Hadrien Tranchart

Laparoscopic Hepatectomy for Hepatocellular Carcinoma: A European Experience

BACKGROUND Some series have suggested that laparoscopy is beneficial for resection of hepatocellular carcinoma. This has to be confirmed in larger series. The aim of this study was to analyze the results of 3 European surgical centers on laparoscopic liver resections for hepatocellular carcinoma. STUDY DESIGN Prospective databases of 3 European centers involved in the development of laparoscopic liver surgery were combined. Between 1998 and 2008, 163 liver resections for hepatocellular carcinoma were performed. Liver parenchyma was cirrhotic in 120 (73.6%) patients. Liver resection was anatomic in 107 (65.6%) patients and was a major resection (>or=3 segments) in 16 (9.8%). A totally laparoscopic approach was used in 155 (95.1%) patients. RESULTS Median surgical duration was 180 minutes. Median operative blood loss was 250 mL, and 16 (9.8%) patients received blood transfusion. Conversion to open surgery was required in 15 (9.2%) patients. Median tumor size was 3.6 cm and median surgical margin was 12 mm. Liver-specific and general complications occurred in 19 (11.6%) and 17 (10.4%) patients, respectively. Hospital length of stay was 7 days. A further analysis of early (n = 75) and recent (n = 88) experiences showed improved results in the latter group. Overall and recurrence-free survival rates at 1, 3, and 5 years were 92.6%, 68.7%, 64.9%, and 77.5%, 47.1%, 32.2%, respectively. CONCLUSIONS This study demonstrates that laparoscopic resection for hepatocellular carcinoma is feasible in selected patients, with good operative and oncologic results. Laparoscopy should be routinely considered in centers experienced in liver surgery and advanced laparoscopy.

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.

Laparoscopic resection of hepatocellular carcinoma: a French survey in 351 patients.

OBJECTIVES Current clinical studies report the results of laparoscopic resection of hepatocellular carcinoma (HCC) obtained in small cohorts of patients. Because France was involved in the very early development of laparoscopic surgery, the present study was conducted in order to report the results of a large, multicentre experience. METHODS A total of 351 patients underwent laparoscopic liver resection for HCC during the period from 1998 to 2010 in nine French tertiary centres. Patient characteristics, postoperative mortality and morbidity, and longterm survival were retrospectively reviewed. RESULTS Overall, 85% of the study patients had underlying liver disease. Types of resection included wedge resection (41%), left lateral sectionectomy (27%), segmentectomy (24%), and major hepatectomy (11%). Median operative time was 180 min. Conversion to laparotomy occurred in 13% of surgeries and intraoperative blood transfusion was necessary in 5% of patients. The overall morbidity rate was 22%. The 30-day postoperative mortality rate was 2%. Negative resection (R0) margins were achieved in 92% of patients. Rates of overall and progression-free survival at 1, 3 and 5 years were 90.3%, 70.1% and 65.9%, and 85.2%, 55.9% and 40.4%, respectively. CONCLUSIONS This multicentre, large-cohort study confirms that laparoscopic liver resection for HCC is a safe and efficient approach to treatment and can be proposed as a first-line treatment in patients with resectable HCC.

Management of Benign Hepatic Tumors

Advances in imaging techniques will dramatically decrease the number of undiagnosed tumors. New molecular techniques should allow the identification of pathologic factors that are predictive of complicated forms. Surgery should be limited to symptomatic benign tumors or those who have a risk for complication (hemorrhage, rupture, or degeneration). When surgery is indicated, patients with benign disease are the best candidates for laparoscopy.

Laparoscopic major hepatectomy can be safely performed with colorectal surgery for synchronous colorectal liver metastasis

BACKGROUND The optimal strategy for resectable synchronous colorectal liver metastases remains controversial. Although some authors advocate a staged treatment, an increasing number of studies have reported that combined colorectal and liver resection is safe. Laparoscopic combined resection in primary colorectal cancer with synchronous liver metastases has been reported but there are no specific data for major liver resections. In the present study, we evaluated the feasibility of a simultaneous entirely laparoscopic procedure, in the light of the benefits of laparoscopy in both colon and liver surgery, and discussed the benefits of this strategy. METHODS Two cases are presented of totally laparoscopic major liver resections associated with laparoscopic colorectal resections for synchronous liver metastases with the emphasis on the technical aspects. Duration of surgery, blood loss and post-operative outcome were evaluated. RESULTS   Laparoscopic right hepatectomy or left hepatectomy with simultaneous colon resection for liver metastasis was feasible and safe with only one suprapubic 5-mm trocar added to the usual trocar sites. The mean duration of surgery was 327 min with a mean estimated blood loss of 200 ml. The post-operative course was uneventful. DISCUSSION In selected patients, laparoscopic major hepatectomies for unilobular synchronous metastases can be safely performed simultaneously with colorectal surgery.

