Posterosuperior Segments Research Articles

Stepwise development of laparoscopic liver resection using the rubber band traction technique

Introduction: To improve patient’s safety and quality of surgery, we standardized our surgical technique (rubber band traction technique) and strictly implemented a stepwise approach strategy (from simple to complex operation) for laparoscopic liver resection (LLR). These approaches might be the key to overcome the complexity of the procedure and could possibly reduce its learning curve. The aim of this study is to describe the results of the stepwise approach in surgical outcomes through the implementation of standardized LLR. Method: Data from all consecutive patients who had undergone a laparoscopic liver resection from January 2009 to December 2017 were prospectively reviewed. The risk-adjusted cumulative sum (RA-CUSUM) analysis according to surgical failure (conversion to laparotomy, blood transfusion, and Clavien-Dindo grade >3) and CUSUM operative time was used to determine the optimal number of operation needed to achieved the best quality of surgical outcome (less operative time, blood loss, length of hospital stay, and complication rate) as well as the surgical proficiency of a surgeon Result: Among 272 patient, 45 (16.5%) underwent right hepatectomy, 33(12.1%) left hepatectomy, 37 (13.6%) left lateral sectionectomy, 83 (30.5%) minor anterolateral segments resection (30.5%), and 74 (27.2%) minor posterosuperior segment resection. From simple to complex procedures, complications rates, transfusion requirements, and conversion rates did not increase over time. After 53 cases of minor LLR, blood loss and operative time significantly improved after the 21st cases for right hepatectomy. For minor anterolateral and posterosuperior segments resections, blood loss and operative time significantly improved at 37th and 38th case, respectively. However, conversion rates, length of hospital stay, and complications rates showed continuous improvement but did not reach statistical significance. Conclusion: Standardization of operative technique and implementation of stepwise approach in LLR could considerably improve the surgical outcomes and overcome the learning curve of LLR.

Laparoscopic liver surgery in cirrhosis – Addressing lesions in posterosuperior segments

BackgroundMinimal-invasive liver resection has gained considerable attention in recent years, assuming a weighty position in the field of HPB surgery. Even lesions in posterosuperior segments, the technically most challenging localization, have been resected while achieving comparable outcomes to laparotomy. The objective of this study is to evaluate whether the similar beneficial results can be conveyed through minimal-invasive techniques for patients with liver cirrhosis. Materials and methodsWe retrospectively analyzed all consecutive patients undergoing laparoscopic liver resection with at least one lesion in the posterosuperior liver segments (IVa, VII, VIII) at our center between January 2012 and July 2018. Patients were separated in two groups based on the presence (n = 43) or absence (n = 115) of liver cirrhosis. ResultsPreoperative patient characteristics showed that patients with cirrhosis were older (p < 0.001), had more frequently diabetes (p < 0.005) and a history of alcohol consumption (p < 0.0005). Preoperative liver function, as assessed by LiMAx score was markedly decreased in patients with liver cirrhosis (p < 0.005).While a similar percentage in both groups had anatomical resection, significantly more major resections were performed in patients without cirrhosis (cirrhosis: 23.3% vs. no cirrhosis 55.7%; p < 0.0005). Consequently, surgeries were markedly longer in the no cirrhosis group (p < 0.0005). There was no difference with regard to the need for perioperative transfusion or conversion to laparotomy.There was no differences found between both groups with regard to the postoperative course showing similar ICU- and hospital stays. Complication rate, both with regard to minor and major complications, as well as rate of clear resection margins were similar between the two groups as well. ConclusionPatients with liver cirrhosis and a lesion in the posterosuperior liver segments are amenable to the minimal-invasive approaches as no significant differences can be observed with regard to safety and oncologic sufficiency. As these procedures are from a technical perspective challenging, they should be performed in specialized centers.

Pure laparoscopic liver resections in the posterosuperior segments in semiprone position: a single surgeon experience of 111 consecutive cases

Pure laparoscopic liver resections in the posterosuperior segments in semiprone position: a single surgeon experience of 111 consecutive cases

Short term and oncologic outcomes of the first 250 laparoscopic liver resections performed by a laparoscopically trained liver surgeon

