Laparoscopic Right Hepatectomy Research Articles

Open Versus Laparoscopic Right Hepatectomy for Hepatocellular Carcinoma Following Sequential TACE-PVE: A Multicentric Comparative Study.

Right hepatectomy (RH) for hepatocellular carcinoma (HCC) is ideally preceded by transcatheter arterial chemoembolization (TACE) and portal vein embolization (PVE). Laparoscopic approach improves short-term outcome and textbook outcome (TO), which reflects the "ideal" surgical outcome, after RH. However, laparoscopic RH on an underlying diseased liver and after TACE/PVE remains a challenging procedure. The aim of this study was to compare the outcomes in patients who underwent laparoscopic liver resection (LLR) or open liver resection (OLR) following TACE/PVE. All patients with HCC who underwent RH after TACE/PVE in five French centers were retrospectively included. Outcomes were compared between the LLR group and the OLR group using propensity score matching (PSM). Quality of surgical care was defined by TO. Between 2005 and 2019, 117 patients were included (41 in LLR group, 76 in OLR group). Overall morbidity was comparable (51% versus 53%, p=0.24). In LLR group, TO was completed in 66% versus 37% in OLR group (p=0.02). LLR and absence of clamping were the only factors associated with TO completion [hazard ratio (HR) 4.27, [1.77-10.28], p=0.001]. After PSM, 5-year overall survival (OS) and progression-free survival (PFS) were 55% in matched LLR versus 77% in matched OLR, p=0.35, and 13% in matched LLR versus 17% in matched OLR, p=0.97. TO completion was independently associated with a better 5-year OS (65.2% versus 42.5%, p=0.007). Major LLR after TACE/PVE should be considered as a valuable option in expert centers to increase the chance of TO, the latter being associated with a better 5-year OS.

Laparoscopic Right Hepatectomy is as Safe and Feasible as Open Procedure in the Treatment of Liver Tumors: Meta-analysis

The purpose of this study was to compare the clinical effect of laparoscopic right hepatectomy (LRH) and open right hepatectomy (ORH) in the treatment of liver tumor. Patients and Methods We systematically searched PubMed, web of science, EMBASE, clinicaltrials.gov , and Cochrane Central Register for studies (study published August 1947 to December 2019). In this study, the perioperative data of laparoscopic right hepatectomy and open right hepatectomy were analyzed. Our meta-analysis included 7 studies involving 633 patients who underwent two types of surgery, laparoscopic right hepatectomy and open right hepatectomy. This study showed that compared with open right hepatectomy, there was no significant difference in operative time (weighted mean difference (WMD): 35.28, 95% confidence interval (CI): − 9.04–79.60, P = 0.12), but the result of laparoscopic right hepatectomy’s R0 resections (odd ratio (OR): 2.34, 95% confidence interval (CI): 0.60–9.11, P = 0.22), transfusion (odd ratio (OR): 0.64, 95% confidence interval (CI): 0.34–1.20, P = 0.17), mortality (odd ratio (OR): 0.44, 95% confidence interval (CI): 0.14–1.45, P = 0.18) was similar to that of open right hepatectomy. Laparoscopic right hepatectomy resulted in shorter hospital stay (weighted mean difference (WMD): − 4.75, 95% confidence interval (CI): − 5.96–3.55, P<0.00001) and less estimated blood loss (EBL) (weighted mean difference (WMD): − 161.97, 95% confidence interval (CI): − 257.47–66.46, P = 0.0009). The clinical effect of laparoscopic right hepatectomy in the treatment of liver tumor was similar to that of open right hepatectomy, which was safe, feasible, and has a good prognosis.

