Background
The dissemination of robotic liver surgery is slow‐paced and must face the obstacle of demonstrating advantages over open and laparoscopic (LLS) approaches. Our objective was to show the ...current position of robotic liver surgery (RLS) worldwide and to identify if improved short‐term outcomes are observed, including secondary meta‐analyses for type of resection, etiology, and cost analysis.
Methods
A PRISMA‐based systematic review was performed to identify manuscripts comparing RLS vs open or LLS approaches. Quality analysis was performed using the Newcatle‐Ottawa score. Statistical analysis was performed after heterogeneity test and fixed‐ or random‐effect models were chosen accordingly.
Results
After removing duplications, 2728 RLS cases were identified from the final set of 150 manuscripts. More than 75% of the cases have been performed on malignancies. Meta‐analysis from the 38 comparative reports showed that RLS may offer improved short‐term outcomes compared to open procedures in most of the variables screened. Compared to LLS, some advantages may be observed in favour of RLS for major resections in terms of operative time, hospital stay and rate of complications. Cost analyses showed an increased cost per procedure of around US$5000.
Conclusions
The advantages of RLS still need to be demonstrated although early results are promising. Advantages vs open approach are demonstrated. Compared to laparoscopic surgery, minor perioperative advantages may be observed for major resections although cost analyses are still unfavorable to the robotic approach.
Highlight
Ciria and colleagues analyzed the impact of robotics in liver surgery. The largest systematic review and short‐term outcomes meta‐analysis performed to date was done on 2728 cases. Few initial advantages were observed for the robotic approach compared with laparoscopy, contrary to significant higher costs. However, a high potential was highlighted.
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•Liver resection for hepatocellular carcinoma in Child-Pugh B cirrhosis should be considered after careful patient selection.•Patient characteristics, tumor pattern, liver function ...and surgical approach should be considered as selection criteria.•Nomograms to predict surgical risks and survival may help in treatment allocation.
Treatment allocation in patients with hepatocellular carcinoma (HCC) on a background of Child-Pugh B (CP-B) cirrhosis is controversial. Liver resection has been proposed in small series with acceptable outcomes, but data are limited. The aim of this study was to evaluate the outcomes of patients undergoing liver resection for HCC in CP-B cirrhosis, focusing on the surgical risks and survival.
Patients were retrospectively pooled from 14 international referral centers from 2002 to 2017. Postoperative and oncological outcomes were investigated. Prediction models for surgical risks, disease-free survival and overall survival were constructed.
A total of 253 patients were included, of whom 57.3% of patients had a preoperative platelet count <100,000/mm3, 43.5% had preoperative ascites, and 56.9% had portal hypertension. A minor hepatectomy was most commonly performed (84.6%) and 122 (48.2%) were operated on by minimally invasive surgery (MIS). Ninety-day mortality was 4.3% with 6 patients (2.3%) dying from liver failure. One hundred and eight patients (42.7%) experienced complications, of which the most common was ascites (37.5%). Patients undergoing major hepatectomies had higher 90-day mortality (10.3% vs. 3.3%; p = 0.04) and morbidity rates (69.2% vs. 37.9%; p <0.001). Patients undergoing an open hepatectomy had higher morbidity (52.7% vs. 31.9%; p = 0.001) than those undergoing MIS. A prediction model for surgical risk was constructed (https://childb.shinyapps.io/morbidity/). The 5-year overall survival rate was 47%, and 56.9% of patients experienced recurrence. Prediction models for overall survival (https://childb.shinyapps.io/survival/) and disease-free survival (https://childb.shinyapps.io/DFsurvival/) were constructed.
Liver resection should be considered for patients with HCC and CP-B cirrhosis after careful selection according to patient characteristics, tumor pattern and liver function, while aiming to minimize surgical stress. An estimation of the surgical risk and survival advantage may be helpful in treatment allocation, eventually improving postoperative morbidity and achieving safe oncological outcomes.
Liver resection for hepatocellular carcinoma in advanced cirrhosis (Child-Pugh B score) is associated with a high rate of postoperative complications. However, due to the limited therapeutic alternatives in this setting, recent studies have shown promising results after accurate patient selection. In our international multicenter study, we provide 3 clinical models to predict postoperative surgical risks and long-term survival following liver resection, with the aim of improving treatment allocation and eventually clinical outcomes.
