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Robotic liver resection is a new platform for minimally invasive liver resection, and its functional advantages are expected to reduce or overcome the difficulties or limitations of laparoscopic liver resection, such as restricted instrument movement and unstable surgical visual field. Minimally invasive liver resection for malignancy, anatomic liver resection in particular, is technically demanding. In such type of difficult hepatectomy, robotic functions are suggested to confer benefits in vascular or biliary dissection, isolation and division during hilar dissection, as well as benefits in keeping stable visual field, vascular isolation, tying or clipping, and suture hemostasis during liver parenchymal dissection. Previous studies on minimally invasive anatomic liver resection has suggested that robotic liver resection is superior to laparoscopic liver resection in terms of perioperative outcomes including blood loss, postoperative complications, rate of open conversion, and length of hospital stay. There are also studies indicating that the long-term oncologic outcomes of robotic hepatectomy are comparable to those of open or laparoscopic hepatectomies. Furthermore, the usefulness of robot functions has increasingly been reported on cases of liver resection with biliary and vascular reconstruction. Robotic liver resection for malignancy is considered to be sufficiently effective and practical, with acceptable technical accuracy, safety, and cancer curability, particularly in highly difficult anatomic liver resection. Under these backgrounds, robotic liver resection has a potential to become the mainstay of minimally invasive liver resection for malignancy.

The aim of this study was to evaluate the rate of surgical site infection(SSI)after hepatectomy in elderly patients with hepatocellular carcinoma(HCC). From June 2010 through December 2016, 276 cases of hepatectomy for HCC were performed in our hospital, and 39 cases included patients aged>80 years. The rate of SSI in the elderly group compared to the non-elderly group was 15.38%(6/39 cases)vs 7.73%(p=0.0855). The Child-Pugh classification(A/B/C)in the SSI group (n=6)vs in the non-SSI group(n=33)was 6/0/0 vs 32/1/0(p=0.5605), the liver damage classification(A/B/C)was 4/ 2/0 vs 25/8/0(p=0.6467), BMI was 23.3 kg/m / 2 vs 22.8 kg/m2(p=0.6544), PNI was 43.1 vs 46.2(p=0.3804), the operation time was 348.5 minutes vs 315.1 minutes(p=0.4478), blood loss was a small amount vs 401.5mL(p=0.0143), and the hospital stay after the operation was 27.5 days vs 10.0 days(p=0.0401), respectively. Hepatectomy for elderly patients was safe and feasible, and the only significant risk factor for SSI in elderly HCC patients was intraoperative blood loss.

We report 2 cases where afferent loop syndrome after hepatobiliary and pancreatic surgery was successfully treated with percutaneous drainage. Case 1: A 74-year-old man who had undergone pancreaticoduodenectomy for pancreatic cancer presented with cholangitis, obstructive jaundice, and dilatation of the elevated jejunum. These conditions were attributed to obstruction of the elevated jejunum on the anal side due to peritoneal dissemination. Subsequently, percutaneous transhepatic biliary drainage was performed, and the dilated jejunum was drained through the approach route. Case 2: A 71-year-old woman who had undergone left hepatectomy for hilar bile duct cancer presented with peritoneal dissemination. Owing to the dissemination, the elevated jejunum was obstructed, resulting in its dilatation on the oral side. Percutaneous drainage of the dilated jejunum was directly performed. Percutaneous drainage was effective in both the abovementioned cases, and no symptoms related to the obstruction were observed until the death of the patients because of primary cancer. This suggested that percutaneous drainage may be an effective treatment option for afferent loop syndrome after hepatobiliary and pancreatic surgery.

