Manual Open, Laparoscopic and Robotic Hepatic Transection: Tools and Methods

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Hepatol Res ; Short- and long-term outcomes after laparoscopic and open hepatectomy for hepatocellular carcinoma: a global systematic review and meta-analysis. A retrospective analysis has found a good agreement between the difficulty level assessed by the surgeon and a difficulty index based on tumor location, extent of liver resection, tumor size, proximity to major vessels, and liver function [ 25 ]. Appropriate patient selection, practicing and honing LLR skills is paramount for success [ 25 ].

LLR has been found to be significantly better compared to OLR for minor hepatectomies for short-term outcomes such as the operation time, blood loss, and post-operative hospital stay [ 27 ]. Although there are numerous case-reports and retrospective series of LLR, few well-designed randomized controlled trials RCTs and meta-analyses are currently available [ 27 - 35 ].

Meta-analyses show that LLR has clinical benefits over OLR with significant reduction in blood loss, blood transfusion, complications and hospital stay with comparable operative time and resection margin positivity. However potential biases due to low statistical power of many studies included in the meta-analyses cannot be undermined [ 28 - 35 ].

The results of these studies are summarized in Table 2. Current evidence suggests that local tumor recurrence, disease free survival and overall survival are similar between laparoscopic and open resections [ 39 - 42 ]. The results of these studies are summarized in Table 3.

Minimally Invasive Techniques and Outcomes in Hepatic Resection

Recently published meta-analysis on LLR for colorectal liver metastases CRLM concluded that LLR is a beneficial alternative to OLR in selected patients and does not compromise oncological outcomes including surgical margins, tumor recurrence, disease-free survival or 5-year overall survival, with even a possibility of better 3-year overall survival [ 40 ].

Even though this meta-analysis used propensity matching for compensating for selection bias, differences in proportions of major and minor resections and studies with low statistical power might be a potential source of bias [ 40 ]. The scope for LLR is increasing with improvements in LLR skills, availability of surgical gadgets and use of the robotic platform [ 41 ]. Robotic assistance is promising to aid difficult LLRs such as postero-superior resections, non-anatomical resections along angulated or curvilinear resection planes, those requiring complex vascular and biliary reconstructions, but these need further refinement in skills and prospective validation [ 41 ].

Even single incision laparoscopic liver resection has been reported in very suitable tumors [ 42 - 44 ]. Laparoscopic re-resection of liver tumors may be feasible even after previous OLR, up to two prior LLRs, after previous major hepatectomy, even in cirrhotic livers and postero-superiorly located tumors [ 47 ].

Recent advances in LLR also include laparoscopic living donor hepatectomy and laparoscopic associating liver partition and portal vein ligation amongst others [ 48 ].

BLUS Handbook of Laparoscopic and Robotic Fundamentals - American Urological Association

Laparoscopic left lateral sectionectomy and minor laparoscopic liver resection are now considered standard approaches. Major laparoscopic hepatectomy has been shown to be feasible and safe at few select experienced centers. Long-term oncologic and survival outcomes have been found to be similar to open liver resection in case-matched studies.

Although LLR has a steep learning curve, indications for it are expanding fast with advances in laparoscopic techniques and skills.

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  4. LLR is a safe and effective approach to liver surgery for well selected patients in the hands of well trained surgeons with experience in hepatobilliary and laparoscopic surgery. The current scientific support in its favour is limited to case series, expert consensus recommendations, guidelines, meta-analyses with very few matched controlled studies and a single randomised controlled trial. Randomized trials and structured training will help benefit more patients with the advancement in this technique.

    The international position on laparoscopic liver surgery: The Louisville Statement, Ann Surg ; Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. The Southampton consensus Guidelines for laparoscopic liver surgery. Ann surg ; Laparoscopic robot-assisted resection of tumors located in posterosuperior liver segments.