Laparoscopic right posterior hepatic bisegmentectomy (Segments VII-VIII)

The role of laparoscopy in liver surgery is still a subject of debate. Up to now, isolated hepatic lesions requiring a segmental (or bisegmental) resection have been considered to be an indication for laparoscopic surgery only when they are located in the left lobe or in the right lower lobe, whereas an open approach by laparotomy or thoracotomy is still preferred for lesions of the upper right lobe. Here we report a case of a right posterior hepatic bisegmentectomy (segments VII-VIII) performed for a hepatic hemangioma that was carried out entirely laparoscopically. In our opinion, there is not an a priori contraindication to the laparoscopic resection of any hepatic benign lesion, wherever it is located in the liver parenchyma. Nevertheless, major hepatic resections still have to be performed by expert surgeons in specialized centers.     

An initial experience and evolution of laparoscopic hepatic resectional surgery

BACKGROUND: The use of minimally invasive procedures has revolutionized modern surgery. Only recently has laparoscopy been introduced for use in hepatic surgery. METHODS: Patient demographics, tumor characteristics, and outcomes were evaluated for all initial cases of laparoscopic hepatic resection. RESULTS: Twenty-one resections were performed in 17 patients; 5 were performed for malignancy, of which 3 had underlying cirrhosis, and the remaining 12 for benign symptomatic disease. Mean patient age was 55.4 (range, 24-82 years). The mean number of lesions was 1.4 (range, 1-5), having an average size of 7.6 cm (range, 2-30 cm). Mean operative time was 2.8 hours (range, 2-5 hours) hours. Most resections involved 1 or more Couinaud segments. Mean blood loss was 288 cc (range, 50-150 cc). Complications included re-operation for hemorrhage (n=2), biliary leakage (n=1), and death from hepatic failure (n=1). Mean length of stay was 2.9 days (range, 1-14). When compared with our series of 100 patients who underwent open hepatic resection for benign tumors, significantly greater means ( P <.05) were noted for blood loss (485 cc), operative time (4.5 hours), and length of stay (6.5 days). CONCLUSIONS: Laparoscopic hepatic surgery, though complex, can be performed safely and efficaciously. Minimally invasive surgery appears to provide several distinct advantages over traditional open hepatic surgery. However, techniques for the laparoscopic control of bleeding and bile leak remain in their infancy.     

Laparoscopic resection of liver tumors in children

BackgroundLaparoscopy for the resection of liver tumors in children has remained undeveloped in comparison to adults. Most of the indications for pediatric laparoscopic hepatic surgery have been limited to diagnostic laparoscopy (biopsy). Over the past ten years, however, laparoscopic liver resections for pediatric hepatic diseases have been performed successfully, and many case reports have been published.MethodsThe authors report 6 cases of laparoscopic hepatic resection of benign tumors in children. The most important aspects of surgical technique are presented. There were 3 boys and 3 girls, with age between 4 months and 16 years. The lesions were located in the following segments: II and III (4 patients), I (1), V (1). The maximum tumor size was 7 cm.ResultsOne anatomical (left bisegmentectomy) and 5 nonanatomical resections were performed. Conversion to laparotomy was necessary in 1 patient owing to bleeding from the posterior branch of the right hepatic artery. There were no postoperative complications and patients were discharged on postoperative day 4, 5, 5, 5, 7 and 3 accordingly. The postoperative pathology of the specimens confirmed their benign nature: infantile hemangioendothelioma (1), nested stromal epithelial tumor (1), focal nodular hyperplasia (3), mixed benign tumor (hamartoma + vascular malformation) (1).ConclusionsThis report demonstrates the feasibility of a laparoscopic hepatic resection in children. On the other hand, laparoscopic liver resection is challenging and teamwork and specific training are necessary.     