Introduction: To evaluate the results of the first 250 laparoscopic liver resections (LLR) performed by a single surgeon trained in laparoscopic surgery and hepatobiliary surgery,and to investigate whether a learning curve is present. Methods: Retrospective review of a prospectively maintained database of all patients who underwent LLR between October 2011 and November 2017 at a single center.Five consecutive groups of equal size were evaluated to investigate the presence of a learning curve. Results: During 73 months,379 liver resections were performed, of which 251 procedures (66%) were performed by a pure laparoscopic approach.From the first year to the most recent year, the percentage of LLRs increased from 45% to 69.2%.Overall, 111 patients were operated in semiprone position for resections in the posterosuperior segments. Malignancy was present in 217(86.8%) of patients (colorectal liver metastases(CRLM) in 136 cases (54%)).Thirty-two patients (12.8%) underwent a repeat hepatectomy. Median blood loss was 100ml (IQR:50-250ml). Median operative time was 135 minutes (IQR:90-180min).Conversion rate was 2.4%.Peri-operative blood transfusion was needed in 5 patients. Major complication rate (Clavien-Dindo ≥ grade III) was 3.2% (8 patients).R0 resection rate was 94.8%(238 cases).There was no 30-day mortality. In patients with CRLM, 5-year survival rate was 65%.There were no significant differences,apart from a shorter hospital stay (p< 0.001) during the 5 consecutive periods. Conclusion: Trained laparoscopic surgeons with an additional hepatobilairy fellowship may enter practice directly from training and perform LLR with short term and oncologic outcomes in line with early adopters and most experienced laparoscopic liver surgeons.

Technical aspects for laparoscopic liver resections of tumors in proximity to major vessels

Background: Bleeding during parenchymal division of the liver still remains a major complication of hepatectomy leading to 20% of perioperative deaths. The development of several transection devices, laparoscopic techniques for inflow and outflow control and the positive pressure of the CO2-pneumoperitoneum are the main reasons for less blood loss during laparoscopic resections(LLRs).However, tumors in proximity to major vasculature are often resected by open liver surgery. Methods: We describe several techniques which were helpful to prevent blood loss during LLRs with tumors in proximity to major vessels. Results: CVP drop was used to select patients for a laparoscopic approach when the tumor was located in segment 1 or in proximity to the hepatocaval confluence.The use of a laparoscopic Pringle manoeuver and a hanging manoeuver of the right hepatic vein to control the hepatocaval confluence are shown (figure).Advantages of placing the patient in semiprone position during LLRs in the posterosuperior segments are explained.In total 60 patients underwent a LLR for lesions in proximity of the major vessels. Median distance to major vessels was 10 mm (range 0–17). Operative time was 180.0min(IQR:140.0-210.0),median blood loss was 190.0 ml(IQR:100.0–325.0).Transfusion rate was 5.0%.Postoperative complication rate was 15.0%.There was no mortality. There was no significant correlation between the distance to major vasculature and blood loss (p = 0.80) or operative time (p=0.95). Correlation between CVP drop and blood loss was borderline significant (p=0.06) Conclusion: When using a range of techniques to prevent blood loss LLRs for lesions in proximity to major vessels are feasible and safe.

Short and long-term outcomes after laparoscopic or robotic liver resection in patients with HCC located in posterosuperior segments: comparision with open liver resection

Introduction: Hepatocellular carcinoma located in posterosuperior segemtents, especially segments VII and VIII, are considered to be difficult for minimally invasive liver resection (MLR) because of limited visualization, the risk of major bleeding and difficulty in bleeding control. This study compared outcomes after laparoscopic or robotic liver resections for HCCs located in segments VII or VIII with open liver resections. Methods: Between January 2005 to December 2016, 497 patients underwent liver resections for HCCs located in segments VII or VIII. Among them, 63 patients underwent minimally invasive liver resection (MLR), which included 48 patients in laparoscope approach and 15 patients in robotic approach. We retrospectively evaluated perioperative and oncologic outcomes between the groups. Results: In terms of perioperative outcomes, operative time was longer for MLR group than open group (421 min. vs, 274 min., p< 0.001). While intraoperative blood loss was higher for open group (334 ml vs. 773ml, p< 0.001) and postoperative stay was longer (8.3 days vs. 17.5 days, p=0.001), there were no significant differences in postoperative complication rates (20.6% vs. 17.3%, p=0.596), In terms of oncologic outcomes, 5-year overall survival (85.5% vs. 79%, p=0.085) and 5-year disease survival (45.3% vs. 64.3%, p=0.489) rates did not show significant difference between MLR group and open group. Conclusion: MLR for HCC located in segments VII or VIII may be more time-consuming compared to open, but benefits of lower hospital stay and lower blood loss with same oncologic outcomes should make it a more attractive option in deciding operative procedure.

