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.     

Habib 4X双极射频在腹腔镜肝切除术中的应用

目的 本研究应用Habib 4X双极射频辅助腹腔镜切肝,以评价其减少术中出血表现及术后并发症情况.方法 回顾性分析2009年9月至2012年4月期间,我院30例Habib 4X射频辅助切肝病例的临床资料.结果 30例中,1例因术中瘤体破溃中转开腹手术,29例完成腹腔镜下手术.其中左肝外叶切除12例,左半肝切除1例,第Ⅴ段或第Ⅵ段切除8例,ⅤⅥ段联合切除2例,肝缘病灶锲型切除6例.切肝时间10~68 min,中位切肝时间22 min;出血量8~370 mL,平均(145±75) mL;术后住院时间(3~12)d,平均(7.5±2.8)d.无术后出血、胆漏或感染等并发症,肝癌病例术后未见切缘复发.结论 应用Habib4X射频辅助腹腔镜切肝,无需肝门解剖和阻断,可提高切肝速度,减少术中失血,术后恢复快,不增加术后并发症.由于射频本身的治疗作用,肿瘤性病灶切除后可增加切缘的安全性.     

Bleeding and hemostasis in laparoscopic liver surgery

Background

Minimally invasive liver resection is gaining acceptance worldwide. However, the laparoscopic approach often is reserved for small segmental resections due to the fear of significant blood loss. The expansion of laparoscopic liver surgery will depend on the ability of expert surgeons and technological advances to address the management of bleeding and hemostasis with any new approach. The 4½- year experience of a single center performing totally laparoscopic liver resections is presented, with special reference to the techniques the authors have developed to limit blood loss.

Methods

Between 2003 and 2007, 80 patients underwent laparoscopic liver surgery for benign and malignant conditions including colorectal cancer metastases (n = 31), hepatocellular carcinoma (n = 6), neuroendocrine tumor (n = 3), cystic lesion (n = 10), adenoma (n = 8), and focal nodular hyperplasia (n = 7). Totally laparoscopic resections included sectionectomy (n = 27), hemihepatectomy (n = 10), and single/multiple segmentectomies (n = 21). Data for all resections were recorded and analyzed retrospectively to assess blood loss, hospital stay, and morbidity.

Results

The median operative time was 150 min, and the median blood loss was 120 ml, with significantly more blood loss for right-sided transections than for the left liver surgery (821 vs 147 ml; p = 0.012). Four (57%) of seven resections converted to open procedures because of bleeding. No deaths occurred, and only two patients required intraoperative blood transfusions. There were eight complications and one bile leak. The median length of hospital stay was 3 days.

Conclusions

The authors’ experience with 80 totally laparoscopic liver resections over a 4½-year period demonstrates that laparoscopic liver surgery is safe and effective in experienced hands for major resections. An intimate knowledge of the technology and techniques available for preventing and managing significant hemorrhage during laparoscopic liver resection is required for all surgeons performing laparoscopic liver surgery.     

New application of the bipolar vapor plasma coagulation system for laparoscopic major liver resections

Background In recent years, laparascopic techniques have become a more widely used and accepted means for performing various types of liver resections. In this report, the authors describe the use and initial applications of a new approach to laparoscopic liver resection using vapor pulse coagulation. Methods Liver resections using vapor plasma coagulation technology were performed for 11 patients at the authors’ center. Candidates were initially selected because they had benign disease and lesions amenable to standard resections along anatomic planes. Four resections were performed with a hand-assist technique and seven without it. Results All the patients faired well. The length of the hospital stay was 3.4 ± 0.7 days. There were no major surgical complications, bile leaks, or reoperations. None of the patients required blood transfusions. One patient was readmitted for fever and urinary tract infection, and one patient had 1 week of right leg swelling attributable to the use of stirrups. Conclusions Vapor plasma coagulation using a laparoscopic approach for hepatic resection is a promising new technology that deserves further exploration.     

