Impact of hybrid techniques on laparoscopic major hepatectomies

Purpose

To assess the types of liver resection, surgical approaches, and surgical outcomes, a questionnaire survey was undertaken at 32 member hospitals of the Japanese Endoscopic Liver Study Group.

Methods/results

Laparoscopic liver resections were performed on 837 patients. Major hepatectomy, including trisectionectomy, hemihepatectomy, and sectionectomy, constituted 106 of the cases. Laparoscopic major hepatectomy (LMH) was performed as totally laparoscopic (n = 8) (7.5 %), hand-assisted (n = 4) (3.8 %), or laparoscopy-assisted (n = 94) (88.7 %). None of the 106 patients were converted to open surgery. Complications occurred in 18 (17.0 %) of the 106 patients. One patient (0.9 %) had bleeding, two (1.9 %) had liver failure, six (5.7 %) had bile leakage, two (1.9 %) had pleural effusion, five (4.7 %) had surgical site infection, one (0.9 %) had pneumonia, and one (0.9 %) had acute respiratory distress syndrome. There were no perioperative deaths or gas embolisms.

Conclusion

In conclusion, a major hepatectomy using a hybrid technique is safe and feasible.     

Outcomes following laparoscopic versus open major hepatectomy: a meta-analysis

Objective: The role of laparoscopic major hepatectomy (LMH) remains uncertain in current liver surgery. This meta-analysis aimed to compare surgical and oncological outcomes of LMH versus open major hepatectomy (OMH).

Methods: A systematic search was conducted in PubMed, Embase, and the Cochrane Library database to identify all relevant publications. The statistical analysis was performed using Review Manager version 5.3. Continuous variables were calculated by standardized mean differences (SMD) with 95% confidence interval (CI), whereas dichotomous variables were calculated by odds ratio (OR) with 95%CI.

Results: A total of 10 eligible studies with 1130 patients were identified, of which 455 (40.3%) patients in the LMH group and 675 (59.7%) patients in the OMH group. LMH was associated with less blood loss (SMD?=??0.30, 95%CI: ?0.43 to ?0.18, p?p?=?.007), decreased postoperative morbidity (OR?=?0.56, 95%CI: 0.42–0.76, p?=?.0001), and shorter hospital stay (SMD?=??0.46, 95%CI: ?0.69 to ?0.24, p?p?=?.01). Both the two groups achieved similar surgical margin and R0 resection rate for malignant lesions.

Conclusions: This meta-analysis demonstrated that LMH appeared to be feasible and safe in current liver surgery. LMH is associated with less blood loss, decreased postoperative morbidity, shorter hospital stay, and comparable oncological outcomes compared with OMH.     

Gas embolism in laparoscopic hepatectomy: what is the optimal pneumoperitoneal pressure for laparoscopic major hepatectomy?

Laparoscopic hepatectomy (LH) has become popular as a surgical treatment for liver diseases, and numerous recent studies indicate that it is safe and has advantages in selected patients. Because of the magnified view offered by the laparoscope under pneumoperitoneal pressure, LH results in less bleeding than open laparotomy. However, gas embolism is an important concern that has been discussed in the literature, and experimental studies have shown that LH is associated with a high incidence of gas embolism. Major hepatectomies are done laparoscopically in some centers, even though the risk of gas embolism is believed to be higher than for minor hepatectomy due to the wide transection plane with dissection of major hepatic veins and long operative time. At many high-volume centers, LH is performed at a pneumoperitoneal pressure less than 12 mmHg, and reports indicate that the rate of clinically severe gas embolism is low. However, more studies will be necessary to elucidate the optimal pneumoperitoneal pressure and the incidence of gas embolism during LH.     

Evidence supporting laparoscopic major hepatectomy

Laparoscopic liver resection (LLR) has been increasing in frequency with over 9,000 cases done worldwide. Benefits of laparoscopic resection include less blood loss, smaller incisions, decreased postoperative morbidity, and shorter length of stay compared to open liver resection. With increased experience, several centers have reported series of laparoscopic major hepatectomy, although this represents only about 25% of total LLR performed. Evidence is accumulating to support laparoscopic major hepatectomy with the understanding that there is a steep learning curve, and surgeons should begin with minor LLR before moving on to laparoscopic major hepatectomy. Controversy still remains concerning indications, techniques, learning curve, risks, and long‐term cancer outcomes with laparoscopic major hepatectomy.     

