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Background: Surgical treatment of giant hepatic hemangioma larger than 10 cm in diameter often requires major laparoscopic liver resection (LLR), which is very difficult and has a high risk of bleeding. There is no consensus as to whether giant hepatic hemangioma is an indication or a contraindication for laparoscopic surgery.Methods: From 2011/09 to 2018/05, 58 patients with giant hepatic hemangioma larger than 10 cm underwent laparoscopic surgery. They were divided into high-difficulty (HD) group and low-difficulty (LD) group according to the operation difficulty score. The perioperative data of the two groups were analyzed and compared.Results: There were 30 patients in the LD group and 28 in the HD group. No differences were showed in sex, age, ASA grade, tumor size, operation time, conversion rate, intraoperative and post-operative blood transfusion rate, and post-operative complications between the two groups. The amount of bleeding in the HD group was significantly higher than that in the LD group (285.7 ± 224.0 vs 189.6 ± 157.6 ml, p = 0.007). The time of hepatic hilar occlusion in the HD group was longer than that in the LD group (25.4 ± 8.8 vs 20.6 ± 7.3 min, p = 0.001), and the rate of hepatic hilar occlusion in the HD group was also higher than that in the LD group (71.4% vs 33.3%, p = 0.004). The incidence of hospitalization days and discharge time in the LD group were shorter than those in the HD group (6.3 ± 1.6 vs 8.2 ± 1.4 days, p = 0.000; 16.4 ± 5.5 vs 21.9 ± 4.6 h, p = 0.019). There was no significant difference in enzymatic parameters between the two groups after operation.Conclusions: Although there are great difficulties and risks objectively, laparoscopic treatment of giant hepatic hemangioma is safe and feasible. [ABSTRACT FROM AUTHOR]

We present an original surgical technique for identifying the perfusion area of the cystic vein with indocyanine green (ICG) fluorescence imaging and laparoscopic extended cholecystectomy with lymphadenectomy for a 56-year-old woman with diagnosis of clinical T2 gallbladder cancer (GBC). First, we encircled Calot's triangle using the Glissonean approach from the ventral side of the gallbladder plate and then taped the hilar Glissonean pedicles; these were temporally clamped, and ICG was injected into the vein. The perfusion area of the cystic vein was scrutinized, specifically the stained area of the hepatic parenchyma was marked, and extended cholecystectomy was performed along the resection line. Subsequently, we performed lymphadenectomy of the hepatoduodenal ligament to complete the operation. A postoperative histopathological examination revealed moderately differentiated adenocarcinoma with pathological T1bN0M0. Although extended cholecystectomy is currently recommended for clinical T2 GBC, there is no consensus on the definition of the gallbladder bed, and the ideal extent of hepatic resection has, therefore, not yet been determined. In addition, gallbladder bed resection with 2–3 cm of surgical margin is an empirical procedure that lacks scientific verification. Regarding anatomical features, the cystic vein sometimes drains directly into the anterior branch of the portal vein, penetrating the gallbladder plate and Laennec's capsule of the anterior Glissonean pedicle. To address this background, we have developed a technique to identify the perfusion area of the cystic vein to determine the extent of hepatic parenchyma that should be resected during laparoscopic extended cholecystectomy for clinical T2 GBC. [ABSTRACT FROM AUTHOR]

Anatomical liver resections guided by a demarcation line after portal staining or inflow clamping of the target area have been established as essential methods for curative treatment of hepatocellular carcinoma (HCC) and have subsequently been applied to other malignancies. However, laparoscopic anatomical liver resection (LALR) procedures are very difficult to reproduce, and the confirmation of demarcation of the hepatic segment on a monitor is also challenging. Recently, indocyanine green (ICG) fluorescence imaging has been used to identify hepatic tumors and segmental boundaries during hepatectomy. Herein, we describe LALR using ICG fluorescence imaging. Three patients underwent pure LALR using ICG fluorescence imaging at our institute. One patient underwent anatomical partial liver resection for HCC, another underwent segmentectomy 3 for metastatic liver cancer, and the third underwent right anterior sectionectomy for HCC. To visualize hepatic perfusion and the demarcation line by negative staining using an optical imaging system, 2.5 mg ICG was injected intravenously during surgery following clamping or closure of the proximal Glissonean pedicles. For all three cases, ICG fluorescent imaging clearly delineated the demarcation lines and allowed identification of intersegmental planes to some extent because the tumor-bearing hepatic region became non-fluorescing parenchyma during parenchymal transection. This allowed surgeons to recognize the direction and guide the transection of the liver parenchyma when performing LALR. LALR using ICG fluorescence imaging is a feasible procedure for resection of the tumor-bearing hepatic region and facilitates visualization of the demarcation line and identification of the boundaries of the hepatic sections. [ABSTRACT FROM AUTHOR]

Background: Bleeding and carbon dioxide (CO2) gas embolism have been reported as serious complications associated with laparoscopic surgery. We present a case of cerebral infarction presumably caused by CO2 gas embolism during laparoscopic hepatectomy. Case presentation: During liver resection, the end-tidal CO2 suddenly dropped from 40 to 21 mmHg. Simultaneously, ST elevation in lead II and ST depression in lead V5 of the electrocardiogram were observed. After improvement of these electrocardiographic changes, surgery was continued. Postoperatively, incomplete paralysis was present in the right arm and leg. Magnetic resonance imaging revealed cerebral infarction in the broad area of the left cerebral cortex. These complications might have been caused by paradoxical embolism. Conclusion: We should always keep in mind the risk of cerebral infarction with neurological deficits in the case of laparoscopic surgery. Careful monitoring and appropriate treatment for gas embolism are necessary during laparoscopic surgery. [ABSTRACT FROM AUTHOR]