Background: Bile leakage is a serious complication of liver resection, and its treatment is very time-consuming. In open liver resection, Glisson's sheaths are usually disconnected by ligation to the extent possible during the parenchyma dissection. However, in laparoscopic surgery, the ligation, suture, and hemostasis are more difficult than in open surgery. For this reason, in laparoscopic liver resection, liver parenchyma dissection is generally accomplished using electrosurgical or stapling devices., Purpose: The purpose of this study was to verify the authenticity of electrosurgical devices attached an automatic irrigation function (AI) and stapling devices for laparoscopic liver parenchymal dissection., Methods: Four devices were used for liver parenchymal dissection in laparoscopic hepatic wedge resection, in pigs: monopolar high-frequency electric cautery attached AI (MCI) (n = 6), bipolar high-frequency electric cautery attached AI (BCI) (n = 6), bipolar tissue sealing system (LigaSure) attached AI (BSI) and an endoscopic stapling device (ECHELON FLEX ENDOPATH) (ES). In each group, burst pressures were tested using an electronic manometer, paying special attention to the location (s) of the first disruption (s). The dissected tissues were examined histologically., Results: Pressures used in electrosurgical devices attach AI were significantly higher compared to pressures used in a ES (P < 0.001). While thermal denaturation of the liver parenchyma occurred at approximately 2-3 mm of depth when bipolar high-frequency electric cautery was used for dissection, it reached up to more than 10 mm with monopolar high-frequency electric cautery. All of the first disruption points of stapling were at stapling line., Conclusions: Electrosurgical devices with an automatic irrigation function are useful devices to dissect the liver parenchyma.

Background: Continuous epidural analgesia has become an accepted technique used in laparotomy including liver resections. Although American Society of Regional Anesthesia and Pain Medicine recommends that epidural catheter be removed with prothrombin time-international normalized ratio (PT-INR) less than 1.5, it is possible that liver surgery causes coagulation disturbances. We examined the postoperative changes in coagulation profiles of living liver donors to elucidate whether hepatectomy increases the risk of epidural hematoma related to removal of epidural catheters or not., Methods: From January 2007 to October 2009, 42 living liver related transplantations were performed in Hokkaido University Hospital. We reviewed the donor data including PT-INR obtained during perioperative days [preoperative, immediately postoperative, postoperative day 1, 3 and 7] and epidural catheter-related-complications, retrospectively., Results: While in all donors values of PT-INR obtained during preoperative periods were within normal limits, 14 donors had a PT-INR over 1.5 during postoperative periods. There was no epidural hematoma case in this study., Conclusions: Our study suggested that hepatectomy increases the risk of epidural hematoma related to removal of epidural catheters, even in the living liver transplant donors with normal liver function.

A 58-year-old female was admitted to Ogikubo Hospital for advanced hepatocellular carcinoma in April 2007. Pathological examination showed moderately differentiated hepatocellular carcinoma. Tumor marker increased the PIVKA-II level became 129 mAU/mL after the operation. FDG-PET was showed a solitary pelvic tumor sized about 2.5 cm in diameter. No other prominent metastatic lesions were demonstrated, so that a resection of intrapelvic tumor was performed in May 2008. The report which exhibited an asynchronism recurrence of peritoneal dissemination after hepatectomy is very rare. She has survived without a recurrence more than 13 months after the resection.

In patients with multiple hepatocellular carcinomas (HCCs), a liver resection for the main tumor may be performed in combination with local ablation therapy for satellite lesions. Of 63 multiple HCC patients without radiological vascular invasions, 27 were treated with liver resection alone and the other 36 treated with the combination of liver resection and local ablation therapy. No significant differences were found in both groups with regard to age, gender, BMI, etiology of hepatitis, liver damage grade, tumor number, size of the main tumor and size of satellite lesion. In the liver resection group, 11 hemihepatectomies, 12 sectionectomies and 4 partial hepatectomies were performed. In the combination therapy group, 8 hemihepatecomies, 17 sectionectomies and 11 partial hepatectomies were performed. No significant differences were found in both groups with respect to bleeding, transfusion, disease-free survival rate, and survival rate. In the combination therapy group, a resected liver volume was significantly lower (p = 0.003) and an operation time was shorter (p = 0.009). It appears to indicate that the combination of liver resection and local ablation therapy can be useful for multiple HCCs.

