Resections Of Posterosuperior Segments Research Articles

Standardization of robotic right liver mobilization.

Since its introduction 2decades ago, robotics has been increasingly used for resection of benign and malignant liver lesions. The robotic platform seems to preserve minimally invasive approach benefits, overcoming laparoscopy limitations. Robotic right liver mobilisation represents a key step for many robotic resections from non-anatomical resections of posterosuperior segments to right hepatectomy. We present here a standardized technique of right hepatic lobe mobilisation including technical steps and videos. Robotic resection provide all benefits of minimally invasive approaches in terms of preserving abdominal wall, early alimentation, reduced respiratory stress, associated with more ergonomic conditions for surgeon. We present our standardized and feasible right liver lobe mobilisation needed for posterosuperior resections to the right hepatectomy. The standardisation of right liver lobe represented our aim to provide a safe and reproducible initial step for many procedures to reduce the conversion rate and to improve the learning curve in young surgeons.

Perioperative Outcomes of Laparoscopic Liver Resection and Risk Factors for Adverse Events.

The perioperative outcomes and risk factors associated with adverse events (AEs) after initial laparoscopic liver resection (LLR) are unclear. We studied the outcomes of LLR and identified the predictive factors for AEs. Data from 100 adults who underwent LLR between April 2014 and February 2020 were reviewed. Baseline characteristics, surgery details, intraoperative data, and postoperative outcomes were tabulated. The AEs included conversion to open surgery, morbidity, and mortality. Major and minor LLRs accounted for 16% and 84% of cases, respectively. Of the indications for LLR, 88% were malignancies. Conversion to open surgery was necessary for 7% of the patients, the overall morbidity rate was 21%, the major morbidity rate was 7%, and the 90-day mortality rate was 1%. Although the incidence of AEs was higher after major LLR (37.5%) than after minor LLR (21.4%), the difference was not statistically significant (P=0.095); the rate of AEs in the resection of posterosuperior segments (43.7%) did not significantly differ from that of the anteroinferior segments (19.2%; P=0.095). Multivariable analysis revealed that the significant predictors of AEs included American Society of Anesthesiologists (ASA) class III (odds ratio, 5.76; 95% confidence interval, 1.74-19.1; P=0.003) and an operative time longer than 5 hours (odds ratio, 9.20; 95% confidence interval, 2.41-35.07; P<0.001). To improve outcomes in LLR, patients with ASA class III and those in whom surgery is expected to last longer than 5 hours should be taken into account for better patient selection.

Multicentre evaluation of case volume in minimally invasive hepatectomy.

Surgical outcomes may be associated with hospital volume and the influence of volume on minimally invasive liver surgery (MILS) is not known. Patients entered into the prospective registry of the Italian Group of MILS from 2014 to 2018 were considered. Only centres with an accrual period of at least 12 months and stable MILS activity during the enrolment period were included. Case volume was defined by the mean number of minimally invasive liver resections performed per month (MILS/month). A total of 2225 MILS operations were undertaken by 46 centres; nine centres performed more than two MILS/month (1376 patients) and 37 centres carried out two or fewer MILS/month (849 patients). The proportion of resections of anterolateral segments decreased with case volume, whereas that of major hepatectomies increased. Left lateral sectionectomies and resections of anterolateral segments had similar outcome in the two groups. Resections of posterosuperior segments and major hepatectomies had higher overall and severe morbidity rates in centres performing two or fewer MILS/month than in those undertaking a larger number (posterosuperior segments resections: overall morbidity 30·4 versus 18·7 per cent respectively, and severe morbidity 9·9 versus 4·0 per cent; left hepatectomy: 46 versus 22 per cent, and 19 versus 5 per cent; right hepatectomy: 42 versus 34 per cent, and 25 versus 15 per cent). A volume-outcome association existed for minimally invasive hepatectomy. Complex and major resections may be best managed in high-volume centres.