Double swing manoeuver to expose the right posterior segments during laparoscopic liver surgery

The benefits of laparoscopic liver surgery have been well described. Laparoscopic liver resections are now performed widely, but is difficult to accomplish in some anatomical locations such as the posterosuperior segments. Resections including segment 7 and 8 require full mobilisation of the right liver lobe and ability to rotate to the left in an effort to bring the posterior segments in an anterior view. Tilting the operating table to the left to benefit from the gravity effect and the weight of the liver are important but most of the times not enough in laparoscopic surgery. In addition, the falciform is a very strong ligament that can be used to retract the liver. Falciform traction though for exposure of the right posterior segments has the disadvantage of being too far away from the posterosuperior liver and commonly the liver is not fully rotated though the falciform is fully retracted. The gallbladder fundus can be used to further retract/rotate the liver to the left side in order to accomplish the best exposure of the right posterior sector and lower down the segment 8. Following right lobe mobilisation, gallbladder swing can reach the left subdiaphragmatic area/ splenic hilum. In this presentation we show in detail the technique used in most of our resections of right posterior segments through illustration and short videos.

Classification of open liver resection based on operative time, blood loss, and comprehensive complication index

Introduction: A classification system is needed to stratify patients undergoing open liver resection (OLR). The present report aimed to evaluate OLR procedures based on a previously-described laparoscopic liver resection classification (Ann Surg.2018), using operative time, blood loss, and comprehensive complication index (CCI). Method: Consecutive 3707 patients who underwent OLR were included. Patients who underwent multiple wedge/segmentectomy, vascular/biliary reconstruction, and concomitant extra-hepatic procedures were excluded. Wedge/segmentectomy was divided into anterolateral (Couinaud's segments 2, 3, 4b, 5, and 6) and posterosuperior (segments 1, 4a, 7, and 8) segments. Eleven OLRs were divided into 3 groups according to scores based on less (score 0) or more (score 1) than median/mean values of operative time, blood loss, and CCI. Results: Of 3,707 OLRs, 2,047 were selected. Median operative time, median blood loss, and mean CCI were 145 min, 200 ml, and 10.4, respectively. Group I (0 point) included wedge resection and left lateral sectionectomy. Group II (1 points) included anterolateral segmentectomy and left hepatectomy. Group III (2-3 points) included posterosuperior segmentectomy, right hepatectomy, right posterior sectionectomy, central hepatectomy, and extended left/right hepatectomy (Table 1). The 90-day mortality rates (Groups I, II, and III: 0.5%, 1.3% and 2.9%) and major complication rates (4.1%, 8.3%, and 15.2%) were associated with increase from Groups I to III (all P< 0.001, trend test). Conclusions: This classification provides three-level stepwise OLR difficulty: Group I (low), Group II (intermediate), and Group III (high). This can be useful for surgical education and to benchmark surgical procedures.Tabled 1EP01C-090 Table 1Perioperative outcomes by ProceduresWedge-AL†Wedge-PS‡Left lateralSeg-AL†Left HepSeg-PS‡Right HepEx- Right HepRight posteriorColini HepIi-LeA HepTttitNumber1967212125320610860731625171262047OR time, minMedian117133110152120198140196250320246145IQR78-145108-19480-14399-201184-200146-270108-235120-295233-315251-375148-330105-236Blood loss, mLMedian100110125100200200300300225250300200IQR50-20056-25088-20075-250100-313100-300200-500200-600150-525150-500200-470100-400MorbidityCCI§Mean5.25.75.47.47.58.012.816.69.210.311.710.4SD12.411.313.115.314.516.120.521.87.110.911.618.1A1I complication18.925.020.726.526.330.643.256.028.035.340.936.0Major complication4.14.24.15.911.29.213.219.016.023.518.3911.590-day mortality0.500.81.21.503.14.14.001.62.1Score¶00011223223GroupIIIIIIAbbreviations; Wedge-AL, wedge resection of anterolateral segment; Wedge-PS, wedge resection of posterosuperior segment; Left lateral, left lateral sectionectomy; Seg-AL, anterolateral segmentectomy; Left Hep, left hepatectomy; Seg-PS, posterosuperior segmentectomy; Right Hep, right hepatectomy; Ex-Right Hep, extende right hepatectomy; Right posterior, right posterior sectionectomy; Central Hep, central hepatectomy; Ex-Left Hep, ectended left hepatectomy; IQR, interquartile range; CCI, comprehensive complication index;SD, standard deviation.†Couinaud’s segments 2, 3, 4b, 5, and 6; ‡Couinaud’s segments 1, 4a, 7, and 8§Defined by Slankamenac et al.¶One point was allocated as follows; either operative time (145 min and more), the amount of blood loss (200 mL and more), or CCI (10.4 and more). Open table in a new tab Abbreviations; Wedge-AL, wedge resection of anterolateral segment; Wedge-PS, wedge resection of posterosuperior segment; Left lateral, left lateral sectionectomy; Seg-AL, anterolateral segmentectomy; Left Hep, left hepatectomy; Seg-PS, posterosuperior segmentectomy; Right Hep, right hepatectomy; Ex-Right Hep, extende right hepatectomy; Right posterior, right posterior sectionectomy; Central Hep, central hepatectomy; Ex-Left Hep, ectended left hepatectomy; IQR, interquartile range; CCI, comprehensive complication index; SD, standard deviation. †Couinaud’s segments 2, 3, 4b, 5, and 6; ‡Couinaud’s segments 1, 4a, 7, and 8 §Defined by Slankamenac et al. ¶One point was allocated as follows; either operative time (145 min and more), the amount of blood loss (200 mL and more), or CCI (10.4 and more).

