Eric C.H. Lai

Prospective randomized comparative study of single incision laparoscopic cholecystectomy versus conventional four-port laparoscopic cholecystectomy

BACKGROUND This study aimed to compare the outcomes of single-incision laparoscopic cholecystectomy (SILC) versus conventional 4-port laparoscopic cholecystectomy (LC). METHODS From November 2009 to August 2010, 51 patients with symptomatic gallstone or gallbladder polyps were randomized to SILC (n = 24) or 4-port LC (n = 27). RESULTS Mean surgical time (43.5 vs 46.5 min), median blood loss (1 vs 1 mL) and mean hospital stay (1.5 vs 1.8 d) were similar for both the SILC and 4-port LC group. There were no open conversions and no major complications. The mean total wound length of the SILC group was significantly shorter (1.76 vs 2.25 cm). The median visual analogue pain score at 6 hours after surgery was similar (4.5 vs 4.0) but the SILC group had a significantly worse pain score on day 7 (1 vs 0). There was no difference in time to resume usual activity (mean, 5.6 vs 5.0 d). The median cosmetic score of SILC was significantly higher than at 3 months after surgery (7 vs 6). CONCLUSIONS SILC was feasible and safe for properly selected patients in experienced hands.

Robot-assisted laparoscopic pancreaticoduodenectomy versus open pancreaticoduodenectomy – A comparative study

BACKGROUND Traditionally, pancreatic surgery is considered as one of the most complex surgeries. The recently developed robotic technology allows surgeons to perform pancreaticoduodenectomy. A comparative study was undertaken to study outcomes between robotic approach and open approach. METHODS A consecutive patients underwent pancreaticoduodenectomy (robotic approach, n=20; open approach=67) between January 2000 and February 2012 at a single institution were analyzed. RESULTS The robotic group had a significantly longer operative time (mean, 491.5 vs. 264.9 min), reduced blood loss (mean, 247 vs. 774.8 ml), and shorter hospital stay (mean, 13.7 vs. 25.8 days) compared to the open group. Open conversion rate was 5%. There was no significant difference between the two groups in terms of overall complication rates, mortality rates, R0 resection rate and harvested lymph node numbers. CONCLUSIONS This study showed that robot-assisted laparoscopic pancreaticoduodenectomy was safe and feasible in appropriately selected patients. However, it is too early to draw definitive conclusions about the value of robot-assisted laparoscopic pancreaticoduodenectomy. In light of remaining uncertainties regarding short-term and long-term outcome, caution should be exercised in the assessment of the appropriateness of this operation for individual patient.

Robot-assisted laparoscopic liver resection for hepatocellular carcinoma: short-term outcome.

BACKGROUND This study aimed at analyzing the perioperative and early survival outcomes of robotic liver resection of hepatocellular carcinoma (HCC). METHODS The study population included a consecutive series of patients with HCC who underwent robotic liver resection at a single center. RESULTS During the study period, 41 consecutive patients with HCC underwent 42 robotic liver resections. Five resections (11.9%) were carried out for recurrent HCC, and 23.8% (n = 10) were hemihepatectomy procedures. The mean operating time and blood loss was 229.4 minutes and 412.6 mL, respectively. The R0 resection rate was 93%. The hospital mortality and morbidity rates were 0% and 7.1%, respectively. The mean hospital stay was 6.2 days. The 2-year overall and disease-free survival rates were 94% and 74%, respectively. In the subgroup analysis of minor liver resection, when compared with the conventional laparoscopic approach, the robotic group had similar blood loss (mean, 373.4 mL vs 347.7 mL), morbidity rate (3% vs 9%), mortality rate (0% vs 0%), and R0 resection rate (90.9% vs 90.9%). However, the robotic group had a significantly longer operative time (202.7 mins vs 133.4 mins). CONCLUSIONS This study demonstrated the feasibility and safety of robotic surgery for HCC, with favorable short-term outcome. However, the long-term oncologic results remain uncertain.

