Single port laparoscopic liver resection for hepatocellular carcinoma: a preliminary report.
ABSTRACT Single port laparoscopic surgery is an emerging technique, now commonly used in cholecystectomy. The experience of using this technique in liver resection for hepatocellular carcinoma is described in a series of 3 cases with single port laparoscopic liver resection performed during 2010. All patients were male aged 61 to 70 years, with several comorbidities. There were no complications in this early series. The length of hospital stay was 3-5 days. The blood loss was 200-450 mL, with operating time between 142 and 171 minutes. We conclude that this technique is feasible and safe to perform in experienced centers.
- SourceAvailable from: ncbi.nlm.nih.gov[show abstract] [hide abstract]
ABSTRACT: We present the largest, most comprehensive, single center experience to date of minimally invasive liver resection (MILR). Despite anecdotal reports of MILR, few large single center reports have examined these procedures by comparing them to their open counterparts. Three hundred MILR were performed between July 2001 and November 2006 at our center for both benign and malignant conditions. These included 241 pure laparoscopic, 32 hand-assisted laparoscopic, and 27 laparoscopy-assisted open (hybrid) resections.These MILR were compared with 100 contemporaneous, cohort-matched open resections. MILR included segmentectomies (110), bisegmentectomies (63), left hepatectomies (47), right hepatectomies (64), extended right hepatectomies (8), and caudate lobe (8) resections. Benign etiologies encompassed cysts (70), hemangiomata (37), focal nodular hyperplasia (FNH) (23), adenomata (47), and 20 live donor right lobectomies. Malignant etiologies included primary (43) and metastatic (60) tumors. Hepatic fibrosis/cirrhosis was present in 25 of 103 patients with malignant diseases (24%). There was high data consistency within the 3 types of MILR. MILR compared favorably with standard open techniques: operative times (99 vs. 182 minutes), blood loss (102 vs. 325 ml), transfusion requirement (2 of 300 vs. 8 of 100), length of stay (1.9 vs. 5.4 days), overall operative complications (9.3% vs. 22%), and local malignancy recurrence (2% vs. 3%). No port-site recurrences occurred. Conversion from laparoscopic to hand-assisted laparoscopic resection occurred in 20 patients (6%), with no conversions to open. No hand-assisted procedures were converted to open, but 2 laparoscopy-assisted (7%) were converted to open. Our data show that MILR outcomes compare favorably with those of the open standard technique. Our experience suggests that MILR of varying magnitudes is safe and effective for both benign and malignant conditions.Annals of Surgery 10/2007; 246(3):385-92; discussion 392-4. · 6.33 Impact Factor
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ABSTRACT: An increasing number of studies are reporting the outcomes and benefits of laparoscopic liver resection. This article reviews the literature with emphasis on a recent consensus conference on laparoscopic liver resection in 2008, the learning curve for laparoscopic liver surgery, laparoscopic major hepatectomies, oncologic outcomes of laparoscopic liver resection for hepatocellular carcinoma and colorectal cancer liver metastases, and the comparative benefits of laparoscopic versus open liver resection. Current evidence suggests that minimally invasive hepatic resection is safe and feasible with short-term benefits, no economic disadvantage, and no compromise to oncologic principles.Surgical Clinics of North America 08/2010; 90(4):749-60. · 2.02 Impact Factor
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ABSTRACT: The surgical outcome of the first 25 patients in whom the Pelosi single-puncture laparoscopic appendectomy technique was employed demonstrates the new approach as a safe, inexpensive and effective alternative to the currently used multiple-puncture method. The results suggest single-puncture (minilaparoscopy) operative endoscopy as the ultimate goal in the progression of minimally invasive surgery.The Journal of reproductive medicine 08/1992; 37(7):588-94. · 0.75 Impact Factor
SAGE-Hindawi Access to Research
International Journal of Hepatology
Volume 2011, Article ID 579203, 4 pages
SinglePort Laparoscopic LiverResectionforHepatocellular
Stephen Kin Yong Chang,MariaMayasari,Iyer ShridharGanpathi,
Victor LeeTswen Wen,andKrishnakumarMadhavan
Division of Hepatobiliary and Pancreatic Surgery, National University Health System, NUHS Tower Block,
Level 8, 1E Kent Ridge Road, Singapore 119228
Correspondence should be addressed to Stephen Kin Yong Chang, firstname.lastname@example.org
Received 15 January 2011; Revised 18 February 2011; Accepted 27 March 2011
Academic Editor: Pierce Chow
Copyright © 2011 Stephen Kin Yong Chang et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
Single port laparoscopic surgery is an emerging technique, now commonly used in cholecystectomy. The experience of using
this technique in liver resection for hepatocellular carcinoma is described in a series of 3 cases with single port laparoscopic
liver resection performed during 2010. All patients were male aged 61 to 70 years, with several comorbidities. There were no
complications in this early series. The length of hospital stay was 3–5 days. The blood loss was 200–450mL, with operating time
between 142 and 171 minutes. We conclude that this technique is feasible and safe to perform in experienced centers.
