The safety and feasibility of laparoscopic, two-stage hepatectomy for bilobar colorectal liver metastases is poorly evaluated.
We reviewed retrospectively 86 consecutive patients who underwent ...complete two-stage hepatectomy (left lobe clearance as the first stage and standard/extended right hepatectomy as the second stage) for bilobar colorectal liver metastases between 2007 and 2017 in 2 tertiary centers. Short- and long-term outcomes were compared between laparoscopic and open two-stage hepatectomy before and after propensity score matching.
Laparoscopic two-stage hepatectomy was performed in 38 patients and open two-stage hepatectomy in 48. After propensity score matching, 25 laparoscopic and 25 open patients showed similar preoperative characteristics. For the first stage, a laparoscopic approach was associated with lesser hospital stays (4 vs 7.5 days; P < .001). For the second stage, a laparoscopic approach was associated with less blood loss (250 vs 500 mL; P = .040), less postoperative complications (32% vs 60%; P = .047), lesser hospital stays (9 vs 16 days; P = .013), and earlier administration of chemotherapy (1.6 vs 2 months; P = .039). Overall survival, recurrence-free survival, and liver-recurrence-free survival were comparable between the groups (3-year overall survival: 80% vs 54%; P = .154; 2-year recurrence-free survival: 20% vs 18%; P = .200; 2-year liver-recurrence-free survival: 39% vs 33%; P = .269). Although both groups had comparable recurrence patterns, repeat hepatectomies for recurrence were performed more frequently in the laparoscopic two-stage hepatectomy group (56% vs 0%; P = .006).
Laparoscopic two-stage hepatectomy for bilobar colorectal liver metastases is safe and feasible with favorable surgical and oncologic outcomes compared to open two-stage hepatectomy.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
An expert recommendation conference was conducted to identify factors associated with adverse events during laparoscopic cholecystectomy (LC) with the goal of deriving expert recommendations for the ...reduction of biliary and vascular injury. Nineteen hepato‐pancreato‐biliary (HPB) surgeons from high‐volume surgery centers in six countries comprised the Research Institute Against Cancer of the Digestive System (IRCAD) Recommendations Group. Systematic search of PubMed, Cochrane, and Embase was conducted. Using nominal group technique, structured group meetings were held to identify key items for safer LC. Consensus was achieved when 80% of respondents ranked an item as 1 or 2 (Likert scale 1–4). Seventy‐one IRCAD HPB course participants assessed the expert recommendations which were compared to responses of 37 general surgery course participants. The IRCAD recommendations were structured in seven statements. The key topics included exposure of the operative field, appropriate use of energy device and establishment of the critical view of safety (CVS), systematic preoperative imaging, cholangiogram and alternative techniques, role of partial and dome‐down (fundus‐first) cholecystectomy. Highest consensus was achieved on the importance of the CVS as well as dome‐down technique and partial cholecystectomy as alternative techniques. The put forward IRCAD recommendations may help to promote safe surgical practice of LC and initiate specific training to avoid adverse events.
HighlightAn international structured expert recommendation conference for safe laparoscopic cholecystectomy was conducted. Critical recommendations were divided into 7 statements. The highest consensus was achieved on the importance of the critical view of safety and alternative surgical techniques (dome‐down technique, and partial cholecystectomy).
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Background
Tumors located close to major hepatic veins pose a technical challenge to standard laparoscopic liver resection. Hepatic outflow occlusion may reduce the risks of bleeding from hepatic ...vein and gas embolism. The aim of this study was to detail our standardized laparoscopic approach for a safe extrahepatic control of the common trunk of middle and left hepatic veins during laparoscopic liver resection and to assess its feasibility in patients with tumors located in both right and left lobes of the liver.
Methods
Data of 25 consecutive patients who underwent laparoscopic liver resection with extrahepatic control of the common trunk of middle and left hepatic veins were reviewed.