Totally laparoscopic hepatectomy exposing the major vessels

Background

Even during laparoscopic hepatectomy, a technique is often required to expose the major vessels, for example, in anatomical hepatectomy. We have standardized and performed such laparoscopic hepatectomy as successfully as open hepatectomy.

Methods

We divide the liver parenchyma without pre-coagulation, exposing the major vessels using CUSA. To control the bleeding, we keep the central venous pressure low and often perform Pringle’s maneuver. Over 49 months, we performed totally laparoscopic hepatectomies in 41 patients with the technique of exposing the major vessels. These included major hepatectomy in 7, sectorectomy in 17, segmentectomy in 14, and others in 3.

Results

The median operative time was 361 (range 176–605) minutes, with median blood loss of 216 (range 0–1600) g. The conversion rate was 4.9 %. Postoperative morbidity rate was 9.8 % (prolonged ascites in 1, port site infection in 1, peroneal palsy in 2). Mortality was zero. The median length of hospital stay after surgery was 8 (range 5–28) days. No local recurrence was found at the time of writing.

Conclusions

By using our standardized procedure exposing the major vessels, we could raise the quality of laparoscopic hepatectomy toward the level of open hepatectomy significantly.     

Laparoscopic major hepatectomy can be safely performed with colorectal surgery for synchronous colorectal liver metastasis

Background

The optimal strategy for resectable synchronous colorectal liver metastases remains controversial. Although some authors advocate a staged treatment, an increasing number of studies have reported that combined colorectal and liver resection is safe. Laparoscopic combined resection in primary colorectal cancer with synchronous liver metastases has been reported but there are no specific data for major liver resections. In the present study, we evaluated the feasibility of a simultaneous entirely laparoscopic procedure, in the light of the benefits of laparoscopy in both colon and liver surgery, and discussed the benefits of this strategy.

Methods

Two cases are presented of totally laparoscopic major liver resections associated with laparoscopic colorectal resections for synchronous liver metastases with the emphasis on the technical aspects. Duration of surgery, blood loss and post-operative outcome were evaluated.

Results

Laparoscopic right hepatectomy or left hepatectomy with simultaneous colon resection for liver metastasis was feasible and safe with only one suprapubic 5-mm trocar added to the usual trocar sites. The mean duration of surgery was 327 min with a mean estimated blood loss of 200 ml. The post-operative course was uneventful.

Discussion

In selected patients, laparoscopic major hepatectomies for unilobular synchronous metastases can be safely performed simultaneously with colorectal surgery.     

International experience for laparoscopic major liver resection

Although minor laparoscopic liver resections (LLRs) appear as standardized procedures, major LLRs are still limited to few expert teams. The aim of this study was to report the combined data of 18 international centers performing major LLR. Variables evaluated were number and type of LLR, surgical indications, number of synchronous colorectal resections, details on technical points, conversion rates, operative time, blood loss and surgical margins. From 1996 to 2014, a total of 5388 LLR were carried out including 1184 major LLRs. The most frequent indication for laparoscopic right hepatectomy (LRH) was colorectal liver metastases (37.0%). Seven centers used hand assistance or hybrid approach selectively for LRH mostly at the beginning of their experience. Seven centers apply Pringle's maneuver routinely. The conversion rate for all major LLRs was 10% and mean operative time was 291 min. Mean estimated blood loss for all major LLR was 327 ml and negative surgical margin rate was 96.5%. Major LLRs still remain challenging procedures requiring important experience in both laparoscopy and liver surgery. Stimulating the younger generation to learn and accomplish these techniques is the better way to guarantee further development of this surgical field.     