Laparoscopic Right Hepatectomy

Laparoscopic right hepatectomy (LRH) is an important technique in a modern hepatobiliary surgeon’s arsenal. It’s application extends to many different disease processes including both malignant and benign tumors as well as infections and in trauma. The procedure involves using minimally invasive methods to remove Couinaud segments 5-8 delineated by the portion of the liver right and lateral to Cantlie’s line. In this chapter, we explain the approach to performing this operation by delving into preoperative considerations with a focus on high quality imaging, 3D reconstruction, and virtual hepatectomy, optimizing the future liver remnant (FLR) with PVE and use of parenchymal sparing methods, and detailed intraoperative steps emphasizing caudal view, Glissonian approach, MHV roadmap, and communication with anesthesia. We also give context to LRH by discussing the two most common diseases addressed by it, namely colorectal liver metastases (CRLM) and hepatocellular carcinoma (HCC), as well as historical perspectives and how LRH use has evolved. We also address complication management such as post-operative liver failure and intra-operative bleeding accidents, variants on exposure with hand assist and transthoracic view, and comparing the advantages and disadvantages between open and laparoscopic right hepatectomy. This review contains 12 figures, 4 tables, and 111 references. Keywords: augmented reality, laparoscopic right hepatectomy, laparoscopic PVE and ALPPS, low CVP anesthesia, MHV roadmap, minimally invasive liver resection, parenchymal sparing right hepatectomy, Takasaki caudal approach, virtual hepatectomy,

Laparoscopic Right Hepatectomy

Laparoscopic right hepatectomy (LRH) is an important technique in a modern hepatobiliary surgeon’s arsenal. It’s application extends to many different disease processes including both malignant and benign tumors as well as infections and in trauma. The procedure involves using minimally invasive methods to remove Couinaud segments 5-8 delineated by the portion of the liver right and lateral to Cantlie’s line. In this chapter, we explain the approach to performing this operation by delving into preoperative considerations with a focus on high quality imaging, 3D reconstruction, and virtual hepatectomy, optimizing the future liver remnant (FLR) with PVE and use of parenchymal sparing methods, and detailed intraoperative steps emphasizing caudal view, Glissonian approach, MHV roadmap, and communication with anesthesia. We also give context to LRH by discussing the two most common diseases addressed by it, namely colorectal liver metastases (CRLM) and hepatocellular carcinoma (HCC), as well as historical perspectives and how LRH use has evolved. We also address complication management such as post-operative liver failure and intra-operative bleeding accidents, variants on exposure with hand assist and transthoracic view, and comparing the advantages and disadvantages between open and laparoscopic right hepatectomy. This review contains 12 figures, 4 tables, and 111 references. Keywords: augmented reality, laparoscopic right hepatectomy, laparoscopic PVE and ALPPS, low CVP anesthesia, MHV roadmap, minimally invasive liver resection, parenchymal sparing right hepatectomy, Takasaki caudal approach, virtual hepatectomy,

Benchmark performance of laparoscopic left lateral sectionectomy and right hepatectomy in expert centers

Herein, we aimed to establish benchmark values - based on a composite indicator of healthcare quality - for the performance of laparoscopic left lateral sectionectomy (LLLS) and laparoscopic right hepatectomy (LRH) using data from expert centers. Data from a nationwide multicenter survey including all patients undergoing LLLS and LRH between 2000 and 2017 were analyzed. Textbook outcome (TO) completion was considered in patients fulfilling all 6 of the following characteristics: negative margins, no transfusion, no complication, no prolonged hospital stay, no readmission and no mortality. For each procedure, a cut-off laparoscopic liver resection (LLR) volume by center was associated with TO on multivariable analysis. These cut-offs defined the expert centers. The benchmark values were set at the 75th percentile of median outcomes among these expert centers. Among 4,400 LLRs performed in 29 centers, 855 patients who underwent LLLS and 488 who underwent LRH were identified. The overall incidences of TO after LLLS and LRH were 43.7% and 23.8%, respectively. LLR volume cut-offs of 25 LLR/year (odds ratio [OR] 2.45; bootstrap 95% CI 1.65-3.69; p= 0.001) and 35 LLR/year (OR 2.55; bootstrap 95% CI 1.34-5.63; p= 0.003) were independently associated with completion of TO after LLLS and LRH, respectively. Eight centers for LLLS and 6 centers for LRH, including 516 and 346 patients undergoing LLLS/LRH respectively, reached these cut-offs and were identified as expert centers. After LLLS, benchmark values of severe complication, mortality and TO completion were defined as ≤5.3%, ≤1.2% and ≥46.6%, respectively. After LRH, benchmark values of severe complication, mortality and TO completion were ≤20.4%, ≤2.8% and ≥24.2%, respectively. This study provides an up-to-date reference on the benchmark performance of LLLS and LRH in expert centers. In a nationwide French survey of laparoscopic liver resection, expert centers were defined according tothe completion of a textbook outcome, which is a composite indicator of healthcare quality. Benchmark values regarding intra-operative details and outcomes were established using data from 516 patients with laparoscopic left lateral sectionectiomy and 346 patients with laparoscopic right hepatectomy from expert centers. These values should be used as a reference point to improve the quality of laparoscopic resections.