Results
All patients underwent primary hepatectomy. The vast majority (84%) of patients had malignant tumors. The control of the common trunk of middle and left hepatic veins was achieved in 96% of patients. There were 14 (56%) major hepatectomies and 11 (44%) minor hepatectomies. Some form of vascular clamping was performed in 23 (62%) patients: Pringle maneuver in 17 (median time = 45 min; range, 10–109) and selective vascular exclusion of the liver in 6 patients (median time = 30 min; range, 15–94). The median duration of operation was 254 min (range, 70–441). There was one case (4%) of gas embolism but without any complications during the postoperative course. Conversion to open surgery was performed in 2 (7.7%) patients: 1 for oncologic reason and 1 for non-progression during the transection plane. Perioperative blood transfusion rate was nil. The overall morbidity rate was 24%.
Conclusions
The laparoscopic approach for an extrahepatic control of the common trunk of middle and left hepatic veins is reproducible, safe, and effective, and can be applied during laparoscopic liver resection for tumors close to major hepatic veins.
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EMUNI, FZAB, GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Liver tumors located in segments 7 and 8 pose a technical challenge to standard laparoscopic liver resection. Intraoperative placement of a surgical glove behind the right liver after the ...right triangular ligament and coronary ligament are divided facilitates liver exposure during parenchymal transection and control of the bleeding at the deeper part of the parenchymal plane. The aim of this study was to describe our standardized technique in detail and to assess the feasibility of this technique in patients with different clinical backgrounds and clarify the limits of this technique.
Methods
Medical records of 20 consecutive patients considered for laparoscopic liver resection using the surgical glove technique were reviewed.
Results
All patients had malignant disease and the vast majority of patients had colorectal metastatic tumors. Overall, 65% of patients had tumors located in segment 8. Placing the surgical water glove could be achieved without complication in all 20 patients. One surgical glove was used in this series (usually size 6.5 to 7.5 is an adequate size). Time for preparing the surgical green water glove was estimated to be less than 1 min. The mean duration of operation ranged from 136 to 332 min (median, 240 min). Intermittent Pringle’s maneuver was applied in all patients with a median time of 33 min. No additional intercostal trocars were required. There was no intraoperative blood transfusion or conversion to open surgery. The median maximum size of the tumor was 23 mm. There was no operative mortality. Overall morbidity was 30%. Surgical margins were negative in 80% of patients.
Conclusions
The surgical glove technique is easy, reproducible, effective, and safe and can be applied to both laparoscopic and robotic liver resection.
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EMUNI, FZAB, GEOZS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background Laparoscopic hepatectomy continues to be a challenging operation associated with a steep learning curve. This study aimed to evaluate the learning process during 15 years of experience ...with laparoscopic hepatectomy and to identify approaches to standardization of this procedure. Study Design Prospectively collected data of 317 consecutive laparoscopic hepatectomies performed from January 2000 to December 2014 were reviewed retrospectively. The operative procedures were classified into 4 categories (minor hepatectomy, left lateral sectionectomy LLS, left hepatectomy, and right hepatectomy), and indications were classified into 5 categories (benign-borderline tumor, living donor, metastatic liver tumor, biliary malignancy, and hepatocellular carcinoma). Results During the first 10 years, the procedures were limited mainly to minor hepatectomy and LLS, and the indications were limited to benign-borderline tumor and living donor. Implementation of major hepatectomy rapidly increased the proportion of malignant tumors, especially hepatocellular carcinoma, starting from 2011. Conversion rates decreased with experience for LLS (13.3% vs 3.4%; p = 0.054) and left hepatectomy (50.0% vs 15.0%; p = 0.012), but not for right hepatectomy (41.4% vs 35.7%; p = 0.661). Conclusions Our 15-year experience clearly demonstrates the stepwise procedural evolution from LLS through left hepatectomy to right hepatectomy, as well as the trend in indications from benign-borderline tumor/living donor to malignant tumors. In contrast to LLS and left hepatectomy, a learning curve was not observed for right hepatectomy. The ongoing development process can contribute to faster standardization necessary for future advances in laparoscopic hepatectomy.