The laparoscopic liver resections—an initial experience and the literature review

The laparoscopic liver resection (LLR) represents a new pathway in hepatic surgery. Several studies have reported its application in both malignant and benign liver diseases. The most common liver resections performed laparoscopically are wedge, segmental resections and metastasectomy; although in large centers the laparoscopic right and left hepatectomies have begun to perform more frequently. We report the initial experience in LLRs at our department including a case of the first laparoscopic left lateral liver bisegmentectomy performed in patient with follicular nodular hyperplasia and the 15 cases of wedge laparoscopic resections of echinococcic liver cysts. According to literature the mortality rate in LLRs is up to 0.3% and morbidity rate up to 10.5%. The most common cause of the death is liver failure, while the most frequent complication is the bile leakage. Advantages for patients include smaller incisions, less blood loss, and shorter lengths of hospital stay. The LLRs in experienced hands were shown to be safe with acceptable morbidity and mortality for both minor and major hepatic resections in benign and malignant diseases.     

Laparoscopic hand-assisted hepatic surgery.

At Ninewells Hospital, we have changed from total to hand-assisted laparoscopic hepatic resections. We report here our initial experience on 10 anatomic hepatic resections with good outcome, and 1 with a significant postoperative complication (fall in the hemoglobin) requiring laparotomy. All resections were undertaken by using the Omniport device (Advanced Surgical Concepts, Dublin, Ireland). The hand-assisted laparoscopic surgery (HALS)-Omniport approach has also been used selectively in 5 patients undergoing in situ ablation for bilateral metastatic disease with lesions not easily accessible to the total laparoscopic approach, ie, situated in the posterior and inferior segments of the right liver. The HALS approach has several advantages; it facilitates and expedites the procedure, reduces the stress factor to the surgeon, greatly improves exposure, and provides an immediate and efficient control of bleeding vessels with the internal hand. The Omniport device, which essentially consists of a handcuff with a spiral inflatable valve, enables withdraw and reinsertion of the hand without loss of pneumoperitoneum during the procedure. The device was effective in maintaining pneumoperitoneum in all cases. All operations were completed with the HALS approach.     

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.     

V6The feasibility of laparoscopic rectal resection for cancer

Introduction:  Total mesorectal excision (TME) has offered the lowest recurrence rates and best survival in rectal cancer patients. Recently several multi-centre trials have demonstrated the feasibility of laparoscopic colonic resections for cancer. However the technical difficulties and lack of supporting data has prevented surgeons from attempting laparoscopic TME for operable rectal cancer. We present a video demonstration of lap TME technique performed at our unit for rectal cancer resections.
Methods:  The surgical technique involves using two 10 mm and two 5 mm ports to perform rectal resections. Adherence to advanced oncological principles like high tie of IMA and IMV is the rule. Splenic flexure is routinely mobilised for mid to low rectal cancers. Total mesorectal excision is performed using diathermy hook. Rectal washout is performed before transection of the rectum using lap stapler device.
Results:  Between October 2006–December 2007, 30 rectal cancers have been operated laparoscopically at our institution using this technique. There were four APER and 26 anterior resections. The median age was 72 years with a median BMI of 25. Median operative time was 235 min with a median hospital stay of 7 days. There were no leaks.
Conclusions:  With proper training and experience, laparoscopic rectal cancer resection is technically feasible and safe to perform with good oncological outcomes.     

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.     