Laparoscopic right hepatectomy using the caudal approach is superior to open right hepatectomy with anterior approach and liver hanging maneuver: a comparison of short-term outcomes.

A standardized laparoscopic right hepatectomy (LRH) approach named the "caudal approach" was recently reported. Yet, the value of this approach compared with state-of-the-art open right hepatectomy (ORH) remains unknown. The purpose of this study was therefore to compare the short-term outcomes of LRH using the caudal approach and ORH with anterior approach and liver hanging maneuver. One-hundred eleven consecutive patients who underwent LRH with caudal approach were prospectively collected; 346 patients who underwent ORH with anterior approach and liver hanging maneuver were enrolled as a control group. Propensity score matching (PSM) of patients in a ratio of 1: 1 was conducted and the perioperative outcomes were compared. After PSM, two well-balanced groups of 72 patients each were analyzed and compared. The conversion rate in the LRH group was 18.1%. Perioperative blood loss and transfusion rates were significantly lower in the LRH group as compared to the ORH group (median, 200ml vs. 500ml, p < 0.001 and 9.9% vs. 26.8%, p = 0.009, respectively), while operation time was significantly longer (median, 348min vs. 290min, p < 0.001). Overall (26.4% vs. 48.6%, p = 0.006) and symptomatic pulmonary (6.9% vs. 19.4%, p = 0.027) complication rates were significantly lower in the LRH group. Hospital stay was significantly shorter in the LRH group (median, 8days vs. 9days, p = 0.013). LRH using the caudal approach is associated with improved short-term outcomes compared to state-of-the-art ORH in patients qualifying for both approaches, and can be proposed as standard practice.

Laparoscopic Right Hepatectomy for Hepatocellular Carcinoma: A Propensity Score Matching Analysis of Outcomes Compared with Conventional Open Surgery

The application of laparoscopic hepatectomy is gaining momentum. However, the safety and efficacy of laparoscopic right hepatectomy (LRH) on hepatocellular carcinoma (HCC) are yet to be adequately evaluated. We aimed to assess the surgical and oncological outcomes of LRH for HCC by comparing it with open right hepatectomy (ORH). Data of patients who underwent hepatectomy for HCC from May 2007 to January 2018 in our hospital were obtained. Baseline characteristics, postoperative recovery, and survival outcomes were compared. One-to-one propensity score matching (PSM) was used to minimize selection biases by balancing factors, including age, sex, preoperative therapy, tumor size, and pattern. The original cohort included 109 patients (LRH, 41 patients; ORH, 68 patients). Of the 41 patients who underwent LRH, 8 patients (19.5%) required conversion to laparotomy. The overall morbidity was 19.5%, and no mortality in LRH was noted. After PSM, LRH was associated with a tendency of prolonged operative time (255.5 ± 93.4 minutes versus 225.9 ± 39.8 minutes, P = .08) and less intraoperative blood loss [300 (100-1200) versus 500 (200-2000) mL, P < .01]. LRH showed up a trend of less overall morbidity without statistical significance (18.4% versus 26.3%, P = .41). Moreover, the 3-year overall and disease-free survival did not differ significantly between the groups during a median follow-up of 19 (3-58) months for the LRH group and 23 (3-97) months for the ORH group. LRH can be performed as safe and effective as ORH for HCC in regard to both surgical and oncological outcomes. LRH holds the benefit in less intraoperative blood loss and appears to achieve less postoperative morbidity, which could serve as a promising alternative to ORH in selected individuals.

