Total laparoscopic limited anatomical resection for centrally located hepatocellular carcinoma in cirrhotic liver

Background

Limited anatomical liver resection for hepatocellular carcinoma (HCC) is complicated in cirrhotic patients with centrally located HCC and limited liver reserve. We present a case of total laparoscopic left medial and right ventroanterior sectionectomy performed using the intrahepatic Glissonian approach in a cirrhotic liver for curative resection of HCC.

Methods

The patient was a 69-year-old man with a 6.5-cm-diameter HCC located at segments 4, 5, and 8 and which was compressing the middle hepatic vein (MHV). Child–Pugh class A liver cirrhosis was noted, and the 15-min retention rate for indocyanine green was 14 %. Preoperative surgical planning suggested the feasibility of limited anatomical subsegmental resection. The patient was placed in the supine position and 5 trocars were used for the procedure. The operation began with cholecystectomy, division of liver ligaments, and exposure of the right hepatic vein root and the umbilical Glissonian pedicles to the left medial segment. Parenchymal transection was performed using a laparoscopic harmonic scalpel and Cavitron Ultrasonic Surgical Aspirator until the MHV was reached. After exposing the ventral branches of the right anterior Glissonian pedicle and dividing them, resection was continued along the demarcation line. Fissure veins draining to the MHV root were identified and divided. The MHV root was closed using an automatic stapler.

Results

The operation time was 565 min and estimated blood loss was 665 ml; blood transfusion was not required. Pathological examination confirmed a moderately differentiated HCC with all resected margins free of malignancy. Postoperative recovery was uneventful and the patient was discharged on the postoperative day 7. There was no tumor recurrence 18 months after the operation.

Conclusions

Total laparoscopic left medial and right ventroanterior sectionectomy via the intrahepatic Glissonian approach is feasible for HCC in a cirrhotic liver with limited liver reserve. Preoperative planning is essential in order to compute successful hepatic function. Standardization of surgical techniques may aid in safely performing this procedure.     

Laparoscopic resection of left liver segments using the intrahepatic Glissonian approach

Background

Recent advances in laparoscopic techniques have resulted in growing indications for laparoscopic hepatectomy. However, this procedure has not been widely developed, and anatomic segmental liver resection is not currently performed due to difficulty controlling the segmental Glissonian pedicles laparoscopically. This study aimed to report a novel technique for laparoscopic anatomic resection of left liver segments using the intrahepatic Glissonian approach based on small incisions according to anatomic landmarks such as Arantius’ and round ligaments.

Methods

Nine consecutive patients underwent laparoscopic liver resection using the intrahepatic Glissonian technique from April 2007 to June 2008. Five patients underwent laparoscopic bisegmentectomy 2–3, one laparoscopic left hemihepatectomy, two resections of segment 3, and one resection of segment 4.

Results

One patient required a blood transfusion. The mean operation time was 180 min (range, 120–300 min), and the median hospital stay was 3 days (range, 1–5 days). No patient had postoperative signs of liver failure or bile leakage. No postoperative mortality was observed.

Conclusion

The main advantage of the intrahepatic Glissonian procedure over other techniques is the possibility of gaining a rapid and precise access to the left Glissonian sheaths facilitating left hemihepatectomy, bisegmentectomy 2–3, and individual resections of segments 2, 3, and 4. The authors believe that the intrahepatic Glissonian technique facilitates laparoscopic liver resection and may increase the development of segment-based laparoscopic liver resection.

     

Pure laparoscopic right hepatectomy in the semi-prone position using the intrahepatic Glissonian approach and a modified hanging maneuver to minimize intraoperative bleeding

Purpose

Although laparoscopic liver resection has been widely adopted, performing a pure laparoscopic right hepatectomy remains a challenging procedure. The aim of this report is to evaluate the efficiency of a pure laparoscopic right hepatectomy (PLRH) in the semi-prone position using the intrahepatic Glissonian approach and a modified hanging maneuver.

Methods

Pure laparoscopic right hepatectomy was performed in the semi-prone position with the use of an intrahepatic Glissonian approach and modified hanging maneuver for patients with primary liver cancer (n = 3) and metastatic liver cancer (n = 1).