Background: Few studies have been performed to evaluate the value of the Glissonian approach (GA) for laparoscopic formal hemihepatectomy. The purpose of this study was to compare the outcomes of extrahepatic GA with those of the conventional hilar dissection approach for laparoscopic formal right and left hepatectomies in patients with hepatocellular carcinoma (HCC).Methods: Between January 2015 and October 2017, a total of 95 HCC patients who underwent pure laparoscopic formal hemihepatectomies, of whom 49 underwent the GA, were included in this study. After a 1:1 propensity score matching, 42 laparoscopic GA hepatectomies were compared to 42 conventional approach (CA) hepatectomies. We have analyzed perioperative and oncologic outcomes of the two different operative approaches for HCC treatments.Results: The GA did not increase the postoperative overall complication rates (P = 0.415) or the mean comprehensive complication index (P = 0.414) when compared with the CA. However, the operative time was significantly shorter (P = 0.006), and intraoperative blood loss was significantly lower (P < 0.001) in the GA group than in the CA group. There were no significant differences between the GA and CA groups regarding 3-year overall survival rate (P = 0.765) or 3-year disease-free survival rate (P = 0.622).Conclusions: Pure laparoscopic extrahepatic GA hemihepatectomy is safe and feasible, and it was associated with similar complication rates and equivalent 3-year survival outcomes compared to the conventional approach in selected patients with HCC. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the effect of autologous blood transfusion (ABT) and Pringle maneuver (PM) on postoperative early liver function and short-term postoperative results following laparoscopic liver resection in patients with benign hepatic neoplasms. Materials and Methods: We retrospectively analyzed the clinical data for 125 consecutive patients who underwent laparoscopic segmental hepatectomy from January 2015 to May 2018 (68 in the ABT group versus 57 in the PM group). We compared patients' characteristics and intra- and postoperative short-term outcomes between the groups. Results: The 2 groups were well matched regarding patients' clinical characteristics, types of liver resection, operative time, and histopathological findings (P > .05). Median blood loss was significantly lower in the PM group versus the ABT group (200 mL versus 750 mL, respectively; P < .01), and overall complication rates were similar (n = 12 [17%] versus n = 9 [16%], respectively; P > .05). The ABT group had significantly lower mean levels of total bilirubin, indirect bilirubin, aspartate transaminase, and alanine aminotransferase on postoperative days 1 and 3 (P < .05). The ABT group had a shorter hospital stay compared with the PM group (5.8 days versus 7.7 days, respectively; P < .05) and lower hospitalization costs (55,400 ± 15,400 versus 667,000 ± 21,600 CN dollars, respectively; P < .05). Conclusions: Compared with Pringle's maneuver, laparoscopic hepatectomy with ABT promoted early recovery of liver function and reduced hospitalization costs in select patients with benign hepatic neoplasms. [ABSTRACT FROM AUTHOR]

• Lung large-cell neuroendocrine carcinoma (LCNEC) is an aggressive and a rare type of lung cancer. • The prognosis of LCNEC with distant metastasis is extremely poor. • Surgical resection for liver metastasis of LCNEC may improve prognosis. Lung large-cell neuroendocrine carcinoma (LCNEC) is an aggressive and a rare type of lung cancer, and the prognosis of LCNEC with distant metastasis is extremely poor, with a five-year survival rate of 0%. Here, we report a case of laparoscopic hepatectomy for liver metastasis of lung LCNEC. A 63-year-old man received a routine physical examination, and abnormal chest radiographic findings were observed; chest computed tomography (CT) in our hospital revealed that the patient had left pneumothorax and a lesion measuring 18 mm in the inferior lingular segment of the lung. The patient underwent thoracoscopic lobectomy, and the final pathological diagnosis was lung LCNEC. Four years after surgery, abdominal CT revealed a mass measuring 27 mm in the liver. The patient underwent laparoscopic partial hepatectomy, and postoperative pathological examination showed liver metastasis of LCNEC. There was no sign of recurrence 6 months after hepatectomy. LCNEC with distant metastasis has a poor response to systemic chemotherapy, and the median survival time of patients with distant metastasis is estimated to be approximately 6 months, with a five-year survival rate of 0%. Although the common site of metastasis from LCNEC is the liver, there are no previous reports of hepatectomy for liver metastasis of LCNEC. We report a case of laparoscopic hepatectomy for liver metastasis of lung LCNEC. It is suggested that surgical resection for solitary distant metastasis of LCNEC may improve prognosis. [ABSTRACT FROM AUTHOR]