Pure laparoscopic versus open right hepatectomy for hepatocellular carcinoma in patients with cirrhosis: A propensity-score matched analysis

Introduction: We aimed to describe our experience with pure laparoscopic right hepatectomy (LRH) and to compare it with open right hepatectomy (ORH) among hepatocellular carcinoma (HCC) patients with liver cirrhosis. Method: We retrospectively reviewed the medical records of 152 patients who underwent pure LRH (n=37) or ORH (n=115) between June 2008 and July 2015 at Asan Medical Center. We performed 1:1 propensity score (PS) matching between the 2 groups. Subsequently, 33 patients were included in each group. Result: There were no statistically significant differences in intraoperative blood loss (p = 0.612) between both groups. The operative time was longer (median, 297 vs. 176 min; p < 0.0001) and the length of postoperative hospital stay was shorter (median, 9.97 vs. 13.94 days; p ≤ 0.0001) in the laparoscopic group. There were no significant differences in the complications rate, 2-year disease-free survival rate, or 2-year overall survival rate between both groups (p = 0.05, p = 0.645, and p = 0.873, respectively). Conclusion: Even in patients with cirrhosis, complication rate was comparable and the length of hospital stay was shorter with pure LRH than with the traditional open approach. The oncological outcomes of HCC were comparable in both groups. Pure LRH for HCC performed in selected patients appears to represent a viable alternative to ORH.

Laparoscopic right hepatectomy with an anterior approach for large hepatocellular carcinoma using a right para caval liver hanging maneuver

Introduction: Laparoscopic right hepatectomy (LRH) for large hepatocellular carcinoma (HCC) with an anterior approach is a complicated procedure. We gradually introduce a modified liver hanging maneuver (LHM) through the retrohepatic tunnel on the right side of the inferior vena cava with the assistant of a Goldfinger Dissector. Method: Between January 2012 and June 2018, 39 patients with large HCC underwent LRH were enrolled in this study. The first 27 patients did not apply the LHM technique (the non-LHM group); the following 12 patients implemented the LHM technique (the LHM group). Perioperative and survival outcomes were compared. Result: The preoperative variables were almost comparable between the two groups. The median tumor size was 12.0 (IQR 10.0-13.0) cm in the LHM group and 12.6 (IQR 9.9-15.0) cm in the non-LHM group (P=0.541). Ten patients (83.3%) in the LHM group and 20 (74.1%) in the non-LHM group had tumor size >10 cm (P=0.693). The median duration of retrohepatic dissection is 14.5 (IQR 12-16) minutes. Total blood loss was significantly greater in the non-LHM group than that in the LHM group (460 vs. 200 ml, P<0.001), especially during the procedure of hepatic parenchyma transection (300 vs. 100 ml, P<0.001). As a result, the operative time was longer (415 vs. 312 min, P<0.001), and intraoperative transfusion rate was higher (55.6% vs. 16.7%) in the non-LHM group than that in the LHM group. Two cases (7.4%) converted to an open approach in the non-LHM group, while no patients experience conversion in the LHM group (P=1.000). However, postoperative complications and long-term survival were comparable between the two groups. Conclusion: The LHM can be quickly established in the laparoscopic approach with the assistant a Goldfinger dissector through the retrohepatic tunnel on the right side of the inferior vena cava. Application of the LHM can increase the safety of LRH for large HCC.

Liver hanging maneuver in laparoscopic right hepatectomy—still to be standardized

Weread with great interest the article by Kim describing pure laparoscopic righthepatectomy (LRH) using a modified liver hanging maneuver (LHM) and thetechnical evolution from caudal approach towards ventral approach (1). Theauthors described their technique in 2016 (2), and have used it for differenttypes of laparoscopic liver resections (LLR) (3-5). The modified LHM describedby Kim et al. (2) adds another solution to overcome the difficulties toperform a LRH. The different published options to perform LRH reflect the lackof standardization of the technique.