Background
Despite the successful oncological results of liver transplantation, patients with hepatocellular carcinoma (HCC) can develop tumor recurrence. When technically feasible, liver resection ...represents the preferred treatment for recurrent HCC, even in the setting of transplanted patients. Recent progresses in minimally invasive liver resections have pushed the surgical community to attempt more challenging cases. We report a full laparoscopic left hepatectomy for HCC recurrence on transplanted liver.
Methods
A routine follow-up computed tomography (CT) scan of a 53-year-old male who previously underwent an orthotopic liver transplantation for alcoholic-related liver disease showed a 3 cm HCC in segment 4 in close relationship with the peripheral portion of the left portal pedicle. A full laparoscopic left hepatectomy was performed using an extrahepatic intraglissonean approach.
Results
Operative time was 332 min and blood loss was 100 mL. The patient had an uneventful postoperative recovery and was discharged home after 3 days.
Conclusions
Laparoscopic liver resection on transplanted patients is feasible. Challenging clinical scenarios should only be attempted in referral centers and after an appropriate learning curve.
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First seen as an innovation for select patients, laparoscopic liver resection (LLR) has evolved since its introduction, resulting in worldwide use. Despite this, it is still limited mainly to ...referral centers. The aim of this study was to evaluate a large cohort undergoing LLR from 2000 to 2015, focusing on the technical approaches, perioperative and oncologic outcomes, and evolution of practice over time.
The demographics and indications, intraoperative, perioperative, and oncologic outcomes of 2,238 patients were evaluated. Trends in practice and outcomes over time were assessed.
The percentage of LLR performed yearly has increased from 5% in 2000 to 43% in 2015. Pure laparoscopy was used in 98.3% of cases. Wedge resections were the most common operation; they were predominant at the beginning of LLR and then decreased and remained steady at approximately 53%. Major hepatectomies were initially uncommon, then increased and reached a stable level at approximately 16%. Overall, 410 patients underwent resection in the posterosuperior segments; these were more frequent with time, and the highest percentage was in 2015 (26%). Blood loss, operative time, and conversion rate improved significantly with time. The 5-year overall survival rates were 73% and 54% for hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM), respectively. The 5-year, recurrence-free survival rates were 50% and 37% for HCC and CRLM, respectively.
Since laparoscopy was introduced, a long implementation process has been necessary to allow for standardization and improvement in surgical care, mastery of the technique, and the ability to obtain good perioperative results with safe oncologic outcomes.
Introduction
A stronger evidence level is needed to confirm the benefits and limits of laparoscopic hemihepatectomies.
Methods
Laparoscopic and open hemihepatectomies from nine European referral ...centers were compared after propensity score matching (right and left hemihepatectomies separately, and benign and malignant diseases sub‐analyses).
Results
Five hundred and forty‐five laparoscopic hemihepatectomies were compared with 545 open. Laparoscopy was associated with reduced blood loss (P < 0.001), postoperative stay (P < 0.001) and minor morbidity (P = 0.002), supported by a lower Comprehensive Complication Index (CCI) (P = 0.035). Laparoscopic right hemihepatectomies were associated with lower ascites (P = 0.016), bile leak (P = 0.001) and wound infections (P = 0.009). Laparoscopic left hemihepatectomies exhibited a lower incidence of bile leak and cardiovascular complications (P = 0.024; P = 0.041), lower minor and major morbidity (P = 0.003; P = 0.044) and reduced CCI (P = 0.002). Laparoscopic major hepatectomies (LMH) for benign disease were associated with lower blood loss (P = 0.001) and bile leaks (P = 0.037) and shorter total stay (P < 0.001). LMH for malignancy were associated with lower blood loss (P < 0.001) and minor morbidity (P = 0.027) supported by a lower CCI (P = 0.021) and shorter stay (P < 0.001).
Conclusion
This multicenter study confirms some associated advantages of laparoscopic left and right hemihepatectomies in malignant and benign conditions highlighting the need for realistic expectations of the minimally invasive approach based on the resected hemiliver and the patients treated.