Postero-superior liver segments resection for colorectal liver metastases. PSM based comparative analysis of minimally invasive and open resections

Introduction: Outcomes of liver postero-superior segments resection for malignant tumors is of ongoing evaluation. We aimed to compare survival after laparoscopic and open resection of postero-superior segments for colorectal liver metastases in two Russian centers. Propensity score matching (PSM) based comparative analysis was performed. Method: Comparison of immediate outcomes and survival after minimally invasive liver resection (MILR) included laparoscopic and robotic procedures, and open liver resection (OLR) of postero-superior segments using PSM. Data were collected for seven years (2010-2017) in two Russian high-volume centers. Result: Outcomes of 88 MILR and 59 OLR were analyzed. After excluding patients without complete follow up data and with extrahepatic metastases immediate treatment outcomes and survival of 54 patients (after 37 minimally invasive and 17 open procedures for metastases in postero-superior segments) were analyzed. Before PS matching 4-year survival was 68% and 62% after MILR and OLR, respectively. Thirteen pairs were matched. MILR demonstrated significantly better outcomes in comparison with OLR in terms of mean blood loss and time of hospital stay before PSM. After PSM there were no differences in mean blood loss and mean length of hospital stay. No differences were revealed in severe morbidity (grade III and more according to Clavien-Dindo classification) as well in duration of liver resection and ICU stay between MILR and OLR before and after PSM. After matching 3-year survival was 81% and 70% for MILR and OLR, respectively, without significant differences. Conclusion: Preliminary analysis of two Russian centers experience confirms assumption that outcomes of MILR and OLR colorectal liver metastases have no differences in terms of safety and survival.

Postero-superior liver segments resection for benign tumors. Short-term results

Introduction: Indication for laparoscopic postero-superior liver segments resection in patients with benign tumors remains controversial. We aimed to evaluate the short-term results of minimally invasive resections (MILR) for benign tumors of postero-superior liver segments. Method: Data were accumulated since 2014 to 2018. Indications for liver resection were giant (>8 cm) growing lesions with clinical signs (abdominal pain on physical activity) and suspicion for malignancy. Result: Liver resection were performed in 75 patients. MILR were applied in 68 (91%), including 55 lap and 13 robotic resections. The benign lesions were presented by hemangioma (36), adenoma (13), FNH (12) and cystadenoma (7). Mean tumor size 8,8 cm (max 20 cm). Tumor size in 62% of cases was more than 8 cm. In 32 (47%) cases tumor adjoining to vessels. Partial resection of postero-superior segments and caudate lobe was performed in 25 (37%) patients. Robotic system was used in 8 of them. Open approach was applied only for 7 major hepatectomy (9%). Major morbidity after MILR of postero-superior segments was observed in 2 (2,9%) patient (IIIA, Clavien-Dindo): hematoma, after lap S6,7 resection and biloma after lap S3,4,8 resection, requiring additional drainage. There was no mortality. After major open liver resections bile leakage took place in 3 patients and required additional drainage. Mean operation time of MILR and open resection was comparable: 273 (160-490) min and 324 (260-395) min, respectively. The mean blood loss for MILR and open procedures was 300 (10-1000) ml and 1542 (100-4500) ml, respectively. The mean postoperative hospital stay after MILR and open resection was 6 (4-12) and 7(6-10) days, respectively. Conclusion: MILR for benign lesions located in postero-superior segments is the safe option for treatment of symptomatic and large benign tumors and may be considered as the first choice approach if surgery is indicated.

Open versus laparoscopic liver resection for colorectal metastases located in the posterosuperior segments

Background: Laparoscopic liver resection of tumors located in the posterosuperior segments is considered to be technically challenging.This study aimed to compare the perioperative outcomes for laparoscopic versus open resection of colorectal liver metastases (CRLM) located in the posterosuperior 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 CLRM. Inclusion was from February 2012 to February 2016. Patients with CRLM in posterosuperior 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 complication. Results: 62 patients underwent laparoscopic and 78 patients open liver resections. Postoperative complications developed in 22 cases (28.2%) in open group and 16 cases (25.4%) in laparoscopic group (p=0.71). The median postoperative hospital stay was 2 days in the laparoscopic and 4 days in the open group (p<0.001). Further perioperative outcomes will be presented at the congress. Conclusion: We found similar postoperative complications rate and decreased hospital stay, following laparoscopic resection of posterosuperior segments in patients with CRLM.

