[Technical aspects of laparoscopic liver surgery : Transfer from open to laparoscopic liver surgery].
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Background Laparoscopic surgery has become the standard for most visceral surgery procedures in many hospitals. Now, liver resections are also being increasingly carried out laparoscopically. The advantages of the laparoscopic technique have been demonstrated in numerous case series and in a recent randomized controlled trial. Aims The aim of this review article is to present the available techniques for laparoscopic liver surgery (LLS). Methods The technical variations reported in the literature as well as the own experience with LLS are reported. Results Optimal patient and trocar positions are crucial for successful LLS and they are chosen according to the planned type of liver surgery: the literature offers several options in particular for surgery of the cranial and dorsal liver segments. As for open liver surgery, a restrictive volume management and the application of the Pringle maneuver are helpful to reduce intraoperative blood loss in LLS. In addition, several dissection techniques have been adopted from open liver surgery. The Cavitron Ultrasound Surgical Aspirator (CUSA™) is particularly suitable for parenchymal dissection close to major vascular structures, since it guarantees a meticulous parenchymal dissection with minimal vascular injuries. Conclusion The developments of minimally invasive surgery nowadays allow complex liver resections, which can mostly be performed comparable to open liver surgery. Hopefully, minimally invasive liver surgery will further develop in Germany in the near future, since it offers several advantages over open liver surgery.Keywords:
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This chapter describes a conceptual framework for the indications and contraindications for liver resection for achieving the healthcare goals set forth by the Institute of Medicine's publication Safe, Effective, Patient-Centered, Timely, Efficient, and Equitable Care. This review of the available literature indicates that the majority of minimally invasive liver resections have been minor procedures. Only a limited number of highly specialized centers have reported major minimally invasive liver resections. To us, these data indicated that there is a need for greater diffusion of surgical concepts and techniques that would allow for the safe and oncologically sound expansion of more advanced laparoscopic liver surgery - a prime impetus for creating this work. Further, the author calls for introspective professionalism, oversight, and monitoring of exact indications on a case-by-case basis to safely expand the experience to more extensive laparoscopic liver resection. These are concepts that certainly are not limited to minimally invasive liver resections, but the complex nature of advanced minimally invasive liver resection demands apprehension of a significant number of oncological, patient management, and technical concepts that have been presented to the reader throughout this work.
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Laparoscopic liver surgery has evolved over the last two decades. Advancements in surgical technology, surgical technique, and postoperative care have aided in lifting barriers to laparoscopic liver resection (LLR). In this review, the authors highlight the modern indications, benefits, safety, and feasibility of laparoscopic liver resections. Moreover, they analyze various studies comparing laparoscopic major hepatectomies to open surgery. Morbidity and mortality rates are at an all-time low in this era of laparoscopic liver surgery. The role of laparoscopy for oncologic resections is compared with open liver resections. Attention is given to oncologic margins and survival rates. In addition, the authors examine the safety and efficacy of LLR for nontraditional laparoscopic segments and tumors abutting major hepatic vasculature. Various resection techniques are reviewed including the use of the hanging-maneuver and modern stapling devices. Finally, they examine several novel techniques for laparoscopic liver resections including the hybrid technique, as is used in laparoscopic living donor hepatectomies, the use of hand-assistance to avoid conversion to open surgery, and the use of the robotic platform to aid in complex biliary or vascular reconstructions. Current barriers to laparoscopic liver surgery will continue to fall over the next decade.
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After an initial period of scepticism, especially concerning technical and oncological problems, laparoscopic liver surgery (LLS) has become a feasible and safe technique. Over the past decade, the minimally invasive approach has been used increasingly in to manage hepatic diseases, showing that this technique in liver surgery, despite the technical challenges, reduces operative blood loss and results in fewer early postoperative complications, less postoperative analgesic drug consumption, and shorter hospital stay, with an oncologic clearance and a survival rate similar to that of open surgery [1–5]. Therefore, the place of laparoscopy in liver surgery is increasing, and many types of liver resections, including major hepatectomies, are now performed by laparoscopy in specialized centers [6–9]. Nevertheless, no international consensus on laparoscopic surgical management of liver lesions has been published, and no worldwide criteria exist for the indications for minimally invasive liver resection. Thus, there are no evidence-based criteria assisting the surgeon with management strategies for the laparoscopic treatment of liver tumors. For example, how large should the lesion be? Where should the lesion be located? Should we modify the well-accepted surgical indication only because we can perform a liver resection using a minimally invasive approach? Should we perform laparoscopic liver resection (LLR) only for benign lesions, or can we resect even malignant lesions by laparoscopy?
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