Glisson蒂横断式解剖性肝切除120例治疗体会

目的探讨Glisson蒂横断式解剖性肝切除术的应用价值。方法回顾性分析临沧市人民医院2014年1月至2017年3月行Glisson蒂横断式解剖性肝段切除术120例患者的临床资料。其中原发性肝癌65例,胆管细胞癌4例,肝门部胆管癌4例,胆囊癌6例,肝内胆管结石33例,肝血管瘤8例,肝寄生虫病10例。采用Glisson蒂横断式解剖性肝切除Ⅰ段切除3例,Ⅰ+Ⅱ段切除1例,Ⅰ+Ⅱ+Ⅲ+Ⅳ段切除1例,Ⅰ+Ⅱ+Ⅲ+Ⅳ+Ⅴ+Ⅷ段切除1例,Ⅱ+Ⅲ+Ⅳ+Ⅷ段切除1例,Ⅱ+Ⅲ+Ⅴ+Ⅵ+Ⅶ+Ⅷ段切除1例,左外叶(Ⅱ+Ⅲ段)切除33例,左半肝(Ⅱ+Ⅲ+Ⅳ段)切除22例,左三叶(Ⅱ+Ⅲ+Ⅳ+Ⅴ+Ⅷ段)切除3例,Ⅳb+Ⅴ段切除6例,Ⅳ+Ⅴ+Ⅷ段切除3例,右半肝切除(Ⅴ+Ⅵ+Ⅶ+Ⅷ段)25例,右三叶切除(Ⅳ+Ⅴ+Ⅵ+Ⅶ+Ⅷ段)3例,右前叶(Ⅴ+Ⅷ段)切除5例,Ⅵ段切除2例,右后叶切除术(Ⅵ+Ⅶ段)4例,Ⅶ段切除2例,Ⅷ段切除4例。其中9例同时行肝管空肠RouxY吻合术。结果全组均完成手术。术中平均出血量630 mL。平均手术时间3.7 h。术后发生并发症34例(28.33%),为胆漏、胸腔积液、多重耐药菌感染等。结论 Glisson蒂横断式解剖性肝切除术操作简便,快速安全,能明显减少出血,提高疗效,是一种可选择的手术方式。     

A new approach to hand-assisted laparoscopic liver surgery

Background  The best type of laparoscopic approach in solid liver tumours (SLTs), whether total laparoscopic surgery or hand-assisted laparoscopic surgery (HALS), has not yet been established. Our objective is to present our experience with laparoscopic liver resections in SLTs performed by HALS using a new approach. Methods  We performed 35 laparoscopic resections in SLTs, of which 26 were carried out using HALS (in 25 patients) and 21 patients had liver metastases of a colorectal origin (LMCRC) (1 patient had 2 resections), 1 metastasis from a neuroendocrine tumour of the pancreas, 1 hepatocarcinoma on a healthy liver, 1 primary hepatic leiomyosarcoma and 1 giant haemangioma. Mean follow-up was 22 months. Operation  One right hemihepatectomy, one left hemihepatectomy, five bisegmentectomies II–III, three bisegmentectomies VI–VII and 16 segmentectomies (five of S. VI, three of S. VIII; three of S. V; two of S. IVb; one of S. II; one of S. IV; and in the remaining case resection of S. III and VI plus resection of a metastasis in S. VIII). Main outcome measures  Morbidity and mortality, conversion to open procedure, intraoperative blood loss, intra- and postoperative transfusion, length of stay and survival. Results  There were no intra- or postoperative deaths, nor were there any conversions. One patient presented with morbidity (3.8%) (liver abscess). Mean blood loss was 200 ml (range 0–600 ml). One patient required transfusion (3.8%). Mean operative time was 180 min (range 120–360 min). Mean length of hospital stay was 4 days (range 2–5 days). The actuarial survival rate of the patients at 36 months with liver metastases from colorectal carcinoma (LMCRC) was 80%. Conclusions  Liver resection with HALS reproduces the low morbidity and mortality rates and effectiveness (3-year survival) of open surgery in SLTs when indicated selectively.     