Background: We reported that recovery from total intravenous anesthesia with propofol was delayed in hepatectomy patients, and the hazard ratio was half against controls. This study was designed to evaluate recovery from sevoflurane anesthesia in patients for hepatectomy., Methods: Sixteen patients receiving hepatectomy and 17 patients receiving other epigastric surgeries (controls) were anesthetized with sevoflurane. Fentanyl was injected repeatedly to insure maintenance of the effect-site concentration of 2.0 ng x ml(-1). Propofol was administered for induction of general anesthesia, and then inhaled sevoflurane was titrated to maintain a Bispectral Index (BIS) value between 40 and 50. The intervals to emergence and extubation after sevoflurane discontinuation, and the predicted fentanyl concentrations were recorded., Results: The amount of sevoflurane and concentration of fentanyl in hepatectomy were similar to those in controls. The extubation time was longer in hepatectomy patients than in control subjects, and the hazard ratio was half against controls., Conclusions: Recovery from anesthesia with sevoflurane was delayed in hepatectomy, and the hazard ratios were half against controls. We speculate that the influence of hepatectomy caused delay of recovery from anesthesia in hepatectomy patients.

The postoperative complications, morbidity and mortality of hepatopancreatoduodenectomy (HPD) are reviewed based on reports by the Japanese Biliary Surgery Association, Japanese Pancreatectomy Association, and leading surgeons. Postoperative hepatic failure, the most important and lethal complication, is significantly correlated with patient age (older than 70 years), resected hapatic volume (hepatic bisegmentectomy or greater), combined resection of the portal vein, or temporal bypass of portal blood flow. In patients who undergo HPD with more than bisegmentectomy, the operative mortality rate is high rate, with reports of 39.7%, 23.0%, 12.5%, and 38.0%. To reduce the morbidity and mortality rates after HPD, it is important to avoid intraoperative hepatic ischemia and to maintain sufficient hepatic blood flow and high oxygen saturation of portal blood postoperatively using a respirator and inotropic agents.

The combined effects of thoracic epidural anesthesia and vasodilators on hemodynamics, stress responses, sodium excretion and liver function were investigated in eight patients who received hepatectomy. As vasodilators, phentolamine and/or prostaglandin E1 were chosen. Under these conditions, systemic vascular resistance decreased and cardiac index increased by afterload reduction. This hemodynamic changes were induced by sympathetic nerve blocking, vasodilator and hemodilution. The increase of epinephrine and norepinephrine levels were suppressed during the surgery and there were no significant changes in plasma renin activity, angiotensin II and aldosterone levels. Sodium excretion was maintained during the surgery. Arterial ketone body ratio did not decrease and lactic acid/pyrvate acid ratio showed low values. None of the patients developed respiratory complications nor liver failure after the surgery. Combined use of epidural anesthesia and vasodilators kept stable hemodynamics and suppressed endocrine stress responses. These were considered beneficial for liver function and sodium excretion during and after the hepatectomy.

The effects of platelet activating factor antagonist (PAF-A) for sublethal endotoxemia after 70% or 84% hepatectomy in rats were studied. Endotoxin of 1mg/kg b.w. was intravenously given once on the first, third or fifth day hepatectomy. One week survival rates of 84%-hepatectomized rats with endotoxin injection on the third postoperative day was the lowest at 20%, and the lowest survival rate improved to 80% with PAF-A administration. Pathophysiology of PAF-A treated and nontreated rats with endotoxemia was investigated on the third day after 84% hepatectomy. There was no significant difference in SGOT, SGPT and blood glucose level between the two groups. PAF-A nontreated rats' prothrombin time was prolonged (p < 0.05) and serum fibrinogen level significantly decreased (p < 0.01), compared to treated rats. Platelet count distinctly decreased in both groups. Fibrin was pathologically proved in the glomeruli of the kidney in both groups. However, single cell necrosis of hepatocytes was significantly reduced by PAF-A administration. Rats without PAF-A had bloody ascites in 75% of cases and showed shock and pathologically pulmonary congestion. PAF may be related to DIC, shock, bloody ascites and high mortality rate in sublethal endotoxemia after massive hepatectomy. PAF-A was significantly effective for endotoxemia after hepatectomy.

