Laparoscopic liver resections for hepatocellular carcinoma. Is it a feasible option for patients with liver cirrhosis?

Background  Laparoscopic surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver, above all for patients with hepatocellular carcinoma (HCC) and cirrhosis. This approach mainly includes diagnostic procedures and interstitial therapies. However, we believe there is room for laparoscopic liver resections in well-selected cases. The aim of this study is to assess: (a) the risk of intraoperative bleeding and postoperative complications, (b) the safety and the respect of oncological criteria, and (c) the potential benefit of laparoscopic ultrasound in guiding liver resection. Methods  A prospective study of laparoscopic liver resections for hepatocellular carcinoma was undertaken in patients with compensated cirrhosis. 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. Tumor location and its transection margins were defined by laparoscopic ultrasound. Results  From January 1997, 22 out of 250 patients with HCC (9%) underwent laparoscopic liver resections. The mean patient age was 61.4 years (range, 50–79 years). In three patients, conversion to laparotomy was necessary. The laparoscopic resections included five bisegmentectoies (2 and 3), nine segmentectomies, two subsegmentectomies and three nonanatomical resections for extrahepatic growing lesions. The mean operative time, including laparoscopic ultrasonography, was 199 ± 69 min (median, 220; range, 80–300). Perioperative blood loss was 183 ± 72 ml (median, 160; range, 80–400 ml). There was no mortality. Postoperative complications occurred in two out of 19 patients: an abdominal wall hematoma occurred in one patient and a bleeding from a trocar access in the other patient requiring a laparoscopic re-exploration. Mean hospital stay of the whole series was 6.5 ± 4.3 days (median, 5; range, 4–25), while the mean hospital stay of the 19 laparoscopic patients was 5.4 ± 1 (median, 5; range, 4–8). Conclusion  Laparoscopic treatment should be considered in selected patients with HCC and liver cirrhosis in the left lobe or segments 5 and 6 of the liver. It is clear that certain types of laparoscopic resection are feasible and safe when carried out by adequately skilled surgeons with appropriate instruments.     

Laparoscopic liver resection without portal clamping: a prospective evaluation

Background  Previous comparative studies have demonstrated that laparoscopic liver resection is associated with more frequent use and longer duration of portal camping than open liver resection, a fact that may partially explain the improvement in operative blood loss reported by most series of laparoscopic liver resection. The aim of this prospective study was to evaluate the real need for portal clamping in laparoscopic liver surgery. Study design  Surgical outcomes of 40 consecutive patients who underwent laparoscopic liver resection for benign and malignant lesions from September 2005 to August 2007 were evaluate. Portal clamping was not systematically used. Results  No patient required blood transfusion and median blood loss was 160 ml (range 100–340 ml). Mean operating time was 267 min (range 220–370 min) and portal clamping was necessary in only one patient. Surgical complications included two grade I complication, three grade II, and one case of postoperative hemorrhage (grade III). Conclusions  Laparoscopic liver surgery without clamping can be performed safely with low blood loss.     

Laparoscopic and robot-assisted one-stage resection of colorectal cancer with synchronous liver metastases: a pilot study

Background/purpose  One-stage resection of primary colon cancer and synchronous liver metastases is considered an effective strategy of cure. A laparoscopic approach may represent a safe and advantageous choice for selected patients with the aim of improving the early outcome. Methods  Between January 2008 and October 2008, 7 patients underwent one-stage laparoscopic resection for primary colorectal cancer combined with laparoscopic or robot-assisted liver resection. Results  A total of five laparoscopic left-colon, one right-colon, and one rectal resections were performed. Three patients underwent preoperative left-colon stenting and two received neoadjuvant chemotherapy. The patient with rectal cancer underwent neoadjuvant radiotherapy. Liver procedures included one bisegmentectomy (segments 2, 3), 3 segmentectomies, 6 metastasectomies, and four laparoscopic ultrasound-guided radiofrequency ablations (LUG-RFAs). One patient with multiple liver metastases was managed by a two-stage hepatectomy partially conducted by a totally laparoscopic approach. The overall postoperative morbidity was null. The median hospital stay was 10 days (range 7–10 days). Conclusions  This pilot study suggests that laparoscopic one-stage colon and liver resection is feasible and safe. Robot assistance may facilitate liver resection, increasing the number of patients who may benefit from a minimally invasive operation.     