Background
The recent development of 3D vision in laparoscopic and robotic surgical systems raises the question of whether these two procedures are equivalent. The aim of this study was to evaluate ...the surgical and long-term oncological outcomes of 3D laparoscopic (3D-LLR) and robotic liver resection (RLR) for hepatocellular carcinoma (HCC).
Methods
The data for operative time, morbidity, margins, and survival were reviewed for 3D-LLR and compared with RLR.
Results
From 2011 to 2017, 93 patients with HCC, including 58 (62%) with cirrhosis, underwent 3D-LLR 49 (53%) or RLR 44 (47%). No difference was observed in operative time (269 vs. 252 min;
p
= 0.52), overall (27% vs. RLR: 16%;
p
= 0.49) and severe morbidity (4% vs. 2%;
p
= 0.77) or in the surgical margin width (9 vs. 11 mm;
p
= 0.30) between the 3D-LLR and RLR groups. The 3-year overall and recurrence-free survival rates after 3D-LLR and RLR were 82% and 24% and 91% (
p
= 0.16) and 48% (
p
= 0.18), respectively.
Conclusions
The 3D-LLR and RLR systems provide comparable surgical margins with similar short- and long-term oncological outcomes.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Although adjuvant chemotherapy (AC) is widely used after liver resection (LR) for colorectal liver metastasis (CRLM), surgical invasiveness may lead to delay in starting AC, which is ...preferably started within 8 weeks postoperative. We investigated whether laparoscopic liver resection (LLR) for CRLM facilitates AC start without delay.
Methods
Between November 2014 and December 2016, 117 consecutive CRLM patients underwent LR followed by AC. LLR and OLR were performed in 30 and 87 patients, respectively. After propensity score matching on clinical characteristics, oncologic features, and type of resection, the time interval between liver resection and AC start was compared between LLR (
n
= 22) and OLR (
n
= 44) groups.
Results
After propensity score matching, major LR was performed in 8/22 (36%) and 15/44 (34%) cases of LLR and OLR groups, respectively (
P
= 1.0). Clinical-pathological characteristic and intraoperative findings were comparable between two groups. There was no significant difference in postoperative complications between the two groups. The time interval between liver resection and AC start was significantly shorter in LLR than in OLR group (43 ± 10 versus 55 ± 18 days,
P
= 0.012). While 15/44 (34%) patients started AC after 8 weeks postoperative in OLR group, all patients in LLR group started AC within 8 weeks.
Conclusions
LLR for CRLM is associated with quicker return to AC when compared to OLR. The delivery of AC without delay allows CRLM patients to optimize the oncologic treatment sequence.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Major liver resection for hepatocellular carcinoma (HCC) ideally involves preoperative portal venous embolization (PVE) coupled with preoperative transarterial chemoembolization (TACE) to ...improve postoperative course and oncological results. Laparoscopic right hepatectomy (RH) following sequential TACE–PVE for HCC, although challenging, may help improve both immediate and long-term patient outcomes. This study is the first to describe and compare laparoscopic to open RH following sequential TACE–PVE for HCC in terms of feasibility, safety, and patient outcomes.
Study design
All patients who underwent laparoscopic RH following successful TACE–PVE sequence (video provided) were retrospectively reviewed from a prospective database maintained at our center. Preoperative characteristics, operative data, and postoperative outcomes were analyzed and compared with those of patients who underwent open RH after TACE–PVE sequence during the same period.
Results
The laparoscopic and open RH groups each included 16 patients. F3 or F4 fibrosis was present in 81 % of patients. The conversion rate was 25 %. The 90-day postoperative complication rate was 25 % in the laparoscopic group versus 50 % in the open group (
p
= 0.27). The incidence of postoperative liver failure grade B was higher in the open group than in the laparoscopic group (5 vs. 0 patients,
p
= 0.043). Severe complications, Clavien grade ≥ IIIb, only occurred in the open group and included one postoperative death. Hospital stay was significantly shorter in the laparoscopic group than in the open group (7 vs. 12 days,
p
= 0.001). R0 resection was accomplished in 93.8 % of laparoscopic patients.
