Laparoscopic Major Liver Resection Research Articles

International experience for laparoscopic major liver resection.

Although minor laparoscopic liver resections (LLRs) appear as standardized procedures, major LLRs are still limited to few expert teams. The aim of this study was to report the combined data of 18 international centers performing major LLR. Variables evaluated were number and type of LLR, surgical indications, number of synchronous colorectal resections, details on technical points, conversion rates, operative time, blood loss and surgical margins. From 1996 to 2014, a total of 5388 LLR were carried out including 1184 major LLRs. The most frequent indication for laparoscopic right hepatectomy (LRH) was colorectal liver metastases (37.0%). Seven centers used hand assistance or hybrid approach selectively for LRH mostly at the beginning of their experience. Seven centers apply Pringle's maneuver routinely. The conversion rate for all major LLRs was 10% and mean operative time was 291 min. Mean estimated blood loss for all major LLR was 327 ml and negative surgical margin rate was 96.5%. Major LLRs still remain challenging procedures requiring important experience in both laparoscopy and liver surgery. Stimulating the younger generation to learn and accomplish these techniques is the better way to guarantee further development of this surgical field.

Minimally Invasive Approaches in Pancreatic and Liver Surgery

The rapid expansion of minimally invasive techniques over the last two decades has dramatically expanded the use of these approaches in hepatopancreaticobiliary surgery. While implementation of minimally invasive surgery has been slowed by the technically complex nature of liver and pancreatic surgery, the feasibility of laparoscopic and robotic major liver and pancreatic resections has been demonstrated at select centers. This review discusses the preoperative evaluation, indications and contraindications, operative techniques, and outcomes of minimally invasive major pancreatic and hepatic resections; including distal pancreatectomy, pancreaticoduodenectomy, right and left hepatectomy, segmentectomy, and ablative liver surgery. Tables list the clinical outcomes of large series of patients treated with laparoscopic and robotic approaches to each operation. Figures detail port placement and include a number of intraoperative photographs demonstrating anatomic and technical considerations. Videos of a robotic pancreaticojejunostomy and a robotic retropancreatic dissection are included to highlight some of the technical advantages of this approach. While the current literature suggests the safety and feasibility of minimally invasive pancreatic and liver surgery with encouraging early results, ongoing study is needed to more definitively demonstrate outcome benefits of these approaches while maintaining patient safety and oncologic principles and justifying costs associated with the technology. As more data emerges, it is likely that utilization of minimally invasive approaches for hepatopancreaticobiliary surgery will continue to expand. This review contains 12 figures, 2 videos, 10 tables, and 129 references.

Laparoscopic liver resection for centrally located tumors close to the hilum, major hepatic veins, or inferior vena cava

Despite the accumulation of favorable results from laparoscopic liver resection (LLR), centrally located tumors close to the hilum, major hepatic veins, or inferior vena cava (IVC) are still considered contraindications for LLR. We evaluated the feasibility and safety of LLR for centrally located tumors. Of the 182 patients who underwent LLR for benign or malignant tumors between September 2003 and June 2010, the clinical outcomes of 13 patients with tumors within 1 cm or less of the major vascular structures, including the hilum, major hepatic veins, and IVC, were retrospectively analyzed. The perioperative outcomes of the patients were compared with those of the 23 patients who underwent open liver resection for tumors with similar criteria in terms of location and size during the same period. Anatomic liver resection, including left and right hepatectomy, central bisectionectomy, right anterior and posterior sectionectomy, and extended S4 segementectomy, was performed in 10 patients. The remaining 3 patients underwent subsegmentectomy for tumors located in the Spiegel lobe of the caudate. There was no open conversion or postoperative mortality. Compared with the open group, the laparoscopic group showed similar rates of intraoperative transfusion, postoperative complications, and operative time. However, the laparoscopic group spent less time in the hospital postoperatively and had shorter resection margins. After a median follow-up of 34.3 months, there were no statistically significant differences between the 2 groups in reference to the overall survival rates and the disease-free survival rates. This study shows that LLR can be safely performed in selected patients with centrally located tumors close to the liver hilum, the major hepatic veins, or the IVC that were previously considered to be contraindications for LLR. Recent technical developments in the performance of laparoscopic major liver resection may have contributed to the successful application of LLR for centrally located tumors.

