Totally Laparoscopic Extended Left Hepatectomy

This video will discuss the main steps necessary to perform a totally laparoscopic extended left hepatectomy including partial or complete resection of the middle hepatic vein and resection of segment I. Although totally laparoscopic extended liver resections are currently only being performed in several centers with experience in both minimally invasive and hepatobiliary surgery, it will likely become more common, as more surgeons gain expertise in both of these disciplines. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Totally Laparoscopic Central Hepatectomy

This video will show the pertinent steps to perform a totally laparoscopic central hepatectomy. The main steps of this procedure include control of the hepatic inflow, mobilization of the right liver, control of the hepatic outflow, and specimen removal. This technique is feasible and safe via laparoscopic techniques, but should currently be performed at high volume centers by surgeons with expertise in both HPB surgery and minimally invasive techniques. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Laparoscopy-assisted right hepatectomy in a case of Fasciola hepatica

Laparoscopic hepatectomy provides the usual advantages of a minimally invasive surgery. This study presents a case of Fasciola hepatica infection that was successfully treated with laparoscopic hepatectomy. The patient was referred because of persistent fever and right hypochondralgia with a huge mass occupying the right lobe of the liver, which was detected by imaging analysis. Serologic tests indicated an F. hepatica infection. The patient underwent a laparoscopic resection because the anthelmintic agent, triclabendazole was not effective. During the surgical technique, 5 trocars were inserted. After liver mobilization, the Glissonian pedicles and right hepatic veins were safely taped. A Penrose drain was placed behind the liver for a liver-hanging maneuver. A liver parenchymal transection was performed through an 8 cm handport site using a dissecting sealer (TissueLink Medical) after precoagulating its superficial layer by microtaze. Glissonian pedicles and the right hepatic vein were divided using an endolinear stapler (endcutter 45, Ethicon). Finally, the resected specimen was extracted from the handport. The surgical time was 450 minutes and the surgical blood loss was 370 mL. The patient was discharged 10 days after the surgery with an uneventful postoperative course. The laparoscopy-assisted hepatectomy in this case was beneficial for the patient's quality of life as a minimally invasive operation with a high degree of safety.     

A current update on the evolution of robotic liver surgery

Laparoscopic liver surgery has evolved significantly over the past decade. Increasing understanding of hepatic anatomy and advancements in technology have extended the scope of the minimally invasive approach. Robotic-assisted technology offers solutions to the fundamental limitations of conventional laparoscopic liver resection. Several centers have begun to utilize robotic technology to perform complex liver surgeries. The purpose of this review is to provide a comprehensive analysis of published literature about the role of robotic-assisted laparoscopic technology in liver surgery. A literature search of Pubmed was used to identify all English publications about robotic liver surgery. Publications were selected to examine all unique patient series. Outcomes analyzed included operative time, estimated blood loss, length of stay, complication rate, conversion rate to open, cost, and oncologic outcomes. A total of eight series containing 134 unique patients were selected for review. Sixty-nine percent of patients had malignant lesions resected, while 31% had benign lesions. Segmentectomy/wedge (36%) was the most common resection performed, followed by left lateral sectionectomy (28%) right hepatectomy (16%) and left hepatectomy (9%). A meta-analysis of the remaining data was not possible due to heterogeneity in methods for reporting. Outcomes varied widely between studies. Based on analysis of early published series, robotic liver surgery is a feasible and safe tool for the minimally invasive resection of hepatic lesions. Further evaluation is required to assess for improvement in outcomes, and long-term oncologic outcomes are still pending.     