3D vision and maintenance of stable pneumoperitoneum: a new step in the development of laparoscopic right hepatectomy

Background: Although laparoscopic liver resection is widely performed, many technical difficulties remain, such as accurate isolation/division of hepatic vessels in laparoscopic right hepatectomy (LRH). Innovative surgical devices, such as three-dimensional (3D) laparoscopy and optimized carbon dioxide (CO2) insufflation system, may help to overcome technical difficulties in LRH. The purpose of this study was to analyze the efficacy of 3D vision associated to active pneumoperitoneum maintenance in LRH. Methods: In our prospectively maintained database from 2006, 75 consecutive LRH from May 2011 to June 2017 were included in this study. All LRH were performed with 2D vision and standard CO2 insufflator (2D-LRH group, 45 cases) or 3D vision with optimized CO2 insufflator (3D-LRH group, 30 cases). Preoperative clinical characteristics, surgical data including operation time of separate steps within the procedure, and postoperative complications were compared between the two groups. Results: Clinical and pathological factors were comparable between two groups. Total operative time was significantly shorter in 3D-LRH group than in 2D-LRH (360 vs 390 min, P = 0.029). Right hepatic pedicle dissection time was significantly shorter in 3D-LRH group (101 vs 123 min, P = 0.003). Liver parenchyma transection time was also shorter in 3D-LRH group (138 vs 151 min, P = 0.089), although not significant. There was no significant difference in liver mobilization time, intraoperative bleeding/transfusion, and postoperative complications. Conclusions: 3D vision with maintenance of pneumoperitoneum facilitates hepatic vascular isolation/division, and may contribute to the development of LRH.

Pure laparoscopic right hepatectomy: a risk score for conversion for the paradigm of difficult laparoscopic liver resections

Introduction: Converted laparoscopic liver resection (LLR) are known to lose some advantages of the minimally-invasiveness, and factors are identified to predict patients at risk. Specific evidence for laparoscopic right hepatectomy (LRH) is expected of uttermost usefulness in clinical practice, given the peculiarities and technical differences with other complex hepatectomies. Methods: Data of LRH (2007-'17) were analysed. Risk factors for conversion were identified by uni- and multivariable analysis. A conversion risk score (CRS) was built assigning each factor 1point, and comparing the score with the conversion status for each patient. Accuracy was assessed by calculating the area-under-the-receiver-operator-characteristic-curve (AUROC). The outcomes of converted and completed LRH were compared after propensity score matching with the risk factors identified acting as covariates. Results: Among 100 LRH, 18 procedures were converted (18%), and reasons were: 44.4%oncologic radicality, 33.3%bleeding, 11.1%adhesions, 11.1%impossibility to proceed, 5.5%biliostasis. Risk factors for conversion (multivariable analysis) were: previous liver surgery (HR4.5,p0.013), preoperative chemotherapy (HR6.7,p0.023), malignant diagnosis (HR3.8,p0.018), closeness to hepatocaval confluence (HR4.2,p0.038), tumour volume (HR3.4,p0.010). Conversion rates correlated with the CRS, raising from 0 to 100% when CRS increased from 0 to 5 (Spearman p0.020). The CRS showed accuracy with a 0.76 AUROC. Converted patients exhibited longer operative time (376vs340min,p0.045); greater blood loss (619vs364ml,p0.002), transfusions (27vs13%,p0.028) and morbidity rates (55vs19%,p0.003); longer hospital stay (8.5vs6.5days,p0.026). Conclusions: Specific risk factors for conversion are identified for LRH. Since the outcomes of converted patients are less favourable than those completed laparoscopically, this CRS may help in choosing the best approach for such a challenging procedure.

3D vision and maintenance of stable pneumoperitoneum: a new step in the development of laparoscopic right hepatectomy.