The purpose of this study was to determine the feasibility and outcome of laparoscopic hepatectomy in pediatric patients with liver tumors and introduce surgical techniques to minimize complications. This was a retrospective study of 19 patients less than the age of 18 years old who underwent LLR for liver tumors between November 2005 and May 2017. Ten females and nine males with a median age of 26 months and a median body weight of 14.7 kg were enrolled. Diseases of these patients were hepatoblastoma, neuroblastoma, biliary atresia, and liver abscess. The numbers of resected hepatic segments were more than two in thirteen patients and one in six patients. One patient required conversion to laparotomy to control bleeding caused by injury to the left hepatic vein. Nine patients received transfusions perioperatively. Median duration of operation was 230 min, and median postoperative hospital stay was 7.0 days. There was no postoperative complication. Only one patient showed nonhepatic recurrence of neuroblastoma which caused mortality. LLR for benign and malignant liver tumors showed acceptable amount of bleeding and low complication rate. Therefore, LLR would be a safe and feasible option for liver tumors in children with proper technical efforts and selection of patients. Level III. [ABSTRACT FROM AUTHOR]

We performed this study in order to investigate the impact of liver cirrhosis (LC) on the difficulty of minimally invasive liver resection (MILR), focusing on minor resections in anterolateral (AL) segments for primary liver malignancies. This was an international multicenter retrospective study of 3675 patients who underwent MILR across 60 centers from 2004 to 2021. 1312 (35.7%) patients had no cirrhosis, 2118 (57.9%) had Child A cirrhosis and 245 (6.7%) had Child B cirrhosis. After propensity score matching (PSM), patients in Child A cirrhosis group had higher rates of open conversion (p = 0.024), blood loss >500 mls (p = 0.001), blood transfusion (p < 0.001), postoperative morbidity (p = 0.004), and in-hospital mortality (p = 0.041). After coarsened exact matching (CEM), Child A cirrhotic patients had higher open conversion rate (p = 0.05), greater median blood loss (p = 0.014) and increased postoperative morbidity (p = 0.001). Compared to Child A cirrhosis, Child B cirrhosis group had longer postoperative stay (p = 0.001) and greater major morbidity (p = 0.012) after PSM, and higher blood transfusion rates (p = 0.002), longer postoperative stay (p < 0.001), and greater major morbidity (p = 0.006) after CEM. After PSM, patients with portal hypertension experienced higher rates of blood loss >500 mls (p = 0.003) and intraoperative blood transfusion (p = 0.025). The presence and severity of LC affect and compound the difficulty of MILR for minor resections in the AL segments. These factors should be considered for inclusion into future difficulty scoring systems for MILR. [ABSTRACT FROM AUTHOR]

Abstract Background Laparoscopic hepatectomy for hepatocellular carcinoma (HCC) located in segment VI, VII, or VIII of the liver is usually difficult because of poor operative exposure, due to the unique anatomical structure. In this study, we evaluated the practice of laparoscopic hepatectomy with the left jackknife position for patients with HCC located in segment VI, VII, or VIII. Methods A total of 10 patients were enrolled to undergo laparoscopic hepatectomy with the left jackknife position. Tumors located in segment VI, VII, or VIII were assessed by preoperative dynamic computed tomography or magnetic resonance imaging. Operation time, intraoperative blood loss, postoperative fasting time, postoperative drainage time, major postoperative complications, and duration of postoperative hospital stay were recorded. Results All surgeries were successfully completed. None of the patients required conversion to open surgery during the procedure, and no serious postoperative complications were observed. The median tumor size was 31 mm (range 23–41 mm) in diameter, the mean operation time was 166 ± 38 min, the mean intraoperative blood loss was 220 ± 135 mL, and the median postoperative hospital stay was 4 days (range 2–7 days). Conclusions For HCC located in segment VI, VII, or VIII, laparoscopic hepatectomy with this novel position—the left jackknife position—is safe and effective during tumor resection by exposing a sufficient operating field. Trial registration ClinicalTrials.gov ID: NCT02809287

Objective: To compare the effects of laparoscopic hepatectomy (LH) on the short-term and long-term outcomes in hepatocellular carcinoma (HCC) patients with and without clinically significant portal hypertension (CSPH)., Methods: A systematic literature search of the PubMed, EMBASE, and Cochrane databases was performed for articles published from inception to March 1, 2023. Meta-analysis of surgical and oncological outcomes was performed using a random effects model. Data were summarized as mean difference and risk ratio with 95% confidence intervals., Results: Five cohort studies with a total of 310 HCC patients were included (CSPH 143; Non-CSPH 167). In terms of surgical outcomes, estimated blood loss and the length of hospital stay were significantly lower in the Non-CSPH group than in the CSPH group. There were no significant differences between the two groups regarding other surgical outcomes, including the operative time, ratio of conversion to open surgery, and overall complication rate. In addition, there were also no significant differences between the two groups regarding the oncological outcomes, such as 1-, 3-, and 5-year overall survival., Conclusions: HCC patients with and without CSPH who underwent LH had comparable surgical and oncological outcomes. LH is a safe and effective treatment for HCC patients with CSPH under the premise of rational screening of patients., (© 2023. The Author(s).)

