Search

Background: Minimally invasive liver resection (MILR) has been increasingly adopted over the past decade, and its application has been expanded to the management of extrapancreatic biliary malignancies (EPBMs). We aimed to evaluate the peri-Â and post-operative outcome of patients undergoing MILR for suspected EPMB. Methods: Forty-four consecutive patients who underwent MILR with a curative intent for EPBM at Singapore General Hospital between 2011 and 2018 were identified from a prospectively maintained surgical database. Clinical and operative data were analysed and compared to provide information and make comparisons on peri-Â and post-operative outcomes. Results: A total of 26, 5 and 13 patients underwent MILR for intrahepatic cholangiocarcinoma (ICC), perihilar cholangiocarcinoma (PHC) and gallbladder carcinoma (GBCA), respectively. Six major hepatectomies were performed, of which one was laparoscopic assisted and another was robot assisted. Ten patients underwent posterosuperior segmentectomies. There was one open conversion. The mean operative time was 266.5 min, and the mean blood loss was 379 ml. The mean length of hospital stay was 4.7 days with no incidences of 30-Â and 90-day mortality. The rate of recurrence-free survival (RFS) was 75% (at least 12-month follow-up). There was a significantly higher rate of robot-assisted procedures in patients undergoing MILR for GBCA/PHC as compared to ICC (P = 0.034). Patients undergoing posterosuperior segmentectomies required longer operative time (P = 0.018) with an increased need for (P = 0.001) and duration of (P = 0.025) Pringles manoeuvre. There were no differences in operative time, blood loss, morbidity, mortality or RFS between the above groups. Conclusion: Minimally invasive surgery can be adopted safely with a low open conversion rate for EPBMs. [ABSTRACT FROM AUTHOR]

Background: A recent study analysing the experience of fellowship‐trained early adopting surgeons during stage 3 of the IDEAL paradigm demonstrated that the learning curve (LC) of minimally invasive hepatectomy (MIH) can be shortened compared to the long steep LC of pioneering surgeons. In this study, we aimed to critically appraise the contemporary learning experience with MIH of a 'self‐taught' early adopter during stage 3 of the IDEAL paradigm. Methods: A review of the first 200 patients who underwent MIH over an 88‐month period since 2011 by a single surgeon who had no prior training in MIH was conducted. The cohort was divided into four groups of 50 patients. Risk‐adjusted cumulative sum analysis of the LC was performed. Results: Two hundred patients underwent MIH and there were 13 (6.5%) open conversions. There were 55 (27.5%) major resections and 94 (47.0%) were graded as high/expert difficulty according to the Iwate criteria. Fifty‐one (25.5%) patients had cirrhosis and 98 (49%) had previous abdominal surgery including 28 (14%) with previous liver resections. There were five (2.5%) major (Grade 3b–5) morbidities, zero 30‐day mortality and one (0.5%) 90‐day mortality. Comparison across the four groups demonstrated a significant trend towards increased adoption of total MIH, increased multifocal tumours, increased performance of major hepatectomies and decreased blood loss. Risk‐adjusted cumulative sum analysis demonstrated that the LC in terms of blood loss, blood transfusion rate, open conversion rate, operation time and post‐operative length of stay to be 65 cases. The LC for MIH of Iwate low/intermediate difficulty and of Iwate high/expert difficulty were 35 and 30 cases, respectively. Conclusion: MIH of all difficulty levels is feasible and can be safely adopted today even by surgeons with no prior formal training. The LC of the 'self‐taught' early adopter is about 65 cases. [ABSTRACT FROM AUTHOR]