First quarter century of laparoscopic liver resection.

The beginnings of laparoscopic liver resection (LLR) were at the start of the 1990s, with the initial reports being published in 1991 and 1992. These were followed by reports of left lateral sectionectomy in 1996. In the years following, the procedures of LLR were expanded to hemi-hepatectomy, sectionectomy, segmentectomy and partial resection of posterosuperior segments, as well as the parenchymal preserving limited anatomical resection and modified anatomical (extended and/or combining limited) resection procedures. This expanded range of LLR procedures, mimicking the expansion of open liver resection in the past, was related to advances in both technology (instrumentation) and technical skill with conceptual changes. During this period of remarkable development, two international consensus conferences were held (2008 in Louisville, KY, United States, and 2014 in Morioka, Japan), providing up-to-date summarizations of the status and perspective of LLR. The advantages of LLR have become clear, and include reduced intraoperative bleeding, shorter hospital stay, and - especially for cirrhotic patients-lower incidence of complications (e.g., postoperative ascites and liver failure). In this paper, we review and discuss the developments of LLR in operative procedures (extent and style of liver resections) during the first quarter century since its inception, from the aspect of relationships with technological/technical developments with conceptual changes.

Robotic liver resection including the posterosuperior segments: initial experience

BackgroundRobot-assisted laparoscopy has been introduced to overcome the limitations of conventional laparoscopy. This technique has potential advantages over laparoscopy, such as increased dexterity, three-dimensional view, and a magnified view of the operative field. Therefore, improved dexterity may make a robotic system particularly suited for liver resections, which require nonlinear manipulation, such as curved parenchymal transection, hilar dissection, and resection of posterosuperior segments. MethodsBetween August 2014 and March 2016, 16 patients underwent robot-assisted laparoscopic liver resection at University Medical Center Utrecht. ResultsFifteen robot-assisted laparoscopic liver resections were performed in a minimally invasive manner. One procedure was converted. In eight patients, we performed a resection of a posterosuperior segment (segment 7 or 8). Median operating time was 146 (60-265) min, and median blood loss was 150 (5-600) mL. Four patients had a Clavien–Dindo grade III complication. Median length of stay was 4 (1-8) days. There was no mortality. ConclusionsThis prospective study reporting on our initial experience with robot-assisted laparoscopic liver resection demonstrates that this technique is easily adopted, safe, and feasible for minor hepatectomies in selected patients. Moreover, it shows that the robotic platform also enables fully laparoscopic resections of the posterior segments.

Hemorrhage control for laparoscopic hepatectomy: technical details and predictive factors for intraoperative blood loss.

Controlling bleeding during laparoscopic hepatectomy (LH) is technically demanding, but reportedly associated with less estimated blood loss (EBL) than open surgery. The present study aimed to describe and evaluate hemorrhage control techniques during LH and identify predictors of high intraoperative EBL. The data of 438 consecutive patients undergoing LH between 1995 and 2012 were reviewed. Bleeding control was facilitated by the proper use of hemostatic devices and surgical maneuvers unique to LH and by preserving intra-abdominal pressure. EBL was evaluated among three groups of 146 patients in each group: 1995-2006 (group A), 2006-2009 (group B), and 2009-2012 (group C). We also sought factors that predicted EBL ≥800mL. Mean EBL decreased overtime from groups A to C: group A, 378±619mL; group B, 293±391mL; groups C, 257±366mL; P=0.127. Transfusion rate was 6.7% in group A, 5.5% in group B, and 4.8% in group C (P=0.743). Hypertension (odds ratio (OR) 2.82, 95% confidence interval CI 1.37-5.78; P=0.006), preoperative chemotherapy (OR 2.55, 95% CI 1.26-5.31; P=0.009), resection of posterosuperior segments (OR 3.73, 95% CI 1.33-12.17; P=0.012), and major hepatectomy (OR 4.21, 95% CI 1.64-13.02; P<0.001) independently predicted high EBL. Improvements in bleeding control techniques over time have reduced EBL during LH. The use of these techniques and an understanding of the predictive factors for high EBL will help surgeons improve outcomes after LH.