加速康复外科理念在腹腔镜肝切除术中的应用

目的初步探讨加速康复外科(ERAS)应用于腹腔镜肝切除中的安全性及效果。方法选取2014年1月-2016年12月在南京大学医学院附属鼓楼医院肝胆外科接受腹腔镜肝切除的患者55例,随机分为ERAS组(27例)和围手术期常规处理组,即对照组(28例),比较2组患者术后肝功能恢复情况、CRP、术后并发症发生率、术后康复情况、术后康复体力评分及生活状况。计量资料2组间比较采用独立样本t检验,2组间指标变化趋势的比较采用重复测量方差分析,计数资料组间比较采用χ~2检验。结果2组患者术前术中各方面指标差异无统计学意义(P值均>0.05)。与对照组相比,ERAS组除术后第5天AST、CRP水平显著低于对照组,差异均有统计学意义(t值分别为2.168、2.291,P值均<0.05),其余肝功能指标差异均无统计学意义(P值均>0.05)。ERAS组术后非手术部位并发症发生率显著低于对照组,差异有统计学意义(χ~2=4.150,P<0.05),并发症总发生率、手术部位并发症发生率以及Clavien-Dindo并发症分级差异无统计学意义(P值均>0.05)。术后康复评分中综合评分、疼痛评分、活动评分ERAS组均显著优于对照组,差异均有统计学意义(t值分别为1.297、2.777、3.009,P值均<0.05),且排气时间、排便时间和术后住院时间均明显短于对照组,差异均有统计学意义(t值分别为6.291、2.577、4.229,P值均<0.05)。结论 ERAS应用于腹腔镜肝切除可减少手术应激,降低非手术部位并发症发生,加速患者术后康复。     

腹腔镜肝切除术在肝癌合并肝硬化患者的应用

目的：探讨腹腔镜下肝切除（LH）与开腹肝切除（OH）在治疗肝癌合并肝硬化患者近期疗效之间的差别。方法选取2010年9月至2012年6月武汉大学人民医院住院的肝癌合并肝硬化患者78例,分为2组,其中LH组32例,OH组46例,分析比较2组术中、术后恢复以及术后复发之间的差别。计量资料采用成组t检验和配对t检验,计数资料采用χ2检验。结果2组比较,术中失血量,LH组显著低于OH组（t＝0．057,P＝0．040）;手术时间,LH组高于OH组（t＝3．101,P＝0．003）;术后并发症方面,电解质紊乱、胆漏、腹水,LH组显著低于OH组（t＝3．001,3．241,4．255,P均＜0．05）;术后第1天肝功能水平（AST、ALT）,LH组显著低于OH组（t＝3．427、3．201,P＝0．001、0．002）;术后开始经口摄食的时间,LH组显著短于OH组（t＝3．012,P＝0．001）;住院时间LH组显著低于OH组（t＝2．157,P＝0．003）;肿瘤复发方面,LH组显著少于OH组（t＝2．751,P＝0．006）。结论对于肝癌合并肝硬化患者,LH较OH,无论在手术切口、术中失血量、术后腹水发生率、术后并发症、住院时间以及术后肿瘤的复发的发生方面都具有显著优势。     

Comparison of laparoscopic and open living donor hepatectomy: A meta-analysis

Laparoscopic donor hepatectomy (LDH), accepted as a minimally invasive approach, has become increasingly popular for living donor liver transplant. However, the outcomes of LDH remain to be fully clarified when compared with open living donor hepatectomy. Thus, our meta-analysis was designed to assess the efficacy of laparoscopic in comparison with conventional open donor hepatectomy.The PubMed, Cochrane, and Embase electronic databases were searched to identify the articles concerning the comparison of the efficacy of laparoscopic versus open surgery in treatment of living donor liver transplantation updated to March, 2020. The main search terms and medical Subject Heading terms were: “living donor,” “liver donor,” “minimally invasive,” “laparoscopic surgery,” and “open surgery.” After rigorous evaluation on quality, the data was extracted from eligible publications. The outcomes of interest included intraoperative and postoperative results.The inclusion criteria were met by a total of 20 studies. In all, 2001 subjects involving 633 patients who received laparoscopic surgery and 1368 patients who received open surgery were included. According to the pooled result of surgery duration, the laparoscopic surgery was associated with shorter duration of hospital stay (MD = −1.07, 95% CI −1.85 to −0.29; P = .007), less blood loss (MD = −57.57, 95% CI −65.07 to −50.07; P < .00001), and less postoperative complications (OR = 0.61, 95% CI 0.44–0.85; P = .003). And the open donor hepatectomy achieved a trend of shorter operation time (MD = 30.31, 95% CI 13.93–46.69; P = .0003) than laparoscopic group. Similar results were found in terms of ALT (P = .52) as well as the AST (P = .47) peak level between the 2 groups.LDH showed the better perioperative outcomes as compared with open donor hepatectomy. The findings revealed that LDH may be a feasible and safe procedure for the living donor liver transplantation.     

