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Minimally invasive hepatectomy is safe and feasible in properly selected patients.
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Preoperative workup, anesthetic management, and postoperative management are similar to open hepatectomy.
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Minimally invasive hepatectomy is associated with fewer perioperative complications and shorter hospital length of stay.
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Short- and long-term oncologic outcomes are similar between minimally invasive and open hepatectomy done for malignancy.
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Minimally invasive hepatectomy is best performed by surgeons who are
Minimally Invasive Hepatic Surgery
Section snippets
Key points
Preoperative planning
All patients should undergo a comprehensive history and physical examination. Although not absolute contraindications, multiple prior abdominal surgeries or the presence of underlying comorbidities, such as chronic obstructive pulmonary disease or congestive heart failure, should be kept in mind when choosing patients for minimally invasive hepatectomy.
Standard workup of patients with primary or metastatic hepatic malignancies includes a triphasic computed tomographic (CT) scan (noncontrast,
Surgical technique
Techniques for minimally invasive hepatopancreaticobiliary surgery include pure laparoscopic, hand-assisted laparoscopic, hybrid (laparoscopic mobilization with open parenchymal transection), and robotic-assisted approach.37, 38, 39 The choice of technique is surgeon-specific. Preferences are influenced by a combination of surgeon experience and comfort with each technique and patient factors (tumor size, tumor location, body habitus, prior abdominal surgery), which contribute to the technical
Postoperative care
The orogastric tube should be removed. The patient may be observed in the intensive care unit or a monitored floor bed depending on the patient’s overall health, operative duration, intraoperative complications, and surgeon preference. The authors start subcutaneous heparin prophylaxis on the evening of the day of surgery. A clear liquid diet is routinely started on the first postoperative day and advanced as tolerated. Central venous catheters, if present, are removed between the first and
Results
Minimally invasive hepatectomy is being performed with increasing frequency. In the largest review of laparoscopic liver resections to date, Nguyen and colleagues7 analyzed case series totaling more than 2800 cases. The overall findings suggested that minimally invasive liver resection is both safe and feasible. Nearly 75% of the cases were performed purely laparoscopically; 17% were performed with hand assistance, and 2% were performed in hybrid fashion. The overall conversion rate was 4%.
Summary
The literature demonstrates that in properly selected patients, minimally invasive liver resection is a feasible and safe option, best performed by surgeons trained in open liver surgery who are skilled in minimally invasive techniques. Available data suggest that open, laparoscopic, and robotic approaches have similar perioperative outcomes, but the robotic approach comes at a higher cost. Short- and long-term oncologic outcomes appear to be equivalent. Currently, most minimally invasive
References (52)
- et al.
Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial
Lancet
(2005) - et al.
Laparoscopic colon surgery: past, present and future
Surg Clin North Am
(2006) - et al.
Pancreaticoduodenectomy with major vascular resection: a comparison of laparoscopic versus open approaches
J Gastrointest Surg
(2015) - et al.
Major venous resection during total laparoscopic pancreaticoduodenectomy
HPB (Oxford)
(2011) - et al.
Robotic-assisted major pancreatic resection
Adv Surg
(2011) - et al.
Short- and long-term outcomes after laparoscopic and open hepatic resection: systematic review and meta-analysis
HPB (Oxford)
(2011) - et al.
Minimally invasive liver resection: robotic versus laparoscopic left lateral sectionectomy
J Gastrointest Surg
(2012) - et al.
Laparoscopic hepatic lobectomy: advantages of a minimally invasive approach
J Am Coll Surg
(2010) - et al.
Laparoscopic versus open right hepatectomy: a comparative study
Am J Surg
(2009) - et al.
Single-centre comparative study of laparoscopic versus open right hepatectomy
J Gastrointest Surg
(2011)
Robotic versus laparoscopic resection of liver tumours
HPB (Oxford)
Robotic-assisted minimally invasive liver resection
Asian J Surg
A comparison of laparoscopically assisted and open colectomy for colon cancer
N Engl J Med
Laparoscopic versus open radical hysterectomy for stage IB2-IIB cervical cancer in the setting of neoadjuvant chemotherapy: a multi-institutional cohort study
Ann Surg Oncol
Laparoscopic radical prostatectomy: a review of techniques and results worldwide
Minerva Urol Nefrol
Outcomes after minimally invasive esophagectomy: review of over 1000 patients
Ann Surg
World review of laparoscopic liver resection—2,804 patients
Ann Surg
Randomized trial of laparoscopic-assisted resection of colorectal carcinoma: 3-year results of the UK MRC CLASICC Trial Group
J Clin Oncol
A comparison of surgeons' posture during laparoscopic and open surgical procedures
Surg Endosc
Feasibility of robotic laparoscopic surgery: 146 cases
World J Surg
Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka
Ann Surg
Total laparoscopic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: oncologic advantages over open approaches?
Ann Surg
Laparoscopic and robotic resection for pancreatic cancer
Cancer J
Total laparoscopic pancreaticoduodenectomy: feasibility and outcome in an early experience
Arch Surg
Comparative benefits of laparoscopic vs open hepatic resection: a critical appraisal
Arch Surg
Robotic versus laparoscopic hepatectomy: a matched comparison
Ann Surg
Cited by (18)
Equivalency of short-term perioperative outcomes after open, laparoscopic, and robotic ileal pouch anal anastomosis. Does procedure complexity override operative approach?
2022, Surgery Open ScienceCitation Excerpt :However, all of these studies were institutional series with small sample sizes. Corresponding findings have also been seen in other complex operations such as major hepatic resections [13,14], pancreatoduodenectomies [15], and esophagectomies, [16] where minimally invasive approaches, including robotic and laparoscopic surgery, were found to have similar perioperative outcomes compared to traditional open surgery. We therefore hypothesized that among patients undergoing an IPAA, the perioperative outcomes would be equivalent for all 3 approaches as minimally invasive techniques cannot overcome the impact of the surgical complexity of an IPAA on perioperative morbidity.
The annual AHPBA HPB fellows' course: an analysis of impact and feedback
2020, HPBCitation Excerpt :The landscape of MIS HPB surgery has undergone a clear transformation over the past decade. There have been reported advantages to MIS distal pancreatectomy,9 major hepatectomy,10,11 and even pancreaticoduodenectomy (PD),12,13 though claiming the superiority of any MIS technique over its open counterpart remains a recipe for spirited debate. As might be expected, not all centers are embracing MIS procedures with equal enthusiasm.
Minimally invasive orthognathic surgery: a systematic review
2018, International Journal of Oral and Maxillofacial SurgeryComparative Effectiveness of Minimally Invasive Surgery and Conventional Approaches for Major or Challenging Hepatectomy
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2017, Seminars in Oncology NursingCitation Excerpt :To date, laparoscopic hepatectomy are primarily performed for non-anatomic resections because of challenges such as complex vascular and biliary anatomy and risk for bleeding.104 Compared with open hepatectomy, laparoscopic hepatectomy affords similar universal benefits observed in other organs, including reduced blood loss, reduced postoperative pain and decreased length of stay.105 Oncologic outcomes to date for margin status and local recurrence rates are similar when compared with open approach.106