Effects of TPE on prevention of hepatic failure after massive hepatectomy were studied experimentally using dogs. A 70% or 85% hepatectomy (Hx) was performed two weeks after TPE. All of the 70%Hx groups with(+)/without(-) TPE were alive for over two weeks after hepatectomy. While all of the 85%Hx group without TPE died, eight of ten in the 85%Hx group with TPE survived. Without TPE, total bilirubin levels in sera were elevated markedly in the 85%Hx group and moderately in the 70%Hx group after hepatectomy. The levels of escaped enzymes in sera, such as GOT or GPT, were also elevated remarkably in the TPE(-) groups. Although the levels of these enzymes were also high in the 85%Hx.TPE(+) group, these values were as same as those of 70%Hx.TPE(-) group. In the 85%Hx.TPE(-) group, critical diminution of functional hepatic cell mass and severe portal hypertension occurred after hepatectomy and coagulopathy and death followed to these phenomena. TPE might prevent the onset of these critical phenomena, and diminish the damage caused by massive hepatectomy. These results suggest that TPE is useful for prevention of postoperative hepatic failure so that we could perform massive hepatectomy safely, and extend the operative indication.

The tissue injury caused by Microwave Tissue Coagulator (MTC) was assessed clinically and experimentally with dogs. Following hepatic transection using MTC on condition that the output was 60 watts and radiation lasted for 60 seconds at one time, GOT, GPT, lactic acid, FDP and endotoxin concentration increased and coagulation parameters such as hepaplastin test were deteriorated transiently. Of tissue injury, following results were obtained. 1) The mechanism of tissue injury by MTC consists of direct heat injury and infarct by circulatory disturbance. The extent of injury from the needle electrode is approximately 10 mm in the former mechanism and 20mm in the latter. 2) Injury of vessels in Glisson's sheath was confirmed up to 50mm apart from the needle electrode by labelling index of bromodeoxyuridine in bile duct epithelial cells. 3) The granulation formation at the site of necrosis was considerably retarded by wound infection. Accordingly, when MTC is utilized on hepatectomy, followings should be noted: 1) To prevent the large intrahepatic vessels from heat injury, MTC may be utilized at the surface of the liver and the needle electrode must be punctured more than 10mm apart from them. 2) Bile leakage at the resected stump should be eliminated to prevent infection at the stump.

Sixty percent hepatectomy under two times of the Pringle maneuver (temporal occlusion of the hepatic inflow of the hepatic artery and portal vein) for 25 min was carried out on rats with obstructive jaundice. Hepatic energy charge which was markedly decreased during the Pringle maneuver did not recover 3 hrs after release of the maneuver. In addition, systemic endotoxemia associated with increased level of malondialdehyde and decreased levels of total glutathione and alpha-tocopherol in the liver was demonstrated. These changes were more dominant in rats with obstructive jaundice for 3 weeks than those for 1 week. It can be said that deteriorated hepatic energy charge after release of the Pringle maneuver may partly be caused by the production of oxygen free radicals which may be enhanced by endotoxemia in resection of the jaundiced liver. In contrast, after release of the Pringle maneuver, deterioration of hepatic energy charge due to oxidative attack was not found in jaundiced rats without hepatic resection.