Robotic versus open minor liver resections of the posterosuperior segments: a multinational, propensity score matched study

Robotic versus open minor liver resections of the posterosuperior segments: a multinational, propensity score matched study

Safety and Efficacy of Laparoscopic Liver Resection for Lesions Located on Posterosuperior Segments: A Meta-Analysis of Short-term Outcomes.

Laparoscopic liver resections (LLR) are currently acknowledged as safe and efficient procedures. LLR in posterosuperior (PS) segments are considered highly challenging procedures. The aim of our meta-analysis was to evaluate the effect of LLR versus open liver resection on short-term outcomes for PS segment lesions. A systematic search of Medline, Scopus, Google Scholar, Cochrane CENTRAL Register of Controlled Trials and Clinicaltrials.gov databases for articles was performed. Five studies involving 531 patients who underwent resection for PS liver segments lesions were included. LLR were associated with reduced blood loss and overall complications. Operative time, blood transfusion, R0 resection, resection margin, hospital stay, and mortality were not found different among the 2 groups. Notwithstanding their highly demanding nature, LLR in PS segments are safe and efficient procedures in the hands of experienced surgeons. Further studies are mandatory to evaluate their effect in these challenging liver resections.

Changing trends and outcomes associated with the adoption of minimally invasive hepatectomy: a contemporary single-institution experience with 400 consecutive resections.

Several studies published mainly from pioneers and early adopters have documented the evolution of minimally invasive hepatectomy (MIH). However, questions remain if these reported experiences are applicable and reproducible today. This study examines the changing trends, safety, and outcomes associated with the adoption of MIH based on a contemporary single-institution experience. This is a retrospective review of 400 consecutive patients who underwent MIH between 2006 and 2017 of which 360 cases (90%) were performed since 2012. To determine the evolution of MIH, the study population was stratified into four equal groups of 100 patients. Analyses were also performed of predictive factors and outcomes of open conversion. Four hundred patients underwent MIH of which 379 (94.8%) were totally laparoscopic/robotic. Eighty-eight (22.0%) patients underwent major hepatectomy and 160 (40.0%) had resection of tumors located in the posterosuperior segments. There were 38 (9.5%) open conversions. Comparison across the four groups demonstrated that patients were older, had higher ASA score, and had increased frequency of previous abdominal surgery and repeat liver resections. There was also an increase in the proportion of patients who underwent totally laparoscopic/robotic surgery, major liver resection, resection of ≥ 3 segments, and multiple resections. Comparison of outcomes demonstrated that there was a significant decrease in open conversion rate, longer operation time, and increased use of Pringles maneuver. The presence of cirrhosis and institution experience (1st 100 cases) were independent predictors of open conversion. Patients who required open conversion had significantly increased operation time, blood loss, blood transfusion rate, morbidity, and mortality. The case volume of MIH performed increased rapidly at our institution over time. Although the indications of MIH expanded to include higher risk patients and more complex hepatectomies, there was a decrease in open conversion rate and no change in other perioperative outcomes.

Segment 7 Laparoscopic Liver Resection: Is It Possible to Resect When Metastatic Lesions Border Suprahepatic Veins?