The learning curve in laparoscopic major liver resection

Laparoscopic major hepatectomy remains a relatively rare operation because it is a difficult and technically demanding procedure, and a standard, safe, reproducible technique has not been widely adopted. This is compounded by "major hepatectomy" encompassing multiple different operations each with their own anatomic and procedural considerations. In 2010, we investigated our learning curve for laparoscopic liver resection. We found a significant increase in the number of major hepatectomies performed over a 12-year period, with concurrent reductions in the use of hand-assistance, pedicle clamping, median clamping time, median operative time, blood loss and morbidity. This learning curve was confirmed by a subsequent multinational study. Both hospital and surgeon volume have been shown to affect outcomes, and defining a sufficient number of repetitions before the learning curve plateaus is not easy for laparoscopic major hepatectomy. We recommend that laparoscopic competencies be developed upon a foundation of open liver surgery and that laparoscopic major hepatectomy should only be attempted after competency with less technically complex laparoscopic resections. A center advanced along its institutional learning curve provides the collective expertise necessary for safe patient selection and management. An environment with colleagues willing to share their acquired proficiency allows the surgeon to observe and critique his or her performance against colleagues. Also, the guidance of like-minded surgeons supports technical development and improved outcomes. In conclusion, steady progress can be made along the learning curve through committed practice of increasingly complex tasks and with proper coaching in a high-volume environment.

Laparoscopic major hepatectomy: pure laparoscopic approach versus hand‐assisted technique

Laparoscopic liver resections are being performed with increasing frequency, with several groups having reported minimally invasive approaches for major anatomic hepatic resections. Some surgeons favor a pure laparoscopic approach, while others prefer a hand-assisted approach for major laparoscopic liver resections. There are clear advantages and disadvantages to a hand-assisted technique. The purpose of this study is to summarize the literature comparing pure laparoscopic and hand-assisted approaches for minimally invasive hepatic resection, and to describe our approach in 432 laparoscopic liver resections.

Laparoscopic major liver resection in Korea: a multicenter study

We report our experience with laparoscopic major liver resection in Korea based on a multicenter retrospective study. Data from 1,009 laparoscopic liver resections conducted from 2001 to 2011 were retrospectively collected. Twelve tertiary medical centers with specialized hepatic surgeons participated in this study. Among 1,009 laparoscopic liver resections, major liver resections were performed in 265 patients as treatment for hepatocellular carcinoma, metastatic tumor, intrahepatic duct stone, and other conditions. The most frequently performed procedure was left hemihepatectomy (165 patients), followed by right hemihepatectomy (53 patients). Pure laparoscopic procedure was performed in 190 patients including 19 robotic liver resections. Hand-assisted laparoscopic liver resection was performed in three patients and laparoscopy-assisted liver resection in 55 patients. Open conversion was performed in 17 patients (6.4 %). Mean operative time and estimated blood loss in laparoscopic major liver resection was 399.3 ± 169.8 min and 836.0 ± 1223.7 ml, respectively. Intraoperative transfusion was required in 65 patients (24.5 %). Mean postoperative length of stay was 12.3 ± 7.9 days. Postoperative complications were detected in 53 patients (20.0 %), and in-hospital mortality occurred in two patients (0.75 %). Mean number and mean maximal size of resected tumors was 1.22 ± 1.54 and 40.0 ± 27.8 mm, respectively. R0 resection was achieved in 120 patients with hepatic tumor, but R1 resection was performed in eight patients. Mean distance of safe resection margin was 14.6 ± 15.8 mm. Laparoscopic major liver resection has become a reliable option for treatment of liver disease in Korea.

Extrahepatic Glissonean approach for laparoscopic major liver resection (with video)

Although recent technological developments and improved endoscopic procedures have further spread the application of laparoscopic liver resection, laparoscopic major liver resection remains a highly specialized field because there are major technical difficulties, such as hilar dissection and pedicle control. The entire length of the primary branches of the Glissonean pedicle and the origin of the secondary branches are located outside the liver. In contrast, the trunks of the secondary branches and more peripheral branches run inside the liver. The right, left, anterior, or posterior Glissonean pedicle can thus be tied and divided en bloc extrahepatically during open anatomical liver resection. Each Glissonean pedicle can be easily and safely encircled and divided en bloc extrahepatically during laparoscopic anatomical liver resection using an Endo Retract Maxi or Endo Mini-Retract. This report describes a novel technique by which the extrahepatic Glissonean approach appears to be both feasible and safe for the performance of laparoscopic major liver resection.