Results

The intraoperative total blood loss was only 95?C140 g (mean: 126.2 g). None of the patients required a blood transfusion, and no serious complications were encountered. The durations of the surgeries ranged from were 308 to 445 min (mean: 394.8 min). The postoperative hospital stay was 8?C11 days (mean 9.5 days).

Conclusion

Pure laparoscopic right hepatectomy in the semi-prone position using the intrahepatic Glissonian approach and a modified hanging maneuver is thus considered to be a safe modality, which minimizes intraoperative bleeding.     

Exploring the role of laparoscopic surgery in two-stage hepatectomy for bilobar colorectal liver metastases

Abstract Background: The role of laparoscopy in two-stage hepatectomy for bilobar colorectal liver metastases (CRLMs) has not yet been extensively investigated. Patients and Methods: We reviewed a prospectively collected database of 302 consecutive patients undergoing laparoscopic liver resection at our institution between 2003 and 2011. Results: Eight patients undergoing laparoscopic first/second-stage hepatectomy for bilobar CRLMs (male/female 6:2; median age, 64 years) were analyzed. The first stage consisted of laparoscopic clearance of the left lobe in all patients with no postoperative morbidity and mortality. Seven patients underwent portal vein embolization or ligation. The median interval between first- and second-stage hepatic resections was 89 days (range, 36-123 days). Second-stage hepatectomy with right lobar clearance (open, n=5; laparoscopic, n=2; laparoscopic to open, n=1) was associated with no mortality and an operative morbidity rate of 50%. Adhesions were judged to be minimal or absent during the second-stage procedure. Complications included intra-abdominal collection (n=2), bleeding requiring re-operation (n=1), and bile leak (n=1). R0 resection was obtained in 7 of 8 cases after first-stage resection and in 8 of 8 cases after second-stage resection. Three patients (38%) died from disease recurrence. Of the remaining 5 patients, 4 are disease-free at a median follow-up of 24 months (range, 9-27 months). Conclusions: The well-recognized advantages of laparoscopy may play a favorable role in the management of patients with bilobar CRLMs candidate for a two-stage resection. The first-stage laparoscopic clearance of the left lobe could progressively become the "gold standard." Laparoscopic second-stage hepatectomy should be limited to selected cases.     

Parenchyma-sparing anatomical liver resection based on Hjortsjo’s concept

Purpose

Anatomical liver resection is usually based on Couinaud’s anatomical concept. In contrast, Hjortsjo’s concept, which divides the right anterior section of the liver into ventral and dorsal segments by the vertical plane named the ventral segment fissure (VSF), has been rarely utilized for liver resection. Identification of the VSF is the most difficult step in liver resection based on Hjortsjo’s concept. This study aimed to detail liver resection based on Hjortsjo’s concept and report surgical outcomes of this procedure.

Methods

We reviewed the records of 166 consecutive patients who underwent liver resection between September 2009 and June 2012 at Kyoto Medical Center and identified seven liver resections in which Hjortsjo’s concept was utilized. These patients consisted of four men and three women aged 55–79 years. Four patients had hepatocellular carcinoma and cirrhosis and three patients had metachronous colorectal liver metastasis.

Results

Liver resection along the VSF consisted of two extended left medial sectionectomies, three extended right posterior sectionectomies, and one Sg 7+8-dorsal resection by a venous-drainage-guided approach and one Sg 8-dorsal resection by a Glissonian approach. In all patients, the VSF was successfully identified as a congested or ischemic border on the liver surface. Mortality and major morbidity were nil. No patients underwent blood transfusion. After a median follow-up of 15 months, there were no deaths or local recurrence.

Conclusions

Anatomical liver resection based on Hjortsjo’s concept is feasible and advantageous over conventional liver resection because it preserves more parenchyma. The venous-drainage-guided approach is an effective method for identifying the VSF.     

Systematic review of robotic liver resection

Background

Robotic liver resection has emerged as a new modality in the field of minimally invasive surgery. However, the effectiveness of this approach for liver resection is not yet known.