Laparoscopic hemihepatectomy offers several advantages over open hemihepatectomy. However, laparoscopic right hemihepatectomy and left hemihepatectomy, as well as laparoscopic hemihepatectomy for benign and for malignant disease, exhibit different benefits. Cipriani and colleagues highlighted the need for realistic expectations based on the laterality of the resection and the nature of the disease.
Background
Although the number of minimally invasive liver resections (MILRs) has been steadily increasing in many institutions, minimally invasive anatomic liver resection (MIALR) remains a ...complicated procedure that has not been standardized. We present the results of a survey among expert liver surgeons as a benchmark for standardizing MIALR.
Method
We administered this survey to 34 expert liver surgeons who routinely perform MIALR. The survey contained questions on personal experience with liver resection, inflow/outflow control methods, and identification techniques of intersegmental/sectional planes (IPs).
Results
All 34 participants completed the survey; 24 experts (70%) had more than 11 years of experience with MILR, and over 80% of experts had performed over 100 open resections and MILRs each. Regarding the methods used for laparoscopic or robotic anatomic resection, the Glissonean approach (GA) was a more frequent procedure than the hilar approach (HA). Although hepatic veins were considered essential landmarks, the exposure methods varied. The top three techniques that the experts recommended for identifying IPs were creating a demarcation line, indocyanine green negative staining method, and intraoperative ultrasound.
Conclusion
Minimally invasive anatomic liver resection remains a challenging procedure; however, a certain degree of consensus exists among expert liver surgeons.
Highlight
Morimoto and colleagues summarized the opinions of the world's minimally invasive anatomic liver resection (MIALR) experts on detailed anatomical knowledge, landmarks, and techniques regarding inflow control and liver parenchymal resection with hepatic vein exposure. Although many challenges remain, these expert opinions will promote the spread and development of safe MIALR.
Background
Laparoscopic ablation (LA) of colorectal liver metastases (CRLMs) is frequently performed in combination with laparoscopic liver resection or as a stand-alone procedure. However, LA is ...technically demanding and whether the results are comparable with those of open ablation (OA) has not been determined to date. This study compared the effectiveness of LA and OA in achieving local tumor control of CRLMs.
Methods
Patients undergoing LA or OA of CRLMs at Ghent University Hospital between June 2007 and February 2018 were identified from a prospective database. Lesions treated by LA and OA were matched 1:1 using a propensity score based on lesions (liver segment, size, deepness, proximity to a vessel), patients, and procedural characteristics. Ablation sites were followed up with computed-tomography or magnetic resonance imaging to assess the completeness of the ablation and ablation-site recurrence (ASR). Analysis of ASR was performed with the Kaplan–Meier method and Cox regression.
Results
In this study, 163 patients underwent the surgical ablation (78 LA, 85 OA) of 333 CRLMs (143 LA, 190 OA). After matching, 220 lesions (110 LA, 110 OA) were analyzed. Ablation was complete in 93.7% (LA) and 97.3% (OA) of the sites (
p
= 0.195). No difference in ASR was observed (
p
= 0.351), with a cumulative risk of ASR at 12 months of 9.1% (LA) and 8.2% (OA). After multivariable analysis, ASR was confirmed to be independent of the surgical approach.
Conclusion
The findings showed that LA and OA achieve a comparable local control of CRLMs. This result further supports the adoption of a laparoscopic approach for the treatment of CRLMs.
Background
There is no clear consensus over the optimal width of resection margin for colorectal liver metastases (CRLM), with evolving definitions alongside the advances on the management of the ...disease. In addition, data on the impact of resection margin after laparoscopic liver resection are still scarce.
Methods
Prospectively maintained databases of patients undergoing open or laparoscopic CRLM resection in 7 European tertiary hepatobiliary referral centres were reviewed. After propensity score matching (PSM), the influence of 1 mm and wider margins on OS and DFS were evaluated in open and laparoscopic cohorts.
Results
After PSM, 648 patients were comparable in each group. The incidence of positive margins (< 1 mm) was similar in open and laparoscopic groups (17% vs 13%,
p
= 0,142).