Laparoscopic liver resection: results for 70 patients

Background Laparoscopy is slowly becoming an established technique for liver resection. This procedure still is limited to centers with experience in both hepatic and laparoscopic surgery. Preliminary reports include mainly minor resections for benign liver conditions and show some advantage in terms of postoperative recovery. The authors report their experience with laparoscopic liver resection, the evolution of the technique, and the results. Methods From 1999 to 2006, 70 laparoscopic liver resections were performed using a procedure similar to resection by laparotomy. Results There were 38 malignant tumors (54%) and 32 benign lesions (46%). The malignant tumors were mainly hepatocellular carcinomas (19 of 24 patients had cirrhosis). The tumor mean size was 3.8 ± 1.9 cm (range, 2.2–8 cm). There were 19 major hepatectomies, 34 uni- or bisegmentomies, and 17 atypical resections. The operative time was 227 ± 109 min. Conversion to laparotomy was required for seven patients (10%), mainly for continuous bleeding during transection. Nine patients (13%) required blood transfusion. One patient had both brisk bleeding and gas embolism from a tear in the section line of the right hepatic vein requiring laparoscopic suture. Blood loss and transfusion requirements were significantly lower in recent than in early cases and in resections with prior vascular control than in those without such control. Postoperative complications were experienced by 11 patients (16%), including one bleed from the hepatic stump requiring hemostasis and two subphrenic collections requiring percutaneous drainage. One cirrhotic patient died of liver failure after resection of a partially ruptured tumor. No ascites was observed in other cirrhotic patients. The mean hospital stay was 5.9 days. Conclusion The study results confirm that laparoscopic liver resection, including major hepatectomies, can be safely performed by laparoscopy. Presented at the 2006 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Meeting, Dallas, Texas, 26–29 April 2006     

肝脏良恶性肿瘤行腹腔镜解剖性肝左外叶切除术的初步经验

目的 初步总结肝脏良恶性肿瘤行腹腔镜解剖性肝左外叶切除的安全性及疗效.方法 2005年4月至2008年5月共对11例肝脏良恶性肿瘤患者行腹腔镜下解剖性肝左外叶切除术(男性7例、女性4例,平均年龄51.7岁).其中原发性肝癌4例,伴不周程度肝硬化;结肠癌术后转移性肝癌1例;肝血管瘤5例(2例合并胆囊结石同时切除胆囊);巨大肝血平滑肌脂肪瘤1例.肿瘤最大径2.1～12.0 com,平均5.8cm,所有肿瘤均位于肝左外叶(Ⅱ、Ⅲ段).结果 手术时间为120～180 min,平均147 min.无中转开腹手术病例,无输血,无手术并发症.术后平均住院5.9 d.结论 对于位于Ⅱ、Ⅲ段的肝脏肿瘤施行腹腔镜下肝左外叶切除术是安全的.     

腹腔镜肝切除术11例临床报告

目的:探讨腹腔镜肝切除术的适应证和可行性。方法:回顾分析10例病灶位于肝脏边缘及左肝外叶(Ⅱ～Ⅵ段)及1例位于Ⅷ段的肝占位患者的临床资料。其中原发性肝细胞癌8例,肝海绵状血管瘤2例,胆管细胞癌1例,肝功能Child-Pugh评分A级9例,B级2例;AFP(+)7例;位于左肝外叶实质中的肿瘤,行规则性左肝外叶切除;位于肝脏边缘或右肝表面的肿瘤,行肝脏局部切除。结果:11例均成功完成腹腔镜肝切除术,无中转开腹。其中局部切除术7例,左肝外叶切除术4例,腹腔镜脾切除+胆囊切除术2例。平均手术时间105min,术中平均出血220ml,切除病灶最大直径10cm。全部肿瘤均完整切除,肿瘤包膜完整,无破裂。术后未发生胆漏和出血等并发症,恢复良好,术后平均住院8.5d。结论:位于肝脏边缘、右肝表面或左半肝(Ⅱ～Ⅵ段)的肝脏占位,行腹腔镜肝切除术是安全可行的。     