IntroductionAfter nearly 25 years of experience, laparoscopic liver resection (LLR) is now recognized as being feasible and safe.1 However, laparoscopic resections of the posterosuperior segments are more technically demanding. They are associated with higher conversions rates, more intraoperative bleeding, and increased operating time.2 Appropriate training is required to approach these resections safely.3 This video demonstrates the technical maneuvers to laparoscopically approach a segment 7 tumor in contact with the right supra hepatic vein. MethodThe pertinent aspect to perform a segment 7 metastasis resection using minimally invasive techniques is shown. The main steps of this operation include (1) complete release of the right liver from the coronary and triangular ligament, (2) dissection of the retrohepatic vena cava and transection of the hepatocaval ligament, (3) the use of intercostal trocars for direct vision of the inferior vena cava and the right suprahepatic vein,4,5 (4) the use of intraoperative ultrasound to evaluate the position and limits of vascular structures compared to the lesion, (5) careful transection of the hepatic parenchyma, and (6) dissection of the right hepatic vein to separate it from the lesion. ResultsThe surgery was performed in a 68-year-old male patient. The patient developed synchronous metastases to the liver from a sigmoid colon tumor. Two lesions were identified; a 15 mm subcapsular lesion located in segment 5 and a 45 mm lesion located in segment 7 in contact with the right hepatic vein and inferior vena cava confluence. Previously, laparoscopic sigmoidectomy was performed without complications (TNM classification of the specimen: T3N0, with 31 resected lymph nodes, KRAS gene mutated). Following chemotherapy with FOLFOX + bevacizumab, a good response to the liver lesion was noted on imaging. Subsequently, a laparoscopic resection of the metastases in segment 7 and 5 was performed. The surgery lasted 210 min, intraoperative blood loss was 200 cm3, no Pringle maneuver was required, and the postoperative period was uneventful with the patient being discharged on postoperative day number four. Pathology of the liver specimens confirmed metastases from colon adenocarcinoma with free surgical margins. DiscussionSome important points achieving easier and safer approach of the posterior segments of the liver by laparoscopic route should be discussed. First, the patient’s semi-lateral position showed in the video allows placing the ports and the optic in a more comfortable position since the lateral portion of the abdominal and thoracic wall becomes anterior. Another important point is the complete liberation of the hepatorenal, falciform, triangular, and right coronary ligaments in order to fully mobilize the liver and convert a segment that is posterior in the anatomical position to an anterior segment for the surgeon. And finally, the use of intercostal trocars that allows a direct and perpendicular view of the right hepatic vein and vena cava represents the most important point. Interestingly, these specific trocars should be inserted through the pleural cavity, during a forced expiration or apnea to avoid lung injury. In this context, the trocar balloon helps the surgeon to avoid displacement or that pneumoperitoneum enters the pleural cavity. At the end of the procedure, we strongly recommend to stitch laparoscopically these diaphragmatic openings after removing the trocars in order to avoid migration of abdominal fluid or bowel incarceration into the pleural cavity during the postoperative period and also to avoid future diaphragmatic hernia. In the present case, the parenchymal transection was performed with Thunderbeat (Olympus®, Japan), a device integrating both ultrasound dissection and advanced bipolar energy. We use this device because it saves time by sealing vessels up to 7 mm in diameter avoiding the need to use clips in the majority of intrahepatic veins and portal branches. However, currently, several techniques and devices are equivalent for parenchymal transection in laparoscopic liver resection and should be left to the surgeon’s preference, as in open liver procedures. ConclusionUsing laparoscopy to remove lesions in the posterior segments of the liver is safe and feasible. Vision from transthoracic port has the added benefit of making the dissection of right hepatic vein and inferior vena cava safer. Mastery of the anatomy is paramount before attempting this approach with minimally invasive techniques. Surgeons who attempt this operation should have expertise with both laparoscopy and liver surgery.

Application of ICG fluorescence staining by laparoscopic ultrasound and 3D visualization guided portal branch puncture approach in anatomical segmentectomy

Objective To investigate the feasibility and safty of indocyanine green (ICG) fluorescence staining by laparoscopic ultrasound and three-dimensional (3D) visualization guided portal branch puncture approach in anatomical segmentectomy. Methods The retrospective cross-sectional study was conducted. The clinical data of 26 patients who underwent anatomical segmentectomy using ICG fluorescence staining by laparoscopic ultrasound and 3D visualization guided portal branch puncture approach in the Zhongshan Hospital of Fudan University between December 2016 and April 2018 were collected. The preoperative 3D visualization reconstruction and areas of portal branch perfusion were analyzed, laparoscopic ultrasound localization was intraoperatively applied to tumor and portal vein of targeted hepatic segment, and then portal branch puncture and staining were done under laparoscopic ultrasound and 3D visualization, finally laparoscopic anatomical segmentectomy was performed. Observation indicators: (1) intraoperative situations: success rate of portal vein puncture, targeted hepatic segment, effect of ICG fluorescence staining, intraoperative complications, operation time, volume of intraoperative blood loss, blood transfusion, conversion to open surgery, tumor diameter, the minimum resection margin to tumor; (2) postoperative situations: postoperative complications (Clavien-Dindo classification as a criteria) and duration of hospital stay; (3) follow-up situations: cases with follow-up, follow-up time and postoperative tumor recurrence. Follow-up using outpatient examination and telephone interview was performed to detect postoperative tumor recurrence up to April 2018. Measurement data with normal distribution and count data were respectively described as average (range) and percentage. Results (1) Intraoperative situations: a success rate of laparoscopic ultrasound and 3D visualization guided portal branch puncture in 26 patients was 100.0%(26/26), and punctures in S8, S7, S2, S3, S6, S5 and S4 of the liver were respectively performed to 7, 6, 4, 3, 3, 2 and 1 patients. Of 26 patients, 22 achieved expected effect of ICG fluorescence staining, with a statisfaction of 84.6%(22/26) and 4 failed to get expected effect, including 2 with uneven dying, 1 with staining-uncovered partial areas of targeted liver segment and 1 with adjacent hepatic segmental staining induced to unclear boundary. All the 26 patients were not complicated with ICG injection induced to allergy. Average operation time and volume of intraoperative blood loss were 184 minutes (range, 60-315 minutes) and 97 mL (range, 10-400 mL), without intraoperative blood transfusion and conversion to open surgery. Average tumor diameter and average minimum resection margin to tumor in 26 patients were respectively 3.2 cm (range, 1.2-10.0 cm) and 1.5 cm (range, 0.4-3.0 cm). (2) Postoperative situations: of 26 patients, 2 with gradeⅠ-Ⅱ of Clavien-Dindo classification were improved by drug treatments (1 with deep venous thrombosis of the lower extremities and 1 with pleural effusion), no patient had grade Ⅲ and above complications, and there was no bile leakage, infection and hepatic dysfunction. Average duration of hospital stay in 26 patients was 6.9 days (range, 5.0-14.0 days). (3) Follow-up situations: 26 patients were followed up for 0.3-17.0 months, with a median time of 6.0 months. During the follow-up, 1 patient with hepatocellular carcinoma had adrenal metastasis and 25 had tumor-free survival. Conclusion Laparoscopic anatomical segmentectomy with ICG fluorescence staining by laparoscopic ultrasound and 3D visualization guided portal branch puncture approach is safe and feasible, especially suitable in posterosuperior liver segments. Key words: Hepatic neoplasms; Anatomical hepatic segmentectomy; Laparoscopy; Interventional ultrasonography; Three-dimensional visualization; Portovenography; Indocyanine green