Thermal effects of laparoscopic saline-enhanced radiofrequency cautery on renal parenchyma in a porcine model

PURPOSE: Advances in the field of surgery have recently developed a number of devices and materials to improve surgical hemostasis. The effects of one such device, saline-cooled monopolar radiofrequency electrocautery, has been well scrutinized in splenic and hepatic applications. Despite the utilization of this device in urologic surgery, the classification of the thermal effects has been poorly characterized to date. The purpose of this study was to discern the thermal characteristics of the device in the laparoscopic environment when used on renal parenchyma. MATERIALS AND METHODS: After institutional approval, four domestic swine were randomized to receive laparoscopic renal lesions randomly generated by either saline-cooled (25 W with saline flow rate of 4 mL/min) or standard monopolar radiofrequency electrocautery. The energy source was applied for between 1 and 11 seconds for each device in order to create a total of 64 renal lesions. Each kidney was harvested and examined by a genitourinary pathologist blinded to the treatment interval. RESULTS: The saline-cooled device provided a greater depth of coagulation effect compared to standard monopolar electrocautery at all points in time (P < 0.05). The diameter of the lesions created using saline-cooled monopolar electrocautery was greater than those created with standard electrocautery (P < 0.05). CONCLUSIONS: The saline-cooled monopolar electrocautery provided an improved coagulation effect compared to standard electrocautery in the laparoscopic setting. Recognition of the time and resultant thermal consequences can help the laparoscopic surgeon plan surgical approaches for renal lesions and improve hemostasis.     

Laparoscopic liver surgery for everyone: the hybrid method

Minimally invasive techniques have been described recently for liver resections. We have developed a surgical approach to liver resection that combines the benefits of minimally invasive surgery with the safety of open liver resection. We have applied this hybrid approach to selected cases, and we feel that it can be adopted by most hepatobiliary surgeons, even those with minimal or no laparoscopic experience. Briefly, this technique consists of laparoscopic mobilization of the target liver lobe, followed by standard open liver resection through the extraction site. The required incisions parallel those needed for hand-assisted laparoscopic liver resections. We have compared these hybrid procedures with contemporaneous laparoscopic, hand-assisted, and open liver resections at our institution and have found that they compare favorably with minimally invasive procedures. A wider utilization of this approach by both general and hepatobiliary surgeons will result in a more generalized acceptance of minimally invasive liver resection that ultimately will advance the field and benefit patients in need of liver surgery.     

Experience With Ultrasound Scissors and Blades (UltraCision) in Open and Laparoscopic Liver Resection

OBJECTIVE: The authors used new ultrasonically activated scissors and blades in open and laparoscopic liver resections to investigate their capabilities. SUMMARY BACKGROUND DATA: Despite standardized techniques for liver resection, the surgical death rate ranges from 4% to 20%. Dissection of liver parenchyma may cause considerable blood loss. Further complications include liver failure, hematoma, infections, and bile leakage. The surgical technique is an important factor in preventing intraoperative and postoperative complications. Various techniques have been developed for safe and careful dissection of the liver parenchyma. In addition to blunt dissection using the "finger fracture" technique, various ultrasonic dissectors, water jet dissectors, laser systems, and specially prepared suction devices have been used, but none of these techniques can achieve complete hemostasis during dissection. METHODS: The instrument was used in open and laparoscopic liver resections. It works by means of a longitudinally vibrating blade or scissors in tissue dissection, coagulation, and preparation. Denaturation of protein and coagulation of vessels up to 2 to 3 mm is possible as a result of the vibration. In this prospective study of a consecutively sampled case series of 41 patients, the author sought to gain experience in handling this instrument and in its capabilities, and they also measured the extent of intraoperative and postoperative blood loss. RESULTS: The UltraCision was used for 64 open liver resections in 39 patients and for 2 laparoscopic liver resections in 2 patients. Blood loss in laparoscopic resections was less than 50 mL; in open resections it averaged 820 mL. Eleven patients (28%) needed blood transfusions. There were no biliary leakages or abscesses. One patient died after postoperative bleeding leading to fatal liver failure after 4 weeks. Handling of the instrument and cutting and coagulation quality were satisfactory. CONCLUSIONS: The advantages over other resection techniques are limited heat and smoke generation and the lack of current flow through the patient. The handling and coagulation and cutting quality of the UltraCision appeared satisfactory and safe. The new instrument can be recommended for laparoscopic and open resections of the liver.     