一种理想的腹腔镜下肝实质离断方法：超声刀联合双极电凝

目的探讨腹腔镜下超声刀联合双极电凝实施肝实质离断的可行性。方法自2006年10月至2009年9月,采用上述肝实质离断方法共完成腹腔镜下肝切除（LLR）33例,男21例,女12例,年龄25～80岁,平均（47-3±14．9）岁;所有患者均为单发病灶,术前诊断良性占位20例,恶性占位13例,其中包括复发性肝癌1例;病灶大小2．0—11．0cm,平均（6．1±3．5）cm,位于肝左叶24例,其中20例于肝左外叶,肝右叶9例。结果全组33例手术无一例中转开腹,共行规则性LLR21例,非规则性LLR12例。手术时间45—220min,平均（116．4±63．4）min,术中出血20～700ml,平均（97．3±140．4）ml,术后胃肠恢复时间1—3d,平均（1．1±0．6）d,腹腔引流时间2～8d,平均（3．4±1．8）d,术后住院时间3—10d,平均（4．9±2．1）d。4例发生术后并发症,其中腹水2例,肺部感染1例,少量胆瘘1例（腹腔引流8d后自愈）,所有并发症均通过保守治疗治愈。结论超声刀联合双极电凝在腹腔镜下进行肝实质离断可以充分利用两者的优势,互补各自的缺点,该方法断肝速度快,出血少,显著缩短了手术时间,提高了手术安全性,推荐在当前LLR中常规应用。     

腹腔镜肝切除术临床应用体会

目的探讨腹腔镜肝切除术的应用指征、技术要点和疗效。方法回顾分析笔者所在医院2007年1月至2012年12月期间完成各类腹腔镜肝切除术61例患者的临床资料和随访结果。结果 61例中原发性肝癌16例,肝腺癌1例,转移性肝癌2例,肝血管瘤31例,其他肝脏良性占性病变（肝包虫病、肝细胞腺瘤、局灶性结节增生、肝囊肿及黏液性囊腺瘤）11例,肿瘤直径平均为5.6 cm（2～15 cm）。手术方式包括腹腔镜下左肝外叶切除术42例,右肝后叶切除术2例,Ⅵ段肝切除术3例,Ⅶ/Ⅷ段、Ⅳa及尾状叶肝切除术各1例,病变局部不规则性切除11例。手术时间为（124±65）min（50～200 min）,术中出血量为（251±145）mL（50～1 000 mL）,无一例手术死亡,术后住院时间为（7.3±3.6）d（4～11 d）。并发症总发生率为16.4%（10/61）。19例肝脏恶性肿瘤患者中15例随访1～48个月,平均26个月,失访4例;其中1例于术后12个月时因多器官功能衰竭死亡,其余均存活。结论经验丰富的腹腔镜肝胆胰外科医生选取合适的病例,采用恰当的血流阻断及断肝方法,注意术中的无瘤原则,可以安全有效地开展肝脏良、恶性肿瘤的腹腔镜肝切除术。     

Are major laparoscopic pancreatic resections worthwhile? A prospective study of 32 patients in a single institution