Laparoscopic liver resection has been increasingly performed
over the last two decades. The technique has improved
since the first time it was published  in 1992. Each year,
there has been considerable number of cases undergoing
this technique. Consecutive reports have shown that liver
resection can be done efficiently and safely using laparo-
scopic approach. Several potential advantages include less
abdominal pain, less hospital stay, and some reports [2, 3]
even suggest less operating time with less morbidity.
Single port laparoscopic surgery was reported as early as
1992 . First described as an effort to reduce abdominal
trauma in appendix removal, this approach has extended
its indications to a variety of cases. One potential problem
arising from this approach is the loss of triangular move-
ment traditionally achieved with conventional laparoscopic
surgery. In 2010, there were several publications [5–9] rega-
for hepatocellular carcinoma (HCC). This study aims to
report the feasibility and safety of single port laparoscopic
liver resection technique for treatment of hepatocellular
cancer in a single institution.
During 2010, all single port laparoscopic liver resection cases
with proven histology findings of HCC were included in
technique, resection margin, blood loss, early post-op comp-
lications, and length of stay were evaluated for these patients.
Postoperative followup was done until the end of 2010.
Patients were put under general anaesthesia in the French
position. Incision was made according to the need to place
the port. For GelPort (Applied Medical, Calif, USA), a 5cm
upper umbilical midline incision was made. For the SILS
port (Covidien, Dublin, Ireland), a midline incision through
the umbilicus measuring 2.5cm was made. Port was inserted
using open technique, and pneumoperitoneum of 12mmHg
was created using CO2. A 30◦laparoscopic camera was used
from Covidien, Dublin, Ireland) was used to manipulate the
liver, together with the normal laparoscopic instruments.
Liver was mobilized from falciform ligament and left
2 International Journal of Hepatology
Table 1: Patient comorbidities.
Ischemic heart disease with
previous coronary artery
Type II diabetes mellitus
Type II diabetes mellitus
Hepatitis B carrier
Ischemic heart disease
Old cerebrovascular accident
Type II diabetes mellitus
Ischemic heart disease
Beta thalassaemia trait
triangular ligament using harmonic scalpel and diathermy.
Intraoperative ultrasound with laparoscopic ultrasound
probe was done to assess the tumor, and margin of resec-
tion was marked using diathermy. Liver parenchyma was
transected using Harmonic scalpel (Ethicon Endo-Surgery,
Ohio, USA) and/or LigaSure (Covidien, Dublin, Ireland).
and hepatic veins were divided using laparoscopic vascular
stapler. Tissue glue was applied to the cut surface of liver.
The specimen was retrieved using a plastic bag. Hemostasis
was checked after desufflation of the abdomen. No drain was
inserted at the end of the operation.
In 2010, we have performed 3 cases of single port laparo-
scopic liver resection for HCC in our institution. All patients
were male and had several comorbidities (Table 1).
Case 1 was known to have non viral hepatitis cirrhosis
likely secondary to non alcoholic steatohepatitis for 3 years,
with a family history of liver cancer. He was found to have
a nodule in segment 2 on the followup of the CT scan.
Liver Disease) score before operation was 8. Platelet count
Case 2 has been diagnosed with HCC previously and un-
derwent laparoscopic liver resection twice for segment 5 and
right posterior resection, respectively. Previous resections
were 2 years and 6 months before the single port resection.
Patient was ambulating independently, with MELD score
of 6 and Child-Pugh class A status. Platelets count before
operation was normal.
Case 3 presented with lesion in segment 2 liver, found
during investigation for thrombocytopenia. Patient was also
known to have fatty liver. MELD score before operation
was 6. The total platelet count was in low borderline of
163 × 109/L. Patient was ambulating independently when
None of the operations were converted to open surgery.