Completely laparoscopic nonanatomic hepatic resection using saline-cooled cautery and hydrodissection

The technical aspects of laparoscopic hepatic resection have evolved rapidly. The key to any approach is establishing a reliable method to prevent or control hemorrhage during parenchymal transection. Although combining a hand-assist technique with laparoscopy allows improved control of bleeding risk, this requires the addition of a hand-port incision. The development of novel devices that can be used to safely divide liver parenchyma laparoscopically may lessen the need for hand-assist. Here, we report a series of laparoscopic hepatic resections that were attempted without the use of hand-assistance (completely laparoscopic). Resections were performed using saline-cooled cautery (Tissue-Link Endohook) and/or hydrodissection (Erbe Helix Hydrojet). Fifteen laparoscopic hepatic resections were attempted by a single surgeon from 2002 to 2006. In each case, a nonanatomic, completely laparoscopic approach was attempted. Patients with lesions at the hepatic dome or those requiring lobectomy or hilar dissection were excluded. Fourteen of 15 cases (93%) were accomplished completely laparoscopically, while one patient required placement of a hand port. Resected tumors averaged 3.9 cm diameter. There were no bile leaks and no patient required transfusion. Average length of stay was 4.1 days (range 1-5). Complications included ileus (1) and atrial fibrillation (1). In six patients with malignancies, margins were negative and there have been no local or port recurrences. This report demonstrates the feasibility of completely laparoscopic hepatic resection using novel devices for parenchymal transaction. Hand-assist techniques remain useful as a salvage strategy or for larger resections.     

Totally laparoscopic extended right hepatectomy

Background  This video demonstrates the relevant technical maneuvers necessary for performing a totally laparoscopic extended right hepatectomy. Methods  The five principal steps of this procedure include mobilization of the liver, control of hepatic inflow, division of the hepatic parenchyma, control of the hepatic outflow, and removal of the specimen. Results  A total of five totally laparoscopic extended right hepatectomies have been performed successfully at our institution. Our short- and long-term results have been similar to those for our open historical control subjects. No mortalities have been observed. Conclusion  The minimally invasive approach to hepatic resections is limited by the comfort level of the operator and not the technique itself. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Hand port-assisted laparoscopic surgery

The dramatic benefits of laparoscopic cholecystectomy or appendectomy for patients encouraged surgeons to use minimal access operative technique in the treatment of other more complex surgical procedures [2, 3]. The authors report on their experiences with 14 patients operated by hand-port assisted laparoscopic technique for benign colorectal diseases. The mortality rate was zero. The operation times compared to the laparoscopically operated previous 14 patients with equal diagnosis did not differ significantly (hand-port: 124-186 min; lap.: 121-176 min). The begin of bowel movements and the postoperative hospital stay were comparable to those of laparoscopic surgery. There were no major complications. No conversion to an open procedure was necessary. As the hand-port device allows the surgeon to insert his (usually non-dominant) hand into the abdominal cavity during the procedure, the hand-port device seems to combine the laparoscopic benefits with the advantages of a conventional open approach (manual exploration, blunt dissection, control of hemostasis) without loss of pneumoperitoneum [10]. Even though hand-assisted operations have not gained widespread acceptance, they recently demonstrated their value especially in more complex laparoscopic procedures like splenic and gastric resections, nephrectomy and colorectal surgery [6, 10, 18, 21, 23-24]. The regaining of tactile sensation which is an essential surgical tool may encourage less experienced colleagues to perform more complex operations. The authors suggest that the hand-port device could be a useful tool in the armentarium for colorectal surgery. Further randomized trials are needed to evaluate the benefits of this technique.     

Totally laparoscopic pericystectomy in hepatic hydatid disease

Hepatic hydatid disease is still a commonly seen problem in endemic areas as well as in our country. There is a wide spectrum of therapeutic modalities ranging from simple medical treatment to radical liver resection. Progress in laparoscopic procedures made it possible to consider laparoscopic approaches in selected patients with hepatic hydatid disease. The current laparoscopic approach seems to be limited to cystotomy and drainage. There are fewer reports on hepatic resections or pericystectomy in the literature. In this article we present a case of laparoscopic pericystectomy performed in a selected patient.     