Although laparoscopic liver resection is widely performed, many technical difficulties remain, such as accurate isolation/division of hepatic vessels in laparoscopic right hepatectomy (LRH). Innovative surgical devices, such as three-dimensional (3D) laparoscopy and optimized carbon dioxide (CO2) insufflation system, may help to overcome technical difficulties in LRH. The purpose of this study was to analyze the efficacy of 3D vision associated with active pneumoperitoneum maintenance in LRH. In our prospectively maintained database from 2006, 75 consecutive LRH from May 2011 to June 2017 were included in this study. All LRH were performed with 2D vision and standard CO2 insufflator (2D-LRH group, 45 cases) or 3D vision with optimized CO2 insufflator (3D-LRH group, 30 cases). Preoperative clinical characteristics, surgical data including operation time of separate steps within the procedure, and postoperative complications were compared between the two groups. Clinical and pathological factors were comparable between two groups. Total operative time was significantly shorter in 3D-LRH group than in 2D-LRH (360 vs 390min, P = 0.029). Right hepatic pedicle dissection time was significantly shorter in 3D-LRH group (101 vs 123min, P = 0.003). Liver parenchyma transection time was also shorter in 3D-LRH group (138 vs 151min, P = 0.089), although not significant. There was no significant difference in liver mobilization time, intraoperative bleeding/transfusion, and postoperative complications. 3D vision with maintenance of pneumoperitoneum facilitates hepatic vascular isolation/division, and may contribute to the development of LRH.

Minimally invasive right hepatectomy for living liver donation: a systematic review of the literature

Living donor liver transplantation (LDLT) has emerged as one of the possible solutions for improving the donor pool. However, mainly in case of adult-to-adult donation, performing a right hepatectomy (RH) in a healthy individual should represent a challenge. A way for reducing this shortcoming is the use of mini-invasive surgery. The aim of the present study was, then, to perform a systematic review of the literature investigating the results of the laparoscopic right lobe donation, mainly looking at the different surgical methodologies adopted and the donor complication rates. A systematic search was done following the Preferred Reporting Items for Systemic Reviews and Meta-Analysis (PRISMA) guidelines: 176 articles were initially screened: eventually, 32 articles were identified, with a total of 501 investigated cases. Pure laparoscopic and robotic right hepatectomies were done in 84 (16.8%) and 14 (2.8%) donors, respectively. Hybrid or assisted procedures were done in 199 (39.7%) and 204 (40.7%) cases, respectively. In the 464 cases in which the postoperative course was exhaustively described for each patient, a total of 85 (18.3%) subjects experienced at least one complication. Twenty-six (5.6%) individuals had a grade III according to the Clavien-Dindo classification: no cases of organ dysfunction nor death were experienced. After stratification of the entire population according to the type of laparoscopic approach adopted (pure-robotic vs. hybrid-assisted), it was interesting to observe that hybrid-assisted cases presented an increased risk of experiencing any complication after RH, with an odds ratio (OR) of 2.53 (P value=0.01). Laparoscopic RH for living donation is a safe procedure. After 501 reported procedures, no deaths have been described. Pure laparoscopic approaches look to consent a lower risk of donor complication respect to hybrid ones. More studies comparing the different laparoscopic approaches with the open procedure are required.

Standardization of operative technique in laparoscopic right hepatectomy: improving cost-value relationship through value stream mapping

Background: With the current emphasis on improving quality and cost reduction in medicine, it is imperative to critically evaluate cost-value relationships for surgical procedures. Previously our group had demonstrated comparable clinical outcomes, reduced length of stay (LOS) and reduced operative time for Laparoscopic Right Hepatectomy (LRH) compared to open right hepatectomy (ORH). Though the two groups had similar overall costs, intraoperative cost in the LRH group was higher. Methods: We decoded LRH into its component critical steps using value stream mapping (VSM), and analyzed the associated costs. We prospectively modified our surgical technique to target those steps that had high intraoperative costs (parenchymal transection, hemostasis) and measured the changes in outcomes. We reviewed medical records at our institution for patients who underwent elective LRH before (pre-LRH n = 22) and after (post-LRH n = 22) the intervention and those who had ORH (n = 65), between January 1, 2008 and November 30, 2016. Results: Average overall cost for the procedure was significantly lower for the post- standardization LRH group (post-LRH $21,768, pre-LRH $28,066, ORH $33,020; p < 0.0001). Average intraoperative blood loss was significantly reduced with LRH (post-LRH 167 mL, pre-LRH 292 mL, ORH 509 mL; p < 0.001). Operative times were significantly shorter for LRH (post-LRH 147 mins, pre- LRH 190 mins, ORH 229 mins; p < 0.001). LOS was significantly reduced for LRH (post-LRH 3 days, pre- LRH 4 days, ORH 7 days; p < 0.002). Conclusion: Using a common quality improvement tool (VSM), we have established a model for cost effective clinical care in hepatobiliary surgery. These tools allow surgeons to overcome personal and traditional biases such as stapler choices, but most importantly eliminate nonvalue added interventions for patients.

