Laparoscopic Liver Surgery

doi:10.1016/j.yasu.2009.02.014

Advances in Surgery

Volume 43, Issue 1, September 2009, Pages 159-173

https://doi.org/10.1016/j.yasu.2009.02.014 Get rights and content

Section snippets

In the beginning

Contrary to many publications regarding laparoscopic liver surgery, the first report of a laparoscopic liver resection was published in Obstetrics and Gynecology in 1991 by Reich and colleagues [4], who reported their experience with two incidentally found benign masses in the liver during laparoscopy. The surgeons used bipolar forceps and laparoscopic scissors in one case and a CO₂ laser in the second case. The widely sited first report in the general surgical literature was by Gagner and was

The basics

While many centers with large clinical experiences differ in their technique for patient positioning, use of portal inflow occlusion, and techniques of parenchymal transection, several aspects of laparoscopic hepatic surgery are relatively constant and should be considered standard of care. Insufflation pressures are maintained at between 10 mm Hg and 12 mm Hg during parenchymal transsection to reduce the risk of air embolism. Extensive experience with intraoperative ultrasound is mandatory for

Technology

As mentioned earlier, the remarkable growth in laparoscopic hepatic surgery occurred to a large degree because of improvements in technology. As one examines the literature on laparoscopic hepatic resection, it becomes clear that there are many ways to perform the same operative procedure and many different approaches to the innovative technologic advances that have occurred. It is clear that the most important determinant of device choice is the personal experience and preferences of the

Major laparoscopic resections

While the vast majority of laparoscopic hepatic resections have been wedge resections, segmentectomies, or left-lateral sectionectomies, several experienced groups are now performing more formal hemi- and extended-hepatectomies. The first report of a right hepatectomy was in 1997 by Huscher and colleagues [44]. O'Rourke and Fielding [13] published a series dedicated to the technique of right hepatectomy in 2004, where they reported on 12 attempted resections. The indications for resection were

Advanced laparoscopic techniques

Even though many investigators have converted formal hepatectomies into large wedge resections by use of endovascular staplers, others have taken a more anatomic approach. Machado and colleagues [48] recently reported their experience with the intrahepatic glissonian approach for laparoscopic right segmental liver resections, which was first described in the open hepatic surgery literature by Galperin and Karagiulian in 1989 [49]. In their report of seven patients who underwent three segment 6

Recent comparison studies

In 2007, Simillis and colleagues [51] published a meta-analysis of laparoscopic versus open liver resections for both benign and malignant disease, which included studies performed before 2006 [52], [53], [54], [55], [56], [57], [58], [59]. Overall, 165 resections were included in the laparoscopic group and 244 in the open group. The conversion rate was 3.7%. Blood loss was lower by 123 mL in the laparoscopic group, with no significant differences in need for blood transfusion, operating time,

Major resection series

In 2002, Gigot and colleagues [63] presented the European experience with 37 laparoscopic liver resections for malignancy (10 HCC, 27 liver metastases) with long-term follow-up. They reported no mortality and 2-year disease-free survival of 44% for patients with HCC and 53% for patients with colorectal liver metastases. The investigators noted that complications were much higher in those patients with cirrhosis and HCC and stressed the importance of use of laparoscopic ultrasound to ensure at

Laparoscopic living-donor hepatectomy

Cherqui and colleagues were the first to report a series of two totally laparoscopic living donor hepatectomes in 2002 [18]. The dissection was performed in a similar manner to the open procedure, which used the CUSA to transect liver parenchyma after isolating the portal vascular structures, and then the endovascular stapler for segment 4 branches. The graft was removed through a Pfannenstiel incision. Operating time was 6 to 7 hours and patients lost between 150 cc and 450 cc of blood, with

The Louisville Statement

During the first week of November 2008, an International Consensus Meeting on Laparoscopic Liver Surgery was held in Louisville, Kentucky. This meeting brought together the majority of major laparoscopic hepatic resection groups from around the world. Essential issues, such as indications for resection, techniques, economics, and surgeon credentialing were discussed. This consensus closed with broad agreement that indications for open surgery should not be changed with the increased use of the

Summary

Great advances have occurred in the field of laparoscopic hepatic surgery. It is now clear that in experienced hands, the laparoscopic method of liver resection is as safe as an open procedure. The key phrase in this last sentence is “in experienced hands.” The new devices that are available might make an inexperienced hepatic surgeon, well-trained in laparoscopic surgery, embark on hepatic resection without thorough knowledge of hepatic anatomy. The converse may also be true. As no criteria

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