Standardization of basic skills for laparoscopic liver surgery towards laparoscopic donor hepatectomy

Introduction  We have accumulated over 170 patients since 1995 who underwent laparoscopic partial liver resection, laparoscopic left lateral sectionectomy, and laparoscopy-assisted hepatectomy. Bleeding control, which is a basic element of liver resection, needs to be better managed by methods suitable for safer laparoscopic liver resection. The aim of this study was to standardize the basic skills and to establish safer techniques for laparoscopic liver surgery in order to perform safe laparoscopic donor hepatectomy. Materials and methods  We analyzed initial results from the viewpoint of operative techniques of laparoscopic liver resection in our series. Laparoscopic liver resections have been successfully performed by the application of automatic suturing devices and the radiofrequency method. Results  We have performed 105 laparoscopic partial liver resections, 26 laparoscopic left lateral sectionectomies, and 45 laparoscopy-assisted major hepatectomies. A total of 176 patients underwent minimally invasive liver resections. Conclusion  For safer laparoscopic liver resection, efficient bleeding control techniques, such as radiofrequency pre-coagulation and the liver hanging maneuver, are needed during parenchymal transection of the liver. Laparoscopy-assisted donor hepatectomy can be safely performed without increasing operative risks with mini-laparotomy.     

腹腔镜右肝肿瘤切除术的初步探讨(附15例报告)

目的:探讨腹腔镜右肝肿瘤切除术的可行性、安全性。方法:回顾分析2012年9月至2014年2月为15例右肝肿瘤患者行腹腔镜肝切除术的临床资料。其中肝血管瘤9例,原发性肝癌6例。结果:12例成功完成完全腹腔镜下手术,3例行手辅助腹腔镜手术,无一例中转开腹。其中10例行肝右后叶切除术,5例行右前叶肿瘤切除术。术中13例需阻断肝门,阻断时间平均(17.3±3.5)min。手术时间平均(150±55)min,术中出血量平均(168±39)ml,术后平均住院(11.2±2.7)d。结论:腹腔镜右肝肿瘤切除术受技术问题、手术风险性、肿瘤治疗原则的限制,对术者腹腔镜技术要求较高,操作过程复杂,但在严格把握手术适应证、熟练掌握腹腔镜技术的前提下,肝右叶的肿瘤行腹腔镜肝肿瘤切除术是安全、可行的。     

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.     

Stellenwert laparoskopischer Leberresektionen

Whereas in other fields of surgery minimally invasive techniques have replaced the open surgery approach, liver resection is still a domain of conventional surgery. However, it is internationally emerging that laparoscopic hepatic surgery will become more important by conceptional improvements. This article describes the technical aspects of laparoscopic liver resection, in particular the procedure with respect to the individual liver segments. The advantages and disadvantages of the minimally invasive technique and also the indications for laparoscopic liver resection will be discussed.     

经脐单孔腹腔镜技术用于肝脏恶性肿瘤手术的体会(附2例报告)

目的:探讨经脐单孔腹腔镜手术治疗肝脏恶性肿瘤的可行性及临床应用前景。方法:回顾分析2010年3月至2011年5月为2例患者施行单孔腹腔镜右肝恶性肿瘤切除术的手术方法及临床效果。结果:2例均成功完成单孔手术,无一例中转开腹或增加切口。手术时间分别为75 min和89 min,术中出血60 ml和50 ml,切除肿瘤直径分别为3.5 cm与3.6 cm,术后病理检查结果与术前诊断一致,肿块切缘未见癌细胞浸润。术后无感染、腹腔积液及胆漏等并发症发生,术后1周内出院。结论:单孔腹腔镜右肝恶性肿瘤切除术安全、可行,但术者需同时具备单孔腹腔镜手术及传统腹腔镜肝脏手术的操作经验。相信随着器械的改进,此项技术有望进一步推广应用。     

腹腔镜肝切除术临床应用的经验体会

目的探讨腹腔镜肝切除术的应用指征、技术要点和疗效.方法回顾分析本研究所463例腹腔镜肝切除术患者的临床资料和随访结果.结果2007年3月1日至2011年3月31日共完成各类腹腔镜肝切除手术463例.其中原发性肝癌165例,转移性肝癌29例,肝血管瘤143例,肝胆管结石病81例,其他肝脏良性占位病变(肝血管平滑肌脂肪瘤、肝细胞腺瘤、局灶性结节增生、慢性肝脓肿等)45例.手术方式包括腹腔镜下左肝外叶切除术93例,左半肝切除71例,超左半肝切除4例,右半肝切除29例,右肝后叶切除24例,Ⅵ段切除56例,超右半肝切除2例,中肝切除8例,特殊部位肝段切除(Ⅶ/Ⅷ段、Ⅳa、尾叶及Ⅵ段、Ⅶ段交界处)41例,病变局部不规则性切除121例,两个以上部位联合切除14例.手术时间(244.71±105.07)min,术中出血量(460.26±425.81)ml,无手术死亡,术后并发症发生率9.29%,平均住院时间(15.51±4.36)d.194例肝脏恶性肿瘤患者中185例获得2～50个月随访,术后1年、3年总体生存率为90.8%和84.2%,无瘤生存率为87.9%和73.7%.结论腹腔镜肝切除术作为一种微创治疗手段,可选择性应用于肝脏各个部位、各类病变的手术治疗.该法且具有创伤小、恢复快、切口美容的优点.其近期疗效优于开腹手术,远期疗效与开腹手术相当.肝脏良性病变、小肝癌和转移性肝癌是现阶段腹腔镜肝切除术较理想的适应证.     

