0.25 in favour of the open surgery cohort (95%CI: 0.17-0.37), P < 0.001. Patients under-going laparoscopic surgery had significantly shorter length of stays in hospital compared to the open cohort, SMD of -0.53 (95%CI: -0.73 to -0.32), P < 0.001. This review suggests that laparoscopic resection of hepatocellular carcinoma in patients with cirrhosis is safe and may provide improved patient outcomes when compared to the open technique.

Laparoscopic resection vs. open liver resection for peripheral hepatocellular carcinoma in patients with chronic liver disease: a case-matched study

Studies that compare laparoscopic to open liver resection for hepatocellular carcinoma (HCC) in cirrhotic patients are rare and may have suffered from low patient numbers. This work was designed to determine the impact of laparoscopic resection on postoperative and long-term outcomes in a large series of cirrhotic patients with hepatocellular carcinoma (HCC) compared with open resection. From 2002 to 2009, 36 patients with chronic liver disease with complicating HCC were selected for laparoscopic resection (laparoscopic group, LG). The outcomes were compared with those of 53 patients who underwent open hepatectomy (open group, OG) during the same period in a matched-pair analysis. The two groups were similar in terms of tumor number and size and number of resected segments. Morbidity and mortality rates were similar in the two groups (respectively 25 and 0% in LG vs. 35.8 and 7.5% in OG; p = 0.3). Severe complications were more frequent in OG (13.2%) than in LG (2.8%; p = 0.09). Despite similar portal hypertension levels, complications related to ascites (namely evisceration or variceal bleeding) were fatal in 4 of 12 affected patients in OG but 0 of 5 cases in LG (p = 0.2). The mean hospitalization durations were 6.5 ± 2.7 days and 9.5 ± 4.8 days in LG and OG, respectively (p = 0.003). The surgical margins were similar in the two groups. Although there was a trend toward better 5-year overall survival in LG (70 vs. 46% in OG; p = 0.073), 5-year disease-free survival was similar (35.5 vs. 33.6%). Laparoscopic resection of HCC in patients with chronic liver disease has similar results to open resection in terms of postoperative outcomes, surgical margins, and long-term survival.

Laparoscopic Hepatectomy for Hepatocellular Carcinoma: A European Experience

Some series have suggested that laparoscopy is beneficial for resection of hepatocellular carcinoma. This has to be confirmed in larger series. The aim of this study was to analyze the results of 3 European surgical centers on laparoscopic liver resections for hepatocellular carcinoma. Prospective databases of 3 European centers involved in the development of laparoscopic liver surgery were combined. Between 1998 and 2008, 163 liver resections for hepatocellular carcinoma were performed. Liver parenchyma was cirrhotic in 120 (73.6%) patients. Liver resection was anatomic in 107 (65.6%) patients and was a major resection (>or=3 segments) in 16 (9.8%). A totally laparoscopic approach was used in 155 (95.1%) patients. Median surgical duration was 180 minutes. Median operative blood loss was 250 mL, and 16 (9.8%) patients received blood transfusion. Conversion to open surgery was required in 15 (9.2%) patients. Median tumor size was 3.6 cm and median surgical margin was 12 mm. Liver-specific and general complications occurred in 19 (11.6%) and 17 (10.4%) patients, respectively. Hospital length of stay was 7 days. A further analysis of early (n = 75) and recent (n = 88) experiences showed improved results in the latter group. Overall and recurrence-free survival rates at 1, 3, and 5 years were 92.6%, 68.7%, 64.9%, and 77.5%, 47.1%, 32.2%, respectively. This study demonstrates that laparoscopic resection for hepatocellular carcinoma is feasible in selected patients, with good operative and oncologic results. Laparoscopy should be routinely considered in centers experienced in liver surgery and advanced laparoscopy.

Laparoscopic resection for hepatocellular carcinoma: a matched-pair comparative study