BACKGROUND: Laparoscopic surgery has been used increasingly as a less invasive alternative to conventional open surgery. Recently, laparoscopic therapy for pancreatic diseases has made significant strides. The current investigation studied pancreatic resection by laparoscopy. The objective of this study was to assess the feasibility, safety, and outcome of laparoscopic pancreatic major resection for benign and malignant lesions of the pancreas. METHODS: A prospective study of laparoscopic pancreatic resections was undertaken in patients with benign and malignant lesions of the pancreas. Over an 8-year period, 32 patients underwent laparoscopic pancreatic major resection: 21 left pancreatectomies (1 performed using a retroperitoneal approach), and 11 pancreatoduodenectomies (10 Whipple procedures and 1 total pancreatectomy). All the operations were performed in a single institution. RESULTS: The operations were performed without serious complications. Only one left pancreatectomy was converted to laparotomy because of massive splenic bleeding, and one Whipple procedure was converted because of adhesion to the portal vein. In four of the Whipple operations, the resection was performed completely laparoscopically, and the reconstruction was done via a small midline incision. There was no operative mortality. In 16 patients of the left pancreatectomy group, the spleen was preserved. The mean blood loss was 150 and 162 ml; and the mean operating time was 154 and 284 min, respectively, for the left pancreatectomy and the Whipple procedure. Postoperative complications occurred for five patients after left pancreatectomy and for three patients after the Whipple procedure. Two patients needed surgical reexploration after left pancreatectomy because of intraperitoneal haemorrhage and eventration of the extraction site. Two patients underwent reoperation after the Whipple procedure: one because of intraabdominal bleeding and the other because of small bowel obstruction.The mean hospital stay was 10.8 days after left the pancreatectomy and 13.6 days after the whipple procedure. CONCLUSION: Laparoscopic left pancreatectomy for benign and malignant lesions is feasible, safe, and beneficial. We believe that pancreatoduodenectomy should be performed only in selected cases and by a highly skilled laparoscopic surgeon. If there is any doubt, an open resection should be performed.     

左侧半旋转体位下腹腔镜肝脏Ⅶ段部分切除术治疗肝脏良性病灶临床疗效分析

目的评估左侧半旋转体位腹腔镜下肝脏Ⅶ段部分切除术治疗肝脏良性病灶的临床效果。方法回顾性分析2019年1月至12月青岛大学附属医院肝脏外科收治的20例肝脏Ⅶ段良性病灶的临床资料。所有病人均采用左侧半旋转体位,接受了腹腔镜下以Ⅶ段为主肝部分切除手术。结果手术无中转开腹和二次手术,没有输库血(3例病人因血管瘤较大,术中收集了自体血回输)。病人术后无胆漏及出血,均顺利康复出院,平均住院时间9.6 d。结论位于肝脏Ⅶ段的良性病灶,即使大于5 cm,靠近右肝静脉,也能通过左侧半旋转体位充分显露病灶,结合戳卡的布局调整,降低手术难度,保证腹腔镜下安全的切除以肝脏Ⅶ段为主的良性病灶,使对开腹手术有顾虑的病人从微创手术中获益。     

Hand-assisted laparoscopic hepatectomy for solid tumor in the posterior portion of the right lobe: initial experience

OBJECTIVE: To prove the feasibility of hand-assisted laparoscopic liver resection for tumors located in the posterior portion of the right hepatic lobe. SUMMARY BACKGROUND DATA: Use of laparoscopic liver resection remains limited due to problems with technique, especially when the tumor is located near the diaphragm, or in the posterior portion of the right lobe. METHODS: Between October 2001 and June 2002, a total of 7 patients with solid hepatic tumors involving the posterior portion of the right lobe of liver underwent hand-assisted laparoscopic hepatectomy with the HandPort system at our hospital. Surgical techniques used included CO2 pneumoperitoneum and the creation of a wound on the right upper quadrant of the abdomen for HandPort placement. The location of tumor and its transection margin were decided by laparoscopic ultrasound. The liver resection was performed using the Ultrashear without portal triad control, with the specimens obtained then placed in a bag and removed directly via the HandPort access. RESULTS: The 5 male and 2 female patients ranged in age from 41 to 76 years (mean 62.3 +/- 14.4). Surgical procedures included partial hepatectomy for 6 patients and segmentectomy for one, all successfully completed using a variant of the minimally invasive laparoscopic procedure without conversion to open surgery. The mean duration of the operation was 140.7 +/- 42.2 minutes (90-180). The blood loss during surgery was 257.1 +/- 159 mL (250-500), without any requirement for intraoperative or postoperative transfusion. Pathology revealed hemagioma (n = 2), colon cancer metastasis (n = 2), and hepatocellular carcinoma (n = 3). There were no deaths postoperatively, with 1 patient suffering bile leakage. Mean hospital stay was 5.3 +/- 1.3 days postsurgery. CONCLUSION: The results of this study suggest that laparoscopic liver resection using the HandPort system is feasible for selected patients with lesions in the posterior portion of the right hepatic lobe requiring limited resection. Individuals with small tumors may benefit; because a large abdominal incision is not required, the wound-related complication rate might be reduced.     