Background: The role of minimally invasive major hepatectomy (MIMH) remains controversial and questions remain about its safety and reproducibility outside expert centres. This study examines the changing trends, safety and outcomes associated with the adoption of MIMH based on a contemporary single institution experience. Methods: This study is a review of 120 consecutive patients who underwent MIMH between 2011 and 2018. To determine the evolution of MIMH, the study population was stratified into four equal groups of patients. Both conventional major hepatectomies (CMHs) (≥3 segments) and technical major hepatectomies (right anterior and posterior sectionectomies) were included. Results: There were 70 CMHs and 50 technical major hepatectomies. Seven MIMHs were laparoscopic‐assisted and 113 (94.2%) were totally laparoscopic/robotic. There were 10 (8.3%) open conversions. Comparison across the four groups demonstrated that with increasing experience, there was a significant trend in a higher proportion of higher American Society of Anesthesiologists score patients, increasing frequency of CMH performed, increasing frequency of multifocal tumours resected, decreasing use of laparoscopic‐assisted approach and decrease in blood loss. Conclusion: MIMH can be adopted safely today with a low open conversion rate. Over time with increasing experience, we performed MIMH with increasing frequency in higher risk patients and in patients with multifocal tumours but with a decrease in median estimated blood loss. [ABSTRACT FROM AUTHOR]

Background: Presently, the adoption of laparoscopic hepatectomy is rapidly increasingly worldwide. However, the application of robotic hepatectomy (RH) remains limited and its role remains undefined today. Methods: A retrospective review of 43 consecutive patients who underwent RH at two institutions in the Singapore Health Services Group. Results: Forty‐three consecutive patients underwent 48 resections during the study period. Seven (16.3%) patients underwent major resections and seven (16.3%) underwent right posterior sectionectomies. Nineteen (44.2%) patients had tumours located in the difficult posterosuperior segments, five had multiple resections and three underwent repeat resections for recurrent tumours. RH was performed for malignant tumours in 32 (74%) patients and 16 (37.2%) had cirrhosis. Seven RH was performed with other concomitant procedures including three colectomies, three hilar lymphadenectomies and one portal vein ligation. The median operation time was 360 min (range 75–825) and the median blood loss was 300 mL (range 25–4500). There was one (2.3%) open conversion for bleeding. The median post‐operative stay was 4 days (range 2–33) and there was one (2.3%) readmission. There was one (2.3%) major (>grade 2 morbidity) in a patient with concomitant anterior resection who underwent reoperation for anastomotic leak. There was no 90 day/in‐hospital mortality. Comparison between RH for tumours in the anterolateral segments versus posterosuperior segments demonstrated no significant difference in perioperative outcomes. Conclusion: Our initial experience demonstrated that RH is safe, feasible and associated with excellent post‐operative outcomes. It can be performed successfully with low morbidity even for complex resections such as major hepatectomies, posterior sectionectomies, tumours in difficult posterosuperior segments and repeat liver resections. [ABSTRACT FROM AUTHOR]

Introduction: We aimed to analyse the changing trends, safety and outcomes associated with the adoption of laparoscopic liver resection (LLR) at a single centre.Methods: A retrospective review of patients who underwent LLR from 2006 to 2014 at our institution was performed. To explore the evolution of LLR, the study was divided into three equal consecutive time periods (Period 1: 2006-2008, Period 2: 2009-2011, and Period 3: 2012-2014).Results: Among 195 patients who underwent LLR, 24 (12.3%) required open conversions, 68 (34.9%) had resection of tumours in the difficult posterosuperior segments and 12 (6.2%) underwent major (≥ 3 segments) hepatectomies. Median operation time was 210 (range 40-620) minutes and median postoperative stay was 4 (range 1-26) days. Major postoperative morbidity (> Grade II) occurred in 11 (5.6%) patients and 90-day/in-hospital mortality was 1 (0.5%). During the study, the number of LLRs performed showed an increasing trend (Period 1: n = 22; Period 2: n = 19; Period 3: n = 154). Other statistically significant trends were: (a) increase in malignant neoplasms resected; (b) increase in resections of difficult posterosuperior segments; (c) longer median operation time; and (d) decrease in open conversion rates.Conclusion: Over the study period, the number of LLRs increased rapidly. LLR was increasingly performed for malignant neoplasms and lesions located in the difficult posterosuperior segments, resulting in longer operation times. However, open conversion rates decreased, and there was no change in postoperative morbidity and other perioperative outcomes. [ABSTRACT FROM AUTHOR]

