D. Tzanis

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 Pringles 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.

Single incision laparoscopic cholecystectomy: for what benefit?

BACKGROUND A single-incision laparoscopic cholecystectomy (SILC) was developed to improve outcomes as compared with the four-port classic laparoscopic cholecystectomy (CLC). Any potential benefits associated with a SILC have been suggested by previous studies reporting few patients with different surgical techniques. The aim of this study was to describe the experience with a standardized SILC as compared with CLC. METHODS From June 2010 to January 2012, 40 patients underwent a SILC [median age: 47.5 years (25-92)] and operative and peri-operative data were prospectively collected. Over the same period, 37 patients underwent a CLC. A 10-point visual analogue scale (VAS) was used for qualitative data. The costs of SILC and CLC were also compared. RESULTS For those patients undergoing a SILC the median operating time was 70 min (24-110). There were no conversions. An additional trocar was necessary in 16 patients. Four patients developed post-operative complications. The median immediate post-operative pain score was 5 (0-10). The median quality of life and cosmetic satisfaction at the initial post-operative visit were 10 (6-10) and 10 (5-10), respectively (VAS). Although the surgical results of both groups were similar, post-operative complications were exclusively reported in the SILC group (two incisional hernias). CONCLUSION Standardization of SILC is possible but associated with an important rate of additional trocar placement and a disturbing rate of incisional hernias.

Atypical as well as anatomical liver resections are feasible by laparoendoscopic single-site surgery☆

INTRODUCTION Liver surgery was one of the last fields to be conquered by laparoscopy, which has become safe and effective, especially for left lateral sectionectomy (LLS) and limited peripheral resections. However, major hepatectomies remain challenging. Laparoendoscopic single-site (LESS) surgery is being employed for an increasing variety of surgical sites and indications. PRESENTATION OF CASE Three patients underwent LESS hepatectomy. A 36-year-old woman had LLS for a 38-mm adenoma, an 85-year-old woman an atypical resection of segment VI for a 12-mm hepatocellular carcinoma and a 41-year-old woman an atypical right anterior resection for a 9 cm symptomatic FNH. Procedures were performed transperitoneally with a single-port device, via a 20-mm or 30-mm incision. Operative times were 110 min for LLS, 100 min for the atypical segment VI resection and 120 min for the atypical right anterior liver resection. Blood loss was less than 50 ml in the first two patients and 150 ml in the third. Postoperative courses were uneventful. The first two patients were discharged on postoperative day 3 and the third on postoperative day 1. DISCUSSION To date, some case reports and series of LESS liver surgery have been published. We performed the reported hepatectomies after a considerable experience in laparoscopic hepatic surgery and after applying the LESS approach to other procedures. Our hepatectomy technique was not modified by the use of the single-port and results were very encouraging. CONCLUSION We believe that in selected patients, both peripheral resections and LLS are feasible by LESS surgery, with good intra-operative and post-operative results.

Ambulatory laparoscopic minor hepatic surgery: Retrospective observational study

INTRODUCTION Over the last decade, laparoscopic hepatic surgery (LHS) has been increasingly performed throughout the world. Meanwhile, ambulatory surgery has been developed and implemented with the aims of improving patient satisfaction and reducing health care costs. The objective of this study was to report our preliminary experience with ambulatory minimally invasive LHS. METHODS Between 1999 and 2014, 172 patients underwent LHS at our institution, including 151 liver resections and 21 fenestrations of hepatic cysts. The consecutive series of highly selected patients who underwent ambulatory LHS were included in this study. RESULTS Twenty patients underwent ambulatory LHS. Indications were liver cysts in 10 cases, liver angioma in 3 cases, focal nodular hyperplasia in 3 cases, and colorectal hepatic metastasis in 4 cases. The median operative time was 92 minutes (range: 50-240 minutes). The median blood loss was 35 mL (range: 20-150 mL). There were no postoperative complications or re-hospitalizations. All patients were hospitalized after surgery in our ambulatory surgery unit, and were discharged 5-7 hours after surgery. The median postoperative pain score at the time of discharge was 3 (visual analogue scale: 0-10; range: 0-4). The median quality-of-life score at the first postoperative visit was 8 (range: 6-10) and the median cosmetic satisfaction score was 8 (range: 7-10). CONCLUSION This series shows that, in selected patients, ambulatory LHS is feasible and safe for minor hepatic procedures.

Single incision laparoscopic splenectomy with hilar dissection for massive splenomegaly (with video).

Splenectomy;Laparoscopy;Single incision;Hilar dissection;SplenomegalyThe first laparoscopic splenectomy was performed in 1992 [1]. This approach is now thetechnique of choice for splenectomy. Single trocar surgery has been developed since theend ofthe1990s. Several teams have described advantages single trocar splenec-tomy [2,3]. However, most of these studies have been on relatively small size spleens withroutine stapling ofthesplenic hilum. This video shows technique single incisionsplenectomy withsplenic hilar dissection in a patient massive splenomegaly.A 16-year-old girl with hereditary spherocytosis requiring blood transfusions forsymptomatic anemia was referred for splenectomy. Abdominal MRI showed massivesplenectomy, measuring 21cm in the longitudinal axis.The patient was positioned supine, legs apart with the operator standing between thepatient’s legs while freeing the lower pole of the spleen, and then moving to the patient’sright side for the rest of the operation. A 2cm incision was made at the level of theumbilicus to insert a four port single trocar (Quadriport