Background: Minimally invasive liver resections (MILR) offer potential benefits such as reduced blood loss and morbidity compared with open liver resections. Several studies have suggested that the impact of cirrhosis differs according to the extent and complexity of resection. Our aim was to investigate the impact of cirrhosis on the difficulty and outcomes of MILR, focusing on major hepatectomies., Methods: A total of 2534 patients undergoing minimally invasive major hepatectomies (MIMH) for primary malignancies across 58 centers worldwide were retrospectively reviewed. Propensity score (PSM) and coarsened exact matching (CEM) were used to compare patients with and without cirrhosis., Results: A total of 1353 patients (53%) had no cirrhosis, 1065 (42%) had Child-Pugh A and 116 (4%) had Child-Pugh B cirrhosis. Matched comparison between non-cirrhotics vs Child-Pugh A cirrhosis demonstrated comparable blood loss. However, after PSM, postoperative morbidity and length of hospitalization was significantly greater in Child-Pugh A cirrhosis, but these were not statistically significant with CEM. Comparison between Child-Pugh A and Child-Pugh B cirrhosis demonstrated the latter had significantly higher transfusion rates and longer hospitalization after PSM, but not after CEM. Comparison of patients with cirrhosis of all grades with and without portal hypertension demonstrated no significant difference in all major perioperative outcomes after PSM and CEM., Conclusions: The presence and severity of cirrhosis affected the difficulty and impacted the outcomes of MIMH, resulting in higher blood transfusion rates, increased postoperative morbidity, and longer hospitalization in patients with more advanced cirrhosis. As such, future difficulty scoring systems for MIMH should incorporate liver cirrhosis and its severity as variables., (© 2023. Society of Surgical Oncology.)

Hepatocellular carcinoma (HCC) is a life-threatening complication of hemophilia. Reports of patients with hemophilia undergoing hepatectomy for HCC are scarce. We report the cases of patients with hemophilia A and B who underwent laparoscopic hepatectomy for HCC. Perioperative hemophilia management was supervised by the hematology team. The patients received coagulation factor bolus injections immediately preoperatively, then continuous intravenous infusions intra- and postoperatively. A laparoscopic segment II partial hepatectomy was performed in case 1. Due to severe adhesions, intermittent pedicle clamping could not be used during parenchymal transection. The surgical duration was 235 min, and the estimated blood loss was 13 mL. The patient was discharged 11 days postoperatively without any complications. In case 2, laparoscopic partial hepatectomy for segments V/VI was performed. An intermittent pedicle clamp (Pringle method) was used during parenchymal transection. The surgical duration and estimated blood loss were 219 min and 18 mL, respectively. The patient was discharged 8 days postoperatively without complications. In both cases, intraoperative bleeding was minimal, and the patients were discharged without postoperative hemorrhage with appropriate perioperative coagulation factor management. Laparoscopic hepatectomy can be safely performed and appears to be a feasible treatment option for HCC in patients with hemophilia., (© 2023. Japanese Society of Gastroenterology.)

Background: Although laparoscopic-assisted donor hepatectomy (LADH) has become the definitive procedure for harvesting living donor livers, its surgical outcomes in association with donor body shape have not been elucidated., Methods: The impact of donor factors, including thoracic shape, on LADH outcomes was retrospectively investigated. Thoracic anthropometric data were examined in all LADHs with a left/right graft between 2013 and 2022., Results: The study included 210 LADHs, consisting of 106 left- and 104 right-lobe donors with similar blood loss and similar operation time. Males have greater thoracic depth and greater thoracic width compared with females, respectively. Thoracic depth was associated with graft weight ( p  < 0.001), blood loss ( p  < 0.001), and operation time ( p  < 0.001). On multivariate analyses, blood loss >500 mL and operation time >8 h were associated with graft weight in the left-lobe donors, and blood loss >500 mL was associated with thoracic depth in the right-lobe donors., Conclusion: The greater thoracic depth is associated with massive blood loss in right-lobe donors. Anthropometric parameters might be helpful for estimating LADH outcomes., Competing Interests: The authors declare no conflicts of interest for this article., (© 2023 The Authors. Annals of Gastroenterological Surgery published by John Wiley & Sons Australia, Ltd on behalf of The Japanese Society of Gastroenterological Surgery.)