Methods

A literature survey was performed using specific search phrases in PubMed. Case series that focused on biliary reconstruction were excluded. Characteristics, such as patient demographics, perioperative outcomes, and oncological results for colorectal liver metastasis and hepatocellular carcinoma were analyzed.

Results

Nineteen series that described the cases of 217 eligible patients were reviewed. The most commonly performed procedures were wedge resection and segmentectomy. Right hepatectomy was performed in a few specialized centers. The conversion and complication rates were 4.6 and 20.3 %, respectively. The most common reason for conversion was unclear tumor margin. Intra-abdominal fluid collection was the most frequently occurring morbidity. Mean operation time was 200–507 min. Mean intraoperative blood loss was 50–660 mL, with a tendency toward increased blood loss observed in series that included major hepatectomies. Mean postoperative hospital stay was 5.5–11.7 days. The longest mean follow-up time was 36 months for colorectal liver metastasis and 25.1 months in hepatocellular carcinoma. Disease-free survival for mixed malignancies was comparable to that after laparoscopic procedures. Overall survival was not reported.

Conclusions

Robotic liver resection is safe and feasible for experienced surgeons with advanced laparoscopic skills. Long-term oncologic outcomes are unclear, but short-term perioperative results seem comparable to those of conventional laparoscopic liver resection.     

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.     

ALPPS Procedure with the Use of Pneumoperitoneum

Background

A new method for liver hypertrophy was recently introduced, the so-called associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure. We present a video of an ALPPS procedure with the use of pneumoperitoneum.

Methods

A 29-year-old woman with colon cancer and synchronous liver metastasis underwent a two-stage liver resection by the ALPPS technique because of an extremely small future liver remnant.

Results

The first operation began with 30 min pneumoperitoneum. Anatomical resection of segment 2 was performed, followed by multiple enucleations on the left liver. The right portal vein was ligated and the liver partitioned. The abdominal cavity was partially closed, and a 10 mm trocar was left to create a pneumoperitoneum for additional 30 min. The patient had an adequate future liver remnant volume after 7 days, but she was not clinically fit for the second stage of therapy, so it was postponed. She was discharged on day 7 after surgery. The second stage took place 3 weeks later and consisted of an en-bloc right trisectionectomy extended to segment 1. The patient recovered and was discharged 9 days after second-stage surgery. Postoperative CT scan revealed an enlarged remnant liver.

Conclusions

The ALPPS procedure is a new revolutionary technique that permits R0 resection even in patients with massive liver metastasis. The use of pneumoperitoneum during the first stage is an easy tool that may prevent hard adhesions, allowing an easier second stage. This video may help oncological surgeons to perform and standardize this challenging procedure.     

Totally laparoscopic strategies for the management of colorectal cancer with synchronous liver metastasis

Introduction

Laparoscopy is an accepted treatment for colorectal cancer and liver metastases, but there is no consensus for its use in the management of synchronous liver metastases (SCRLM). The purpose of this study was to evaluate totally laparoscopic strategies in the management of colorectal cancer with synchronous liver metastases.

Methods

Patients presenting to Ninewells Hospital between July 2007 and August 2010, with adenocarcinoma of the colon and rectum with synchronous liver metastases were considered. Patients underwent simultaneous laparoscopic liver and colon cancer resection, a staged laparoscopic resection of SCRLM and colon cancer, or simultaneous colon resection and radiofrequency ablation (RFA) of SCRLM. Primary endpoints were in-hospital morbidity and mortality, total hospital stay, intraoperative blood loss, duration of surgery, and resection margin status.

Results

Twenty-eight patients presented with synchronous colorectal liver metastases. Thirteen patients underwent a simultaneous laparoscopic liver and colon resection (median operating time, 370 (range, 190–540) min; median hospital stay, 7 (range, 3–54) days), seven patients had a staged laparoscopic resection of SCRLM and primary colon cancer (median operating time, 530 (range, 360–980) min; median hospital stay 14, (range, 6–51) days), and eight patients underwent laparoscopic colon resection and RFA of SCRLM (median operating time, 310 (range, 240–425) min; median hospital stay, 8 (range, 6–13) days). There were no conversions to an open procedure. Overall in-hospital morbidity and mortality was 28 and 0?% respectively. An R0 resection margin was achieved in 91?% of the resection group. At a median follow-up of 26 (range, 18–55) months, 19 (90?%) patients remain disease-free.