Laparoscopic versus open liver segmentectomy: prospective, case-matched, intention-to-treat analysis of clinical outcomes and cost effectiveness

Introduction  Reduction in hospital stay, blood loss, postoperative pain and complications are common findings after laparoscopic liver resection, suggesting that the laparoscopic approach may be a suitable alternative to open surgery. Some concerns have been raised regarding cost effectiveness of this procedure and potential implications of its large-scale application. Our aim has been to determine cost effectiveness of laparoscopic liver surgery by a case-matched, case–control, intention-to-treat analysis of its costs and short-term clinical outcomes compared with open surgery. Methods  Laparoscopic liver segmentectomies and bisegmentectomies performed at Ninewells Hospital and Medical School between 2005 and 2007 were considered. Resections involving more than two Couinaud segments, or involving any synchronous procedure, were excluded. An operation-magnitude-matched control group was identified amongst open liver resections performed between 2004 and 2007. Hospital costs were obtained from the Scottish Health Service Costs Book (ISD Scotland) and average national costs were calculated. Cost of theatre time, disposable surgical devices, hospital stay, and high-dependency unit (HDU) and intensive care unit (ICU) usage were the main endpoints for comparison. Secondary endpoints were morbidity and mortality. Statistical analysis was performed with Student’s t-test, χ ² and Fisher exact test as most appropriate. Results  Twenty-five laparoscopic liver resections were considered, including atypical resection, segmentectomy and bisegmentectomy, and they were compared to 25 matching open resections. The two groups were homogeneous by age, sex, coexistent morbidity, magnitude of resection, prevalence of liver cirrhosis and indications. Operative time (p < 0.03), blood loss (p < 0.0001), Pringle manoeuvre (p < 0.03), hospital stay (p < 0.003) and postoperative complications (p < 0.002) were significantly reduced in the laparoscopic group. Overall hospital cost was significantly lower in the laparoscopic group by an average of ￡2,571 (p < 0.04). Conclusions  Laparoscopic liver segmentectomy and bisegmentectomy are feasible, safe and cost effective compared to similar open resections. Large-scale application of laparoscopic liver surgery could translate into significant savings to hospitals and health care programmes.     

Laparoscopic hepatic resection

Background Although laparoscopy in general surgery is increasingly being performed, only recently has liver surgery been performed with laparoscopy. We critically review our experience with laparoscopic liver resections. Methods From January 2000 to April 2004, we performed laparoscopic hepatic resection in 16 patients with 18 hepatic lesions. Nine lesions were benign in seven patients (five hydatid cysts, three hemangiomas, and one simple cyst), five were malignant in five patients (five hepatocarcinoma), and four patients had an uncertain preoperative diagnosis (one suspected hemangioma and three suspected adenomas). The mean lesion size was 5.2 cm (range, 1–12). Twelve lesions were located in the left lobe, three were in segment VI, one was in segment V, one was in segment IV, and one was in the subcapsular part of segment VIII. Results The conversion rate was 6.2%; intraoperative bleeding requiring blood transfusions occurred in two patients. Mean operative time was 120 min. Mean hospital stay was 4 days (range, 2–7). There were no major postoperative complications and no mortality. Conclusions Hepatic resection with laparoscopy is feasible in malignant and benign hepatic lesions located in the left lobe and anterior inferior right lobe segments (IV, V, and VI). Results are similar to those of the open surgical technique in carefully selected cases, although studies with large numbers of patients are necessary to drawn definite conclusions.     