Background/aim: Laparoscopic hepatectomy (LH) requires accurate visualization and appropriate handling of hepatic veins and the Glissonean pedicle that suddenly appear during liver dissection. Failure to recognize these structures can cause injury, resulting in severe bleeding and bile leakage. This study aimed to develop a novel artificial intelligence (AI) system that assists in the visual recognition and color presentation of tubular structures to correct the recognition gap among surgeons., Patients and Methods: Annotations were performed on over 350 video frames capturing LH, after which a deep learning model was developed. The performance of the AI was evaluated quantitatively using intersection over union (IoU) and Dice coefficients, as well as qualitatively using a two-item questionnaire on sensitivity and misrecognition completed by 10 hepatobiliary surgeons. The usefulness of AI in medical education was qualitatively evaluated by 10 medical students and residents., Results: The AI model was able to individually recognize and colorize hepatic veins and the Glissonean pedicle in real time. The IoU and Dice coefficients were 0.42 and 0.53, respectively. Surgeons provided a mean sensitivity score of 4.24±0.89 (from 1 to 5; Excellent) and a mean misrecognition score of 0.12±0.33 (from 0 to 4; Fail). Medical students and residents assessed the AI to be very useful (mean usefulness score, 1.86±0.35; from 0 to 2; Excellent)., Conclusion: The novel AI presented was able to assist surgeons in the intraoperative recognition of microstructures and address the recognition gap among surgeons to ensure a safer and more accurate LH., (Copyright © 2023 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Laparoscopic hepatectomy is more conducive to the rapid rehabilitation of patients after surgery compared with open hepatectomy. However, there have been no reports on performing laparoscopic resection for liver metastases in enterostomy patients. Materials: From December 2016 to April 2017, the Liver Surgery Department of the Peking Union Medical College Hospital received three patients who had focal liver lesions after colorectal cancer surgery and enterostomy. We performed laparoscopic hepatectomy for these three patients and reviewed relevant literature. Results: All of these three patients' post-operative recovery was good. We found three different positions of the stomas and the corresponding abdominal adhesions in these three patients. We also summarised several possible related surgical techniques. Conclusion: For patients with colorectal cancer and enterostomy after an operation, implementation of laparoscopic hepatectomy is feasible. Further research is still required for a more comprehensive assessment of this surgical approach. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to compare radiofrequency ablation (RFA) with minimally invasive liver surgery (MIS) in the treatment of small hepatocellular carcinoma (SHCC) and to assess short-term and long-term clinical outcomes.Methods: PubMed, Embase, Cochrane Library, Web of science, and CBM were systematically searched for articles from inception to July 2018, comparing RFA and MIS in SHCC treatment. We evaluated overall survival (OS), disease-free survival (DFS), local recurrence, and complication rates, as well as hospitalization duration and operation times.Results: Six retrospective studies were analyzed, including a total of 597 patients, 313 treated with RFA and 284 treated with MIS. OS rates were significantly higher in patients treated with MIS at 3 years, when compared to RFA (OR 0.55; 95% CI 0.36 to 0.84). The 3-year DFS MIS rates were also superior to RFA (OR 0.63; 95% CI 0.41 to 0.98). In contrast, when compared to MIS, RFA demonstrated a significantly higher rate of local intrahepatic recurrences, (OR 2.24; 95% CI 1.47 to 3.42), and a lower incidence of postoperative complications (OR 0.34; 95% CI 0.22 to 0.53), as well as shorter operation times (OR - 145.31, 95% CI - 200.24 to - 90.38) and hospitalization duration (OR - 4.02,95% CI - 4.94 to - 3.10).Conclusions: We found that MIS led to higher OS, DFS, and lower local recurrences in SHCC patients. Meanwhile, RFA treatments led to significantly lower complication rates, shorter operation times, and hospitalization duration. Considering long-term outcomes, MIS was found to be superior to RFA. However, RFA may be an alternative treatment for patients presenting a single SHCC nodule (≤ 3 cm), given its minimally invasive nature and its comparable long-term efficacy with MIS. Nevertheless, our findings should be explained with caution due to the low level of evidence obtained. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic liver resection is recommended as the standard operation for left lateral sectionectomy (LLS). Robotic liver resection is theoretically better than laparoscopic liver resection in complex cases of liver resection. However, in a complex case of LLS, whether robotic LLS (R-LLS) is still better than laparoscopic LLS (L-LLS) is unclear. This study aims to assess the perioperative outcomes of R-LLS and L-LLS in the overall and in the subgroup of complex cases of LLS.Methods: From January 2015 to June 2017, the data on consecutive patients who underwent R-LLS were retrospectively compared with those who underwent L-LLS. Based on defined criteria for complex cases, the subgroup of such patients who underwent R-LLS were compared with the subgroup of patients who underwent L-LLS. The patient characteristics and surgical outcomes in the whole groups and subgroups of patients were analyzed.Results: The overall R-LLS and L-LLS groups showed no significance differences in operative time, intraoperative blood loss, postoperative hospital stay, blood transfusion and morbidity rates. The overall medical costs were significantly higher in the R-LLS group than in the L-LLS group (12786.4 vs. 7974.3 USD; p < 0.001). On subgroup analysis of the complex cases, the estimated blood loss was significantly less in the R-LLS subgroup than the L-LLS subgroup (131.9 vs. 320.8 ml, p = 0.003). The two subgroups showed no significant differences in postoperative hospital stay (4.7 vs. 5.3 days; p = 0.054) and operative times (126.4 vs. 110.8 min; p = 0.379). The R-LLS subgroup had significantly higher overall medical costs than the L-LLS subgroup (13536.9 vs. 9186.7 USD, p = 0.006).Conclusion: The overall R-LLS group was comparable to the overall L-LLS group in perioperative outcomes. Although the overall medical costs in the robotic subgroup was higher, R-LLS might be a better choice for the subgroup of patients with complex cases when compared to L-LLS. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic hepatectomy (LH) has been reported as a safe and efficacious treatment for hepatocellular carcinoma (HCC) patients. However, in cirrhosis patients, LH may be more complex and challenging. So, the short- and long-term outcomes should be well evaluated between LH and open hepatectomy (OH) in HCC patients with cirrhosis. Objectives: To compare the short- and long-term outcomes of LH with OH in HCC patients with cirrhosis. Materials and Methods: The PubMed, EMBASE, and Web of Science were systematically searched to identify the clinical trials published until July 2018 on the comparison of LH and OH in HCC patients with cirrhosis. The statistical analysis was conducted by the Review Manager 5.3 (Cochrane Collaboration, Oxford, United Kingdom). Short-term outcomes included blood loss, operation time, blood transfusion, postoperative complications, mortality, postoperative hospital stay, tumor size, and surgical margin. Long-term outcomes included 1-, 3-, 5-year overall survival (OS) and 1-, 3-, 5-year disease-free survival (DFS). Results: Seventeen studies with 2004 patients were included in this meta-analysis. For short-term outcomes, LH suggested less blood loss, lower blood transfusion rates, reduced occurrence of postoperative complications, wider surgical margin, shorter postoperative hospital stay, and declined rate of mortality (all P < .05). However, there was no significant difference in operation time (P = .67) between the two groups, whereas tumor size was larger in OH (P = .004). As to long-term outcomes, 1-, 3-, 5-year OS and 1-year DFS were higher in LH group (all P < .05). Nevertheless, there were no significant differences in 3- and 5-year DFS (P = .23 and .83, respectively). Conclusions: For the HCC patients with cirrhosis, current evidence suggests that LH shows not only better outcomes in short term, but also a comparable and even improved long-term prognosis. [ABSTRACT FROM AUTHOR]