Laparoscopic right hemihepatectomy following a standardized technique

Objective To determine the clinical value of laparoscopic right hepatectomy (LRH) carried out following a standardized technique. Methods The medical records of 15 patients who underwent LRH at the First Affiliated Hospital of Soochow University were retrospectively reviewed. The perioperative indicators which included the operation duration, blood loss, tumor diameter, hospitalization duration and postoperative complications were analyzed. Results There was no conversion to open surgery. The operation duration was (251.1±73.3) min. The resected tumor diameter was (8.5±4.2) cm, the blood loss was (550.8±343.6) ml, and the hospitalization duration was (10.2±3.7) days. There was one patient who developed postoperative bile leakage. There was no other complication and there was no perioperative death. Conclusions The standardized technique of LRH was easy and effective. This technique shortened the operation duration and improved patient safety. Key words: Laparoscope; Right hemihepatectomy; Liver neoplasm; Minimally invasive procedure; Standardized procedure

Laparoscopic right hepatectomy after radioembolization using yttrium-90 resin microspheres

BackgroundLiver surgery after selective internal radiation therapy (SIRT) has been scarcely reported. The combination of laparoscopic approach in post-SIRT major liver surgery is a complex scenario to our knowledge not reported so far. MethodFrom July' 2007–July' 2016, 40 patients underwent post-SIRT R0 resections in our center: 30 resections and 10 liver transplants. From March'2011, 5 (out of those 30) were full-laparoscopic resections: Three patients underwent laparoscopic right hepatectomy (LRH) after previous right hemiliver radiation lobectomy: two cirrhotic patients with HCC and one with colorectal cancer liver metastasis; one segment-VI resection in a cirrhotic patient, due to HCC and finally, a patient with a Budd-Chiari Syndrome and an infiltrating HCC in segment-III underwent left lateral seccionectomy. In all cases, the procedure was uneventfully completed full-laparoscopic and none required transfusion. Hospital stay was 3, 2, 5, 3 and 3 days respectively. We herein present a LRH in a 71 year-old patient after right hemiliver radiation lobectomy (due to a 7 cm unresectable HCC in a HCV cirrhotic liver). Case presentation, surgical findings and technique are detailed in this video, which also demonstrates the comparative hypoperfusion of the treated hemiliver revealed with ICG fluorescence, a hitherto undescribed finding. ResultsHospital stay was 3 days. No early or late morbidity occurred. At this writing, 18 months after the resection and 43 months after the initial diagnosis the patient is alive and free of disease. ConclusionThis experience suggests that laparoscopic liver resection after SIRT is feasible and safe, even in major hepatectomies.

Can retrohepatic tunnel be quickly and easily established for laparoscopic liver hanging maneuver by Goldfinger dissector in laparoscopic right hepatectomy?