Laparoscopic liver resections: a feasibility study in 30 patients

OBJECTIVE: To assess the feasibility and safety of laparoscopic liver resections. SUMMARY BACKGROUND DATA: The use of the laparoscopic approach for liver resections has remained limited for technical reasons. Progress in laparoscopic procedures and the development of dedicated technology have made it possible to consider laparoscopic resection in selected patients. METHODS: A prospective study of laparoscopic liver resections was undertaken in patients with preoperative diagnoses including benign lesion, hepatocellular carcinoma with compensated cirrhosis, and metastasis of noncolorectal origin. Hepatic involvement had to be limited and located in the left or peripheral right segments (segments 2-6), and the tumor had to be 5 cm or smaller. Surgical technique included CO2 pneumoperitoneum and liver transection with a harmonic scalpel, with or without portal triad clamping or hepatic vein control. Portal pedicles and large hepatic veins were stapled. Resected specimens were placed in a bag and removed through a separate incision, without fragmentation. RESULTS: From May 1996 to December 1999, 30 of 159 (19%) liver resections were included. There were 18 benign lesions and 12 malignant tumors, including 8 hepatocellular carcinomas in cirrhotic patients. Mean tumor size was 4.25 cm. There were two conversions to laparotomy (6.6%). The resections included 1 left hepatectomy, 8 bisegmentectomies (2 and 3), 9 segmentectomies, and 11 atypical resections. Mean blood loss was 300 mL. Mean surgical time was 214 minutes. There were no deaths. Complications occurred in six patients (20%). Only one cirrhotic patient developed postoperative ascites. No port-site metastases were observed in patients with malignant disease. CONCLUSION: Laparoscopic resections are feasible and safe in selected patients with left-sided and right-peripheral lesions requiring limited resection. Young patients with benign disease clearly benefit from avoiding a major abdominal incision, and cirrhotic patients may have a reduced complication rate.     

Hand-assisted laparoscopic management of liver tumors

Background Laparoscopy has clearly advanced the treatment of many diseases related to the liver and biliary tree. The addition of hand assistance can further facilitate minimally invasive liver surgery by providing tactile feedback, atraumatic and versatile retraction, finger-fracture parenchyma dissection, and more precise placement of probes and staplers. Methods Over a 7-year period, 28 patients with liver tumors underwent 31 hand-assisted laparoscopic operations at a tertiary care center. The candidates for hand-assisted laparoscopic resection were patients with lesions involving two hepatic segments or fewer located at the inferior edge of the liver (segments 5 and 6), or confined to the left lateral segment (segments 2 and 3). Ablation was reserved for patients with poor functional status or limited hepatic reserve, and hand-assistance was added for laparoscopic ablation of centrally located tumors (segments 7, 8, and 4a). Results The selection criteria were met by 52 patients, 6 of whom had benign lesions. The remaining 46 patients had malignant disease, and 15 of these patients (33%) were found to have extrahepatic disease: 11 at initial laparoscopy and 4 at hand-assisted abdominal exploration. Manual exploration also detected additional intrahepatic treatable lesions in two cases. A total of 19 patients (68%) had metastatic disease, and 3 (11%) had primary liver cancer. The most extensive resections were five left lateral segmentectomies. All margins were negative. The mean operative time was 2.75 h, and the mean blood loss was 230 ml. Two diaphragmatic injuries occurred during ablation of segment 8 lesions. Three cases were converted to open surgery because of adhesions. The mean hospital stay was 3.7 days. A group of 15 patients who had metastatic colorectal cancer treated with resection and/or ablation had a mean follow-up period of 24 months (range, 2–61 months) and a mean survival time of 36 months. Conclusions For selected patients, the hand-assisted technique can be applied safely and effectively to laparoscopic liver surgery and may identify the presence of previously undetectable intrahepatic or extrahepatic disease. Poster presentation at the 2006 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Scientific Session, April 26–29, 2006, Dallas, TX     