Outcome of laparoscopic major liver resection for colorectal metastases

Minimally invasive liver resection (MILR) for colorectal liver metastases (CRLM) is gaining widespread acceptance. However, data are still lacking on the feasibility, long- and short-term outcomes of laparoscopic major hepatectomy (i.e., three or more liver segments). Between October 2002 and December 2008, prospectively collected data of 117 patients who underwent major liver resection [97 open (OMLR) and 20 laparoscopic (LMLR) procedures] for CRLM were analyzed. Twenty patients in the LMLR group were matched with 20 patients of the OMLR based on 13 parameters. We compared the long- and short-term outcomes between these two groups. Median duration of surgery was 257.5 (range 75-360) min in LMLR versus 232.5 (range 120-400) min in OMLR (P = 0.228). Median blood loss during surgery was 550 ml in each group (range 100-4,000 vs. 100-2,500 ml, P = 0.884). There was no statistically significant difference in the rate of postoperative complications (both severity and location). Median magnitude of tumor-free resection margin was 7.5 versus 5.5 mm in the laparoscopy versus open group, respectively (P = 0.651). Median disease-free survival (DFS) of the entire study population was 18.4 months [95% confidence interval (CI) 11.9-50.0 months]. Median overall survival (OS) was 50.7 months (95% CI 36.2 months to undetermined). The estimated DFS and OS rates at 1, 2, and 5 years were comparable in the two groups (P = 0.637 and 0.872, respectively). Laparoscopic MLR for selected CRLM is feasible and might result in comparable oncologic outcomes as in open liver resection.

Laparoscopic right hepatectomy: a challenging, but feasible, safe and efficient procedure

Background Few centers are undertaking major laparoscopic liver resections, because of the well-recognized technical difficulties and lack of training opportunities. Methods The authors describe their technique for laparoscopic right hepatectomy, highlighting relevant details for accomplishing a safe and efficient procedure. Patients were chronologically divided into 2 groups to evaluate the impact of increasing experience on the surgical outcomes. Results Group I included 17 patients and group II 18 patients. The conversion rate to open or hybrid techniques significantly decreased from 36% in group I to 6% in group II ( P = .03). The hospital stay decreased from a median of 6 days in group I to a median of 4 days in group II ( P = .05). Complications occurred in 4 patients (11%), of whom 3 were in group I. The mortality was zero. Conclusions Laparoscopic right hepatectomy is a safe and efficient procedure when performed at specialized centers with extensive experience in hepatic surgery. Long-term training is necessary to acquire adequate expertise.

Laparoscopic major hepatectomy can be safely performed with colorectal surgery for synchronous colorectal liver metastasis

BackgroundThe optimal strategy for resectable synchronous colorectal liver metastases remains controversial. Although some authors advocate a staged treatment, an increasing number of studies have reported that combined colorectal and liver resection is safe. Laparoscopic combined resection in primary colorectal cancer with synchronous liver metastases has been reported but there are no specific data for major liver resections. In the present study, we evaluated the feasibility of a simultaneous entirely laparoscopic procedure, in the light of the benefits of laparoscopy in both colon and liver surgery, and discussed the benefits of this strategy. MethodsTwo cases are presented of totally laparoscopic major liver resections associated with laparoscopic colorectal resections for synchronous liver metastases with the emphasis on the technical aspects. Duration of surgery, blood loss and post-operative outcome were evaluated. ResultsLaparoscopic right hepatectomy or left hepatectomy with simultaneous colon resection for liver metastasis was feasible and safe with only one suprapubic 5-mm trocar added to the usual trocar sites. The mean duration of surgery was 327min with a mean estimated blood loss of 200ml. The post-operative course was uneventful. DiscussionIn selected patients, laparoscopic major hepatectomies for unilobular synchronous metastases can be safely performed simultaneously with colorectal surgery.