The liver hanging maneuver (LHM) is rarely applied in laparoscopic right hepatectomy (LRH) because of the difficulty encountered in retrohepatic tunnel (RT) dissection and tape positioning. Thus far no report has detailed how to quickly and easily establish RT for laparoscopic LHM in LRH, nor has employment of the Goldfinger dissector to create a total RT been reported. This study's aim was to evaluate the safety and feasibility of establishing RT for laparoscopic LHM using the Goldfinger dissector in LRH. Between March 2015 and July 2015, five consecutive patients underwent LRH via the caudal approach with laparoscopic LHM. A five-step strategy using the Goldfinger dissector to establish RT for laparoscopic LHM was adopted. Perioperative data were analyzed. The median age of patients was 58 (range, 51-65) years. Surgery was performed for one intrahepatic lithiasis and four hepatocellular carcinomas with a median size of 90 (40-150) mm. The median operative time was 320 (282-358) min with a median blood loss of 200 (200-600) ml. Laparoscopic LHM was achieved in a median of 31 (21-62) min, and the median postoperative hospital stay was 14 (9-16) d. No transfusion or conversion was required, and no severe liver-related morbidity or death was observed. The Goldfinger dissector is a useful instrument for the establishment of RT. A five-step strategy using the Goldfinger dissector can quickly and easily facilitate an RT for a laparoscopic LHM in LRH.

Liver mobilization and liver hanging for totally laparoscopic right hepatectomy: an easy way to do it.

The purpose of this study is to describe a technical modification that facilitates right liver mobilization in laparoscopic right hepatectomy (LRH). In the supine position, an inflatable device is placed under the patient's right chest. For right hemiliver mobilization, the table is placed in 30° anti-Trendelenburg and full-left tilt. Balloon inflation offers an additional 30° left inclination that places the patient in an almost left lateral position. Foot and lateral supports are placed to prevent patient slippage during changes in the patient positioning. From December 2013 to October 2015, this technique has been used in 10 consecutive LRH. The indications for these procedures were as follows: four donor hepatectomies for living donor liver transplant, three hepatocellular carcinomas and one peripheral cholangiocarcinoma in cirrhotic patients, one hepatocellular carcinoma in a non-cirrhotic patient, and one case of colorectal cancer metastases. In this period, it has also been used to facilitate mobilization and resection in the posterior segments of the liver in seven patients. In every case, right hemiliver mobilization was easily performed in a maximum time of 15min and placement of a tape or plastic tube for liver hanging was prepared. We have not observed any complication directly attributable to the technique herein described (i.e. right brachialgia; arms, back or left flank pain) in the early or late postoperative follow-up. The additional left inclination obtained with the inflation of a balloon under the right chest facilitates right hemiliver mobilization. Its use may help in the performance and adoption of LRH.

From the left to the right: 13-year experience in laparoscopic living donor liver transplantation

Living Donors are the best theoretical candidates to benefit from the advantages of laparoscopy, but development was slow because of concerns about graft integrity and donor safety. Herein our 13-year experience in laparoscopic Living Donor Liver Transplantation (LDLT) is presented. Laparoscopic Left Lateral Section (LLLS) was performed in children receiver, while Laparoscopic Left Hepatectomy (LLH)-including or not the middle hepatic vein-and Laparoscopic Right Hepatectomy (LRH) in adults. Two senior surgeons were always involved for each procedure. All donors were first-degree relatives. From 2001 to 2014, 71 procedures were performed: 63 LLLS (88.7%, 6 LLH (8.4%), and 2 LRH (2.8%). Surgical procedures required a mean of 271.1 ± 65.9, 318 ± 40.2, and 480 ± 0 min for LLLS, LLH, and LRH, respectively with a learning curve toward LLLH over the years (r = 0.09). Seven procedures (9.8%) required conversion. The mean hospital stay was 5.5 ± 3.4, 5.3 ± 0.6, and 8 ± 0 days for LLLS, LLH, and LRH, respectively. Complications occurred in 11 patients (17.3%) undergoing LLLS: 8 (12.7%) grade I and 3 (4.7%) grade II, according to the Modified Clavien-Dindo classification. Laparoscopic liver resection for LDLT requires an equivalent and parallel expertise in open LDLT and LLR. If LLLS for LDLT is now in an exploration phase in highly specialized centers, LLH and LRH for LDLT in adults lack evidence and cannot be recommended for wide introduction. For laparoscopic LDLT beginners, LLLS offers optimal conditions.