Bleeding control during laparoscopic liver resection: a review of literature

Despite the established advantages of laparoscopy, bleeding control during laparoscopic liver resection (LLR) is a liver‐specific improvement. The 2nd International Consensus Conference on Laparoscopic Liver Resection was held in October 2014 at Morioka, Japan. One of the most capital questions was: What is essential in bleeding control during LLR? In order to correctly address this question, we conducted a comprehensive review of the literature. Essential points based on personal experience of the expert panel are also discussed. A total of 54 publications were identified. Based on this analysis, the working group built these recommendations: (1) a pneumoperitoneum of 10–14 mmHg should be used as it allows a good control of the bleeding without significant modifications of hemodynamics; (2) a low central venous pressure (<5 mmHg) should be used; (3) laparoscopy facilitates inflow and outflow control; and (4) surgeons should be experienced with the use of all surgical devices for liver transection and should master laparoscopic suture before starting LLR. Precoagulation with radiofrequency can be useful, particularly in cases of atypical resection. These recommendations are mostly based on experts’ opinions and on B or C quality of evidence grade studies. More prospective data are required to confirm these results.

Laparoscopic Versus Open Liver Resection for Colorectal Metastases in Elderly and Octogenarian Patients: A Multicenter Propensity Score Based Analysis of Short- and Long-term Outcomes

Objective: This study aims to compare the perioperative and oncological outcomes of laparoscopic and open liver resection for colorectal liver metastases in the elderly. Background: Laparoscopic liver resection has been associated with less morbidity and similar oncological outcomes to open liver resection for colorectal liver metastases (CRLMs). It has been reported that these benefits continue to be observed in elderly patients. However, in previous studies, patients over 70 or 75 years were considered as a single, homogenous population raising questions regarding the true impact of the laparoscopic approach on this diverse group of elderly patients. Method: Prospectively maintained databases of all patients undergoing liver resection for CRLM in 5 tertiary liver centers were included. Those over 70-years old were selected for this study. The cohort was divided in 3 subgroups based on age. A comparative analysis was performed after the implementation of propensity score matching on the 2 main cohorts (laparoscopic and open groups) and also on the study subgroups. Results: A total of 775 patients were included in the study. After propensity score matching 225 patients were comparable in each of the main groups. Lower blood loss (250 vs 400 mL, P = 0.001), less overall morbidity (22% vs 39%, P = 0.001), shorter High Dependency Unit (2 vs. 6 days, P = 0.001), and total hospital stay (5 vs. 8 days, P = 0.001) were observed after laparoscopic liver resection. Comparable rates of R0 resection (88% vs 88%, P = 0.999), median recurrence-free survival (33 vs 27 months, P = 0.502), and overall survival (51 vs 45 months, P = 0.671) were observed. The advantages seen with the laparoscopic approach were reproduced in the 70 to 74-year old subgroup; however there was a gradual loss of these advantages with increasing age. Conclusions: In patients over 70 years of age laparoscopic liver resection, for colorectal liver metastases, offers significant lower morbidity, and a shorter hospital stay with comparable oncological outcomes when compared with open liver resection. However, the benefits of the laparoscopic approach appear to fade with increasing age, with no statistically significant benefits in octogenarians except for a lower High Dependency Unit stay.

Laparoscopic liver resection with selective prior vascular control.

BACKGROUND Selective control of vascular inflow can reduce blood loss and transfusion rates and may be particularly efficient in laparoscopic liver resection (LLR). The aim of this study was to evaluate the efficacy of selective prior vascular control (PVC) in patients undergoing laparoscopic or open liver resections (OLR). METHODS Between 1999 and 2008, 52 patients underwent LLR with PVC with prospective data collection and were compared with patients undergoing OLR with PVC. RESULTS There was no difference in the operative time between the 2 groups. Blood loss and transfusion rates were lower in patients who underwent LLR (367 vs 589 mL, P = .001; 3.8% vs 17.3%, P = .05, respectively). Morbidity did not differ significantly between the 2 groups. Hospital stay was longer in the OLR group (11.0 vs 7.4 days, P = .001). CONCLUSIONS PVC during LLR was feasible and improved intraoperative and postoperative results. Selective PVC should be obtained in LLR whenever possible.

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.

Laparoscopic liver resections for hepatocellular carcinoma:Current role and limitations

Liver resection for hepatocellular carcinoma (HCC) is currently known to be a safer procedure than it was before because of technical advances and improvement in postoperative patient management and remains the first-line treatment for HCC in compensated cirrhosis. The aim of this review is to assess current indications, advantages and limits of laparoscopic surgery for HCC resections. We also discussed the possible evolution of this surgical approach in parallel with new technologies.