Early experience with laparoscopic approach for solid liver tumors: initial 16 cases

OBJECTIVE: To evaluate the feasibility and outcome of laparoscopic hepatectomy in patients with solid liver tumors. SUMMARY BACKGROUND DATA: Although the laparoscopic approach has become popular in the surgical field, the value of laparoscopy in liver surgery is unknown. METHODS: Fifteen patients with solid liver tumors underwent 16 consecutive laparoscopic resections at the authors' institution between 1994 and 1999. Indications were symptomatic hemangioma, focal nodular hyperplasia, liver cell adenoma, isolated metastasis from a colon cancer, and hepatocellular carcinoma. The laparoscopic procedure was performed using four to seven ports (four 10-mm, two 5-mm, and one 12-mm). RESULTS: One patient underwent a major hepatic resection (right lobectomy); the others underwent minor hepatic resections (left lateral segmentectomies, IVb subsegmentectomies, segmentectomy, and nonanatomical excisions). The laparoscopic procedure was uneventful in 15 patients; one patient required conversion to open laparotomy because of inadequate free surgical margins. CONCLUSION: Laparoscopic surgery of the liver is feasible. The use of this new technical approach offers many advantages but requires extensive experience in hepatobiliary surgery and laparoscopic skills. The authors' experience suggests that laparoscopic procedures should be reserved for benign tumors in selected cases. Its application must be verified by further studies.     

Laparoscopic-Assisted Right Lobe Donor Hepatectomy

The major impediment to a wider application of living donor hepatectomy, particularly of the right lobe, is its associated morbidity. The recent interest in a minimally invasive approach to liver surgery has raised the possibility of applying these techniques to living donor right lobectomy. Herein, we report the first case of a laparoscopic, hand-assisted living donor right hepatic lobectomy. We describe the technical aspects of the procedure, and discuss the rationale for considering this option. We propose that the procedure, as described, did not increase the operative risks of the procedure; instead, it decreased potential morbidity. We caution that this procedure should only be considered for select donors, and that only surgical teams familiar with both living donor hepatectomy and laparoscopic liver surgery should entertain this possibility.     

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。     

腹腔镜手术治疗肝癌128例的疗效评析

目的 探讨腹腔镜手术治疗肝癌的临床价值.方法 回顾性分析2007年3月至2009年10月第三军医大学西南医院采用腹腔镜手术治疗128例肝癌患者的临床资料.其中原发性肝癌116例,转移性肝癌12例.行腹腔镜肝切除术107例,单纯腹腔镜下RFA治疗15例,腹腔镜下门静脉右支结扎降期治疗6例.结果 107例行腹腔镜肝切除术患者中7例中转开腹手术,5例中转手助式腹腔镜肝切除术.规则性肝切除88例,包括左外叶切除21例、左半肝切除15例、超左半肝切除2例、中肝切除1例、右半肝切除11例、右后叶切除9例、单肝段切除29例;两个以上部位联合切除4例;非规则性肝切除15例.肝切除术的平均手术时间(228±92)min,术中平均出血量(393±213)ml,无手术死亡,16例术后出现并发症,术后平均住院时间(8±4)d.126例患者随访1～42个月,12例行腹腔镜肝切除术者于术后3～16个月死亡,术后平均生存时间(118±7)周,平均无瘤生存时间(105±7)周.行腹腔镜下BFA治疗的2例患者分别于术后9个月及11个月死亡;行腹腔镜下门静脉结扎的2例患者于术后行二期根治性切除.结论 腹腔镜手术治疗肝癌安全可行,具有创伤小、恢复快的优点.     

