Chapter 90E Minimally invasive techniques in hepatic resection
Overview
Over the latter portion of the twentieth century, liver surgery has rapidly progressed from a risky procedure to a safe therapy for benign and malignant liver disease. As with many surgery disciplines, minimally invasive approaches were pursued in the 1990s. Gagner is credited for the first laparoscopic partial hepatectomy in 1992 (Gagner et al, 1992), and in a prospective series of 30 patients published in 2000, we demonstrated the safety and reproducibility of laparoscopic partial hepatectomy (Cherqui et al, 2000), which was followed by the safe application of these techniques to living donor left lateral sectionectomy in 2002 (Cherqui et al, 2002). Despite close to 20 years of development and nearly 3000 reported cases internationally, minimally invasive liver surgery remains an emerging field that should be approached with caution by surgeons experienced in the perioperative care and planning of both liver and laparoscopic surgery (Nguyen et al, 2009). Six centers have reported series of more than 100 patients, and most perform fewer than half of their total cases laparoscopically (Bryant et al, 2009; Buell et al, 2008; Chen et al, 2008; Cho et al, 2008; Koffron et al, 2006, 2007; Topal et al, 2008;). We have performed more than 200 laparoscopic partial hepatectomies since 1996, which represents 23% of our hepatectomy volume.
Terminology
In 2008, leaders in the field met to discuss the current status of laparoscopic liver surgery (Buell et al, 2009). In the so-called Louisville Statement that resulted, those in attendance agreed on three procedural definitions: 1) pure, 2) hand-assisted, and 3) hybrid laparoscopy. Pure laparoscopy involves complete mobilization and resection via laparoscopic ports, with an incision for specimen extraction only. Hand-assisted laparoscopy involves the elective placement of a hand port for mobilization or resection, which is then used for specimen extraction. Hybrid laparoscopy refers to a procedure in which the resection and extraction are performed through a minilaparotomy, but laparoscopy, with or without hand assistance, is utilized for mobilization.
According to a comprehensive international review performed by Nguyen and colleagues (2009), 75% of reported laparoscopic resections were pure laparoscopy, 17% were hand-assisted procedures, and 2% used the hybrid technique. In addition, 4.8% were conversions to laparotomy or hand-assisted procedures, with the remaining 2% using less common techniques, such as a thoracoscopic approach.
Laparoscopic resections should be categorized no differently than open resections, based on the Brisbane 2000 terminology of liver anatomy and resections (Pang, 2002). Anterior and lateral segments II, III, IVb, V, and VI are most amenable to laparoscopic resection. Isolated resections of segments I, IVa, VII, and VIII have been reported, as surgeons extend the limits after safe mastery of anterior resections. Of the nearly 3000 internationally reported laparoscopic liver resections, the majority (44.9%) were wedge resections or segmentectomies, followed by left lateral sectionectomies (20.3%). Major resections, consisting of three or more Couinaud segments, included right hemihepatectomy (9%) and left hemihepatectomy (6.8%). Extended right hepatectomy, caudate lobectomy, central hepatectomy, and extended left hepatectomy each made up less than 1% of the total reported cases (Nguyen et al 2009).
We performed 96% of our resections using pure laparoscopy, with hand assistance (4%) selectively used for right hepatectomies or posterior segmentectomies. Major resections comprise 19% of our experience, and limited resections comprise 81% (Bryant et al 2009).
Indications
Liver pathology under consideration for open partial hepatectomy should be evaluated for the feasibility of a laparoscopic resection (see Chapter 90A); however, the potential benefits of a minimally invasive resection do not confer a prescription to resect all hepatic lesions for the purpose of providing a definitive diagnosis. Specifically, the laparoscopic approach should not be used to resect incidental, asymptomatic lesions convincingly recognized by imaging and markers to be benign and without harmful potential (cysts, hemangiomas, focal nodular hyperplasia), nor should laparoscopic resection be performed for the purpose of diagnosis, when lesions are safely amenable to percutaneous biopsy.
The indications for laparoscopic resection do not vary from those for open resection (Box 90E.1); however, lesion size and location are the most important determinants of when laparoscopic resection is appropriate. Resection of benign and malignant solid lesions and cystic and parasitic lesions are possible laparoscopically. The most favorable lesions for laparoscopic resection are solitary, 5 cm or less, and located in peripheral liver segments II to VI (Fig. 90E.1; Buell et al, 2009). Pedunculated tumors greater than 5 cm are often easily resectable laparoscopically. In experienced hands, laparoscopic left lateral sectionectomy should be the standard approach for pathology in segments II and III (Buell et al, 2009; Chang et al, 2007).
Box 90E.1 Indications and Contraindications for Laparoscopic Partial Hepatectomy
FIGURE 90E.1 The anterolateral liver—composed of segments II, III, IVb, V, and VI—is most amenable to the laparoscopic approach.