Laparoscopic liver resection: preliminary results from a UK centre

Background and aims  Advancements in surgical technique and technology have facilitated safe laparoscopic liver resection in selected patients. The aim of this study is to evaluate the feasibility and outcome of laparoscopic liver resection. Methods  Patients with lesions situated in the anterior and left lateral segments were selected for laparoscopic resection. Data were collected prospectively. Results  Between 2003 and 2007, 24 patients (12 males) with a median (range) age of 65 (30–83) years underwent 24 laparoscopic hepatic resections for presumed colorectal metastases (n = 20) and other indications (n = 4). The resections included left hepatic lobectomy (n = 14), other resections of two or three segments with or without metastasectomy (n = 5), left hemihepatectomy (n = 2) and unisegmentectomy (n = 3). All procedures were completed laparoscopically. Median operating time was 155 min. Estimated median (range) blood loss was 100 (25–1100) ml and one patient received two units blood transfusion. The operative morbidity rate was 4%, and there were no operative deaths. The median (range) postoperative hospital stay was 3 (1–14) days. At median (range) follow-up of 13.5 (5–36) months, 4 patients (21%) had disease recurrence and 17 patients (89%) remained alive. Conclusions  In selected patients with lesions in the anterior and left lateral segments, laparoscopic liver resection is feasible, achieves adequate cancer resection and is associated with smooth and rapid recovery. Long-term follow-up data are required for oncological results.     

New: Single-incision transumbilical laparoscopic surgery

Summary  BACKGROUND: On the way to "no-scar" techniques novel single-incision laparoscopic methods are developed, which result in a non-visible postoperative scar. METHODS: A total of 136 patients (age 10–86a; 68f/68m) underwent single-incision laparoscopic surgery at our Department for diseases of the appendix, gallbladder, colon, esophagus, liver, adrenal gland, inguinal hernia, or symptomatic adhesions. The entire operations were carried out transumbilically following the standardized procedural principles. RESULTS: Operative time ranged from 17 to 218 min. In 16 patients (11.8%) additional trocars were inserted for procedural safety. No intraoperative adverse event or significant perioperative complication was noticed. Operative estimated blood loss yielded minimal, blood suction was needed only for liver resection and adrenalectomy. Specimen retrieval was carried out either by means of an endo-bag or directly utilizing a transumbilical protection sheet. Patients resumed oral intake at the day of surgery after cholecystectomy, hernia repair or appendectomy, or within 24 h after major surgery according to the principles of fast-track abdominal surgery. Patients' discharge was on postoperative days 1–12 (Mean 3.8 d). At follow-up after 1–4 weeks patients presented with an optimal cosmetic result without apparent scarring. CONCLUSIONS: Single-incision transumbilical laparoscopy allows further reduction of the surgical trauma and to obviate any visible scar in various procedures.      

Clinical study of laparoscopic versus open hepatectomy for malignant liver tumors

Background  The number of reported laparoscopic hepatectomies for liver malignancy is increasing, but comparative data on the survival outcomes between the patients who have undergone laparoscopic hepatectomy versus open surgery are still lacking. Methods  We compared 31 laparoscopic liver resections with 31 open liver resections in a pair-matched retrospective analysis with the aim of evaluating the intraoperative hazards, recovery, and survival outcomes of these procedures for liver cancer. The laparoscopic group and the open group were matched for age, sex, the size and location of the tumor, and the presence or absence of cirrhosis. Results  Thirty cases in the laparoscopic group were performed successfully while one case was converted to open surgery due to intraoperative hemorrhage. The length of hospital stay was 7.5 (5–15) days, which was significantly shorter than those in open group (p < 0.01). The mean operative time and blood loss in the laparoscopic group were 140.1 (60–380) min and 502.9 (50–2000) ml, respectively, which were lower than those in open group but without significant difference. There were no operative complications and no deaths in the laparoscopic group. The mean and median survival times of laparoscopic group were 59.3 and 70 months, compared with 49.4 and 60 months in the open group, respectively. The 1-, 3-, 5-year survival rates in the laparoscopic group were, respectively, 96.55%, 60.47%, and 50.40%, and 96.77%, 68.36%, and 50.64% in the open group. By log-rank test, these two survival curves were not significantly different (p = 0.8535). Conclusion  This study shows that laparoscopic hepatectomy for liver malignancy in selected patients is a safe, effective, and oncologically efficient procedure with better short-term results and similar survival outcomes to open hepatectomy for liver malignancy after midterm follow-up.     