The purpose of this study was to evaluate the mechanism of development of lung edema and to determine adequate components and amounts of transfusion solution after major hepatic resection in normal and Dimethylnitrosamine (DMNA)-induced cirrhotic dogs. The dogs were administered maintenance dose (1-2 ml/kg/h) or large volumes (10-20 ml/kg/h) of lactated Ringer's solution (RL), 10% Dextrose or Dextran 40 (D40) after surgery. 1) In the groups transfused with maintenance dose or large volumes of RL, or large volumes of D40 after 80% and 70% hepatectomy in normal dogs and 40% hepatectomy in DMNA-induced cirrhotic dogs, the extravascular lung water (EVLW) increased with a high incidence of the development of lung edema. On the other hand, in the groups transfused with maintenance dose or large volumes of 10% Dextrose, or maintenance dose of D40, EVLW did not increase, thus preventing the development of lung edema. 2) The lower the functional reserve of the remaining liver and reticuloendothelial function, the more the volume of EVLW increased. The increments in plasma endotoxin titers through the spill over phenomenon, due to the decline of reticuloendothelial function after hepatectomy, caused an increase in the permeability of lung capillaries. Moreover, the decrease of colloid hydrostatic pressure gradient (CHPG) also caused an increase in EVLW. It is clear that both the permeability of lung capillaries and CHPG contribute to the development of lung edema after hepatectomy.

Using 70% hepatectomized rat, morphological and functional changes of the spleen after partial hepatectomy were investigated. The results were as follows; 1. The weight of the spleen was maximum on the 7th and 10th day after partial hepatectomy and still high on the 14th day. There was no definite relationship between the weight of the spleen and the portal pressure. 2. Histologically and morphometrically, there was neither congestion nor enlargement in the red pulp after hepatectomy. Until the 3rd day after hepatectomy, the white pulp was developed. From the second day through the 14th day the marginal zone was enlarged. 3. The incorporation of 3H-thymidine into DNA of the spleen cells increased from the first day through the 7th day after hepatectomy. By autoradiography the labeled cells were mainly large mononuclear cells. 4. Both macrophages phagocytizing carbon particles in the red pulp and endogenous peroxidase-positive macrophages in the marginal zone were increased on the third day but not on the 7th day after hepatectomy. 5. Studied by immunohistochemistry with monoclonal antibodies, both T and B cells in the spleen were increased after hepatectomy. 1 and 3 days after hepatectomy T cell zone was predominant, but 7 days after hepatectomy B cell zone was predominant. Most of cells in the marginal zone were B cells and they were increased on the 7th day after hepatectomy. These results suggest that the splenomegaly after 70% hepatectomy is due to not only portal congestion or increase of macrophages but increase of lymphocytes.

The cardiorespiratory dynamics following hepatic resection was investigated with the use of Swan-Ganz catheter in 34 patients with major hepatic resection. In the patients without cirrhosis or jaundice, cardiac index (CI) appeared to decrease with increased systemic vascular resistance (SVR) during the first postoperative day. CI tended to increase on the second or third postoperative day with normal SVR. In the majority of the patients without hepatic cirrhosis or jaundice who underwent more than 50% hepatectomy the circulating blood volume decreased immediately after the operation and increased after the second postoperative day. In the cirrhotic patients, hyperdynamic state was noted pre- and post-operatively, and was prominent in the cases with poor prognosis. These patients had relatively higher pulmonary arterial and wedge pressure, and were liable to yield to cardiorespiratory insufficiency by overhydration. In the jaundiced patients, the patterns of hemodynamic change were similar to those of the patients without cirrhosis or jaundice except for decreased SVR. The jaundiced patients did not develop severe respiratory distress in spite of having lower PO2 and higher AaDO2.