Laparoscopic major hepatectomy: pure laparoscopic approach versus hand-assisted technique

Laparoscopic liver resections are being performed with increasing frequency, with several groups having reported minimally invasive approaches for major anatomic hepatic resections. Some surgeons favor a pure laparoscopic approach, while others prefer a hand-assisted approach for major laparoscopic liver resections. There are clear advantages and disadvantages to a hand-assisted technique. The purpose of this study is to summarize the literature comparing pure laparoscopic and hand-assisted approaches for minimally invasive hepatic resection, and to describe our approach in 432 laparoscopic liver resections.     

A standard definition of major hepatectomy: resection of four or more liver segments

BackgroundWhile commonly used to describe liver resections at risk for post-operative complications, no standard definition of ‘major hepatectomy’ exists. The objective of the present retrospective study is to specify the extent of hepatic resection that should describe a major hepatectomy.MethodsDemographics, diagnoses, surgical treatments and outcomes from patients who underwent a liver resection at two high-volume centres were reviewed.ResultsFrom 2002 to 2009, 1670 patients underwent a hepatic resection. Post-operative mortality and severe, overall and hepatic-related morbidity occurred in 4.4%, 29.7%, 41.6% and 19.3% of all patients. Mortality (7.4% vs. 2.7% vs. 2.6%) and severe (36.7% vs. 24.7% vs. 24.1%), overall (49.3% vs. 40.6% vs. 35.9%) and hepatic-related (25.6% vs. 16.4% vs. 15.2%) morbidity were more common after resection of four or more liver segments compared with after three or after two or fewer segments (all P < 0.001). There were no significant differences in any post-operative outcome after resection of three and two or fewer segments (all P > 0.05). On multivariable analysis, resection of four or more liver segments was independently associated with post-operative mortality and severe, overall, and hepatic-related morbidity (all P < 0.01).ConclusionsA major hepatectomy should be defined as resection of four or more liver segments.     

创面封闭胶在肝胆管结石腹腔镜手术中的应用

目的探讨创面封闭胶在肝胆管结石腹腔镜肝叶切除手术中的应用。方法将84例肝左外叶肝胆管结石行腹腔镜手术患者随机分为使用创面封闭胶组（治疗组）与对照组。治疗组行腹腔镜胆道探查、左肝外叶切除术,喷涂创面封闭胶方法处理肝断面;对照组则行肝断面大网膜填塞对拢缝合。观察手术时间、术后腹腔引流管引流量、性质、有无胆瘘、引流管留置时间、术后肝功能情况、住院时间等指标。结果治疗组手术时间、转氨酶及胆红素升高幅度、肝功能恢复正常时间、术后引流量、引流液红细胞计数及血红蛋白含量、拔管时间、住院时间明显低于对照组（P〈0.05）,发生轻微胆瘘2例（占4.7%）,无膈下脓肿。对照组共发生胆瘘5例（占11.9%）,其中较严重胆瘘3例（占7.1%）,膈下脓肿1例。结论肝胆管结石腹腔镜手术肝创面处理中应用创面封闭胶,可以节省手术时间,减少对肝功能损害,有效减少术后出血、渗出和胆瘘的发生,优于腹腔镜常规肝断面处理方法。     