Laparoscopic right hepatectomy: Surgical technique

The objective of this study was to demonstrate the safety of laparoscopic right hepatectomy for benign or malignant disease. Many reports document the success of minor or segmental liver resections performed laparoscopically. Major hepatic resection has rarely been reported. This report documents our experience with 12 laparoscopic right hepatectomies. Ten patients had suspected malignancy, but all had lesions well clear of the midplane of the liver. The surgery followed three distinct phases: (1) Portal dissection during which diathermy and harmonic shears are used, clips are applied to the right hepatic duct and right hepatic artery, and a vascular stapler is used to divide the right portal vein; (2) dissection of the vena cava, which is usually done by tunneling below the liver using harmonic shears, clips, and a linear stapler to divide the right hepatic vein; and (3) parenchymal division during which harmonic shears and multiple firings of linear staplers are used to divide the liver substance. In five patients the procedure was completed totally laparoscopically, five patients had a laparoscopic-assisted procedure, and two patients had to be converted to formal open hepatectomy. Four patients required blood transfusion. There were no deaths and two cases of major morbidity—bile leakage in one and wound dehiscence in one. The average hospital stay was 8 days, but for those whose operations were completed totally laparoscopically, 4 days was the average. Two of the nine patients with documented cancer have since died—one with widespread intrahepatic hepatocellular carcinoma and another with widespread metastatic melanoma after resection of a colorectal metastasis. Seven patients with colorectal cancer are alive and disease free with follow-up of 6 to 24 months. Laparoscopic right hepatectomy is feasible in selected patients. It is technically demanding but can be safely accomplished by surgeons who have experience in advanced laparoscopic procedures and open hepatic surgery.     

腹腔镜肝切除术在肝脏局灶性结节性增生中的应用

目的探讨完全腹腔镜肝切除术治疗肝脏局灶性结节性增生(FNH)的可行性。方法回顾性分析我院2014年3月至2016年9月间施行完全腹腔镜肝切除术的15例FNH的临床资料,其中施行腹腔镜下局部切除术7例,施行肝段或肝叶解剖性切除术8例。断肝方式为超声刀+单极电凝,结合腹腔镜下切割缝合器。结果本组均成功实施腹腔镜肝切除术,无中转开腹病例。平均手术时间95 min(45~150 min),术中平均出血量230 m L(30~560 m L)。全组患者均在手术后24~48 h内恢复胃肠功能,1例出现胸水,经B超定位下穿刺引流3 d后好转,全组无胆漏、术后出血、腹腔内感染与气栓等并发症,术后平均住院时间5.6 d(4~7 d)。结论腹腔镜肝切除术用于治疗肝脏局灶性结节性增生是安全、有效、微创的,可有效用于局部、肝段及半肝切除术,特别适用于肝良性肿瘤。     

Hand-assisted laparoscopic anatomical left lobectomy using hemihepatic vascular control technique

We report a new approach for laparoscopic anatomical left lobectomy. Although laparoscopic limited resection of the liver has been reported, major liver surgery with a laparoscopic approach remains uncommon. Obstacles to routine laparoscopic surgery on the liver are mainly related to difficulty in retraction with current instrumentation, difficulty in assessing safe margins of resection without the use of tactile sense, and the difficulty of safe parenchymal dissection laparoscopically. We introduce a hand-assisted method that can help in resolving the difficulties and pitfalls associated with laparoscopic liver resection, and in making this surgery safer. The hand is the best atraumatic liver retractor in laparoscopic resection and facilitates the use of laparoscopic ultrasonography. Stable hemostasis can be achieved by proper manual application of vascular clips in case of vascular injury. The hemihepatic inflow control technique used in the present case was the en masse occlusion of Glisson's sheath of the left hemipedicle at the bifurcation. This technique was used exactly the same as in open surgery. Major vessels such as the left hemipedicle and left hepatic vein were dissected by endovascular cutter. The patient had an uneventful, quick postoperative recovery. This technique allows a minimally invasive anatomical major surgery for liver tumors.     

