Laparoscopic Segmentectomy Research Articles

Simultaneous occurrence of a hepatocellular carcinoma and a hepatic non-Hodgkin’s lymphoma infiltration

To investigate the simultaneous occurrence of hepatocellular carcinoma and non-Hodgkin's lymphoma, we report the case of a 70 year old patient with a primary diagnosis of non-Hodgkin's lymphoma in 2002. In a routine follow up investigation of his chronic lymphocytic leukemia a newly detected mass in the Couinaud's segments 2 and 3 was found. No hepatitis C virus or hepatitis B virus infection or cirrhosis was evident. After laparoscopic segmentectomy the histological examination revealed a hepatocellular carcinoma. While the relation between liver parenchyma damages and hepatocellular carcinoma or non-Hodgkin's lymphoma is well known, only a few publications have focused on the coexistence of hepatocellular carcinoma and non-Hodgkin's lymphoma. With this case we demonstrate the coexistence of these diseases without having a predamaged liver parenchyma.

1154: Laparoscopic ultrasonography for abdominal tumors

Accurate preoperative staging of gastrointestinal malignancies is of major importance in the decision for adequate stage-related therapy. There is evidence that laparoscopy in combination with laparoscopic ultrasound (L-LUS) is more accurate in the detection of intraabdominal tumors than conventional preoperative imaging. Staging L-LUS is a minimally invasive technique that reveals local tumor extent and intraabdominal disseminated tumor spread. Therefore, laparoscopic ultrasound is an ideal adjunct to laparoscopy because this technique may compensate for the lack of tactile feedback with laparoscopic instruments. The concept of using ultrasound through a laparoscopic access for liver tumors was first described by Yamakawa et al. in 1958, but it was only since the end of the 1980s that laparoscopic ultrasound probes were introduced in the clinical practice. Currently available data indicate that L-LUS provides information similar to that obtained by intraoperative ultrasound and can identify lesions that are too small to be visible by preoperative imaging techniques. Furthermore, L-LUS also allows performance of US-guided biopsy or interstitial therapies as ethanol injection, cryoablation or radiofrequency thermal ablation in the same session. Laparoscopic radiofrequency represents a safe and effective treatment for patients with hepatocellular carcinoma not amenable to surgical resection, especially when the percutaneous approach to the lesion is deemed very difficult or impossible. Better protection of vital structures and a more accurate staging are major advantages of this approach. In the future, these advantages and the possibility to perform a more aggressive approach (in association with local vascular exclusion) could favor a more extensive use of the laparoscopic radiofrequency. More recently, some series of laparoscopic segmentectomy were reported; the authors showed that laparoscopic resections are feasible and safe in selected patients with left-sided and right-peripheral lesions requiring limited resections. Staging L-LUS can also provide a significant effect in the multimodal approach to a population of patients undergoing regional treatment of hepatic colorectal metastases. Staging L-LUS also acts as a bridge to a potential laparoscopic approach of both primary colon tumor and liver metastases. Patients with hilar cholangiocarcinoma and gallbladder cancer frequently have unresectable disease that is not apparent on preoperative imaging studies. L-LUS can correctly identify unresectable disease and prevents unnecessary laparotomy in about one third of patients. Color-coded Doppler imaging can be very valuable for the assessment of resectability in patients with pancreatic cancer. Current data confirm that laparoscopic ultrasound is capable of enhancing the accuracy of staging laparoscopy. Compared to standard laparoscopy, a combination of both techniques markedly increases the sensitivity of staging laparoscopy in the determination of unresectable disease. This is of major importance in the assessment of occult liver metastases and lymph node involvement. Laparoscopic ultrasonography improves the diagnostic accuracy compared to conventional imaging techniques and should be considered as integral part of staging laparoscopy. It may help in choosing the most suitable treatment for the patient. However, a steep learning curve for L-LUS has been reported, and a training workshop experience with LUS will be needed to improve both accuracy rates and LUS technique.

Laparoscopy versus open left lateral segmentectomy for recurrent pyogenic cholangitis