完全腹腔镜肝切除时出血问题的探讨

目的　探讨腹腔镜肝切除手术的出血原因和预防措施。　方法　 2 1例中包括原发性肝癌 13例、肝血管瘤 3例、肝脓肿 2例、肝囊肿伴感染、局灶结节性增生、肝脏腺瘤各 1例。肝功能Child分级 :A级 16例 ,B级 5例 (均为肝癌病人 )。　结果　 2 1例在全气腹条件下完成腹腔镜肝切除手术 ,包括肝局部切除 12例 ,左肝解剖性切除 9例。手术时间 80～ 32 0 (平均 193 8± 78 3)min ,出血量 10 0～ 10 0 0ml (平均 333 1± 2 91 4 )ml,有 2例出血 10 0 0ml,术中输血各 80 0ml。术后恢复顺利 ,术后平均住院时间 6 3± 1 5d ,术后恢复时间较常规开腹方法肝切除患者明显缩短。　结论　本组研究表明在现有的手术器械条件和不阻断肝门血流的情况下 ,可以安全方便地处理术中出血。腹腔镜肝切除微创手术的前景广阔 ,不仅适于对肝良性肿瘤的手术 ,也为肝脏恶性肿瘤患者提供了切除肿瘤的新途径     

Laparoscopic management of benign liver disease

Minimally invasive techniques may be used for treating a variety of benign hepatic lesions in selected patients. The size of the lesions is less important than the anatomic location in anterolateral regions. Laparoscopic unroofing of solitary liver cysts is the surgery of choice for this indication. The laparoscopic management of patients with PLD should be reserved for patients with a few, large, anteriorly located, symptomatic cysts. Active hydatid cysts present technical difficulties because of their complex biliovascular connections and the inherent nature of the parasite. The authors' results do not support the widespread use of laparoscopy in these cases. Uncomplicated benign liver tumors located in the left lobe or in the anterior segments of the right lobe can be resected safely using a four-hand technique. Open surgery is the treatment of choice when primary tumors are malignant, located posteriorly, or in proximity to major hepatic vasculature. Laparoscopic resection of liver metastases with a safety margin of 1 cm, when the total number is less than four, is not unreasonable and can be offered to patients without evidence of extrahepatic disease.     

Laparoscopic approach for solitary insulinoma: a multicentre study

Background Surgical resection of insulinomas is the preferred treatment in order to avoid symptoms of hypoglycaemia. During the past years, advances in laparoscopic techniques have allowed surgeons to approach the pancreas and treat these lesions laparoscopically. We analysed the feasibility, safety, and outcome of patients undergoing laparoscopic resection of insulinomas in a large, retrospective, multicentre study.Methods Thirty-six patients with pancreatic insulinomas were enrolled in this study. All patients were suspected of having solitary insulinomas after preoperative localisation tests and underwent a laparoscopic approach. Patients, operating characteristics and outcome were analysed.Results Mean patient age was 48 years (range 20–77 years). Insulinomas were localised in the head (n=7), isthmus (n=2), body (n=14) or tail (n=13) of the pancreas before laparoscopic approach. Mean size of the lesions was 15.5 mm (range 4–25 mm). The surgical procedure was enucleation in 19 cases (52%), spleen-preserving distal pancreatectomy in 12 cases (33%), spleno-pancreatectomy in three cases (8%), one duodenopancreatectomy and one central pancreatectomy. Conversion rate was 30%. The reason for conversion in seven patients (63%) was the inability to localise the tumour during the laparoscopic procedure. In six of these cases laparoscopic ultrasonography was not performed. Mean operating time was 156 min (range 50–420 min). Postoperative course was uneventful in 23 patients (64%). Eleven patients (30%) developed specific complications of pancreatic surgery: intra-abdominal abscess (n=6) or pancreatico-cutaneous fistula (n=5). Mean duration of fistulae was 55 days (range 5–130 days) and all the fistulae were dry at follow-up. After a mean follow-up period of 26 months (range 2–87 months), 33 patients (91%) are free of symptoms, and three patients have been lost to follow-up.Conclusion The laparoscopic approach is safe to treat preoperatively localised insulinoma, with a morbidity rate comparable to that for the open approach. When the tumour is not found during laparoscopy, laparoscopic ultrasonography seems to be the most efficient tool to localise it and probably to prevent conversion.     