Conclusions

Totally laparoscopic strategies for the radical treatment of stage IV colorectal cancer are feasible with low morbidity and favorable outcomes. A laparoscopic approach for the simultaneous management of SCRLM and primary colon cancer is associated with reduced surgical access trauma, postoperative morbidity, and hospital stay with no compromise in short-term oncological outcome.     

Extending the limitations of liver surgery: outcomes of initial human experience in a high-volume center performing single-port laparoscopic liver resection for hepatocellular carcinoma

Background

Single-port laparoscopic surgery is slowly but steadily gaining popularity among surgeons performing minimally invasive abdominal surgeries. The aim of the present study is to assess our initial experience with single-port laparoscopic liver resection for hepatocellular carcinoma.

Methods

Between March 2009 and April 2011, 24 patients underwent single-port laparoscopic liver resection for hepatocellular carcinoma. Of these, 13 were laparoscopic segmentectomies, 4 were laparoscopic left lateral sectionectomies, 1 was a right hepatectomy, 1 was a left hepatectomy, and 4 were nonanatomical resections.

Results

Median operating time and blood loss were 205?min (95–545?min) and 500?ml (100–2,500?ml), respectively. Two procedures were converted to multiport laparoscopic hepatectomy due to instrument length limitations, and four were converted to open surgery. There were no serious intraoperative or postoperative complications in this series. Median postoperative stay was 8.5?days (5–16?days).

Conclusions

Although the procedure requires a lot of technical expertise added to the skill of liver surgery, single-port laparoscopic liver resection for hepatocellular carcinoma seems a feasible approach in a variety of well-selected cases. In spite of the demanding nature of the procedure and the requirement of better instrumentation for single-port laparoscopic surgery, the results seem to compare favorably with conventional laparoscopic surgery and open surgery.     

Comparison of various surgical approaches for extensive bilateral colorectal liver metastases

Purpose

Tailored operative strategies have been proposed for patients with bilobar colorectal liver metastases (CLM). The aim of the study was to evaluate the long-term outcome, safety and efficacy, including cancer-specific survival, morbidity, and mortality, of three different surgical strategies for extensive bilateral CLM.

Methods

This is a retrospective study of a prospective database of 356 consecutive patients, who underwent hepatic resection due to CLM between January 2003 and January 2009. Fifty-nine patients underwent three different therapeutic approaches: 22 patients with portal vein embolization (PVE) + staged resections, 11 patients with staged resections solely, and 26 patients with an extensive liver resection and simultaneous or subsequent radiofrequency ablation (RFA).

Results

The three groups were comparable regarding their general patient characteristics. The overall morbidity and mortality rates were 27.1 and 1.7 %, respectively. There were no significant differences in morbidity, mortality, or survival between the three groups. The median survival of all patients was 48 months, with a recurrence-free survival of 30 months.

Conclusions

The clearance of bilobar CLM can be achieved by various strategies, all of them providing an acceptable mortality rate and survival for the patients. Therefore, patients with bilobar liver metastases should receive a procedure tailored for their individual extent of disease.     

Robotic versus laparoscopic liver resection: a comparative study from a single center

Purpose

The significant advantages of robotic surgery have expanded the scope of surgical procedures that can be performed through minimally invasive techniques. The aim of this study was to compare the perioperative outcomes between robotic and laparoscopic liver surgeries at a single center.

Methods

From July 2007 to October 2011, a total of 206 patients underwent laparoscopic or robotic liver surgery at the Asan Medical Center, Seoul, Korea. We compared the surgical outcomes between robotic liver surgery and laparoscopic liver surgery during the same period. Only patients who underwent left hemihepatectomy or left lateral sectionectomy were included in this study.

