Laparoscopic liver resection for centrally located tumors close to the hilum, major hepatic veins, or inferior vena cava

doi:10.1016/j.surg.2012.10.004

Surgery

Volume 153, Issue 4, April 2013, Pages 502-509

https://doi.org/10.1016/j.surg.2012.10.004 Get rights and content

Background

Despite the accumulation of favorable results from laparoscopic liver resection (LLR), centrally located tumors close to the hilum, major hepatic veins, or inferior vena cava (IVC) are still considered contraindications for LLR. We evaluated the feasibility and safety of LLR for centrally located tumors.

Methods

Of the 182 patients who underwent LLR for benign or malignant tumors between September 2003 and June 2010, the clinical outcomes of 13 patients with tumors within 1 cm or less of the major vascular structures, including the hilum, major hepatic veins, and IVC, were retrospectively analyzed. The perioperative outcomes of the patients were compared with those of the 23 patients who underwent open liver resection for tumors with similar criteria in terms of location and size during the same period.

Results

Anatomic liver resection, including left and right hepatectomy, central bisectionectomy, right anterior and posterior sectionectomy, and extended S4 segementectomy, was performed in 10 patients. The remaining 3 patients underwent subsegmentectomy for tumors located in the Spiegel lobe of the caudate. There was no open conversion or postoperative mortality. Compared with the open group, the laparoscopic group showed similar rates of intraoperative transfusion, postoperative complications, and operative time. However, the laparoscopic group spent less time in the hospital postoperatively and had shorter resection margins. After a median follow-up of 34.3 months, there were no statistically significant differences between the 2 groups in reference to the overall survival rates and the disease-free survival rates.

Conclusion

This study shows that LLR can be safely performed in selected patients with centrally located tumors close to the liver hilum, the major hepatic veins, or the IVC that were previously considered to be contraindications for LLR. Recent technical developments in the performance of laparoscopic major liver resection may have contributed to the successful application of LLR for centrally located tumors.

Section snippets

Patients

Between September 2003 and June 2010, LLR was performed on a total of 252 patients at the Department of Surgery at Seoul National University Bundang Hospital. Among those patients, 182 patients underwent LLR for benign or malignant tumors. In the early period, the indications for LLR included peripheral tumors located away from the major vascular structures, such as the hilum, major hepatic veins, and IVC. The most common operative procedures were peripheral nonanatomic liver resection or left

Patients' characteristics

The baseline characteristics for the 13 patients included in this study are shown in Table I. There were 7 men and 6 women with a mean age of 52.6 years (range, 26–78 years). The pathology of the resected tumors after LLR included the following pathologic types: hepatocellular carcinoma (HCC) (n = 9); cholangiocarcinoma (n = 2); metastatic colorectal cancer (n = 1); and focal nodular hyperplasia (n = 1). Cholangiocarcinoma was diagnosed postoperatively in 2 patients in whom HCC and metastatic

Discussion

The indications for and applications of LLR have changed since the introduction of this procedure. Only tumorectomy was possible in the early period of performing LLR, and major liver resections, such as right and left hepatectomy, were challenging procedures. With the encouraging postoperative outcomes after LLR, there have been pioneering attempts to apply this procedure to more difficult cases.5, 10, 11, 12 The previous limitations of applying the laparoscopic approach to the posterior and

References (26)

J.Y. Cho et al.
Feasibility of laparoscopic liver resection for tumors located in the posterosuperior segments of the liver, with a special reference to overcoming current limitations on tumor location
Surgery
(2008)
N. O'Rourke et al.
Laparoscopic right hepatectomy: surgical technique
J Gastrointest Surg
(2004)
K.G. Billingsley et al.
Segment-oriented hepatic resection in the management of malignant neoplasms of the liver
J Am Coll Surg
(1998)
Z.Z. Hamady et al.
Resection margin in patients undergoing hepatectomy for colorectal liver metastasis: a critical appraisal of the 1 cm rule
Eur J Surg Oncol
(2006)
S. Nara et al.
Prognostic impact of marginal resection for patients with solitary hepatocellular carcinoma: evidence from 570 hepatectomies
Surgery
(2012)
L. Vigano et al.
Laparoscopic liver resection: a systematic review
J Hepatobiliary Pancreat Surg
(2009)
J.F. Buell et al.
The international position on laparoscopic liver surgery: The Louisville Statement, 2008
Ann Surg
(2009)
M.T. Huang et al.
Hand-assisted laparoscopic hepatectomy for solid tumor in the posterior portion of the right lobe: initial experience
Ann Surg
(2003)
J.L. Dulucq et al.
Isolated laparoscopic resection of the hepatic caudate lobe: surgical technique and a report of 2 cases
Surg Laparosc Endosc Percutan Tech
(2006)
Y.S. Yoon et al.
Total laparoscopic liver resection for hepatocellular carcinoma located in all segments of the liver
Surg Endosc
(2010)

Y.S. Yoon et al.