Background: Few studies had been performed to concern the outcomes of pure laparoscopic Glissonian pedicle approach hepatectomy (LGAH) for hepatocellular carcinoma (HCC). The aim of this study was to compare the outcomes of LGAH versus open Glissonian pedicle approach hepatectomy (OGAH) for HCC, especially in patients with cirrhosis.Methods: Hepatocellular carcinoma patients who underwent pure LGAH and OGAH between January 2015 and July 2017 in our institution were retrospectively enrolled in this study. Propensity score matching (PSM) of patients in a ratio of 1:1 was conducted to adjust the known confounders. The perioperative and oncological outcomes were compared between the two groups after PSM.Results: Some 80 patients underwent pure LGAH and 134 had OGAH. After PSM, 67 patients in each group were well matched for analysis. Both the postoperative overall complication rates (13.4% vs. 29.9%, P = 0.021) and mean comprehensive complication index (2.63 vs. 7.40, P = 0.035) were significantly lower in the LGAH group than those in OGAH group. Although the operative time was longer in the LRH group (P < 0.001), the length of postoperative hospital stay was shorter in the LRH group (P = 0.024). Furthermore, both the 3-year overall survival rate (73.3% for LGAH vs. 77.8% for OGAH, P = 0.338) and 3-year disease-free survival rate (56.4% for LGAH vs. 62.5% for OGAH, P = 0.455) were not significantly different between the groups.Conclusion: Pure laparoscopic Glissonian approach may be a better alternative to open Glissonian approach in selected HCC patients, which provided fewer complications, shorter postoperative hospital stay and comparable oncological outcomes. [ABSTRACT FROM AUTHOR]

Background: This retrospective study compared the short- and long-term outcomes of laparoscopic liver resection (LLR) and open liver resection (OLR) and identified patients who might gain more benefits from LLR.Methods: The demographic and perioperative data, short-term surgical outcomes, and long-term oncological results of all 313 patients who received elective liver resection for hepatocellular carcinoma (HCC) between January 2010 and June 2017 were analyzed. The patients were then divided into stage-specific subgroups according to the TNM staging system for comparison.Results: LLR was performed in 153 patients and OLR in 160 patients. LLR is associated with less blood loss (p < 0.001), shorter surgical time (p = 0.001), shorter length of hospital stay (p < 0.001), and lower morbidity rate (p = 0.034). The 5-year overall survival (OS) rates in the LLR group were higher than those in the OLR group (78.1 vs. 57.6%; p = 0.002). Stage-specific subgroup analysis revealed similar 5-year OS in the two groups (stage I: 82.8 vs. 82.6%, p = 0.845; stage II: 80.3 vs. 69.2%, p = 0.638; stage III: 55.6 vs. 34.8%, p = 0.681), as did the 5-year recurrence-free survival. Moreover, the short-term outcomes were better in the LLR group in terms of surgical time, blood loss, and length of hospital stay, and these benefits attenuated with advancing tumor stage.Conclusions: LLR for HCC is a safe and feasible procedure that does not compromise long-term oncological outcomes. In early tumor stages, LLR might be better in terms of short-term surgical outcomes. [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]

Background: Hemorrhage during the liver transection is the major hazard for laparoscopic hepatectomy (LH). We aimed to evaluate the feasibility and safety of a 915-MHz microwave device used in LH.Methods: Data were retrospectively analyzed regarding 60 patients who underwent LH with or without 915-MHz microwave coagulation at our center from January 2016 to June 2016. 30 patients underwent the 915-MHz microwave-assisted LH (MW group), and 30 patients otherwise were considered as control group.Results: No perioperative mortality was observed. Intraoperative blood loss amounts in microwave group and control group were 26.83 ml and 186.33 ml, respectively (P < 0.001). The durations of parenchyma transaction (55.17 vs. 70.83 min, P < 0.001), blood occlusion (2.17 vs. 25.33 min, P < 0.001), and operation (120.67 vs. 148.00 min, P < 0.001) were much shorter in microwave group compared with control group. Lower incidence of postoperative complications (0.0 vs. 14.3%, P = 0.038) and shorter length of postoperative hospital stay (6.00 vs. 7.23 days, P = 0.027) were also noted in the microwave group, compared with the control group.Conclusion: 915-MHz microwave-assisted LH was found to be safe and efficient. [ABSTRACT FROM AUTHOR]