Laparoscopic liver resection for hepatocellular carcinoma

Background Single, small hepatocarcinomas (HCC) are still an indication for partial liver resection in patients ineligible for transplantation. Anatomical resections are recommended for oncological reasons. The mini-invasive approach of laparoscopy should minimize hepatic and parietal injury, thereby decreasing the risk of liver failure and ascites. However, the oncological results of this approach and its presumed benefits remain undemonstrated. We evaluated the short- and midterm results of laparoscopic liver resections for HCC. Methods Between 1999 and 2006, we performed 32 laparoscopic liver resections for HCC. Mean tumor size was 3.8 ± 2 cm and the mean age of the patients was 65 ± 11 years. Twenty-two patients had cirrhosis (21 Child A and one Child C). Operative and postoperative results were analyzed, together with recurrence and survival rates. Results We carried out 13 unisegmentectomies, nine bisegmentectomies, one trisegmentectomy, two right hepatectomies, one left hepatectomy, and six atypical resections. The duration of the operation was 231 ± 101 minutes. Conversion to laparotomy was required in three patients (9%), none in emergency situations. Mean blood loss was 461 ml, with five patients (15.6%) requiring blood transfusion. The mean surgical margin was 10.4 mm. One cirrhotic patient (Child C) underwent surgery for a partially ruptured tumor and died of liver failure. Two patients had ascites and no transient liver failure occurred in the other 19 cirrhotic patients. Mean hospital stay was 7.1 days. During a mean follow-up of 26 months, 10 patients (31%) presented recurrence within the liver. None of the patients had peritoneal carcinomatosis or trocar site recurrence. Three-year overall and disease-free survival rates were 71.9% and 54.5%, respectively. Conclusions Laparoscopic liver resection for HCC is feasible and well tolerated. Midterm survival and recurrence rates are similar to those after laparotomy.     

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     

Intrahepatic Glissonian approach for laparoscopic right segmental liver resections

Background

Experience with laparoscopic procedures and recent advances in laparoscopic devices have created an evolving interest in the application of these techniques to liver resection. However, laparoscopic liver resection has not been widely developed and anatomical segmental liver resection is not currently performed due to difficulty to control segmental Glissonean pedicles laparoscopically.

Methods

Seven consecutive patients underwent laparoscopic liver resection using an intrahepatic Glissonian approach from April 2007 to September 2007. Three patients underwent laparoscopic bisegmentectomy 6-7 and 4 patients underwent laparoscopic right hemihepatectomy.

Results

Blood transfusion was required in 1 patient. Mean operation time was 460 minutes (range 300-630 minutes). The median hospital stay was 5 days (range 3-8 days). One patient developed bile leakage that was treated conservatively. No patient had postoperative signs of liver failure. No postoperative mortality was observed.

Conclusions

The main advantage over other techniques is the possibility to gain a rapid and precise access to the right posterior and anterior sheaths facilitating right hemihepatectomy, and right anterior and posterior sectionectomies. We believe that the described technique facilitates laparoscopic liver resection by reducing the technical difficulties in pedicle control and may increase the development of segment-based laparoscopic liver resections.     