Results

The robotic group consisted of 13 patients who underwent robotic liver resection including 10 left lateral sectionectomies and three left hemihepatectomies. The laparoscopic group consisted of 17 patients who underwent laparoscopic liver resection during the same period including six left lateral sectionectomies and 11 left hemihepatectomies. The groups were similar with regard to age, gender, tumor type, and tumor size. There were no significant differences in perioperative outcome such as operative time, intraoperative blood loss, postoperative liver function tests, complication rate, and hospital stay between robotic liver resection and laparoscopic liver resection. However, the medical cost was higher in the robotic group.

Conclusions

Robotic liver resection is a safe and feasible option for liver resection in experienced hands. The authors suggest that since the robotic surgical system provides sophisticated advantages, the retrenchment of medical cost for the robotic system in addition to refining its liver transection tool may substantially increase its application in clinical practice in the near future.     

Laparoscopic liver resection and the learning curve: a 14-year,single-center experience

Background

Laparoscopic liver resection has not been widely used because of intraoperative bleeding. This problem should be solved with instruments and techniques that require a short learning curve.

Materials and methods

The aim of this work was to present the technique used in our center to perform laparoscopic liver resection using the ‘curettage and aspiration’ technique with laparoscopic Peng’s multifunctional operational dissectors and regional occlusion of inflow and outflow. We retrospectively analyzed patients who underwent a laparoscopic liver resection from August 1998 to August 2012, and collected the conversion rate, operating time, blood loss, hospitalization, bile leakage rate, bleeding rate, and other complications on a yearly basis and in total. We used SPSS software to analyze whether there was a significant difference, and summarized the learning curve of laparoscopic liver resection with various procedures.

Results

We performed 365 cases of laparoscopic liver resection, including left hemihepatectomy, left lateral lobectomy, segmental hepatectomy, non-anatomic liver resection, right hemihepatectomy, and caudate lobectomy. The diseases included liver cancer, hepatolithiasis, liver hemangioma, focal nodular hyperplasia, liver abscess, and metastatic hepatic carcinoma. In total, 63 cases (17.20 %) were converted to open surgery because of severe adhesions, bleeding, or anatomical limitation. Mean blood loss was 370.6 ± 404.0 ml; mean operating time was 150.8 ± 73.0 min; and mean postoperation hospitalization was 9.2 ± 5.3 days. There were four cases (1.32 %) with the complication of bile leakage and two cases of hemorrhage (0.66 %). No intraoperative or postoperative deaths occurred. After finishing 15–30, 43, 35, and 28 cases of laparoscopic left hemihepatectomy, left lateral hepatectomy, non-anatomic liver resection, and segmentectomy, respectively, the average operating time, blood loss, and hospitalization were almost the same as the overall mean results.

Conclusion

The technique used in our center is a safe, fast, and effective approach to laparoscopic liver resection. Our 14 years of experience demonstrates that this technique can prevent postoperative bleeding and bile leakage. A surgeon can master the skill of laparoscopic left hemihepatectomy, left lateral hepatectomy, non-anatomic liver resection, and segmentectomy after ～15–30, 43, 35, and 28 case procedures, respectively.     

28例转移性肝癌腹腔镜肝切除术

目的 总结转移性肝癌的腹腔镜肝切除术经验.方法 对1999-2006年度布里斯班医院所实施的转移性肝癌腹腔镜肝切除术病人进行回顾性研究.结果 经病理证实的28例转移性肝癌病人进行了腹腔镜肝切除,13例进行左肝外侧叶切除,9例进行了右半肝切除,其余6例行肝段或不规则切除.追踪随访12例由直结肠转移的转移性肝癌病人2年存活率和无瘤生存率分别为75%和67%.结论 在严格选择过的恶性肿瘤病人中行腹腔镜肝切除术是安全可行的.对病人要有适当的分期,术者需具丰富的开腹肝切除术经验和腹腔镜操作技能.     