腹腔镜下肝切除术中转开腹的相关因素初步分析

目的:探讨腹腔镜肝切除术的手术经验、中转开腹相关因素及预防措施。方法:回顾分析2013年11月至2015年11月45例施行腹腔镜肝切除术患者的临床资料,包括是否中转开腹、年龄、性别、术后病理诊断、既往手术史、手术时间、术中出血及住院时间。结果:42例行完全腹腔镜肝切除术,3例中转开腹,其中2例因术中出现不可控的大出血,1例为肿瘤位置不能充分暴露,中转开腹率6.67%。手术时间平均(80±25)min,出血量平均(150±55)ml,术后平均住院(7.1±1.5)d。除术中出血及暴露不充分为腹腔镜肝切除中转开腹的主要因素外,上腹部手术史(P=0.016)、病程(t=3.94,P=0.013)也是中转开腹的相关因素。结论:术中难以控制的出血、手术视野暴露不充分是腹腔镜肝切除术中转开腹的主要原因,上腹部手术史、病程也是中转开腹的因素之一。术前评估患者的既往手术史、病史、肝功能、凝血等情况极为重要,完全腹腔镜下肝切除是安全、有效、微创的术式,但因为肝脏血供丰富、体积较大,对术者技术水平的要求相对较高。     

Robotic liver resection: technique and results of 30 consecutive procedures

Background

Robotic surgery can enhance a surgeon’s laparoscopic skills through a magnified three-dimensional view and instruments with seven degrees of freedom compared to conventional laparoscopy.

Methods

This study reviewed a single surgeon’s experience of robotic liver resections in 30 consecutive patients, focusing on major hepatectomy. Clinicopathological characteristics and perioperative and short-term outcomes were analyzed.

Results

The mean age of the patients was 52.4?years and 14 were male. There were 21 malignant tumors and 9 benign lesions. There were 6 right hepatectomies, 14 left hepatectomies, 4 left lateral sectionectomies, 2 segmentectomies, and 4 wedge resections. The average operating time for the right and left hepatectomies was 724?min (range 648–812) and 518?min (range 315–763), respectively. The average estimated blood loss in the right and left hepatectomies was 629?ml (range 100–1500) and 328?ml (range 150–900), respectively. Four patients (14.8%) received perioperative transfusion. There were two conversions to open surgery (one right hepatectomy and one left hepatectomy). The overall complication rate was 43.3% (grade I, 5; grade II, 2; grade III, 6; grade IV, 0) and 40% in 20 patients who underwent major hepatectomy. Among the six (20.0%) grade III complications, a liver resection–related complication (bile leakage) occurred in two patients. The mean length of hospital stay was 11.7?days (range 5–46). There was no recurrence in the 13 patients with hepatocellular carcinoma during the median follow-up of 11?months (range 5–29).

Conclusions

From our experience, robotic liver resection seems to be a feasible and safe procedure, even for major hepatectomy. Robotic surgery can be considered a new advanced option for minimally invasive liver surgery.     

完全腹腔镜肝切除25例临床报告

目的 探讨腹腔镜肝切除手术的可行性与适应证。方法 27例拟行肝切除的病例中，其中原发性肝癌16例、肝血管瘤5例、肝脓肿2例、肝囊肿伴感染l例、肝门部胆管癌l例、肝脏腺瘤l例、肝脏局灶结节性增生l例。25例在全气腹条件下完成，l例在手助下完成，l例中转开腹。结果 本组25例在全气腹条件下完成27个病灶的腹腔镜肝切除手术。肝局部切除16例，左肝解剖性切除9例。手术时间平均205min，出血量平均460ml。术中未出现不能控制的并发症，腹腔引流管放置时间2至4d，术后平均住院6．8d，术后恢复时间较常规开腹方法肝切除患者明显缩短。结论 本组研究表明腹腔镜肝切除手术具有广阔前景，熟练开腹手术经验及熟悉的肝段解剖是腹腔镜肝脏解剖性切除时控制出血的关键。