Total laparoscopic right posterior sectionectomy for hepatocellular carcinoma

J Laparoendosc Adv Surg Tech A

(2006)

H.S. Han et al.

Techniques for performing laparoscopic liver resection in various hepatic locations

J Hepatobiliary Pancreat Surg

(2009)

J.Y. Cho et al.

Experiences of laparoscopic liver resection including lesions in the posterosuperior segments of the liver

Surg Endosc

(2008)

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Robotic liver resection of caudate lobe with 3-D rendering and intraoperative ICG-fluorescence for giant hemangioma
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Parenchyma-sparing liver resections
2020, International Journal of Surgery
Modern liver surgeon must be equipped with excellent theoretical and clinical skills to perform a perfect liver resection. A particular and growing relevance is devoted to parenchyma sparing liver surgery (PSS). Indeed, reducing the sacrifice of functioning parenchyma is one of the keys of a successful surgery, once oncological issues are properly addressed. Intraoperative ultrasound together with oncological and anatomical new insights have enhanced the possibility to offer PSS even in advanced disease usually afforded with major resections or staged procedures or even considered unresectable. These complex hepatectomies are mainly performed with open surgery, while major or staged procedures could be faced with minimal access liver surgery (MALS): that is generating a potential conflict between open PSS and MALS major hepatectomies. An overall evaluation of oncological radicality, safety, salvageability, and quality of life suggest to prioritize PSS, which is always minimal invasive liver surgery in a hepatic-centered perspective, while MALS is not.
Pure laparoscopic anatomical resection of segment IV of the liver for a tumor located close to the middle and left hepatic veins: Hepatic vein-guided approach
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Citation Excerpt :
We believe that the portion of R1Vasc resections is greater in reality, but that some of these resections were defined as R1 resections by the pathologists. However, these results are in line with the previous studies on LLR for lesions close to major vessels [9–11], and with results reported for LLR [36,40,41,43]. Because of the small size of the sample, long term survival was only calculated for patients with CRLM.
With growing popularity and experience in laparoscopic liver surgery, the options for more difficult procedures increase. Only small case series have been published regarding laparoscopic liver resection (LLR) for tumours in proximity to major vessels (MVs). The aim was to compare outcomes of LLR for tumours located less or more than 15 mm from MVs.
This was a retrospective analysis of a prospectively collected database of consecutive LLR (October 2011–August 2017). Proximity to MVs (PMV) was defined as lesions located within 15 mm to the caval vein, hepatic veins and portal vein (main trunk and first branches). The control group were all lesions located more than 15 mm from MVs.
Some 60/235 LLR were performed for lesions in proximity to major vasculature (24%). In the PMV group, median IWATE Difficulty Score was higher (8.5 (IQR: 6.0–9.0) VS 5.0 (IQR: 3.0–6.0), p < 0.001) as was the use of CUSA® (45.0% VS 8.6%, p < 0.001) and Pringle manoeuvre (8.3% VS 1.7%; p = 0.028). Operative time was longer (180min (IQR: 140–210) VS 120min (IQR: 75–150), p < 0.001) and blood loss was higher (190 ml (IQR: 100–325) VS 75 ml (IQR: 50–220), p < 0.001) in the PMV group. There was no difference in perioperative blood transfusion (3.3% VS 1.7%, p = 0.60) or postoperative morbidity (15.0% VS 14.3%, p = 0.89). There was no mortality in both groups. On mean follow-up of 21 months, no significant differences could be found in disease free (p = 0.77) and overall survival (p = 0.12).
In experienced hands, LLR of lesions in proximity to MVs is safe and feasible with acceptable short and long-term results.
Central hepatectomy versus major hepatectomy for patients with centrally located hepatocellular carcinoma: A meta-analysis
2018, International Journal of Surgery
Citation Excerpt :
Preoperative evaluation of hepatic function, including liver function tests, also plays an important role in the management of HCC patients. It has also been reported that central hepatectomy could be performed via a minimally invasive laparoscopic or robotic approach [23–26]. To our knowledge, this is the first meta-analysis comparing the short- and long-term outcomes of CH and MH for patients with CL-HCC.
Both central hepatectomy (CH) and major hepatectomy (MH) are suggested surgical treatments for patients with centrally located hepatocellular carcinoma (CL-HCC). However, no consensus has been reached regarding which method is superior for managing these patients. This meta-analysis was conducted to compare the short- and long-term outcomes of CH and MH in patients with CL-HCC.
An electronic search for studies published in all years up to July 2017 in PubMed (Medline), EMBASE, Cochrane Library and Web of Science was performed. The short-term outcome was the incidence of postoperative complications, and the long-term outcomes included 1-, 3- and 5-year overall survival (OS) and corresponding disease-free survival (DFS), mortality and morbidity. The results were presented as Risk Ratios (RRs) or weighted mean differences with 95% confidence intervals.
Four retrospective studies containing 465 patients with CL-HCC were included (248 in the CH group and 217 in the MH group). The results suggested no significant differences in the 1-, 3- and 5-year DFS, 1, 3 and 5-year OS, total morbidity or mortality between these groups. Nevertheless, the patients in the CH group presented a lower prevalence of vascular invasion (RR 0.70, 95% CI 0.52–0.93, P = 0.020) than did the MH group. In addition, CH led to a higher incidence of biliary fistula, while MH showed a higher incidence of postoperative liver failure.
This study demonstrated that the long-term outcomes of the patients with CL-HCC in these two groups were not significantly different. For short-term outcomes, CH resulted in a lower rate of postoperative liver failure, while MH resulted in a lower incidence of biliary fistula. Nonetheless, compared with MH, CH provided CL-HCC patients with greater future remnant liver volume without an increased risk of early intra-hepatic recurrence. More multi-centre, randomized controlled trials comparing the therapeutic efficacy of CH and MH are urgently warranted.
Outcomes of major laparoscopic liver resection for hepatocellular carcinoma
2018, Surgical Oncology
Citation Excerpt :
The indications for LLR were similar to those for OLR in terms of the preoperative assessment of liver function, type of liver resection, and postoperative care [14]. However, LLR was not usually considered in patients with tumors > 5 cm in diameter and tumors invading or adjacent to the main portal pedicle or inferior vena cava, as well as patients with central lesions in the suprahepatic junction adjacent to the major hepatic vein [23]. The major LLR techniques used at our institution have been described in more detail elsewhere [6,7,11,12,15].
To compare the surgical outcomes of major laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC).
We retrospectively reviewed the medical records of 177 patients who underwent major liver resection for HCC between January 2004 and June 2015. We divided the 177 patients into two groups according to the type of procedure: major LLR (LLR group; n = 67) and major OLR (OLR group; n = 110).
Procedures in the LLR group were right hepatectomy (30 patients), right posterior sectionectomy (28), left hepatectomy (11), right anterior sectionectomy (6), extended right hepatectomy (6), and central bisectionectomy (2). Tumor size was greater in the OLR group than in the LLR group (6.3 ± 3.8 vs 4.1 ± 2.4 cm; P = 0.016). The mean indocyanine green retention rate at 15 min (P = 0.698) and serum α-fetoprotein (P = 0.186) were similar in both groups. The mean operation time was longer in the LLR group (416.6 ± 166.9 vs 332.5 ± 105.4 min; P = 0.002). Blood loss (P = 0.319), transfusion rate (P = 0.260), and R0 rate (P = 0.255) were similar in both groups. Hospital stay was shorter (11.3 ± 8.3 vs. 18 ± 21.4 days; P = 0.007) and the complication rate was lower (20.5% vs. 38.7%; P = 0.005) in the LLR group. The 5-year overall survival (77.3% vs 60.2%; P = 0.087) and disease-free survival (50.8% vs 40.1%; P = 0.139) rates were comparable in both groups.
Major LLR of HCC is feasible and oncologically safe when performed by experienced surgeons. Further refinements of the surgical technique are needed to reduce operation time.