Surgical treatment of liver metastases from colorectal cancer

We analyze our experience over a 10-year period in the surgical treatment of liver metastases from colorectal cancer. Between 01.01.1995 and 08.31.2005 189 liver resections were performed in 171 patients with liver metastases from colorectal cancer (16 re-resections - 2 in the same patient and a "two-stage" liver resection in 2 patients). In our series there were 83 patients with synchronous liver metastases (69 simultaneous resections, 12 delayed resections and 2 "two-stage" liver resection were performed) and 88 metachronous liver metastases. Almost all types of liver resections have been performed. The morbidity and mortality rates were 17.4% and 4.7%, respectively. Median survival was 28.5 months and actuarial survival at 1-, 3- and 5-year was 78.7%, 40.4% and 32.7%, respectively. Between January 2002 and August 2005 hyperthermic ablation of colorectal cancer liver metastases has been performed in 6 patients; in other 5 patients with multiple bilobar liver metastases liver resection was associated with radiofrequency ablation and one patient underwent only radiofrequency ablation for recurrent liver metastasis. In conclusion, although the treatment of colorectal cancer liver metastases is multimodal (resection, ablation, chemotherapy and radiation therapy), liver resection is the only potential curative treatment. The quality and volume of remnant liver parenchyma is the only limitation of liver resection. The morbidity, mortality and survival rates after simultaneous liver and colorectal resection are similar with those achieved by delayed resection. Postoperative outcome of patients with major hepatic resection is correlated with the surgical team experience. The long-term survival was increased using the new multimodal treatment schemes.     

Laparoscopic intrahepatic Glissonian approach for right hepatectomy is safe,simple, and reproducible

Background Hemorrhage from portal and hepatic veins is a major concern with laparoscopic right hepatectomy (LRH). The standard hilar approach is dissection of the portal pedicle outside the liver parenchyma with separate transection of the right hepatic artery, portal vein, and bile duct [1–5, 7, 9]. Variations in anatomy can hamper vascular and biliary control. The intrahepatic Glissonian access avoids these risks by en masse ligation of the portal structures without dissection for each separately [6, 8]. This technique was performed laparoscopically for the last 2 among 10 LRHs, and the results are presented. Methods Total LRH was performed under ultrasound assistance for two patients with malignancy. After lymph node sampling at the hepatoduodenal ligament, dissection was started with the incision of liver parenchyma posterior and anterior to the hilum, then continued outside the portal pedicle bifurcation toward the right and left sheaths. An endoscopic vascular stapling device was placed to transect the right portal pedicle en masse under direct laparoscopic vision and cholangiography guidance. Parenchymal transection and vascular control of the right hepatic vein was accomplished with harmonic scalpel, cavitron ultrasonic aspirator, bipolar diathermy, clips, and endoscopic stapling device, as appropriate. No Pringle’s maneuver was used. The specimen was extracted through a suprapubic incision using an endobag. Results The operative times for the two patients were, respectively, 180 and 240 min. No blood loss occurred during the intrahepatic Glissonian dissection. Intraoperative blood loss (from the right hepatic vein) of 700 and 800 ml, respectively, was controlled laparoscopically. The postoperative periods were uneventful, with discharge, respectively, on days 6 and 7. The surgical resection margins were free of tumor. Conclusions The laparoscopic intrahepatic Glissonian approach used for right hepatectomy is safe, simple, and reproducible. It facilitates the hepatic hilar dissection with minimal operative risk. Further implementation of this technique is encouraged to improve the outcome for patients undergoing laparoscopic liver resection. Electronic supplementary material The online version of this article (doi: ) contains supplementary material, which is available to authorized users     

Hepatic resections for bilobar liver metastases from colorectal cancer

The present study was performed to assess survival benefits in patients who underwent a hepatic resection for isolated bilobar liver metastases from colorectal cancer. Thirty-eight patients underwent a curative hepatic resection for isolated colorectal liver metastasis. Among them, 11 patients had bilobar liver metastases and 19 had a solitary metastasis. The remaining 8 patients had unilobar multiple lesions. We investigated survival in two groups those with bilobar and those with solitary metastatic tumors. Survival and disease-free survival were 36% and 18% at 5 years, respectively, in the patients with bilobar liver metastases, while these survivals were 43% and 34% in the patients with solitary liver metastasis. In the 38 patients, repeated hepatic resections were performed in 15 patients with recurrent liver disease. The 5-year survival and disease-free survival rates for these patients were 38% and 27%, respectively, after the second hepatic resections. Of the 11 patients with bilobar liver metastases, 5 underwent a repeated hepatic resection, and they all survived for over 42 months. Based on our observations, a hepatic resection was thus found to be effective even in selected patients with either bilobar nodules or recurrence in the remnant liver. Received: February 7, 2000 / Accepted: April 26, 2000     