Only a few series have demonstrated the safety of laparoscopic resection for hepatocellular carcinoma (HCC) and the benefits of this approach. Moreover, these studies reported mostly minor and nonanatomic hepatic resections. This report describes the results of a pair-matched comparative study between open and laparoscopic liver resections for HCC in a series of essentially anatomic resections. Patients were retrospectively matched in pairs for the following criteria: sex, age, American Society of Anesthesiology (ASA) score, severity of liver disease, tumor size, and type of resection. A total of 42 patients undergoing laparoscopy were compared with patients undergoing laparotomy during the same period. Surgeons from the authors' department not trained in laparoscopy performed open resections. Operative, postoperative, and oncologic outcomes were compared. The mean duration of surgery was similar in the two groups. Significantly less bleeding was observed in the laparoscopic group (364.3 vs. 723.7 ml; p < 0.0001). Transfusion was required for four patients (9.5%) in the laparoscopic group and seven patients (16.7%) in the open surgery group (p = 0.51). Postoperative ascites was less frequent after laparoscopic resections (7.1 vs. 26.1%; p = 0.03). General morbidity was similar in the two groups (9.5 vs. 11.9%; p = 1.00). The mean hospital stay was significantly shorter for the patients undergoing laparoscopy (6.7 vs. 9.6 days; p < 0.0001). The surgical margin and local recurrence adjacent to the liver stump were not affected by laparoscopy. The overall postoperative survival rates in the laparoscopic group were 93.1% at 1 year, 74.4% at 3 years, and 59.5% at 5 years and, respectively, 81.8, 73, and 47.4% in the open surgery group (p = 0.25). The postoperative disease-free survival rates in the laparoscopic group were at 81.6% at 1 year, 60.9% at 3 years, and 45.6% at 5 years, respectively, 70.2, 54.3, and 37.2% in the open surgery group (p = 0.29). Laparoscopic resection of HCC for selected patients gave a better postoperative outcome without oncologic consequences. Prospective trials are required to confirm these results.

Outcome for Patients Treated with Laparoscopic Versus Open Resection of Hepatocellular Carcinoma: Case-Matched Analysis

This is a case-matched analysis of patients undergoing laparoscopic versus open hepatectomy for hepatocellular carcinoma (HCC), with specific regard to margin status and survival. Laparoscopic cases were matched with open controls by cirrhosis and tumor size (within 10%). Data were evaluated by logistic regression using the generalized estimating equation method. Mixed linear regression models were used to assess operative duration in the groups. Overall and disease-free survival were compared using a Cox proportional frailty model. Twenty laparoscopic cases were matched to 56 open resections. Thirty patients (39%) developed recurrence and 13 patients (17%) died, including one (1.3%) death within 30 days. There were no significant differences in age, gender, cirrhosis or tumor size. Paired univariate and multivariate analyses showed cases of laparoscopic resection had similar rates of transfusion and positive margins compared with open resection. Operative duration was similar in laparoscopic (mean 161 +/- 37 min) and open (mean 165 +/- 53 min) groups. The adjusted odds of length of stay > or = 6 days was significantly lower in patients with laparoscopic resection [odds ratio (OR) = 0.07, 95% confidence interval (CI) = 0.02-0.27]. Both unadjusted and adjusted analyses showed no significant association between type of resection and overall or disease-free survival. Neither margin status, nor recurrence, nor survival was significantly different between the two cohorts. Laparoscopic resection for malignancy is safe, with a similar operative time as open hepatectomy. If tumor location is amenable, laparoscopic resection for HCC is a reasonable alternative to open resection with the added benefits of improved cosmesis and sooner discharge home.

Laparoscopic Liver Resection for Subcapsular Hepatocellular Carcinoma Complicating Chronic Liver Disease—Invited Critique

Hypothesis: Laparoscopic liver resection for subcapsular hepatocellular carcinoma in patients with chronic liver disease is associated with lower morbidity than open resections. Design: A case-comparison study. Setting: A tertiary referral center. Patients and Intervention: From December 1, 1998, to November 30, 2000, 13 patients with chronic liver disease who underwent laparoscopic resection of hepatocellular carcinoma formed the laparoscopic group (LG). Tumors were 5 cm or smaller, subcapsular, and located in anterolateral segments (segments II-VI). A control group was created by matching each laparoscopic case with patients identical for liver disease, tumor size, and location and type of hepatectomy who underwent open liver resection. Fourteen patients fulfilled the criteria and formed the open group (OG). Main Outcome Measures: Postoperative mortality and morbidity. Results: One segment or less was resected in 21 patients and 2 in 6 patients. Operative duration and cumulative portal triad clamping times were longer in the LG (267 ± 79 minutes vs 182 ± 57 minutes, P=.006; 68 ± 24 minutes vs 25 t 19 minutes, P=.006, respectively). Mortality rates were 0% in the LG and 14% (2/14) in the OG (P=.2). Postoperative liver failure and ascites occurred in 8% (1/13) in the LG and 36% (5/14) in the OG (P=.15). Surgical margin was not different in the 2 groups. Three-year survival was significantly higher in the LG (89% vs 55%; P=.04), but 3-year recurrence rates were similar (46% vs 44%). Conclusion: Our study suggests that, despite longer operative and clamping times without clinical consequences, the rate of decompensation of liver disease could be lower after laparoscopy.