Background Repeat liver resection is effective for recurrent hepatocellular carcinoma ( rHCC). This study aimed to determine the outcomes of laparoscopic repeat liver resection ( LRLR) for rHCC. Methods Eight consecutive patients who underwent LRLR for rHCC were retrospectively reviewed. Results Six patients had previous open and two had laparoscopic liver resection (LLR). There was one (12.5%) open conversion for bleeding and one (12.5%) post-operative morbidity. The median tumour size was 24 mm (range: 8-50 mm). LRLR was performed for rHCC in the ipsilateral lobe as compared to the index surgery in 4/8 (50%) patients. Five of eight (62.5%) patients had rHCC in the difficult posterosuperior segments. Six patients had previous open LR, and two had previous LLR. One patient (patient 4) had two prior open LR for rHCC, and LRLR was performed for the second recurrence. The median duration from the first surgery to LRLR was 29 months (range: 6-109 months). The median post-operative stay was 3.5 days. All eight patients had R0 resections, and at a median follow-up of 7.5 months, all patients were disease-free. Conclusion LRLR for rHCC is feasible and safe. This can be performed even for patients with previous open liver resections, cirrhosis, lesions in the posterosuperior segments and prior LR of the ipsilateral lobe. LRLR for rHCC is feasible and safe in highly selected patients. [ABSTRACT FROM AUTHOR]

Introduction: In this study, we report our initial experience with robotic hepatectomy. Methods: Consecutive patients who underwent robotic hepatectomy at Singapore General Hospital, Singapore, from February 2013 to February 2015 were enrolled in this study. The difficulty level of operations was graded using a novel scoring system for laparoscopic hepatectomies. Results: During the two-year period, five consecutive robotic hepatectomies were performed (one left lateral sectionectomy, one non-anatomical segment II/III resection, one anatomical segment V resection with cholecystectomy, one extended right posterior sectionectomy and one non-anatomical segment V/VI resection). Two hepatectomies were performed for suspected hepatocellular carcinoma, two for solitary liver metastases and one for a large symptomatic haemangioma. The median age of the patients was 53 (range 38-66) years and the median tumour size was 2.5 (range 2.1-7.3) cm. The median total operation time was 340 (range 155-825) minutes and the median volume of blood loss was 300 (range 50-1,200) mL. There were no open conversions and no mortalities or major morbidities (> Clavien-Dindo Grade II). The difficulty level of the operations was graded as low in one case (Score 2), intermediate in three cases (Score 5, 6 and 6) and high in one case (Score 10). There was one minor morbidity, where the patient experienced Grade A bile leakage, which resolved spontaneously. The median length of postoperative hospital stay was 5 (range 4-7) days. Conclusion: Our initial experience confirmed the feasibility and safety of robotic hepatectomy. [ABSTRACT FROM AUTHOR]

Background: Totally laparoscopic major hepatectomy (LMH) is a technically challenging procedure with limited studies mainly from high‐volume expert centers reported. In this study, we report our initial experience with totally LMH. Methods: A retrospective review of a prospective database of 340 consecutive patients who underwent laparoscopic liver resection at a single institution was conducted. Thirty‐one consecutive patients who underwent attempted totally LMH between March 2011 to December 2016 were identified. Major hepatectomies were defined as resection of ≥3 contiguous segments which included only right/left hepatectomies, extended hepatectomies or central hepatectomies. Results: The procedures included 11 right hepatectomies, one extended right hepatectomy, nine left hepatectomies (two including middle hepatic vein), two extended left hepatectomies, two left hepatectomies with caudate lobe and six central hepatectomies. The median tumor size was 40 (range, 12–100) mm and the median operation time was 435 (range, 245–585) min. Median blood loss was 500 (range, 100–1900) mls and 10 (32.3%) patients required blood transfusion. There were three (9.7%) open conversions of which two occurred during the first five cases. There was one (3.2%) major (>grade 2) morbidity and there were no 30‐day/in‐hospital mortalities or reoperations. The median postoperative stay was 5 (range, 3–14) days. Conclusion: Our initial experience confirms the feasibility and safety of LMH. There was an increase in the number and proportion of LMH performed at our institution over time. [ABSTRACT FROM AUTHOR]