Laparoscopy for liver resection is highly specialized field because laparoscopic liver surgery presents severe technical difficulties, such as control of bleeding and risk of gas embolism. At present, a limited number of laparoscopic anatomical left lobectomies have been reported in the literature, but we believe that the use of stapling devices has made this technique safer and faster.
From January 2000 to May 2005, eight patients (five men, three women; mean age, 60.5 years) underwent laparoscopic anatomical left lobectomy at our department. Seven patients presented with hepatocellular carcinoma and cirrhosis, while one patient had a large symptomatic angioma. The average size of the lesions was 4.18 cm (range, 3.6-7.1 cm); all the lesions were localized in the anatomical left lobe (segments II-III). Transection of the liver parenchyma, together with sectioning of the vascular pedicle for segment II and III and of the left hepatic vein, was obtained by the use of stapling devices.
The mean operative time was 142 min (range, 120-180 min). There were no intraoperative or postoperative complications, and blood transfusions were not required. The mean postoperative hospital stay was 5.75 days.
The key points of the technique are: late mobilization of the liver; no transection of the round ligament; no surrounding or taping of the portal pedicles or of the left hepatic vein; and the use of three consecutive linear staplers, turned to the left for transecting the liver parenchyma and vascular pedicle together. This technique, in our opinion, should be considered a new good option for patients with isolated lesions of the left lateral segments, but it must be performed by surgeons trained in both liver and advanced laparoscopic surgery.
"Liver resection is reputed to be one of the most difficult procedures in the era of laparoscopic surgery. Laparoscopic techniques for left hepatectomy have been widely described for humans [1,3,5,12,17,24,29]. Additionally, the ability to perform an anatomically reproducible hepatic resection in a large animal model could promote the investigation of liver surgery [5,18,23,26], transplantation [19,22], and regeneration [2,6,13,15,16,20,26,27] for medical research and experimental studies. "
[Show abstract][Hide abstract] ABSTRACT: This work describes a safe and feasible technique for a total laparoscopic left hepatectomy in Bama Miniature Pigs. A purely laparoscopic four-port approach was created in generally anesthetized pigs. A polyethylene loop was installed on the left two lobes for traction and lift, and then a penetrating ligation of the lobes consisting of a double row of silk sutures was used to control bleeding. A direct hepatic transection was completed using a monopolar hook electrode without meticulous dissection of the left hepatic vein. The raw surface of the liver was coagulated and sealed with fibrin glue. Lobes were retrieved through an enlarged portal. The laparoscopic hepatic lobectomy procedures were completed in all pigs without the use of specialized instruments, and with a mean operative time of 179 ± 9 min. There were no significant occurrences of perioperative complications, and the resected liver lobes weighed 180 ± 51g. Main CBC results, serum organics and enzyme (T-Bil, γ-GT, AST, A/G) levels corrected after about 2 weeks. Necropsy showed the adhesion of the hepatic raw surface to the gastric wall and omentum; otherwise, no other abnormalities were identified. This minimally invasive left hepatectomy in swine could serve as a useful model in investigations of liver diseases and regeneration, and offers preclinical information to hepatobiliary surgery.
"However, for patients undergoing combined procedures (bowel–liver resection), a statistically significant LOS was recorded (as intuitively expected), related primarily to differences in intestinal transit time associated with the healing of reconstructive colon surgery. Indeed, overall complications were minimal, and no conversion to open procedure was needed [5, 7, 12, 13]. Actually, LOS was shorter than that recorded for open procedures and has decreased as much as 3 to 5 days in the more recent series compared with earlier experiences [12, 13]. "
[Show abstract][Hide abstract] ABSTRACT: Laparoscopic left lateral sectionectomy (LLS) has gained popularity in its use for benign and malignant tumors. This report describes the evolution of the authors' experience using laparoscopic LLS for different indications including living liver donation.
Between January 2004 and January 2009, 37 consecutive patients underwent laparoscopic LLS for benign, primary, and metastatic liver diseases, and for one case of living liver donation. Resection of malignant tumors was indicated for 19 (51%) of the 37 patients.
All but three patients (deceased due to metastatic cancer disease) are alive and well after a median follow-up period of 20 months (range, 8-46 months). Liver cell adenomas (72%) were the main indication among benign tumors, and colorectal liver metastases (84%) were the first indication of malignancy. One case of live liver donation was performed. Whereas 16 patients (43%) had undergone a previous abdominal surgery, 3 patients (8%) had LLS combined with bowel resection. The median operation time was of 195 min (range, 115-300 min), and the median blood loss was of 50 ml (range, 0-500 ml). Mild to severe steatosis was noted in 7 patients (19%) and aspecific portal inflammation in 11 patients (30%). A median free margin of 5 mm (range, 5-27 mm) was achieved for all cancer patients. The overall recurrence rate for colorectal liver metastases was of 44% (7 patients), but none recurred at the surgical margin. No conversion to laparotomy was recorded, and the overall morbidity rate was 8.1% (1 grade 1 and 2 grade 2 complications). The median hospital stay was 6 days (range, 2-10 days).
Laparoscopic LLS without portal clamping can be performed safely for cases of benign and malignant liver disease with minimal blood loss and overall morbidity, free resection margins, and a favorable outcome. As the ultimate step of the learning curve, laparoscopic LLS could be routinely proposed, potentially increasing the donor pool for living-related liver transplantation.
"Duration and number of the Pringle manoeuvre, operation time, blood loss, number of transfusion, length of hospital stay, and morbidity rate were similar in patients with or without cirrhotic liver disease. Indeed, we perform the Pringle manoeuvre only in selected cases in both open and laparoscopic surgery since it is questionable to apply such manoeuvre especially in cirrhotic patients . We think the USAD may help to avoid this manoeuvre thanks to its haemostatic effect during parenchymal transection , even in cirrhotic liver. "
[Show abstract][Hide abstract] ABSTRACT: The use of new technological devices has gained popularity and has been proposed to improve the safety of liver resection. This study was designed to evaluate the usefulness of the ultrasonically activated device (USAD) during open liver resection.
Indication for surgery, type of resection, need to perform a Pringle manoeuvre, operation time, blood loss, number of blood transfusions, morbidity and mortality rate were analyzed in 60 patients undergoing a formal open liver resection by means of USAD.
The overall mean operation time was 172 minutes (range 120-255 min); an intermittent warm ischemia was applied in 9 cases (15%). The overall mean blood loss was 410 mL (median 400 mL, range 50-950 ml). A median of one blood transfusion was administered in six patients (10%). The mean hospital stay was 10.2 days (median 11, range 8-16). The overall morbidity rate was 20% (12 out of 60 patients). No in-hospital mortality was recorded. By subdividing the patients according to the presence or absence of cirrhosis no statistical significant differences were found between the two subgroups in all peri-and postoperative outcomes.
In conclusion, though there is a lack of data based on well conducted controlled studies and further on a greater number of patients are needed, the utilization of USAD may help to minimize blood loss during liver resection regardless of the condition of the liver, even in case of cirrhosis.
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