Initial experience with robotic hepatectomy in Singapore: analysis of 48 resections in 43 consecutive patients.

Presently, the adoption of laparoscopic hepatectomy is rapidly increasingly worldwide. However, the application of robotic hepatectomy (RH) remains limited and its role remains undefined today. A retrospective review of 43 consecutive patients who underwent RH at two institutions in the Singapore Health Services Group. Forty-three consecutive patients underwent 48 resections during the study period. Seven (16.3%) patients underwent major resections and seven (16.3%) underwent right posterior sectionectomies. Nineteen (44.2%) patients had tumours located in the difficult posterosuperior segments, five had multiple resections and three underwent repeat resections for recurrent tumours. RH was performed for malignant tumours in 32 (74%) patients and 16 (37.2%) had cirrhosis. Seven RH was performed with other concomitant procedures including three colectomies, three hilar lymphadenectomies and one portal vein ligation. The median operation time was 360 min (range 75-825) and the median blood loss was 300 mL (range 25-4500). There was one (2.3%) open conversion for bleeding. The median post-operative stay was 4 days (range 2-33) and there was one (2.3%) readmission. There was one (2.3%) major (>grade 2 morbidity) in a patient with concomitant anterior resection who underwent reoperation for anastomotic leak. There was no 90 day/in-hospital mortality. Comparison between RH for tumours in the anterolateral segments versus posterosuperior segments demonstrated no significant difference in perioperative outcomes. Our initial experience demonstrated that RH is safe, feasible and associated with excellent post-operative outcomes. It can be performed successfully with low morbidity even for complex resections such as major hepatectomies, posterior sectionectomies, tumours in difficult posterosuperior segments and repeat liver resections.

Open versus laparoscopic liver resection for colorectal liver metastases located in the postero-superior segments: a sub-group analysis from the Oslo-CoMet trial

Background: Laparoscopic liver resection of tumors located in the postero-superior segments is considered to be technically challenging. This study aimed to compare the perioperative outcomes for laparoscopic versus open resection of colorectal liver metastases located in the PS segments. Methods: This is a sub-study of the Oslo-CoMet trial. In this trial, 280 patients were randomly assigned to open or laparoscopic parenchyma-sparing liver resections of colorectal metastases. Inclusion was from February 2012 to February 2016. For the current study, patients with metastases in postero-superior segments were identified, and perioperative and short-term oncological outcomes were collected from the prospective trial database. The Accordion system and the Comprehensive Complication Index were used for grading of postoperative complications. Results: 62 patients underwent laparoscopic and 74 patients underwent open liver resections. A total of 257 lesions were removed. A total of 23 patients(31%) in open group and 16 patients(26%) in the laparoscopic group developed postoperative complications (P = 0.49).The mean comprehensive complication index was 32 in the open group and 26 in the laparoscopic group (P = 0.19) Median postoperative hospital stay was 2 days in the laparoscopic and 4 days in the open group (P < 0.001). Blood loss was slightly higher in patients assigned to laparoscopic surgery (500 vs. 250 ml, P = 0.001), whereas the operative time (median, 145 vs. 143 min) was similar between the two groups. Conclusion: In this subgroup-analysis of patients in the Oslo-Comet trial, we found similar postoperative complications rate and shorter hospital stay following laparoscopic resection of posterior-superior segments.