View all citing articles on Scopus

: Supported by grant A102065 from the Korea Healthcare Technology Research and Development Project, Ministry of Health and Welfare, Korea.

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Original CommunicationLaparoscopic liver resection for centrally located tumors close to the hilum, major hepatic veins, or inferior vena cava

Background

Methods

Results

Conclusion

Section snippets

Patients

Patients' characteristics

Discussion

Surgery

J Gastrointest Surg

J Am Coll Surg

Eur J Surg Oncol

Surgery

Laparoscopic liver resection: a systematic review

J Hepatobiliary Pancreat Surg

The international position on laparoscopic liver surgery: The Louisville Statement, 2008

Ann Surg

Hand-assisted laparoscopic hepatectomy for solid tumor in the posterior portion of the right lobe: initial experience

Ann Surg

Isolated laparoscopic resection of the hepatic caudate lobe: surgical technique and a report of 2 cases

Surg Laparosc Endosc Percutan Tech

Total laparoscopic liver resection for hepatocellular carcinoma located in all segments of the liver

Surg Endosc

Total laparoscopic right posterior sectionectomy for hepatocellular carcinoma

J Laparoendosc Adv Surg Tech A

Techniques for performing laparoscopic liver resection in various hepatic locations

J Hepatobiliary Pancreat Surg

Experiences of laparoscopic liver resection including lesions in the posterosuperior segments of the liver

Surg Endosc

Original Communication
Laparoscopic liver resection for centrally located tumors close to the hilum, major hepatic veins, or inferior vena cava