Summary Background Obesity is generally reported to increase the risk of surgical complications. There have been few reports of laparoscopic hepatectomy (LH) in obese patients. The purpose of this study was to compare the safety and efficacy of (1) LH versus open hepatectomy (OH) in obese patients and (2) LH in obese patients versus LH in non-obese patients. Methods We introduced LH at our institution in April 2014. LH was performed in 63 obese patients and 108 non-obese patients from April 2014 to May 2017. OH was performed in 79 obese patients from January 2010 to May 2017. This study retrospectively compared the short-term outcomes of the LH obese group with those of the OH obese group and the LH non-obese group. Results In patient characteristics, the LH obese group included a significantly higher percentage of patients with liver cirrhosis than the OH obese group. The LH obese group had fewer patients with a history of abdominal surgery but more with liver cirrhosis than the LH non-obese group. For short-term outcomes, the LH obese group had significantly less blood loss, fewer intraoperative transfusions, fewer positive surgical margins, and shorter postoperative hospital stays than the OH obese group. In contrast, only operation time was significantly different (longer) in the LH obese group than in the LH non-obese group. There were no significant differences in morbidity or mortality between the LH obese group and either the OH obese or the LH non-obese groups. Conclusion LH in obese patients is safe and effective. [ABSTRACT FROM AUTHOR]

Abstract Aims Hepatic ischemia-reperfusion (I/R) injury is an unavoidable complication of liver surgery, often resulting in postoperative complications and liver dysfunction. Adipose-derived stem cells (ADSCs) have been recognized as a potential tool to be exploited in the field of regenerative medicine for the treatment of a variety of diseases. In the present study, the efficacy of ADSCs in a porcine I/R model of laparoscopic hepatectomy was evaluated. Main methods Twelve Bama miniature pigs were randomly divided into IRI and ADSCs group. ADSCs were injected through the liver parenchyma following a partial laparoscopic hepatectomy. The roles of ADSCs on oxidative stress and autophagy were analyzed. Key findings It was observed that serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin (T-BIL) and lactate dehydrogenase (LDH) was significantly decreased in response to the ADSC treatment. The data were suggestive of the mechanism of action through which ADSCs exert their attenuating effects on oxidative stress by increasing the activity of superoxide dismutase (SOD), and by suppressing the generation of both myeloperoxidase (MPO) and malondialdehyde (MDA). Moreover, the expression of the critical markers of autophagy including Beclin1, ATG5, ATG12 and LC3II all decreased, whereas expression of P62 increased during phagophore expansion. Significance In conclusion, ADSCs attenuate hepatic I/R and hepatectomy-induced liver damage by reducing oxidative stress and inhibiting autophagy. [ABSTRACT FROM AUTHOR]

Background: The value of laparoscopic liver resection (LLR) for difficult lesions (located in segments I, IVa, VII, and VIII) is still controversial nowadays. The aim of this study was to summarize quantitatively the evidence related to this issue. Materials and Methods: Two investigators independently searched the Medline, Embase, Science Citation Index Expanded, and Cochrane Library databases for eligible studies published before December 2017. The RevMan 5.3 software was utilized for statistical meta-analysis. Weighted mean differences (WMDs) and odds ratios (ORs) were calculated for continuous and dichotomous variables, respectively. Results: Five studies with a total number of 638 patients were included in the present meta-analysis, with 274 patients in the LLR group and 364 in the open liver resection (OLR) group. The LLR did not increase the operative time (WMD 12.42 minutes; 95% confidence interval [CI] -8.54 to 33.38 minutes; P = .25) or blood transfusion requirement (OR 0.81; 95% CI 0.40-1.64; P = .57) compared with OLR. Conversely, LLR was associated with significantly lower intraoperative blood loss (WMD -140.57 mL; 95% CI -203.39 to -77.76 mL; P < .001), shorter hospital stay (WMD -2.88 days; 95% CI -4.84 to -0.92 days; P = .004), and lower overall morbidity (OR 0.43; 95% CI 0.28-0.65; P < .001). The oncologic outcomes of R0 resection rate, surgical margin, and tumor recurrence were comparable in the two groups. Conclusion: LLR for difficult lesions in selected patients is safe, technically feasible, and advantageous when performed by experienced surgeons. [ABSTRACT FROM AUTHOR]

Background: Previous guidance and consensus have well-addressed the advantages of laparoscopic procedures in the anterolateral segments of II, III, IVb and V of the liver, as for lesions located in the posterosuperior segments of I, IVa, VII and VIII is challenging but has become more practical recently due to progress in operative techniques.Methods: A systematic review and meta-analysis was conducted to evaluate the safety and efficacy of LH and OH patients with tumors located in posterosuperior segments. The primary sources of the reviewed studies through April 2018, with restriction on the language of English, were Pubmed and Embase.Results: A total of 5 studies qualified for inclusion in this quantified meta-analysis with a total of 647 patients. LH was associated with significantly less overall complication (OR = 0.43, 95%CI: 0.28-0.65; P < 0.0001, I2 = 0%) and non-significantly less severe complication significantly (P = 0.06) compared with OH. Shorter length of hospital stay of 2.08day (95%CI: -3.68day to -0.49day; P = 0.01, I2 = 81%) was observed in LH. As for mortality, transfusion, R0 resection, tumor-free margin and operative time the pooled outcomes were comparable. Long-term survivals were similar between LH and OH for the posterosuperior segments.Conclusion: Laparoscopic hepatectomy could be the preferred option for posterosuperior segments for selected patients. Future well designed and large studies should focus on the impacts of underlined liver chronic diseases such as cirrhosis on patient prognosis. [ABSTRACT FROM AUTHOR]