Laparoscopic liver resections: A single center experience

Background Since the first report of laparoscopic liver resection, by Gagner et al. 1992, an increasing number of small prospective studies have been published. They have shown encouraging results for the feasibility and safety of the procedure. This paper prospectively evaluated the results of a single center’s experience with elective liver resections.Methods From January 1995 to January 2004 a prospective study of laparoscopic liver resections was undertaken in 31 patients with preoperative diagnosis of benign lesions (13 cases, 42.4%), hepatocellular carcinoma in absence of complicated cirrhosis (three cases, 9.1%), and liver metastases (15 cases, 45.5%). Mean tumor size was 34.9 mm (range 10–100 mm).Results The procedures included 11 (37.9%) major hepatectomies and 21 (62.1%) minor resections (one patient was submitted to repeat laparoscopic liver resection) . There were three conversions to open. Mean blood loss was 210 ml (range 0–700 ml). Mean operative time was 115 min (range 45–210 min). There were no deaths and no reoperations for complications. No port-site metastases occurred in patients with malignant lesions.Conclusions Laparoscopic liver resections, including major hepatectomies, are feasible and safe. Major and posterior resections are difficult, though, and conventional surgery remains an option.     

Laparoscopic vs open hepatic resection: a comparative study

Background: Although the feasibility of minor laparoscopic liver resections (LLR) has been demonstrated, data comparing the open vs the laparoscopic approach to liver resection are lacking. Methods: We compared 30 LLR with 30 open liver resections (OLR) in a pair-matched analysis. The indications for resection were malignant disease in 47% of the LLR and 83% of the OLR. The average size of the lesions was 42 mm for LLR and 41 mm for OLR. Five wedge resections, 12 segmentectomies, and 13 bisegmentectomies were performed in each group. Results: The conversion rate for LLR was nil. The mean operative time was 148 min for LLR and 142 min for OLR. Mean blood loss was minimal in the LLR group (320 vs 479 ml; p < 0.05). Postoperative complications occurred in 6.6% of the patients in each group; there were no deaths. The mean postoperative hospital stay was shorter for LLR patients (6.4 vs 8.7 days; p < 0.05). In tumors, the resection margin was <1 cm in 43% of the LLR patients and 40% of the OLR patients (p = NS). Conclusions: Minor LLR of the anterior segments has the same rates of mortality and morbidity as OLR. However, the laparoscopic approach reduces blood loss and postoperative hospital stay.     

Results of laparoscopic liver resection: retrospective study of 68 patients

Background  Although an increasing number of reports and publications have dealt with the laparoscopic approach to liver resection, this procedure remains uncommon, and its feasibility, safety and effectiveness are still not established. There are few reports of the advantages of this approach on postoperative recovery. Methods  From December 1997 to March 2007, laparoscopic hepatic resection were performed in 68 patients. Results  There were 52 malignant tumors (36 hepatocellular carcinomas, three intrahepatic cholangiocarcinomas, one cystadenocarcinoma, liver metastases from ten colorectal carcinomas and two other organs) and 16 benign lesions among our 68 patients. Fifteen patients with hepatocellular carcinoma had cirrhosis. The mean tumor size was 3.1 ± 1.8 cm (range 1.0–14.0 cm), and the tumors were located in every liver segment except segment I. Liver resection was anatomical in 17 patients and consisted of a lobectomy in four patients and a lateral segmentectomy in 13 patients. Non-anatomical resections were performed in 51 patients. The operative time was 214 ± 93 min. Mean blood loss was 393 ± 564 g. A hand-assisted laparoscopic method or mini-laparotomy method was required in 35 patients (51.4%). Operative complications occurred mainly in our early cases and included three patients (4.4%) with operative bleeding, 2 of whom (2.9%) requiring a conversion to open surgery. Postoperative complications occurred in seven patients (10.0%), and two of then eventually required a re-operation. The mean hospital stay was 17 days. There were no complications in the more recent cases. Conclusions  The laparoscopic approach for liver tumors is feasible, if the indication is carefully selected. The safety of this procedure depends on the surgical experience of the surgeon and team and the availability of the necessary technology.     

Laparoscopic liver resection with the water-jet dissector

Laparoscopic liver resection requires careful patient selection. Tumor size and location have a major influence on the feasibility of a laparoscopic operation. Isolation and ligation of blood vessels and bile ducts after selective liver dissection by suitable techniques are important for visual control of the operating field.Since the Jet-Cutter has proven to give excellent clinical results in conventional liver surgery, we carried out laparoscopic liver resections with the Jet-Cutter in six patients. Five tumors were located in the left liver lobe; the fifth was in segment 6. There were no intra- or postoperative complications. The patients were discharged from the hospital after a mean of 5.4±2.1 days.     