Multimodality laparoscopic liver resection for hepatic malignancy – From conventional total laparoscopic approach to robot-assisted laparoscopic approach

INTRODUCTION Laparoscopic liver resection can either be total laparoscopic or hand-assisted laparoscopic approach. The recent introduction of robotic surgical systems has revolutionized the field of minimally invasive surgery. It was developed to overcome the disadvantages of conventional laparoscopic surgery. The role of robotic system in laparoscopic surgery was not well evaluated yet. The aim of this cohort study was to evaluate the outcome of multimodality approach of laparoscopic liver resection for hepatic malignancy METHODS From January 1998 to August 2010, all patients with hepatic malignancy underwent laparoscopic liver resection were included. A prospectively collected data was analyzed retrospectively. RESULTS During the study period, a total of 56 patients with hepatic malignancies (hepatocellular carcinoma, HCC, n = 42; colorectal liver metastases, CLM, n = 14) underwent laparoscopic liver resection in our surgical unit. The majority of cases were performed by hand-assisted laparoscopic approach, n = 31 (55.3%) and the remainder were with total laparoscopic approach, n = 10 (17.9%) and robot-assisted laparoscopic approach, n = 15 (26.8%). The median operation time was 150 min (range, 75-307 min). The median blood loss during surgery was 175 ml (range, 5-2000 ml). Two patients (3.6%) needed open conversion and one patient (1.8%) needed to be converted to hand-assisted laparoscopic approach. The morbidity rate was 14.3%. There was no procedure-related death. 89.3% of patients had R0 resection and 10.7% of patients had R1 resection. The median hospital stay was 6.5 days (range, 2-13 days). The 1-year, 3-year, and 5-year disease-free survival rates for HCC were 85%, 47%, and 38%, respectively. The 1-year, 3-year, and 5-year overall survival rates for HCC were 96%, 67%, and 52%, respectively. The 1-year, and 3-year disease-free survival rates for CLM were 92% and 72%. The 1-year, and 3-year overall survival rates for CLM were 100% and 88%, respectively. CONCLUSIONS Multimodality approach of laparoscopic liver resection of hepatic malignancy was feasible, and safe in selected patients. It was associated with a low complications rate. The mid-term and long-term survival outcome was favorable also.

Laparoscopic approach of surgical treatment for primary hepatolithiasis: a cohort study

BACKGROUND The aim of the current study was to evaluate the perioperative and long-term outcome of a laparoscopic approach for management of primary hepatolithiasis. METHODS From January 1995 to June 2008, 55 consecutive patients with primary hepatolithiasis who underwent laparoscopic partial hepatectomy and laparoscopic bile duct exploration were analyzed. Immediate outcomes included stone clearance rate, operative morbidity, and mortality. Long-term outcomes included stone recurrence rate and hepatolithiasis-related mortality. RESULTS Nineteen patients underwent laparoscopic left lateral sectionectomy and 36 patients underwent laparoscopic bile duct exploration. Twenty-five patients also underwent concomitant laparoscopic choledochoduodenostomy bypass. The operative morbidity and mortality rates were 25.5% and 1.8%, respectively. Four procedures needed open conversion. The immediate stone clearance rate was 90.9%, and the final stone clearance rate was 94.5% after subsequent choledochoscopic treatment. With a mean follow-up of 59 +/- 30 months, recurrent stones developed in 3 patients. One patient died of advanced cholangiocarcinoma. CONCLUSIONS In selected patients with primary hepatolithiasis, a laparoscopic approach of definitive treatment is safe and effective with good immediate and long-term outcomes.

Current status of robot-assisted laparoscopic pancreaticoduodenectomy and distal pancreatectomy: a comprehensive review.

This article reviews the current status of robot‐assisted laparoscopic pancreaticoduodenectomy and distal pancreatectomy.