Totally Thoracoscopic Resection of Recurrent Intrahepatic Cholangiocarcinoma in Segment VII

Introduction: With advancement in surgical techniques, minimally invasive techniques are increasingly being used for liver resection. Although most of the cases could be operated laparoscopically,1 there are few case reports and series describing thoracoscopic approach for liver tumors, especially those located in segment, VII, VIII, and IVa immediately under the diaphragm.2–5 Thoracoscopic approach can be especially useful in recurrent tumors located in posterosuperior segments as laparoscopic approach is more difficult and time consuming because of dense adhesions as seen in our case. Case Description: A 43-year-old woman underwent laparoscopic extended left hepatectomy, including segment, V, VIII, and XI with lymphadenectomy and was converted to open to perform biliobiliary anastomosis for intrahepatic cholangiocarcinoma in January 2014. Subsequently, four cycles of gemcitabine and oxaliplatin-based chemotherapy was administered. After chemotherapy, she developed a limited recurrence of 2.5 and 1.7 cm diameter at the cut surface of the liver treated with laparoscopic metastasectomy in October 2014. Later in February 2016, she underwent thoracoscopic excision of pulmonary metastatic lesion in left superior lobe. Subsequently, she was detected to have a 4 × 3.5 × 3 cm recurrent tumor in segment VII just under the diaphragm. PET-CT did not reveal any other site of metastasis. She underwent thoracoscopic resection of the recurrent liver lesion in September 2016 (Video). The patient was placed in the 45° left lateral position under general anesthesia with double lumen endotracheal tube. First, diagnostic laparoscopy was performed to rule out peritoneal dissemination. Adhesions around the porta hepatis were dissected such that Pringle's maneuver could be applied if required during parenchymal transection. Subsequently thoracoscopic procedure was initiated by using two 12 mm and two 5 mm ports as shown in the video. The tumor was located by using the flexible laparoscopic ultrasound probe through the diaphragm; the diaphragm was opened immediately above the tumor using Thunderbeat® (Olympus, Tokyo, Japan). The diaphragm was separated from the tumor and the limits of liver resection were marked with the help of laparoscopic ultrasound. With the help of Gayet bipolar forceps (MicroFrance CEV134; Integra life) and Thunderbeat (Olympus), wide local excision of the tumor was performed as demonstrated in the video. The specimen was extracted using a retrieval bag by a separate incision between the vertebral ribs. After confirming hemostasis and biliostasis, the diaphragm was closed by continuous suturing using nonabsorbable V-LOC™ (Covidien). Results: The operative time was 180 minutes with blood loss of 150 mL. She had uneventful postoperative recovery and was discharged on postoperative day 4. Histopathology revealed recurrent intrahepatic cholangiocarcinoma with tumor-free resection margin and a small adjoining liver hemangioma as shown in the preoperative imaging. The patient received gemcitabine-based adjuvant chemotherapy after surgery. On the last follow-up at 1 year after surgery, she is doing well without any evidence of recurrence. Conclusion: Thoracoscopic approach could be an interesting alternative to abdominal approach for resection of liver lesions located under the diaphragm. No competing financial interests exist. Runtime of video: 5 mins 56 secs Presented at the AP-HPBA, in Tokyo, June 9, 2017.

Evolution of laparoscopic liver resection at Singapore General Hospital: a nine-year experience of 195 consecutive resections.

We aimed to analyse the changing trends, safety and outcomes associated with the adoption of laparoscopic liver resection (LLR) at a single centre. A retrospective review of patients who underwent LLR from 2006 to 2014 at our institution was performed. To explore the evolution of LLR, the study was divided into three equal consecutive time periods (Period 1: 2006-2008, Period 2: 2009-2011, and Period 3: 2012-2014). Among 195 patients who underwent LLR, 24 (12.3%) required open conversions, 68 (34.9%) had resection of tumours in the difficult posterosuperior segments and 12 (6.2%) underwent major (≥ 3 segments) hepatectomies. Median operation time was 210 (range 40-620) minutes and median postoperative stay was 4 (range 1-26) days. Major postoperative morbidity (> Grade II) occurred in 11 (5.6%) patients and 90-day/in-hospital mortality was 1 (0.5%). During the study, the number of LLRs performed showed an increasing trend (Period 1: n = 22; Period 2: n = 19; Period 3: n = 154). Other statistically significant trends were: (a) increase in malignant neoplasms resected; (b) increase in resections of difficult posterosuperior segments; (c) longer median operation time; and (d) decrease in open conversion rates. Over the study period, the number of LLRs increased rapidly. LLR was increasingly performed for malignant neoplasms and lesions located in the difficult posterosuperior segments, resulting in longer operation times. However, open conversion rates decreased, and there was no change in postoperative morbidity and other perioperative outcomes.