Margins < 1 mm were associated with shorter RFS in open (12 vs 26 months,
p
= 0.042) and in laparoscopic group (13 vs 23,
p
= 0,002). Margins < 1 mm were associated with shorter OS in open (36 vs 57 months,
p
= 0.027), but not in laparoscopic group (49 vs 60,
p
= 0,177).
Subgroups with margins ≥ 1 mm (1–4 mm, 5–9 mm, ≥ 10 mm) presented similar RFS in open (p = 0,251) or laparoscopic cohorts (
p
= 0.117), as well as similar OS in open (
p
= 0.295) or laparoscopic cohorts (
p
= 0.908). In the presence of liver recurrence, repeat liver resection was performed in 70 (30%) patients in the open group and 88 (48%) in the laparoscopic group (
p
< 0.001).
Conclusions
Our study suggests that a positive resection margin (less than 1 mm) width does not impact OS after laparoscopic resection of CRLMs as it does in open liver resection. However, a positive margin continues to affect RFS in open and laparoscopic resection. Wider margins than 1 mm do not seem to improve oncological results in open or laparoscopic surgery.
ABSTRACT Introduction Small-for-size syndrome (SFSS) has an incidence between 0 and 43% in small-for-size graft (SFSG) adult living donor liver transplantation (LDLT). Portal hypertension following ...reperfusion and the hyperdynamic splanchnic state are reported as the major triggering factors of SFSS. Intra- and postoperative strategies to prevent or to reduce its onset are still under debate. We analyzed graft inflow modulation (GIM) during adult LDLT considering the indications, efficacy of the available techniques, changes in hemodynamics and outcomes. Materials and Methods A systematic literature search was performed using PubMed, EMBASE, Scopus and the Cochrane Library Central. Treatment outcomes including in-hospital mortality and morbidity, re-transplantation rate, 1-, 3-, and 5-year patient overall survival and 1-, 3-, and 5-year graft survival rates, hepatic artery and portal vein flows and pressures before and after inflow modulation were analyzed. Results From 563 articles, 12 studies dated between 2003 and 2014 fulfilled the selection criteria and were therefore included in the study. These comprised a total of 449 adult patients who underwent inflow modulation during adult-to-adult LDLT. Types of GIM described were splenic artery ligation, splenectomy, meso-caval shunt, spleno-renal shunt, portocaval shunt, and splenic artery embolization. Mortality and morbidity ranged between 0 and 33% and 17–70%, respectively. Re-transplantation rates ranged between 0% and 25%. GIM was associated with good survival for both graft and recipients, reaching an 84% actuarial rate at 5 years. Through the use of GIM, irrespective of the technique, a statistically significant reduction of PVF and PVP was obtained. Conclusions GIM is a safe and efficient technique to avoid or limit portal hyperperfusion, especially in cases of SFSG, decreasing overall morbidity and improving outcomes.
Purpose
In this systematic review, we aimed to clarify the useful anatomic structures and assess available surgical techniques and strategies required to safely perform minimally invasive anatomic ...liver resection (MIALR), with a particular focus on the hepatic veins (HVs).
Methods
A systematic review was conducted using MEDLINE/PubMed for English articles and Ichushi databases for Japanese articles through September 2020. The quality assessment of the articles was performed in accordance with the Scottish Intercollegiate Guidelines Network (SIGN).
Results
A total of 3372 studies were obtained, and 59 were selected and reviewed. Due to the limited number of published comparative studies and case series, the degree of evidence from our review was low. Thirty‐two articles examined the anatomic landmarks and crucial structures for approaching HVs. Regarding the direction of HV exposure, 32 articles focused on the techniques and advantages of exposing HVs from either the root or the periphery. Ten articles focused on the techniques to perform a segmentectomy 8 in particularly difficult cases of MIALR. In seven articles, bleeding control from HVs was also discussed.
Conclusions
This review may help experts reach a consensus regarding the best approach to the management of hepatic veins during MIALR.
Highlight
This systematic review summarizes and assesses the important anatomy and available surgical techniques for safe performance of minimally invasive anatomic liver resection (MIALR). Of 3372 manuscripts obtained, 59 were selected and reviewed. This review may help experts reach consensus regarding the best approach to manage hepatic veins during MIALR.
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