Liver resection with intraoperative and laparoscopic ultrasound: report of 32 cases

Background  Careful staging of hepatic tumors is mandatory for appropriate selection of patients for liver resection. Number and relationships of liver nodules are issues of utmost importance when evaluating resectability. Sensitivity of preoperative imaging for secondary lesions has been reported between 60–75% with spiral contrast-enhanced computed cosmography (CT), 80–85% with magnetic resonance imaging (MRI), and 90–96% with intraoperative ultrasound (IOUS). Also for primary lesions IOUS has been reported to allow detection of liver nodules in 17% and modify surgical strategy in 10%. The aim of this study was to point out the usefulness of open (IOUS) and laparoscopic (LIOUS) ultrasound in patients undergoing hepatic surgery for liver tumors. Methods  In the years 2004–2006, 50 patients, mean age 66 years (range 44–76 years) were evaluated for resective surgery at the General Surgery Department of Monaldi Hospital, Naples, Italy. All of them were studied with biphasic CT and transabdominal ultrasound. Eighteen (36%) were judged unresectable. The others were scheduled for laparoscopy and LIOUS, by means of an ALOKA SSD–5500 (Aloka Co. Ltd. Tokyo, Japan), equipped with linear flexible tip laparoscopic probe. Results  Six patients (18.7%) were excluded because of pathology diffusion; 26 (81.3%) were resected, using ultrasonic shears (Harmonic ACE, Ethicon Endo-Surgery, Cincinnati Oh., USA) for parenchymal transection, 3 (11.5%) laparoscopically and 23 (88.5%) after laparotomy. IOUS was repeated in the latter group. LIOUS spared useless laparotomies in six patients (18.7%) and, coupled with IOUS, found undetected nodes in five patients (19.2%), changing surgical strategy in three patients (11.5%). Conclusion  In our experience LIUOS and IOUS proved to be of utmost importance both in the selection of patients for resective surgery and in planning surgical approach. Ultrasonic shears device and systematic pedicle clamping sped up resection time and reduced intraoperative bleeding.     

Surgical Management of Hepatocellular Adenoma: Take It or Leave It?

Background  Hepatocellular adenoma (HA) is a rare benign tumor of the liver. Surgical resection is generally indicated to reduce risks of hemorrhage and malignant transformation. We sought to evaluate clinical presentation, surgical management, and outcomes of patients with HA at our institution. Methods  We performed a retrospective review of 41 patients who underwent surgical resection for HA between 1988 and 2007. Results  Thirty-eight patients were women, and the median age at presentation was 36 years (range, 19–65 years). The most common clinical presentation was abdominal pain (70%) followed by incidental radiological finding (17%). Twenty-two patients had a history of oral contraceptive use. Median number of HA was one (range, 1–3). There were 32 open cases (3 trisectionectomy, 15 hemihepatectomy, 7 sectionectomy, 4 segmentectomy, and 3 wedge resection), and 9 laparoscopic cases (1 hemihepatectomy, 5 sectionectomy, 1 segmentectomy, and 2 wedge resection). The median estimated blood loss was 225 mL (range, 0–3400 mL). The median length of stay was 6 days (range, 1–15 days). Surgical morbidities included pleural effusion requiring percutaneous drainage (n = 2), pneumonia (n = 1), and wound infection (n = 1). There was no perioperative mortality. Twelve patients had hemorrhage from HA. Hepatocellular carcinoma was observed in two patients with HA. Median follow-up was 23 months (range, 1–194 months), at which time all patients were alive. Conclusion  In view of 29% hemorrhagic and 5% malignant complication rates, we recommend surgical resection over observation if patient comorbidities and anatomic location of HA are favorable. A laparoscopic approach can be safely used in selected cases. Presented at Society of Surgical Oncology 61st Annual Cancer Symposium, Chicago, Illinois, March 13–16, 2008.     