Laparoscopic bisegmentectomy 6 and 7 using a Glissonian approach and a half-Pringle maneuver

Background

Despite accumulated experience and advancing techniques for laparoscopic hepatectomy, surgeons still face challenging resections that require specific and innovative intraoperative maneuvers [1–3]. The right posterior sectionectomy presents special concerns about its location, the extensive transection area, and the difficult access to the pedicle [4, 5]. The intrahepatic Glissonian approach allows safe en masse control of the portal structures without prolonged dissection [2]. Its association with the half-Pringle maneuver results in less bleeding during parenchymal transection [1, 6].

Methods

A 34-year-old woman was referred for treatment of an 8-cm hepatocellular adenoma located at segments 6 and 7. She was placed in a semi-supine position, and six ports were located in a distribution that resembled a Makuuchi incision. The right liver was mobilized, and preparation for an anatomic Glissonian approach was performed. A vascular clamp was placed to ensure that full control of the right posterior pedicle was possible. Then a vascular stapler replaced it, with division of the right posterior Glissonian pedicle. A vascular clamp was inserted from the inferior right-flank 5-mm trocar for performance of a half-Pringle maneuver of the right pedicle to minimize blood loss during parenchymal transection. The liver parenchyma was transected with a harmonic scalpel and a vascular stapler. The right hepatic vein was divided intraparenchymally with a vascular stapler. The specimen was extracted through a Pfannenstiel incision.

Results

The total surgical time was 210 min, and the estimated blood loss was 200 ml. No blood transfusion was required. The recovery was uneventful, and hospital discharge occurred on postoperative day 5. Pathology confirmed the diagnosis of an hepatocellular adenoma.

Conclusions

Technical issues initially hindered the development of laparoscopic liver resections [7–10]. Surgeons were concerned about hemostasis, bleeding control, safe and effective parenchymal transection, adequate visualization, and the feasibility of working on deeper regions of the liver. During the past decade, many limitations were overcome, but lesions located on the posterosuperior liver are still considered tough to beat [5, 11]. Large series and extensive reviews [12–14] show that resections located on the posterior segments still are infrequent. Limited access to the portal triad, difficult pedicle control, and a large transection area and its anatomic location, attached to the diaphragm and retroperitoneum and hidden from the surgeon’s view, makes such resections defying. The authors’ team has performed 97 laparoscopic hepatectomies, including resection of 6 lesions in the right posterior sector. In their series, half-pedicle clamping was used for 12 patients, and they adopt such a maneuver as an inflow control when operating on peripheric lesions with difficult vascular control (e.g., enucleations or posterosuperiorly located segmentectomies). This technique is safe and useful because it reduces liver ischemic aggression, a very important issue with diseased livers (e.g., steatosis, steatohepatitis, prolonged chemotherapy, cirrhosis) [6, 15]. In their series, the authors applied the Glissonian intrahepatic approach in 7 cases (2 left hepatectomies and 5 right hepatectomies). They understand that laparoscopy applies perfectly to oddly (posterosuperior) located tumors and that right posterior sectionectomy can be accomplished safely. In fact, they share the opinion of other specialized hepatobiliary centers, believing that this may be the preferred approach [16].     

Laparoscopic resection of colon cancer and synchronous liver metastasis

The recommended surgical approach to synchronous colorectal metastasis has not been clarified. Simultaneous open liver and colon resection for synchronous colorectal carcinoma has been shown beneficial when compared to staged resections. A review of the literature has shown the benefits of both laparoscopic colon resection for colorectal cancer and laparoscopic left lateral segmentectomy in liver disease. We present the case of a 60-year-old male with sigmoid colon carcinoma and a synchronous solitary liver metastasis localized to the left lateral segment. Using laparoscopic techniques, we were able to achieve simultaneous resection of the sigmoid colon and left lateral liver segment.     

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.