Laparoscopic stapled left lateral segment liver resection—Technique and results

Because of the favorable anatomy of the left lateral segment of the liver, a totally laparoscopic approach to resection is feasible. Herein we describe a technique for laparoscopic stapled resection of the left lateral segment of the liver, including the necessary anatomic criteria for a safe operation and data on clinical outcome. Five patients at our center underwent laparoscopic exploration, ultrasound examination, and resection of segments II and III. After complete mobilization of the left lateral segment and minimal portal dissection, the totally laparoscopic resections were performed with two endoscopic staple loads (4.5 mm Χ 60 mm) applied sequentially across the portal pedicle and the left hepatic vein. The mean operative time was 182 minutes (range 130 to 240 minutes), blood loss was 41 ml (range 25 to 50 ml), and length of hospital stay was 2.2 days (range 1 to 3 days). All three patients with malignancy had negative surgical margins. All five patients returned to normal activity or work by 1 week postoperatively. There were no complications. Patients with isolated malignant and benign diseases of the left lateral segment of the liver are candidates for totally laparoscopic resection, if evaluation demonstrates a normal liver character and hepatic parenchymal thickness less than 3 cm overlying the ligamentum venosum groove. Such patients benefit from the minimally invasive approach, with no compromise in the surgical result as compared to the open approach. Presented at the Fourth Biennial Americas Hepato-Pancreato-Biliary Congress, Miami Beach, Florida, February 28, 2003. Supported in part by a Minnesota Medical Foundation Laparoscopy Training Grant (T.D.S.) and the Richard Lewis Varco Surgical Research Award (B.C.L.).     

Laparoscopic versus open left lateral hepatic lobectomy: a case-control study

BACKGROUND: After technical advances in hepatic surgery and laparoscopic surgery, some teams evaluated the possibilities of laparoscopic liver resections. The aim of our study was to assess the results of laparoscopic left lateral lobectomy (bisegmentectomy 2-3) and to perform a case-control comparison with the same operation performed by open surgery. STUDY DESIGN: From 1996 to 2002, 60 laparoscopic resections were performed in selected patients, including 18 left lateral lobectomies. The resected lesions were benign tumors, hepatocellular carcinomas with compensated cirrhosis, and metastases. Surgical procedures were performed with a harmonic scalpel, an ultrasonic dissector, linear staplers, and portal pedicule clamping when necessary. Results were compared with those of patients who underwent open left lateral lobectomies selected from our liver resection database in a case-control analysis. Both groups were similar for age, type and size of the tumor, and presence of underlying liver disease. RESULTS: Compared with laparotomy, laparoscopic left lateral lobectomies were associated with a longer surgical time (202 versus 145 minutes, p < 0.01), a longer portal triad clamping (39 versus 23 minutes, p < 0.05), and a decreased blood loss (236 versus 429 mL, p < 0.05). There were no deaths in either group, and the morbidity rates were 11% in the laparoscopic group and 15% in the open group. There were no specific complications of hepatic resection after laparoscopy (no hemorrhage, subphrenic collection, or biliary leak), but some were observed in the open group. CONCLUSIONS: This study demonstrates the safety of laparoscopic left lateral lobectomy. Despite longer operation and clamping time, without any clinical consequences, the laparoscopic approach was associated with decreased blood loss and absence of specific complications of the hepatic resection.