Yoshikuni Kawaguchi

Learning curve for laparoscopic major hepatectomy

Laparoscopic major hepatectomy (LMH) is evolving as an important surgical approach in hepatopancreatobiliary surgery. The present study aimed to evaluate the learning curve for LMH at a single centre.

Portal uptake function in veno-occlusive regions evaluated by real-time fluorescent imaging using indocyanine green

BACKGROUND & AIMS Although recent advances in preoperative imaging have enabled accurate estimation of the regional liver volume with venous occlusion, the extent of functional decrease in such regions remains unclear. In this study, the portal uptake function in postoperative veno-occlusive regions and non-veno-occlusive regions was evaluated by intraoperative fluorescent imaging after intravenous injection of indocyanine green (ICG). METHODS In 22 liver resection patients and 23 recipients and 18 donors of liver transplantation, fluorescent intensity on the remnant liver or the liver graft was evaluated in real time following intravenous injection of ICG (0.0025 mg per 1 ml of remnant liver volume). RESULTS Plateau ICG concentrations were significantly lower in the veno-occlusive regions (C(VO)) than in the non-veno-occlusive regions (C(Non)) in liver resection patients (median [range], 0.75 [0.29-2.0]μg/ml vs. 3.0 [0.46-6.4]μg/ml, p<0.001), donors (0.69 [0.29-1.9]μg/ml vs. 2.4 [0.46-6.4]μg/ml, p<0.001), and recipients (0.75 [0.34-1.8]μg/ml vs. 1.8 [0.54-6.4]μg/ml, p<0.001). Distributions of the C(VO)/C(Non) and the ratio of the hepatic uptake rate constant in the veno-occlusive regions to that in non-veno-occlusive regions were both around 40% (mean ± standard deviation, 0.36 ± 0.17 and 0.42 ± 0.16, respectively). When the functional remnant liver volume was calculated as a sum of non-veno-occlusive regions and veno-occlusive regions multiplied by C(VO)/C(Non), its ratio to the total liver volume was correlated with the improved postoperative/preoperative ratio of prothrombin time. CONCLUSIONS Portal uptake function in veno-occlusive regions is approximately 40% of that in non-veno-occlusive regions. Intraoperative ICG-fluorescent imaging enables real-time evaluation of the extent of the functional decrease in veno-occlusive regions, enhancing accurate estimation of the hepatic functional reserve for determining the surgical indications and procedures.

Hepatobiliary Surgery Guided by a Novel Fluorescent Imaging Technique for Visualizing Hepatic Arteries, Bile Ducts, and Liver Cancers on Color Images

t t i g A fluorescent imaging technique using indocyanine green (ICG) was first introduced for assessing coronary artery bypass graft patency; its use was subsequently extended o visualize lymphatic vessels that need to be anastomosed and to identify sentinel lymph nodes during breast and gastric cancer operations. Recently, the fluorescent imagng technique has also been applied to hepatobiliary opertions, enabling highly sensitive identification of liver ancers and extrahepatic bile ducts. Although the echnique is used by several surgeons in clinical settings in apan, one of the drawbacks of the conventional fluorescent imaging system is that it provides only monochromatic images, which makes it relatively difficult for surgeons to assess the spatial relationships between the fluorescing lesions and the surrounding organs. Here, we describe hepatobiliary procedures using a novel imaging technique that enables visualization of fluorescing liver cancers and/or bile ducts on color images of the surrounding structures in real-time during surgery.

Indocyanine green reinjection technique for use in fluorescent angiography concomitant with cholangiography during laparoscopic cholecystectomy.

Background: For safe laparoscopic cholecystectomy, surgeons must possess detailed knowledge of the anatomy of the bile duct and arterial system as seen through a laparoscope. Study Design: We developed an indocyanine green (ICG) reinjection technique for use in fluorescent angiography. Here, we evaluated the efficacy of the ICG reinjection technique in fluorescent angiography in discriminating the arterial system with the concomitant use of fluorescent cholangiography. Results: Twenty-eight patients were enrolled in the study. All patients underwent laparoscopic cholecystectomy without complication. After reinjection of ICG during surgery, fluorescence of the cystic artery was visualized in 25 patients (89%). Conclusions: Fluorescent angiography using this ICG reinjection technique might enhance the safety of laparoscopic cholecystectomy.

Laparoscopic distal pancreatectomy employing radical en bloc procedure for adenocarcinoma: Technical details and outcomes

BACKGROUND Although laparoscopic distal pancreatectomy (LDP) has increasingly gained popularity, there are only a few reports mentioning application and outcomes of LDP for adenocarcinoma of the body and tail of the pancreas. The aim of our study is to demonstrate technical details of LDP employing radical en bloc procedure (en bloc LDP) and to evaluate the short- and long-term outcomes of en bloc LDP applied for adenocarcinoma. METHODS We evaluated 23 consecutive patients who underwent LDP for adenocarcinoma in the body or tail of the pancreas. Our concepts of en bloc LDP for adenocarcinoma comprise 3 principles: en bloc removal of retroperitoneal structures, lymph node (LN) dissection, and preservation of the spleen. RESULTS En bloc LDP without splenectomy was performed in 17 patients (74%) and en bloc LDP with splenectomy was in 6 patients (26%). Mean ± standard deviation operation time was 203 ± 54 minutes, and mean estimated blood loss was 208 ± 264 mL. Conversion to open distal pancreatectomy was required in 1 patient (4%) owing to the severe adhesions around the pancreas. The overall morbidity rate following en bloc LDP was 47% (n = 11), and the rate of pancreatic fistula was 39% (n = 9). There were no 30-day or in-hospital mortalities. Mean tumor size was 32 ± 12 mm, and mean number of harvested LNs was 19.8 ± 9.3. No patient had positive margins on final histologic diagnosis. The 1-, 3-, and 5-year overall survival rates were 67%, 49%, and 33%, respectively. CONCLUSION En bloc LDP can be applied safely by the surgeon with advanced experience in minimally invasive surgery with satisfactory short- and long-term outcomes, supporting further application of LDP for adenocarcinoma with advances in operative techniques and technological innovations.

