[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:
Open surgery
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Laparoscopic surgery has transformed many procedures over the past three decades. Greater experience along advances in laparoscopic devices have augmented the number of laparoscopic liver resection (LLR). Today laparoscopic hepatectomy is a stablished technique worldwide with more than 9,000 cases reported so far (1). International consensus conferences in 2008 and 2014 established steps to safe implementation of this technique such as dual training in advanced minimally invasive surgery and liver surgery, showed short-term equivalence and suggested that laparoscopy should be the standard of care for minor liver resections and left-lateral sectionectomy (2,3).
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Reduced port surgery has been attracting attention in the field of minimally invasive surgery. Although the use of SILS is becoming widespread, technical difficulty has delayed its adoption for laparoscopic liver resection. Recently, advances in laparoscopic liver resection have been made in tandem with advances in surgical skill and devices. The main driver in conventional laparoscopic liver resection's evolution to become less surgically invasive seems to be single-incision laparoscopic liver resection (SILLR). To date, most reports on SILLR have been single case reports or case series. Only a few cohort studies on conventional laparoscopic surgery and SILLR have been conducted. Recent reports have described the use of SILLR for well-localized lesions and solitary tumors located in the anterolateral segments of the liver or left liver lobe, but its application remains limited to partial resection and left lateral sectionectomy. The feasibility and safety of SILLR have been demonstrated, but additional work is needed for standardization of the procedure.
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We present the largest, most comprehensive, single center experience to date of minimally invasive liver resection (MILR).Despite anecdotal reports of MILR, few large single center reports have examined these procedures by comparing them to their open counterparts.Three hundred MILR were performed between July 2001 and November 2006 at our center for both benign and malignant conditions. These included 241 pure laparoscopic, 32 hand-assisted laparoscopic, and 27 laparoscopy-assisted open (hybrid) resections.These MILR were compared with 100 contemporaneous, cohort-matched open resections. MILR included segmentectomies (110), bisegmentectomies (63), left hepatectomies (47), right hepatectomies (64), extended right hepatectomies (8), and caudate lobe (8) resections. Benign etiologies encompassed cysts (70), hemangiomata (37), focal nodular hyperplasia (FNH) (23), adenomata (47), and 20 live donor right lobectomies. Malignant etiologies included primary (43) and metastatic (60) tumors. Hepatic fibrosis/cirrhosis was present in 25 of 103 patients with malignant diseases (24%).There was high data consistency within the 3 types of MILR. MILR compared favorably with standard open techniques: operative times (99 vs. 182 minutes), blood loss (102 vs. 325 ml), transfusion requirement (2 of 300 vs. 8 of 100), length of stay (1.9 vs. 5.4 days), overall operative complications (9.3% vs. 22%), and local malignancy recurrence (2% vs. 3%). No port-site recurrences occurred. Conversion from laparoscopic to hand-assisted laparoscopic resection occurred in 20 patients (6%), with no conversions to open. No hand-assisted procedures were converted to open, but 2 laparoscopy-assisted (7%) were converted to open.Our data show that MILR outcomes compare favorably with those of the open standard technique. Our experience suggests that MILR of varying magnitudes is safe and effective for both benign and malignant conditions.
Single Center
Focal nodular hyperplasia
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Abstract Background Minimally invasive techniques have increasingly found their way into liver surgery in recent years. A multitude of mostly retrospective analyses suggests several advantages of laparoscopic over open liver surgery. Due to the speed and variety of simultaneous technical and strategic developments, it is difficult to maintain an overview of the current status and perspectives in laparoscopic liver surgery. Purpose This review highlights up-to-date aspects in laparoscopic liver surgery. We discuss established indications with regard to their development over time as well as continuing limitations of applied techniques. We give an assessment based on the current literature and according to our own center experiences, not least with regard to a highly topical cost discussion. Conclusions While in the beginning mainly benign tumors were laparoscopically operated on, liver metastasis and hepatocellular carcinoma are now among the most frequent indications. Technical limitations remain and should be evaluated with the overall aim not to endanger quality standards in open surgery. Financial aspects cannot be neglected with the necessity of cost-covering reimbursement.
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Wedge resection
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Open surgery
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Open surgery
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Abstract Minimally invasive liver surgery has recently undergone an explosion in reported worldwide experience. Given its comparable outcomes to its open counterpart, high‐volume centers are utilizing minimal access liver surgery more frequently under well‐defined criteria. The recent introduction of robot‐assisted surgery has further revolutionized the field of minimally invasive surgery and has expanded the reach of feasibility. Robot‐assisted surgery was developed to help overcome the disadvantages of conventional laparoscopic surgery. As a result, there has been an increase in the reporting of advanced robot‐assisted liver resections. A literature review was performed to identify the current manuscripts describing robot‐assisted liver surgery. Nine case series were identified, yielding 144 unique patient characteristics. Outcomes indicate that robot‐assisted liver resection is feasible and safe for both minor and major liver resections with regard to estimated blood loss, length of stay, and complications. Early data also suggest that robot‐assisted liver surgery is efficacious with regard to short‐term oncologic outcomes. Future studies will be needed to better evaluate advantages and disadvantages compared to laparoscopic liver resections.
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In 2009, the most comprehensive review of published series of minimally invasive liver resection (MILR) reported nearly 3,000 cases performed worldwide, emphasizing an exponential growth in the application of this technique by surgeons experienced with both hepatic and laparoscopic surgery [1]. The goal of our survey was to provide an overview of the spread of the minimally invasive approach to liver resections in Italy.
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Laparoscopic liver resection (LLR) for the treatment of benign and malignant liver lesions is often performed at specialized centers. Technological advances, such as laparoscopic ultrasonography and electrosurgical tools, have afforded surgeons simultaneous improvements in surgical technique. The utilization of minimally invasive techniques for liver resection has been reported to reduce operative time, decrease blood loss, and shorten length of hospital stay with equivalent postoperative mortality and morbidity rates compared to open liver resection (OLR). Non-anatomic liver resection and left lateral sectionectomy are now routinely performed laparoscopically at many institutions. Furthermore, major hepatic resections are performed by pure laparoscopy, hand-assisted technique, and the hybrid method. In addition, robotic surgery and single port surgery are revealing early promising results. The consensus recommendation for the treatment of benign liver disease and malignant lesions remains unchanged when considering a laparoscopic approach, except when comorbidities and anatomic limitations of the liver lesion preclude this technique. Disease free and survival rates after LLR for hepatocellular carcinoma and metastatic colon cancer correspond to OLR. Patient selection is a significant factor for these favorable outcomes. The limitations include LLR of superior and posterior liver lesions; however, adjustments in technique may now consider a laparoscopic approach as a viable option. As growing data continue to reveal the feasibility and efficacy of laparoscopic liver surgery, this skill is increasingly being adopted by hepatobiliary surgeons. Although the full scope of laparoscopic liver surgery remains infrequently used by many general surgeons, this technique will become a standard in the treatment of liver diseases as studies continue to show favorable outcomes.
Liver disease
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