Meta-analysis of laparoscopic vs open liver resection for hepatocellular carcinoma

Laparoscopic liver resections (LLR) are widely accepted as safe and effective procedures for the management of hepatocellular carcinoma (HCC) in the hands of experienced surgeons. The efficacy and extent of benefits of pure as well as hand-assisted laparoscopic and laparoscopy-assisted liver resection over open liver resection (OLR) have been investigated by numerous studies during the last 10 years. The aim of our meta-analysis is to investigate the effect of LLR in short- and long-term outcomes compared to OLR in patients operated for HCC. A total of 5203 patients from forty-four studies were included in our meta-analysis reporting for short- and long-term results for both LLR and OLR for HCC. Among them, 1830 underwent pure laparoscopic hepatectomy, 282 underwent pure laparoscopic or hand-assisted laparoscopic or laparoscopy-assisted hepatectomy, and 3091 were operated through open approach. LLRs were found to be significantly associated with lower blood loss, need for blood transfusion, successful achievement of R0 resection as well as wider resection margin, shorter hospital stay, lower morbidity and 30-day mortality rates. Operative time, tumor recurrence, 1-, 3-, and 5-year overall survival as well as 1-, 3-, and 5-year disease-free survival were not found different between the groups. This meta-analysis clearly demonstrates the superiority of laparoscopic resection over the open approach for patients with small HCC.     

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.     

Impact of intraoperative ultrasonography in laparoscopic liver surgery

Background Laparoscopic surgery has gained growing acceptance, but this does not hold for laparoscopic surgery of the liver. This mainly includes diagnostic procedures, interstitial therapies, and treatment of liver cysts. However, the authors believe there is room for a laparoscopic approach to the liver in selected cases. Methods A prospective study of laparoscopic liver resections was undertaken with patients who had preoperative diagnoses of benign lesion and hepatocellular carcinoma with compensated cirrhosis. The inclusion criteria required that hepatic involvement be limited and located in the left or peripheral right segments (segments 2–6), and that the tumor be 5 cm or smaller. The location of the tumor and its transection margin were defined by laparoscopic ultrasound (LUS). Results From December 1996, 17 (5%) of 313 liver resections were included in the study. There were 5 benign lesions and 12 hepatocellular carcinomas in cirrhotic patients. The mean age of the study patients was 59 years (range, 29–79 years). The LUS evaluation identified the presence of new hepatocellular carcinoma nodules in two patients (17%). The resections included 1 bisegmentectomy, 8 segmentectomies, 3 subsegmentectomies, and 3 nonanatomic resections. The mean operative time, including laparoscopic ultrasonography, was 156 ± 50 min (median, 150 min; range, 60–250 min), and the perioperative blood loss was 190 ± 97 ml. There was no mortality. Conversion to laparotomy was necessary for two patients. Postoperative complications were experienced by 3 of 15 patients, all of them cirrhotics. One of the patients had a wall hematoma, and the remaining two patients had bleeding from a trocar access requiring a laparoscopic reexploration. The mean hospital stay for the whole series was 6.9 ± 4.9 days (median, 6 days; range, 2–25 days) and 5.6 ±1.4 days (median, 6 days; range, 2–8 days) for the 15 laparoscopic patients. Conclusion Laparoscopic treatment should be considered for selected patients with benign and malignant lesions in the left lobe or frontal segments of the liver. Evaluation by LUS is indispensable to guarantee precise determination of the segmental tumor location and the relationship of the tumor to adjacent vascular or biliary structures, excluding adjacent or adjunctive new lesions. The evolution of laparoscopic hepatectomies probably will depend on the development of new techniques and instrumentations.