Minimally invasive liver surgery: an update.

It is a great pleasure for us to introduce this special issue of Updates in Surgery focused on ‘‘Minimally Invasive Surgery of the Liver’’ (MILS). Indeed, this area has recently developed and grown thanks both to advances in new technologies and to efforts done by a new generation of surgeons: in 2015, minimally invasive liver surgery has proved its safety and efficacy when performed by teams with good experience in both laparoscopic and hepatic surgery, allowing a significant reduction of intraoperative blood loss, need for portal clamping, postoperative morbidity and shortening postoperative hospitalization, as a result of a more rapid functional recovery. Initial skepticisms regarding technical challenges and oncological adequacy have been overcome, and great enthusiasm has been raised in this newborn field. In 2014, the 2nd consensus conference on MILS was held in Morioka, Japan, and recommendations based on the strength of scientific evidences have been provided. Many training opportunities are now available for surgeons who want to get specific experience. Overall, the future of MILS seems to be promising. Despite this, many topics still deserve in-depth study: this monographic volume tries to reply to many open issues and to certify and codify what has already been acknowledged in clinical practice; we are witnesses of a dramatic change in the way of approaching many liver diseases and have the duty of offer the best available treatment to our patients. We have the honor of including an Editorial from Professor Wakabayashi who describes current trends of laparoscopic liver surgery and its evolution from Louisville to Morioka. The volume is then structured into two sessions, thanks to the contribution of Italian and international authors: in the first one, four review articles are provided, focusing on hot topics like HCC surgery, definition of segmentectomies, robotic approach and difficulty scores; in the second part, by means of original articles, contributions are provided to scientific knowledge on issues that are still debated, such as indications and contraindications of major resections, resections of posterosuperior segments, outcomes of metastases resection, MILS in highand low-volume Italian centers, advantages and limitations of robotic approach, learning curve and accuracy of laparoscopic ultrasound. We therefore wish to thank all the authors for their effort in providing a better insight into the present and future time of this revolutionary approach to liver surgery. We do hope that this editorial effort may help Italian and foreign colleagues willing to develop their activity in minimally invasive MILS according to the principles of scientific knowledge and evidence-based medicine. Luca Aldrighetti Fulvio Calise

Laparoscopic liver resection: a systematic review

Outcomes of laparoscopic liver resection (LLR) are not clarified. The objective of this article is to depict the state of the art of LLR by means of a systematic review of the literature. Studies about LLR published before September 2008 were identified and their results summarized. Indications for laparoscopic hepatectomy do not differ from those for open surgery. Technical feasibility is the only limiting factor. Bleeding is the major intraoperative concern, but, if managed by an expert surgeon, do not worsen outcomes. Hand assistance can be useful in selected cases to avoid conversion. Patient selection must take both tumor location and size into consideration. Potentially good candidates are patients with peripheral lesions requiring limited hepatectomy or left lateral sectionectomy; their outcomes, including reduced blood loss, morbidity, and hospital stay, are better than those of their laparotomic counterparts. The same advantages have been observed in cirrhotics. Laparoscopic major hepatectomies and resections of postero-superior segments need further evaluation. The results of LLR in cancer patients seem to be similar to those obtained with the laparotomic approach, especially in cases of hepatocellular carcinoma, but further analysis is required. Laparoscopic liver resection is safe and feasible. The laparoscopic approach can be recommended for peripheral lesions requiring limited hepatectomy or left lateral sectionectomy. Preliminary oncological results suggest non-inferiority of laparoscopic to laparotomic procedures.