No additional port insertions were needed to complete the
three operations. All patients stayed 1 night at the surgical
high dependency unit and went to general ward the next
day. Subsequent followup until December 2010 (7 months
for case 1, 7 months for case 2, and 4 months for the
last case) showed no recurrence of HCC. Detailed data on
resection type, blood loss, operation duration, length of stay,
complications, and resection margin can be seen in Table 2.
There were no complications in this early series. The length
of stay was 3–5 days. The blood loss was less than 500mL in
all cases. Operative time was less than 3 hours.
Although there is only one established cirrhosis for the
nonneoplastic histopathology results for the resected speci-
men, case 2 shows occasional portal-portal fibrosis, and both
cases without cirrhosis show portal chronic inflammation
and macrovesicular steatosis.
Laparoscopic liver surgery was firstly described by Gagner
et al.  in 1992. Since that time, a number of studies [2, 3]
regarding the feasibility and safety of the procedure have
been published. During 2010, there have been several pub-
lications of the use of single port surgery for liver resection.
The first report of this technique was by Aldrighetti et al.
 in June 2010 who describes a left lateral sectionectomy
for a single colorectal metastasis. The authors concluded that
cosmetic were questionable.
After the first report, several other publications reporting
a single case or multiple case reports have been published.
However, most of these cases were done for benign lesions
or liver metastases. Only 1 case of single port liver resection
from 5-case series reported by Gaujoux et al.  was done
for hepatocellular carcinoma. Most reports for the single
port laparoscopic liver resection were done for either benign
lesions [6, 7] or metastatic lesions [5, 6, 8]
Single port laparoscopic liver resection is a new and
emerging technique. With the development of special
instruments to facilitate this technique, liver resection has
become feasible and safe, but surgeons have been slow in
applying this technique for HCC due to the presence of
cirrhosis and concern regarding the oncological safety of the
laparoscopy is the loss of instrument triangulation, some-
thing that is crucial in a conventional laparoscopy. However,
this setback can be overcome using new instruments with
International Journal of Hepatology3
Table 2: Operative parameters.
1Left lateral sectionectomy3.5cm+4501714 daysNil 2.5cm
2 Segment 3 liver resection2cm
200142 3 days Nil0.4cm
3Left lateral sectionectomy4.5cm
300 159 5 daysNil 0.7cm
bending and angulating capability. Single port laparoscopy
also requires the surgeon to do some cross-handling of the
instruments that can facilitate the triangulation inside the
Starting in 2008, single port laparoscopic cholecystec-
tomy has also been done regularly at our centre. Our
centre’s initial experience of single incision laparoscopic
cholecystectomy  showed that there is no significant
differenceregarding pain and analgesia requirement between
this technique and the conventional technique. Although
there is still insufficient data to actually validate the clinical
benefits of this technique over the conventional technique,
the single port laparoscopy cholecystectomy feasibility is
already established . Our centre has begun offering the
single incision laparoscopy cholecystectomy for patients on
regular basis and has already exceeded 100 cases for the last 2
In our centre, laparoscopic liver resections have been
performed since 2005. Since then, more than 100 cases
of laparoscopic liver resections have been done with good
results. Combining this technique with the single port
laparoscopic cholecystectomy experience in our centre, the
single port liver resection was started in 2010.
Our experience shows that the single port laparoscopic
liver resection approach can be done with reasonable
operating time. Previous publications [5–7] reported that
operative time for single port liver resection ranged from
55 minutes to 145 minutes. These results were comparable
to our experience, with time range of 142–171 minutes. In
our series, there is a slightly higher blood loss compared to
other publications [5–7] (20–80mL). All our patients were
on anticoagulant therapy prior to their surgery, and this
other reason for the difference was likely due to the size of
the tumor and the underlying cirrhotic liver in one of our 3
patients, resulting in difficulties to achieve hemostasis.
Left segmental/sectional resection of the liver has been
the main type of resection for single port laparoscopic liver
surgery. Patients with lesions limited to the left side of the
liver are appropriate for this technique, as reported in our
series. This type of resection is best suited for single port
technique because the instruments are already aligned to the
liver transection plane and the specimen is small enough to
be retrieved through a small incision (less than 5cm). Of all
the published single port liver resection cases [5–9], none
were converted to open surgery. The postoperative hospital
stay was also shorter. Our experience in this small series has
been the same. As for the resection margin for the specimen,
the result showed that a considerable free margin can be
but also safe to perform in experienced centers.
This early experience with single-port liver resection for
HCC suggests that this operation is safe and feasible in
selected cases of HCC in a unit with experience in laparo-
scopic liver resection and single-port surgery.
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