Radiofrequency ablation versus hepatic resection for hepatocellular carcinoma within the Milan criteria – A comparative study

BACKGROUND To compare the results of radiofrequency ablation (RFA) with hepatic resection in the treatment of hepatocellular carcinoma (HCC) within the Milan criteria. METHODS A nonrandomized comparative study was performed with 111 consecutive patients who underwent laparoscopic RFA (n = 31) or curative hepatic resection (n = 80) for HCC within Milan criteria. RESULTS Procedure related complications were less often and severe after RFA than resection (3.2% vs. 25%). There was no significant difference in hospital mortality (0% vs. 3.8%). Hospital stay was significantly shorter in the RFA group than in the resection group (mean, 3.8 vs. 6.8 days). The 1-, 3-, and 5-year disease-free survival rates for the RFA group and the resection group were 76%, 40%, 40% and 76%, 60%, 60%, respectively. Disease-free survival was significantly lower in the RFA group than in the resection group. The corresponding 1-, 3-, and 5-year overall survival rates for the RFA group and the resection group were 100%, 92%, 84%, and 92%, 75%, 71%, respectively. The overall survival for RFA and resection were not significantly different. CONCLUSIONS Our result showed comparable overall survival between RFA and surgery, although RFA was associated with a significantly higher tumor recurrence rate. RFA had the advantages over surgical resection in being less invasive and having lower morbidity.

Enteric reconstruction of pancreatic stump following pancreaticoduodenectomy: a review of the literature.

Techniques for reconstruction of pancreatic stump with gastrointestinal tract following pancreaticoduodenectomy are closely related to postoperative complications, mortality and quality of life. In order to reduce postoperative complications, particularly pancreatic fistula, many modifications and new surgical techniques have been proposed to replace the traditional pancreaticojejunostomy and pancreaticogastrostomy. The objective of this review, based on large prospective randomized trials and meta-analyses, is to evaluate the different techniques of enteric reconstruction of pancreatic stump following pancreaticoduodenectomy, including: invagination pancreaticojejunostomy, binding pancreaticojejunostomy, duct-to-mucosa pancreaticojejunostomy, Roux-en-Y pancreaticojejunostomy, and pancreaticogastrostomy, so as to provide a comprehensive comparison of these techniques and to assess of their roles and effectiveness.

Robotic distal pancreatectomy versus conventional laparoscopic distal pancreatectomy: a comparative study for short-term outcomes.

Robotic system has been increasingly used in pancreatectomy. However, the effectiveness of this method remains uncertain. This study compared the surgical outcomes between robot-assisted laparoscopic distal pancreatectomy and conventional laparoscopic distal pancreatectomy. During a 15-year period, 35 patients underwent minimally invasive approach of distal pancreatectomy in our center. Seventeen of these patients had robot-assisted laparoscopic approach, and the remaining 18 had conventional laparoscopic approach. Their operative parameters and perioperative outcomes were analyzed retrospectively in a prospective database. The mean operating time in the robotic group (221.4 min) was significantly longer than that in the laparoscopic group (173.6 min) (P = 0.026). Both robotic and conventional laparoscopic groups presented no significant difference in spleen-preservation rate (52.9% vs. 38.9%) (P = 0.505), operative blood loss (100.3 ml vs. 268.3 ml) (P = 0.29), overall morbidity rate (47.1% vs. 38.9%) (P = 0.73), and post-operative hospital stay (11.4 days vs. 14.2 days) (P = 0.46). Both groups also showed no perioperative mortality. Similar outcomes were observed in robotic distal pancreatectomy and conventional laparoscopic approach. However, robotic approach tended to have the advantages of less blood loss and shorter hospital stay. Further studies are necessary to determine the clinical position of robotic distal pancreatectomy.

Robot-assisted laparoscopic approach of management for Mirizzi syndrome.

Mirizzi syndrome is an uncommon cause of common hepatic duct obstruction resulting from gallstone impaction in the cystic duct or gallbladder neck. Mirizzi syndrome is traditionally considered as a contraindication to laparoscopic surgery mainly due to risk of bile duct injury during dissection. We present the surgical experience of 5 patients with Mirizzi syndrome who were diagnosed preoperatively and managed using minimally access surgical technique, either total laparoscopic or robotic-assisted laparoscopic approach. All patients had successful operations and recovered without complications. We concluded that with a correct preoperative diagnosis, careful operative strategy, increasing expertise with laparoscopic technique, and introduction of robotic surgical system, minimally invasive approach of management of Mirizzi syndrome becomes safe and feasible.