The learning curve in laparoscopic major liver resection

Laparoscopic major hepatectomy remains a relatively rare operation because it is a difficult and technically demanding procedure, and a standard, safe, reproducible technique has not been widely adopted. This is compounded by “major hepatectomy” encompassing multiple different operations each with their own anatomic and procedural considerations. In 2010, we investigated our learning curve for laparoscopic liver resection. We found a significant increase in the number of major hepatectomies performed over a 12-year period, with concurrent reductions in the use of hand-assistance, pedicle clamping, median clamping time, median operative time, blood loss and morbidity. This learning curve was confirmed by a subsequent multinational study. Both hospital and surgeon volume have been shown to affect outcomes, and defining a sufficient number of repetitions before the learning curve plateaus is not easy for laparoscopic major hepatectomy. We recommend that laparoscopic competencies be developed upon a foundation of open liver surgery and that laparoscopic major hepatectomy should only be attempted after competency with less technically complex laparoscopic resections. A center advanced along its institutional learning curve provides the collective expertise necessary for safe patient selection and management. An environment with colleagues willing to share their acquired proficiency allows the surgeon to observe and critique his or her performance against colleagues. Also, the guidance of like-minded surgeons supports technical development and improved outcomes. In conclusion, steady progress can be made along the learning curve through committed practice of increasingly complex tasks and with proper coaching in a high-volume environment.     

完全腹腔镜与开腹肝切除术治疗左外叶肝细胞癌的效果比较

目的探索完全腹腔镜肝切除治疗左外叶肝细胞癌(HCC)的安全性、可行性和有效性。方法选取2012年4月~(-2)015年4月攀枝花市中心医院收治的经术后病理证实为左外叶HCC且行完全腹腔镜左肝外叶切除术(LLLR)的患者25例与同时期的另外25例行开腹左肝外叶切除(OLLR)的HCC患者进行病例配对分析。计量资料2组间比较采用t检验,计数资料2组间比较采用χ~2检验或Fisher确切概率法,生存分析采用Kaplan-Meier法,生存曲线的比较采用log-rank检验。结果 LLLR组与OLLR组在手术时间、术中输血例数、R0切缘例数方面比较差异均无统计学意义(P值均0.05),但在术中出血量[(216.40±15.39)d vs(273.20±16.65)d]、平均住院时间[(6.92±0.28)d vs(10.32±0.52)d]和手术并发症发生率(20%vs 48%)方面差异有统计学意义(P值均0.05)。LLLR组与OLLR组在1、3年总体生存率和无进展生存率方面比较差异均无统计学意义(P值均0.05)。结论 LLLR与OLLR治疗左外叶HCC相比,不仅远期效果相似,而且在手术出血量、手术并发症、住院时间等方面更具优势。     

腹腔镜与开腹肝切除术治疗区域型肝胆管结石病的倾向性评分匹配研究

目的比较腹腔镜与开腹肝切除术治疗区域型肝胆管结石病的临床疗效。方法选取2010年1月-2017年6月咸阳市第一人民医院收治的87例肝胆管结石病患者,其中38例行腹腔镜肝切除术(腹腔镜组),49例行开腹肝切除术(开腹组)。利用倾向性评分匹配,均衡2组患者的混杂因素,比较匹配后的围手术期相关指标。计量资料2组间比较采用t检验,计数资料2组间比较采用χ~2检验或Fisher精确检验。结果共27对患者匹配成功。2组患者的肝切除类型、联合胆总管探查术、术中肝门阻断率、手术时间、术中输血率、术中结石清除率及术后结石清除率﹑术后总并发症及严重并发症发生率比较,差异均无统计学意义(P值均>0.05)。但腹腔镜组患者的手术出血量和住院时间均低于开腹组[(126.4±18.7)ml vs(143.2±24.1)ml;(11.7±2.3)d vs(13.4±1.9)d],差异均有统计学意义(t值分别为2.862、2.961,P值分别为0.006、0.004)。结论腹腔镜肝切除术治疗区域型肝胆管结石病效果与开腹手术相当,且具有术中出血量少、术后恢复快等优势。     