Laparoscopic liver resection assisted with radiofrequency

BACKGROUND: Radiofrequency-assisted laparoscopic liver resection is reported. METHODS: Patients suitable for liver resection were carefully assessed for laparoscopic resection. Patient and intraoperative and postoperative data were prospectively collected and analyzed. RESULTS: Eighteen patients underwent laparoscopic liver resection. All operations were performed without vascular clamping and consisting of tumorectomy (n = 9), multiple tumoretcomies (n = 2), segmentectomy (n = 2), and bisegmentectomies (n = 2). Mean blood loss was 121 +/- 68 mL, and mean resection was time 167 +/- 45 minutes. There was no need for perioperative or postoperative transfusion of blood or blood products. One patient developed pneumothorax during surgery as a result of direct puncture of pleura with the radiofrequency probe, and 1 patient had transient liver failure and required supportive care after surgery. The mean length of hospital stay was 6.0 +/-1.5 days. At follow-up, those with liver cancer had no recurrence. CONCLUSIONS: Radiofrequency-assist laparoscopic liver resection can decrease the risk of intraoperative bleeding and blood transfusion.     

Laparoscopic colectomy

Background: Laparoscopic colectomy has developed with the explosion of technology that has followed laparoscopic cholecystectomy. Accumulation of skills in general laparoscopic surgery has made complex surgery, such as colectomy, feasible. Methods: Three hundred fifty-nine laparoscopic cases were prospectively studied. Data has been kept on benign and malignant cases, operative results, hospital stay, and morbidity. Special care has been taken to follow malignant cases, looking for recurrence of disease. Results: There were 359 cases (206 females, 153 male) average age 58.8 years (18–94), and 149 patients had malignancy. All types of resections were performed, including 151 anterior resections, 66 right hemicolectomies (RHC), 36 total colectomies, and 22 rectopexies. Operating times fell with experience—the last 20 cases of anterior resection took 150 min (110–240) and of RHC took 130 min (65–210). Twenty-six (7%) cases were converted to open surgery. Hospital stays for anterior resection lasted 5–7 days (2–33); in the last 20 cases the average stay was 4 days. Morbidity included seven leaks (2.7%), four strictures (1.2%), 12 wound infections (3.3%), and nine ileus (2.5%). There were six deaths within 30 days—sepsis, myocardial infarction, aspiration pneumonia, and disseminated liver metastases. One hundred forty-nine cancer cases have had ten recurrences: one pelvic recurrence, six liver metastases, two para-aortic nodal, and one case of disseminated disease. Average time of recurrence was 33 months (15–46 months). Conclusions: Laparoscopy in the hands of experienced laparoscopic surgeons is a safe, efficient procedure. All types of procedures are possible. Early results in 149 malignancies are encouraging and recurrence rates are low. Prospective studies, now that skills are developed to a level comparable to that of open surgery, are now being performed to further assess laparoscopy's possible role in treating cancer. Received: 26 March 1996/Accepted: 15 October 1996     

Hand-assisted laparoscopic colorectal surgery using GelPort

Background: An easily usable hand access device will optimize success in hand-assisted laparoscopic surgery (HALS). The authors describe their initial series of HALS colorectal resections using GelPort to evaluate their current technique and results with this new device. Methods: A retrospective study investigated 33 HALS colorectal procedures including total colectomy (n = 16) and low anterior resection (n = 10). All operative data, including intraoperative GelPort performance, were prospectively recorded and retrospectively analyzed. Results: In this study, 3 (9.1%) of 33 HALS procedures were converted to open surgery, and 4 (13.3%) of 30 HALS procedures required minimal enlargement of incisions to facilitate extracorporeal procedures. The operative time was 263 ± 85 min, and the blood loss was 282 ± 148 ml. There were no device malfunctions. Three major complications (9.1%) and 7 minor wound infections (21%) were noted postoperatively. The mean hospital stay was 7.9 ± 3.8 days. Conclusion: When performed with GelPort, HALS is safely and reliably applicable for various colorectal procedures.