Relative contraindications include lesions isolated to segments VII and VIII, multiple or bilateral lesions, and lesions located in proximity to the major hepatic veins, the inferior vena cava, or the hepatic hilum. These contraindications are considered relative, because in experienced centers, these lesions are increasingly managed laparoscopically (Buell et al, 2008; Koffron et al, 2007; Vigano et al, 2009a). A more extensive laparoscopic resection than would otherwise be necessary through an open approach may be contraindicated. An example would be a laparoscopic right hemihepatectomy for a posterior lesion that could be resected by a more limited open posterior segmentectomy. For each patient, the surgeon must weigh the risks and benefits of the laparoscopic and open techniques with the benefits of parenchymal preservation.
Surgical margins for benign lesions do not vary between open and laparoscopic resections. If there is concern that an adequate margin cannot be obtained laparoscopically, but it is technically feasible by an open approach, the former is contraindicated. Other contraindications include gallbladder cancer and hilar cholangiocarcinoma, because of the risk of peritoneal and port-site seeding and the necessary complex hilar dissection and extensive resection, respectively (see Chapters 49, 50B, 90B, and 90C).
Safety and Benefits
Laparoscopic partial hepatectomy provides the benefits that laparoscopy has offered to patients undergoing many other abdominal operations. Case-control studies have demonstrated shorter operative times (Bryant et al, 2009; Buell et al, 2008; Koffron et al, 2007), shorter lengths of hospitalization (Buell et al, 2009; Cai et al, 2008; Koffron et al, 2007; Topal et al, 2008), less operative blood loss (Bryant et al, 2009; Buell et al, 2008; Koffron et al, 2007; Lesurtel et al, 2003), reduced transfusion requirements (Buell et al, 2008; Koffron et al, 2007; Topal et al, 2008), a reduced need for analgesia (Cai et al, 2008), quicker return to oral consumption (Cai et al, 2008), lower morbidity (Buell et al, 2008; Koffron et al, 2007; Topal et al, 2008), and fewer postoperative adhesions (Belli et al, 2009; Laurent et al, 2009). Studies have demonstrated decreased costs when accounting for shorter operative times and hospitalizations (Buell et al, 2008; Koffron et al, 2007; Polignano et al, 2008).
The mortality and morbidity rates in these studies are at least equivalent to, if not better than, those of large case series of open liver resections. In their review of 127 published articles on laparoscopic hepatic resection, Nguyen and colleagues (2009) found a cumulative mortality rate of 0.3%. This compares favorably to the 0% to 5.4% reported in the open-resection literature from high-volume centers. All deaths were postoperative, and most often caused by liver and multiorgan system failure. Of 2804 patients, 295 morbid complications were reported (10.5%), with a range of 0% to 50% across the 127 studies (Nguyen et al 2009). Liver-specific complications included bile leaks (1.5%), transient liver failure and ascites (1%), and abscess (2%). The remaining 6% were complications common to all operations, including but not limited to hemorrhage, wound infection, hernia, bowel injury, arrhythmia, and urinary or respiratory tract infections.
Laparoscopy has been utilized with success in cirrhotic patients (see Chapter 90F), with multiple small case-control studies and series demonstrating lower morbidity and improved recovery. The laparoscopic approach also decreases the rate of postoperative ascites in this subgroup. Possible explanations include the preservation of venous and lymphatic collateral pathways in the abdominal wall, less intraoperative mobilization of the liver, and reduced intraoperative volume loading (Belli et al, 2007; Buell et al, 2009; Cherqui, 2006; Gigot et al, 2002; Kaneko et al, 2009; Laurent et al, 2003; Santambrogio et al, 2009; Vigano et al, 2009a). Nearly 40% of our laparoscopic experience has been with those patients who have chronic liver disease. These patients typically require longer operations and more pedicle clamping but globally have a better recovery than their open counterparts (Bryant et al, 2009).
As a consequence of decreased adhesions formed after an initial laparoscopic resection, reoperations, such as repeat hepatectomy and liver transplantation can often be performed more easily, with less blood loss, reduced transfusion requirements, and reduced operative time than following an initial, open partial hepatectomy (Belli et al, 2009; Bryant et al, 2009; Laurent et al, 2003). In our study comparing patients who had undergone a previous open or laparoscopic liver resection, the absence of adhesions at the time of liver transplantation in the laparoscopic group allowed for hepatectomy in a mean of 150 ± 52 minutes versus 247 ± 71 minutes in the open group. Additionally, a median of 2 U blood was transfused during hepatectomy in the open group versus zero in the laparoscopic group (Laurent et al, 2009). These are significant benefits, given that patients who require repeat operations often have diseased parenchyma because of cirrhosis or chemotherapy effects and the negative immune and oncologic impact of blood transfusion.
Barriers to the wide acceptance of laparoscopic surgery—such as threat of gas embolism, violation of oncologic principles, and significant risk of bleeding—have not been apparent in the literature (Vigano et al, 2009a). In addition, studies have consistently demonstrated that operative safety and postoperative morbidity improve with experience (Nguyen et al, 2009). When comparing our early and late groups, we found statistically significant reductions in operative time (210 to 150 minutes), blood loss (300 to 200 mL), conversion (16.9% to 2.4%), and morbidity (17.2% to 3.4%) (Vigano et al, 2009b).