Difficulty of Laparoscopic Liver Resection: Proposal for a New Classification

Objective: We propose an objective and practical classification system to predict difficulty of different laparoscopic liver resections (LLRs). Background: Surgical difficulty is highly subjective and is not influenced only by surgical factors. Consequently, few series have described the degree of difficulty of LLR or attempted to objectively assess the surgical difficulty. Methods: From a prospectively maintained database between 1995 and 2015, patients undergoing LLR without simultaneous procedures were selected, and LLR procedures were divided into 3 groups according to scores based on operative time (< or ≥190 minutes), blood loss (< or ≥100 mL), and conversion rate (< or ≥4.2%). Results: Altogether, 452 LLRs were divided into 3 groups based on their scores. Group I (0 point) included wedge resection and left lateral sectionectomy. Group II (2 points) included anterolateral segmentectomy and left hepatectomy. Group III (3 points) included posterosuperior segmentectomy, right posterior sectionectomy, right hepatectomy, central hepatectomy, and extended left/right hepatectomy. The rates of overall morbidity (groups I, II, and III: 8.4%, 17.3% and 45.7%, respectively, P < 0.001) and major complications (1.1%, 4.0%, and 20.4%, respectively, P < 0.001) increased significantly with a stepwise increase of groups from I to III (P < 0.001). Conclusions: This objective and practical classification system allows the stratification of LLR comprising the low (group I), the intermediate (group II), and the high (group III) grades.

Role of 6-month abstinence rule in living donor liver transplantation for patients with alcoholic liver disease

Although alcoholic liver disease (ALD) is an accepted indication for liver transplantation (LT), there are several controversial issues. The aim of this study is to examine the applicability of the 6‐month abstinence rule prior to LT and to evaluate the results in living donor LT for patients with ALD.

Survey results on daily practice in open and laparoscopic liver resections from 27 centers participating in the second International Consensus Conference

The proportions of laparoscopic approach and surgical procedures in liver resections have been unknown in clinical practice. The aim of this study is to investigate liver resections performed in select centers worldwide and analyze the ratios of laparoscopic approach, major liver resection, and left lateral sectionectomy.

Usefulness of indocyanine green-fluorescence imaging during laparoscopic hepatectomy to visualize subcapsular hard-to-identify hepatic malignancy

Laparoscopic hepatectomy (LH) has advantages including pneumoperitonium and magnified hepatic view over open hepatectomy (OH), and facilitates surgical procedures during LH. However, it lacks hepatic overview and manual palpation, and thus such disadvantages may hinder tumor staging in LH. Recently, fluorescence imaging technique using indocyanine green (ICG) has been clinically applied to open hepatobiliary surgery. This technique enables intraoperative visualization of liver cancers [1,2], bile [3–5], hepatic arterial/portal blood flow [4,6] as well as evaluation of regional portal uptake in the liver [7,8].Application of this technique is expected to be useful during LH. However, there are a limited number of studieswhich focused on this technique for laparoscopic hepatobiliary surgery. The aim of the study was to demonstrate the usefulness of ICG-fluorescence imaging during LH for visualization of the liver cancerswhichwerenot identifiedwith intraoperativevisual inspection and intraoperative ultrasound (IOUS).

Operative techniques to avoid near misses during laparoscopic hepatectomy

BACKGROUND The lack of a complete hepatic overview and tactile feedback during laparoscopic hepatectomy may result in near misses or fatal intraoperative complications despite the advantage of a magnified laparoscopic view. The aim of the study is to describe operative techniques and guiding principles with which to address near misses unique to laparoscopic hepatectomy and evaluate the intraoperative complication rate overtime. METHODS Data of 408 consecutive patients who underwent laparoscopic hepatectomy were reviewed. Representative operative techniques and guiding principles with which to address near misses and pitfalls unique to laparoscopic hepatectomy were evaluated among the patients by 2 surgeons. RESULTS Most near misses were due to lack of understanding of both the laparoscopic view and anatomic aspects unique to laparoscopic hepatectomy. Operative techniques and/or guiding principles with which to address these issues were demonstrated as follows: starting parenchymal transection at the declivitous parts; no ligation of the right or left portal vein before confirming the bifurcation; dissection of the short hepatic vein using a sealing device; dissection of the root of the hepatic vein using scissors; exposure of the middle hepatic vein, which is anatomically close to the hilar plate; and identification of V8 using intraoperative ultrasonography. The intraoperative massive bleeding due to vessel injury or surgical clip slippage occurred in 25 patients (6.1%), and its rate had a significant trend to decrease with increasing years. CONCLUSION We demonstrated operative techniques and guiding principles with which to address near misses in laparoscopic hepatectomy. The intraoperative massive bleeding rate trended to decrease over time.