Systematic review of the feasibility and future of laparoscopic liver resection for difficult lesions.

Laparoscopic liver resection (LLR) is now performed widely, but is difficult to accomplish in some anatomical locations, such as the posterosuperior segments (S7 and S8) and caudate lobe (S1). An international survey revealed that lesions in these locations are less frequently indicated for LLR than those in other segments. Recent reports from experienced centers document several case series and present technical tips for treating such lesions. The lateral approach using intercostal (transdiaphragmatic) trocars was reported to be useful for lesions in the posterosuperior segments with a semi- to full-decubitus position. The thoracoscopic approach was also reported to be useful for lesions just under the diaphragm dome, but the tumor location and patient selection should be considered carefully because pneumoperitoneum pressure and Pringle's maneuver cannot be applied. Several case series have described the feasibility of LLR for caudate lobe lesions, with similar operative outcomes to lesions in the posterosuperior segments, but this demands technical expertise. The caudal view of laparoscopy is advantageous for approaching the caudate lobe. We conducted a systematic review to clarify the feasibility of LLR for difficult lesions and discuss its current and future status.

Critical appraisal of the impact of individual surgeon experience on the outcomes of laparoscopic liver resection in the modern era: collective experience of multiple surgeons at a single institution with 324 consecutive cases.

Most studies analyzing the learning experience of laparoscopic liver resection (LLR) focused on the experience of one or two expert pioneering surgeons. This study aims to critically analyze the impact of individual surgeon experience on the outcomes of LLR based on the contemporary collective experiences of multiple surgeons at single institution. Retrospective review of 324 consecutive LLR from 2006 to 2016. The cases were performed by 10 surgeons over various time periods. Four surgeons had individual experience with <20 cases, four surgeons with 20-30 cases, and two surgeons with >90 cases. The cohort was divided into two groups: comparing a surgeon's experience between the first 20, 30, 40, and 50 cases with patients treated thereafter. Similarly, we performed subset analyses for anterolateral lesions, posterosuperior lesions, and major hepatectomies. As individual surgeons gained increasing experience, this was significantly associated with older patients being operated, decreased hand-assistance, larger tumor size, increased liver resections, increased major resections, and increased resections of tumors located at the posterosuperior segments. This resulted in significantly longer operation time and increased use of Pringle maneuver but no difference in other outcomes. Analysis of LLR for tumors in the posterosuperior segments demonstrated that there was a significant decrease in conversion rates after a surgeon had experience with 20 LLR. For major hepatectomies, there was a significant decrease in morbidity, mortality, and length of stay after acquiring experience with 20 LLR. LLR can be safely adopted today especially for lesions in the anterolateral segments. LLR for lesions in the difficult posterosuperior segments and major hepatectomies especially in cirrhosis should only be attempted by surgeons who have acquired a minimum experience with 20 LLR.

Evolution of Laparoscopic Liver Surgery from Innovation to Implementation to Mastery: Perioperative and Oncologic Outcomes of 2,238 Patients from 4 European Specialized Centers

First seen as an innovation for select patients, laparoscopic liver resection (LLR) has evolved since its introduction, resulting in worldwide use. Despite this, it is still limited mainly to referral centers. The aim of this study was to evaluate a large cohort undergoing LLR from 2000 to 2015, focusing on the technical approaches, perioperative and oncologic outcomes, and evolution of practice over time. The demographics and indications, intraoperative, perioperative, and oncologic outcomes of 2,238 patients were evaluated. Trends in practice and outcomes over time were assessed. The percentage of LLR performed yearly has increased from 5% in 2000 to 43% in 2015. Pure laparoscopy was used in 98.3% of cases. Wedge resections were the most common operation; they were predominant at the beginning of LLR and then decreased and remained steady at approximately 53%. Major hepatectomies were initially uncommon, then increased and reached a stable level at approximately 16%. Overall, 410 patients underwent resection in the posterosuperior segments; these were more frequent with time, and the highest percentage was in 2015 (26%). Blood loss, operative time, and conversion rate improved significantly with time. The 5-year overall survival rates were 73% and 54% for hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM), respectively. The 5-year, recurrence-free survival rates were 50% and 37% for HCC and CRLM, respectively. Since laparoscopy was introduced, a long implementation process has been necessary to allow for standardization and improvement in surgical care, mastery of the technique, and the ability to obtain good perioperative results with safe oncologic outcomes.