The author suspected that the high incidence of early recurrence after macroscopically curative operation in human liver cancers correlated with the production of liver regeneration factor which was induced following partial hepatectomy (PH). The author therefore analyzed whether PH enhanced the growth of liver cancers or not, and the relevant mechanism involved, using rats subcutaneously injected with hepatocellular carcinoma (KDH-8, AH-66) cells. Primarily, it proved that PH significantly enhanced the growth of liver cancers injected in rats. The effect of this enhancement of liver cancer growth appeared as an abrupt increase in tumor volume within 24 hours following PH, which fact was supported by the mitotic indices of the hepatocellular carcinoma (KDH-8) cells. However PH did not affect rats injected with mammary carcinoma (SST-2) cells without estrogen receptor (E2R) or fibrosarcoma (KMT-75) cells. Secondly, based on this result, the author tried to analyze the mechanism of enhanced growth of liver cancers following PH, from the standpoints of; changes in postoperative immunity, expression of cytosol E2R in liver cancer cells or liver regeneration factor, using KDH-8 cells. The changes in postoperative immunity (NK-activity and Blastogenesis) did not correlate with the changes in liver cancer growth. Although serum estradiol (E2) increased significantly after PH, E2R was not detected in the KDH-8 cells used in this experiment. Serum was obtained from healthy rats 24 hours after PH, and 20 mg of serum, as calculated from total protein, was eluted into 50 fractions by high liquid chromatography (column; TSK G3000 SW). When the author examined which fractions stimulated both the growth of primarily cultivated hepatocytes and KDH-8 cells, only the fraction Fr. 30, the molecular weight of which was about 100 Kd, enhanced both. Furthermore, the author performed an in vivo assay to determine the number of days needed for tumor appearance: PHs were carried out 2 months, 5 days and 1 day before, at the same day of, and 1 day and 5 days after KDH-8 cell (500 cells/100 microliters, sc) inoculation. The author also noticed from these in vivo tests that PHs which were performed 1 day before, at the same day of, and 1 day and 5 days after the KDH-8 cell inoculation enhanced significantly the growth of liver cancers.

Acute respiratory failure after hepatic resection, especially in case of concomitant liver dysfunction, is the most troublesome postoperative complication. In order to clarify the pathophysiological mechanism of acute respiratory failure, EVLW (extravascular lung water) was measured by double indicator dilution method in canine model. Mongrel dogs underwent laparotomy and the common bile duct was ligated and divided. After 6 weeks, EVLW was significantly elevated compared with that of normal dogs (p less than 0.05). From 4 hours after 70% hepatic resection dextran-40 was loaded to increase PWP (pulmonary wedge pressure). EVLW was increased accompanying the elevation of PWP in all groups, but in the group with biliary obstruction EVLW was significantly increased for the same elevation of PWP. These results suggest that permeability of pulmonary capillary was highly increased after hepatic resection in biliary obstruction group. Pulmonary edema in this canine model seems to resemble ARDS in human and the pathophysiological mechanism was thought to be related with depression of RES phagocytic function, activation of complement system and pulmonary vascular plugging by aggregates of degenerating granulocytes and endothelial injury. Gabexate mesilate blocked the increase of the lung vascular permeability and was thought to be effective to protect the lung from postoperative acute respiratory failure.

It is known that intrinsic endotoxemia is caused by two main mechanisms, reticuloendothelial system dysfunction and intestinal circulatory failure. We investigated the escape of endotoxin from the intestine under occlusion of the superior mesenteric artery 3 days after 70% liver resection in rabbits. Twelve rabbits were given intra-intestinal antibiotics (Antibiotics group) and other twelve rabbits were given saline only (Control group). The results were as follows. Indocyanine green clearance and lipid clearance were deteriorated in both groups after hepatectomy but the antibiotics group showed a better clearance rate than the control group. Serum endotoxin level was elevated slightly after hepatectomy and then grossly elevated after superior mesenteric artery occlusion, but the antibiotics group showed a lower endotoxin level than that of the control group. Seventy-two hours survival rate was apparently better in the antibiotics group. From those data we conclude that the administration of intraintestinal antibiotics contributed to the maintenance of reticuloendothelial function of remnant hepatic lobe and suppressed the serum endotoxin level after superior mesenteric artery occlusion.