Recurrent pyogenic cholangitis (RPC) is a common disease in Southeast Asia. Its classical presentation is repeated attacks of cholangitis with multiple recurrences of bile duct stones. The stones are commonly located in the left lateral segments (2 and 3) and therefore complete clearance is difficult to achieve by either endoscopic retrograde cholangiopancreatography or surgical exploration of the common bile duct. The definitive treatment usually involves resection of the stone-harboring segments. The recent advent in laparoscopic surgery has shown that hand-assisted laparoscopic segmentectomy is a safe and feasible, alternative. This study aimed to compare hand-assisted laparoscopic segmentectomy with open segmentectomy in patients with recurrent, RPC. This study retrospectively reviewed a prospectively maintained database of both open and laparoscopic treatments for RPC in a single center between 1994 and 2004. During this period, patients with RPC and left intrahepatic (segments 2 and 3) ductal stones not amendable to endoscopic treatment were recruited for analysis. Patients with concomitant gallbladder stones and common bile duct stones were offered left lateral segmentectomy with cholecystectomy and exploration of the common bile duct. Selected patients would have choledochoduodenostomy drainage during the same operation. The operations were performed via either the hand-assisted laparoscopic approach or the open approach using an ultrasonic surgical aspirator. The two cohorts were compared with respect to perioperative parameters to determine whether there would be any advantage in attempting hand-assisted laparoscopic segmentectomy. During the study period from 1994 to 2004, 17 patients underwent left lateral segmentectomy for RPC. Of the 17 patients, 10 had hand-assisted laparoscopic resections, and 7 underwent open resections. All open resections were performed before 1999. Despite the small number of patients and potential type 2 error, there were no differences in age, sex distribution, number of cholangitic attacks, sessions of endoscopic retrograde cholangiopancreatography before surgery, or number of previous operation between the two groups. The median operating time was shorter in the open group (232.5 vs 150 min; p = 0.007), whereas the median blood loss was similar (350 vs 400 ml; p = 0.551). The median postoperative stay was 8 days for hand-assisted laparoscopic group versus 14 days for the open group. This difference was statistically significant (p = 0.019). There was one open conversion in the hand-assisted laparoscopic group because of intraoperative bleeding from the left hepatic vein. Postoperative complication rates were lower in hand-assisted laparoscopic group, but the difference was not statistically significant (20% vs 57%; p = 126). The intramuscular pethidine requirement again was less in hand-assisted laparoscopic group (0 vs 600 mg; p = 0.002). There was no operative mortality in either group of patients. No recurrent cholangitis was noted in either groups during the median follow-up period of more than 3 years. This study not only confirmed the feasibility of hand-assisted laparoscopic segmentectomy for recurrent pyogenic cholangitis, but also showed that this treatment approach is associated with less pain and shorter hospital stay. However, hand-assisted laparoscopic segmentectomy is a lengthier operation and technically more challenging. Nevertheless, the authors believe that with more experience and further improvement of ancillary technology, this procedure can become a standard treatment for recurrent pyogenic cholangitis in selected cases.

Laparoscopic treatment of recurrent pyogenic cholangitis

We reviewed the selective use of hand-assisted laparoscopic segmentectomy (HALS) and laparoscopic choledochoduodenostomy (LCD) in the management of recurrent pyogenic cholangitis (RPC). We carried out a retrospective review of a prospectively maintained database of laparoscopic treatment of RPC during the period 1995 to 2004. The perioperative data were analyzed. There were 33 laparoscopic procedures performed in 30 patients with RPC during the period 1995--2004. There were 23 female and 7 male patients, with a mean age of 63.2+/-14.9 years (range, 29--92 years). All these patients had a history of repeated attacks of cholangitis, and multiple sessions of endoscopic lithotripsy or operative retrieval had previously been attempted. Of these 33 procedures, there were 23 LCDs and 10 HALS. Three patients underwent simultaneous LCD and HALS in the same operation. The mean operative time was 172+/-63.5 min (range, 75--290 min) and there were three open conversions (10%), due to (1) intraoperative bleeding from the left hepatic vein, (2) lost broken tip of ultrasonic dissector, and (3) significant bleeding during choledochotomy, respectively. Average hospital stay was 11.4+/-11.1 days (range, 5--60 days). Eight complications (26.6%) were encountered, which included four bile leaks, three wound infections, and one intraabdominal collection. Complete stone clearance was achieved in all but 1 patient (rate, 96.6%), in whom the residual stones were extracted through a postoperative combined endoscopic and percutaneous approach. Long-term results were satisfactory, and only one stone recurrence was detected, upon a mean follow-up of 34.7 months (range, 1--107 months). Both LCD and HALS are safe, feasible, and effective treatments for patients with RPC.

Hand-assisted laparoscopic segmentectomy in recurrent pyogenic cholangitis.

Recurrent pyogenic cholangitis (RPC) is a prevalent disease in Southeast Asia and presents a unique challenge to both gastroenterologist and hepatobiliary surgeon. Despite rapid development in endoscopic instrumentation and skill maturation, it is still difficult to clear those pigmented stones lodged in the intrahepatic ducts. The alternative approach to stones through the percutaneous transhepatic route can offer access for repeated ductal dilatation and lithotripsy. However, recurrence is still commonly seen. Resection of the atrophic stone-harboring segment has proven to be an effective treatment option associated with the lowest recurrence rate. Compared to the other technique, it is the only treatment that can potentially offer a cure. The complication rate is higher because of existing bacterial colonization and access trauma. With the accumulation of laparoscopic experience and improved instrumentation, laparoscopic liver resection is demonstrated to be safe and feasible for either benign or malignant conditions. This article reviews a single-center experience of hand-assisted laparoscopic segmentectomy (HALS) in patients with RPC.

Laparoscopic liver resection

In experienced hands and with appropriate case selection, laparoscopic liver resection has proven to be a safe procedure with the added benefit of minimal‐assess surgery. Successful laparoscopic liver resection, from wedge resection to formal lobectomy, had been reported for both benign and malignant disease of the liver. We present a young female with a solitary hepatocellular carcinoma in the left lateral segment in whom we successfully performed laparoscopic segmentectomy with the aid of a laparoscopic ultrasonic surgical aspirator, Harmonic Scalpel and laparoscopic ultrasound. She was discharged home on day 5. There was no complication.

Laparoscopic anatomical (hepatic) left lateral segmentectomy—technical aspects

Laparoscopic liver surgery is a tremendous challenge. The authors report a left liver lobectomy and removal by a total laparoscopic approach. Anatomical left lateral laparoscopic segmentectomy was performed on a woman who had a symptomatic hepatic adenoma. The patient was discharged after an uncomplicated postoperative recovery; the hospital stay and convalescence period were very short. The cosmetic result was good.