Laparoscopic Major Hepatectomy

To analyze the results of 6 international surgical centers performing laparoscopic major liver resections. The safety and feasibility of laparoscopy for minor liver resections has been previously demonstrated. Major anatomic liver resections, initially considered to be unsuitable for laparoscopy, are increasingly reported by several centers worldwide. Prospective databases of 3 European, 2 U.S., and 1 Australian centers were combined. Between 1997 and 2008, 210 major liver resections were performed: 136 right and 74 left hepatectomies. Results and differences in surgical techniques between the 6 centers are outlined. Surgical duration was 250 minutes (range: 90-655 minutes). Operative blood loss was 300 mL (range: 20-2500 mL). Thirty patients (14.3%) received blood transfusion. Conversion to open surgery was required in 26 patients (12.4%). Portal triad clamping was performed in 24 patients (11.4%). Median tumor size was 5.4 cm (range: 1-25 cm) and surgical margin was 10.5 mm (range: 0-70 mm). Two patients died during the postoperative period from pulmonary embolism and urosepsis. Liver-specific and general complications occurred in 17 (8.1%) and 29 patients (13.8%), respectively. Hospital length of stay was 6 days (range: 1-34 days). A further analysis of early (n = 90) and late (n = 120) experience showed improved surgical and postoperative results in the latter group. This multicenter study demonstrates that laparoscopic major liver resections are feasible in selected patients and results improve with experience. However, proficiency in both open liver surgery and advanced laparoscopy is compulsory and surgeons must begin with minor laparoscopic resections.

The International Position on Laparoscopic Liver Surgery

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

Laparoscopic versus open right hepatectomy: a comparative study

Background The safety of laparoscopic major liver resections is still uncertain. The aim of this study was to compare our results for laparoscopic right hepatectomy (LRH) with those for open right hepatectomy (ORH). Methods Patients undergoing LRH were compared with retrospectively selected patients from our ORH database. The 2 groups were well matched for sex, age, American Society of Anesthesiologists score, body mass index, liver disease, and tumor size. Surgical and postsurgical outcomes were compared. Results Seventy-two patients were analyzed: 22 in the LRH group and 50 in the ORH group. Operating time was similar. Blood loss was significantly less in laparoscopic resections ( P = .038). Specific morbidity rates were not different, general morbidity was lower after laparoscopy ( P = .04), and the severity of postsurgical complications was not different. Mean hospital stay was significantly shorter after laparoscopy ( P = .009). Comments Laparoscopy improved surgical and postsurgical outcomes for ORH in selected patients. This is the first comparative study to demonstrate an advantage of laparoscopy for a major liver resection. Prospective randomized studies with a greater number of cases are needed to confirm the role of laparoscopy in major liver resections.

Early Experience With Laparoscopic Major Liver Resections

Laparoscopic major liver resections are regarded as demanding operations whose convenience is still under evaluation. The aim of the present study was to report our early experience and to describe surgical technique of laparoscopic major liver resections. Study group consisted of 6 female patients with benign disease and a mean age of 40.5 years, who underwent right hepatectomy in 4 cases and left hepatectomy in 2 cases. No mortality was observed. Morbidity consists in 1 biliary fistula that requires rehospitalization and a new laparoscopic operation. The mean operative time was of 201.7 minutes, with a mean hospital stay of 5.5 days. The authors conclude that laparoscopic major liver resections could be performed, at least for benign disease and by surgeons experienced in laparoscopy, with good results. Nevertheless, further studies are required before to draw definitive conclusions, especially for neoplastic patients who represent the most relevant group.

New application of the bipolar vapor plasma coagulation system for laparoscopic major liver resections

In recent years, laparascopic techniques have become a more widely used and accepted means for performing various types of liver resections. In this report, the authors describe the use and initial applications of a new approach to laparoscopic liver resection using vapor pulse coagulation. Liver resections using vapor plasma coagulation technology were performed for 11 patients at the authors' center. Candidates were initially selected because they had benign disease and lesions amenable to standard resections along anatomic planes. Four resections were performed with a hand-assist technique and seven without it. All the patients faired well. The length of the hospital stay was 3.4 +/- 0.7 days. There were no major surgical complications, bile leaks, or reoperations. None of the patients required blood transfusions. One patient was readmitted for fever and urinary tract infection, and one patient had 1 week of right leg swelling attributable to the use of stirrups. Vapor plasma coagulation using a laparoscopic approach for hepatic resection is a promising new technology that deserves further exploration.