Feasibility of laparoscopic portal vein ligation prior to major hepatectomy

Background. Patients noted to have an inadequate future liver remnant on pre operative volumetric assessment are considered to be candidates for portal vein embolization (PVE). A subset of patients undergo laparoscopic intervention prior to PVE for staging purposes or to address the primary in Stage IV colon cancer. These patients usually undergo PVE as a subsequent additional procedure by the transhepatic route. The aim of this study was to assess the feasibility of portal vein ligation by the laparoscopic approach in suitable patients. Materials and methods. A retrospective review of a prospectively maintained database was performed to identify patients that underwent laparoscopic portal vein ligation (LPVL). The demographic, clinical, radiographic, operative and volumetric details were collected to determine the feasibility of portal vein ligation. Results. A total of nine patients underwent LPVL as part of a two stage procedure in preparation for subsequent major hepatectomy. With a median age of 67 yrs, the diagnoses included: colorectal metastasis (five patients), cholangiocarcinoma (three patients) and hepatocellular carcinoma (one patient). The ligation involved the right portal vein in all and was performed with silk ligature (seven patients) and clips (two patients). Volumetric data was available in six patients which showed a mean increase from 209.1 cc±97.76 to 495.83 cc±310.91 (increase by 181.5%) In two patients, inadequate hypertrophy mandated later embolization by percutaneous technique. Five patients underwent subsequent major hepatic resection as planned. The remaining four patients were noted to have progression of disease that precluded the planned procedure. There were no complications associated with LPVL. Conclusions. LPVL is feasible and can be safely performed. In a select group of patients, it may be considered as an alternative to subsequent embolization and thereby potentially absolve the need for an additional procedure with its attendant complications.     

Application of devices for safe laparoscopic hepatectomy

The continuing evolution of a variety of laparoscopic instrument and device has been gradually applied to the laparoscopic hepatectomy in many countries. Recent experience has persuaded us that there are great potential benefits derived from laparoscopic hepatectomy and much has been learned about patient selection, the grade of surgical difficulty with respect to tumor location, and the required instrumentation. Among these efforts, various ways of hepatic parenchymal transection with mechanical devices have been attempted and continuing to innovate to perform safe laparoscopic hepatectomy Important technologic developments and improved endoscopic procedures are being established equipment modifications. For safe laparoscopic hepatectomy, it is important to have all necessary equipment. The intraoperative laparoscopic ultrasonography, microwave coagulators, ultrasonic dissection, argon beam coagulators, laparoscopic coagulation shears, endolinear staplers and TissueLink monopolar sealer are essential. This procedure is in need that well experienced endoscopic surgeon and well-experienced liver surgeon should be collaborated in laparoscopic hepatectomy and the indications are strictly followed based upon the location and size of tumors. Finally critical determinant for success and safe laparoscopic hepatectomy is through familiarity with the relevant laparoscopic instruments and equipments. Laparoscopic hepatectomy is expected to develop further in the future as a new surgical instrument, equipment and method, which improves patients' quality of life.     

荧光腹腔镜肝切除术与常规腹腔镜肝切除术治疗HCC患者效果比较

目的 研究荧光腹腔镜肝切除术与常规腹腔镜肝切除治疗肝细胞癌(HCC)患者的临床效果。方法 2014年8月～2017年8月我院收治的148例HCC患者被随机分为观察组74例和对照组74例,分别行荧光腹腔镜肝切除术和常规腹腔镜肝切除术。随访3年。结果 观察组切缘肿瘤细胞阳性率为2.7%,显著低于对照组的13.5%(x²=5.804,P=0.016);两组围术期胸腔积液、发热、切口感染、胆漏和腹腔出血等并发症发生率比较差异无统计学意义(P＞0.05);观察组6 m、1 a和2 a生存率分别为98.6%、94.6%和90.5%,与对照组的95.9%、93.2%和86.5%比,无显著性差异(P＞0.05),但3 a生存率为85.1%,显著高于对照组的70.3%(P＜0.05);观察组3 a肿瘤复发率为27.0%,显著低于对照组的47.3%(P＜0.05)。结论 与常规腹腔镜肝切除术比,采用荧光腹腔镜肝切除术能实现肿瘤切缘的可视化,保证肿瘤切缘安全,有利于提高HCC患者生存率。