Background: Several studies published mainly from pioneers and early adopters have documented the evolution of minimally invasive hepatectomy (MIH). However, questions remain if these reported experiences are applicable and reproducible today. This study examines the changing trends, safety, and outcomes associated with the adoption of MIH based on a contemporary single-institution experience.Methods: This is a retrospective review of 400 consecutive patients who underwent MIH between 2006 and 2017 of which 360 cases (90%) were performed since 2012. To determine the evolution of MIH, the study population was stratified into four equal groups of 100 patients. Analyses were also performed of predictive factors and outcomes of open conversion.Results: Four hundred patients underwent MIH of which 379 (94.8%) were totally laparoscopic/robotic. Eighty-eight (22.0%) patients underwent major hepatectomy and 160 (40.0%) had resection of tumors located in the posterosuperior segments. There were 38 (9.5%) open conversions. Comparison across the four groups demonstrated that patients were older, had higher ASA score, and had increased frequency of previous abdominal surgery and repeat liver resections. There was also an increase in the proportion of patients who underwent totally laparoscopic/robotic surgery, major liver resection, resection of ≥ 3 segments, and multiple resections. Comparison of outcomes demonstrated that there was a significant decrease in open conversion rate, longer operation time, and increased use of Pringles maneuver. The presence of cirrhosis and institution experience (1st 100 cases) were independent predictors of open conversion. Patients who required open conversion had significantly increased operation time, blood loss, blood transfusion rate, morbidity, and mortality.Conclusion: The case volume of MIH performed increased rapidly at our institution over time. Although the indications of MIH expanded to include higher risk patients and more complex hepatectomies, there was a decrease in open conversion rate and no change in other perioperative outcomes. [ABSTRACT FROM AUTHOR]

Abstract Background Laparoscopic hepatectomy is increasingly being used to treat hepatocellular carcinoma (HCC). However, few studies have examined the treatment of recurrent HCC in patients who received a prior hepatectomy. The present prospective study compared the clinical efficacy of laparoscopic surgery with conventional open surgery in HCC patients with postoperative tumor recurrence. Methods We conducted a prospective study of 64 patients, all of whom had undergone open surgery once before, who were diagnosed with recurrent HCC between June 2014 and November 2014. The laparoscopic group (n = 31) underwent laparoscopic hepatectomy, and the control group (n = 33) underwent conventional open surgery. Operation time, intraoperative blood loss, surgical margins, postoperative pain scores, postoperative time until the patient could walk, anal exsufflation time, length of hospital stay, and inpatient costs were compared between the two groups. The patients were followed up for 1 year after surgery, and relapse-free survival was compared between the two groups. Results All surgeries were successfully completed. No conversion to open surgery occurred in the laparoscopic group, and no serious postoperative complications occurred in either group. No significant difference in inpatient costs was found between the laparoscopic group and the control group (P = 0.079), but significant differences between the two groups were observed for operation time (116.7 ± 37.5 vs. 148.2 ± 46.7 min, P = 0.031), intraoperative blood loss (117.5 ± 35.5 vs. 265.9 ± 70.3 mL, P = 0.012), postoperative time until the patient could walk (1.6 ± 0.6 vs. 2.2 ± 0.8 days, P 0.05) between the patients with contralateral HCC recurrence (n = 18) and those with ipsilateral HCC recurrence (n = 13). However, intraoperative blood loss was significantly less (97.7 ± 14.0 vs. 186.3 ± 125.6 mL, P = 0.012) and the hospital stay was significantly shorter (4.2 ± 0.7 vs. 6.1 ± 1.7 days, P = 0.021) for the patients with contralateral recurrence than for those with ipsilateral recurrence. Conclusions For the patients who previously underwent conventional open surgical resection of HCC, complete laparoscopic resection was safe and effective for recurrent HCC and resulted in a shorter operation time, less intraoperative blood loss, and a faster postoperative recovery than conventional open surgery. Laparoscopic resection was especially advantageous for the patients with contralateral HCC recurrence.

Donor operation in adult living donor liver transplantation is associated with significant postoperative morbidity. To avoid laparotomy wound complications and shorten postoperative recovery, laparoscopic liver graft harvest has been developed recently. However, to determine the cut point of bile duct is challenging. Herein, we report the application of totally laparoscopic approach for right liver graft harvest in a donor with trifurcation of the bile duct. A19-year-old man volunteered for living donation to his father who suffered from hepatitis B virus-related cirrhosis of liver and hepatocellular carcinoma. The graft was 880 mL with a single right hepatic artery and portal vein. The graft to recipient weight ratio was 1.06. The middle hepatic vein was preserved for the donor and the liver remnant was 42.3%. Two branches of middle hepatic veins were > 5 mm in diameter and needed reconstruction with cryopreserved allograft. Ductoplasty using laparoscopic intracorporeal suture technique was done to achieve single orifice of the graft bile duct. The postoperative course was uneventful for the donor. This report adds evidence of the feasibility of pure laparoscopic right donor hepatectomy and describes the necessary steps for bile duct division in donors with trifurcation of bile duct.