Conclusion
Laparoscopic approach seems technically feasible and safe. This modern approach may optimize the surgical strategy in the future of HCC management.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
Laparoscopic resection (LLR) of colorectal liver metastases (CRLM) located in the posterosuperior liver (segments 4a, 7, and 8) is challenging but has become more practical recently due to ...progress in operative techniques. We aimed to compare tumor-specific, perioperative, and short-term oncological outcomes after LLR and open liver resection (OLR) for CRLM.
Methods
Patients who underwent curative resection of CRLM with at least 1 tumor in the posterosuperior liver during 2012–2015 were analyzed. Tumor-specific factors associated with the adoption of LLR were analyzed by logistic regression model. One-to-one propensity score matching was used to match baseline characteristics between patients with LLR and OLR.
Results
The original cohort included 30 patients with LLR and 239 with OLR. Median follow-up time was 23.8 months. Logistic regression analysis showed that multiple, diameter ≥30 mm, deep location, and closeness to major vessels were associated with OLR. None of the 24 patients with none or one of these factors were converted from LLR to OLR. After matching, 29 patients with LLR and 29 with OLR were analyzed. The 2 groups had similar preoperative factors. The LLR and OLR groups did not differ with respect to operative time, intraoperative bleeding, incidence of blood transfusion, surgical margin positivity, incidence of postoperative complications, and unplanned readmission within 45 days. Median length of postoperative hospital stay was significantly shorter for LLR versus OLR (4 days 1–12 vs. 5 days 4–18;
p
= 0.0003). Median recurrence-free survival was similar for patients who underwent LLR versus OLR (10.6 months for LLR vs. 13.4 months for OLR;
p
= 0.87).
Conclusions
Compared to OLR, LLR of posterosuperior CRLM is associated with significantly shorter postoperative hospital stay but otherwise similar perioperative and short-term oncological outcomes. Tumor-specific factors associated with safe and routine LLR approach despite challenging location are superficial, solitary, and small (<30 mm) CRLM not associated with major vessels.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
A standardized laparoscopic right hepatectomy (LRH) approach named the “caudal approach” was recently reported. Yet, the value of this approach compared with state-of-the-art open right ...hepatectomy (ORH) remains unknown. The purpose of this study was therefore to compare the short-term outcomes of LRH using the caudal approach and ORH with anterior approach and liver hanging maneuver.
Methods
One-hundred eleven consecutive patients who underwent LRH with caudal approach were prospectively collected; 346 patients who underwent ORH with anterior approach and liver hanging maneuver were enrolled as a control group. Propensity score matching (PSM) of patients in a ratio of 1: 1 was conducted and the perioperative outcomes were compared.
Results
After PSM, two well-balanced groups of 72 patients each were analyzed and compared. The conversion rate in the LRH group was 18.1%. Perioperative blood loss and transfusion rates were significantly lower in the LRH group as compared to the ORH group (median, 200 ml vs. 500 ml,
p
< 0.001 and 9.9% vs. 26.8%,
p
= 0.009, respectively), while operation time was significantly longer (median, 348 min vs. 290 min,
p
< 0.001). Overall (26.4% vs. 48.6%,
p
= 0.006) and symptomatic pulmonary (6.9% vs. 19.4%,
p
= 0.027) complication rates were significantly lower in the LRH group. Hospital stay was significantly shorter in the LRH group (median, 8 days vs. 9 days,
p
= 0.013).
Conclusions
LRH using the caudal approach is associated with improved short-term outcomes compared to state-of-the-art ORH in patients qualifying for both approaches, and can be proposed as standard practice.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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