Search

Laparoscopic hepatectomy for tumors close to the major hepatic veins (HVs) is a technically demanding procedure that is relatively contraindicated. We investigated this surgical technique and the outcomes of intraparenchymal identification of the major HVs using the ventral approach in pure laparoscopic hepatectomy for tumors close to the major HVs. In the present study, tumors

Background Hepatic angiomyolipoma (HAML) is a rare liver tumor, and hepatectomy is the only effective treatment. Due to the difficulty of correct diagnosis of HAML before surgery by image studies, more than 36.6% of reported HAMLs are misdiagnosed as other malignant liver tumors before surgery. As there are only few reported cases in which HAMLs were removed using laparoscopic hepatectomy, the effectiveness of laparoscopic hepatectomy for such HAMLs in which are diagnosed as other malignant liver tumor before surgery has not been reported. Case presentation Case 1: a 58-year-old female with a history of treatment for autoimmune hepatitis was preoperatively diagnosed with hepatocellular carcinoma (size: 20 mm) in segment 7 (S7) of the liver. The tumor was removed by laparoscopic partial resection and was diagnosed as a HAML through a pathological examination. The patient’s postoperative course was good, and she was recurrence-free at 37 months after the hepatectomy. Case 2: a 29-year-old female with a history of surgery for a right mature cystic teratoma was referred to our department to receive treatment for a growing 20-mm liver tumor with some calcification, which arose in S3 of the liver. A metastatic liver tumor derived from the mature cystic teratoma was suspected, and laparoscopic left lateral sectionectomy was performed. The liver tumor was diagnosed as a HAML after a pathological examination. The patient’s postoperative course was unremarkable, and more than 54 months have passed since the hepatectomy without any recurrence. Conclusions Two cases in which HAMLs were preoperatively diagnosed as other malignant liver tumor were successfully removed by laparoscopic hepatectomy with a correct postoperative diagnosis. Laparoscopic hepatectomy for the present 2 cases of HAML seemed to be effective for providing a correct diagnosis after the curative removement of liver tumor with a smaller invasion compared to open hepatectomy, and for denying risk of dissemination of the malignant tumor by needle biopsy that had to be considered before ruling out malignant tumor.

Backgrounds/aims Despite the widespread popularity of laparoscopic surgery, laparoscopic liver resection (LLR) remains in evolution. This study aimed to compare the long-term outcomes for patients undergoing laparoscopic versus open hepatectomy for hepatocellular carcinoma (HCC) ≤7 cm. Methods Patients diagnosed with HCC treated by hepatectomy from October 2000 to May 2019 were included. Excluding tumors larger than 7 cm, 1:2 propensity score matching was performed between laparoscopic and open hepatectomies. The perioperative outcomes, 5-year overall survival (OS) and disease-free survival (DFS) of the two groups were compared. Results Forty-five patients who underwent LLR were matched to 90 open hepatectomy (OH) during the same period. LLR group had shorter median hospital stay (5 days vs. 9 days, p=0.00) but required longer operative time (326.0 minutes vs. 272.5 minutes, p=0.018) than the OH group. The 5-year overall survival was better in the LLR group (84.9% vs. 61.1%; p=0.036), though there was no significant difference in the 5-year disease free survival (20.0% vs. 22.2%, p=0.613). The rate of R0 resection was comparable between the 2 groups with a slightly better margin distance in the LLR (5 mm vs. 3 mm, p=0.043). Conclusions Laparoscopic liver resection is safe and feasible for cirrhotic patients with HCC size up to 7 cm. It has better short-term outcomes and comparable perioperative blood loss and complication rates. The resection margin is not jeopardized and the 5-year overall and disease-free survivals are comparable with the open group.

BACKGROUNDLaparoscopic liver surgery is currently considered the standard of care for various liver malignancies. However, studies focusing on perioperative outcome after laparoscopic hepatectomy (LH) in overweight patients are still sparse and its benefit compared to open hepatectomy (OH) is a matter of debate.AIMTo analyze postoperative outcomes in overweight [body mass index (BMI) over 25 kg/m(2)] and obese (BMI over 30 kg/m(2)) patients undergoing LH and compare postoperative outcome with patients undergoing OH.METHODSPerioperative data of 68 overweight (BMI over 25 kg/m(2)) including a subcohort of obese (BMI over 30 kg/m(2)) patients (n = 27) who underwent LH at our institution between 2015 and 2019 were retrospectively analyzed regarding surgical outcome and compared to an equal number of patients undergoing OH.RESULTSThe mean BMI was 29.8 +/- 4.9 kg/m(2) in the LH group and 29.7 +/- 3.6 kg/m(2) in the OH group with major resections performed in 20.6% (LH) and 26.5% (OH) of cases, respectively. Operative time (194 +/- 88 min vs 275 +/- 131 min; P < 0.001) as well as intensive care (0.8 +/- 0.7 d vs 1.1 +/- 0.8 d; P = 0.031) and hospital stay (7.3 +/- 3.6 d vs 15.7 +/- 13.5 d; P < 0.001) were significant shorter in the LH group. Also, overall complications (20.6% vs 45.6%; P = 0.005) and major complications (1.5% vs 14.7%, P = 0.002) were observed less frequently after LH. An additional investigation analyzing the subgroup of obese patients who underwent LH (n = 27) and OH (n = 29) showed a shorter operative time (194 +/- 81 min vs 260 +/- 137 min; P = 0.009) and a reduced length of hospitalization (7.7 +/- 4.3 d vs 17.2 +/- 17 d; P < 0.001) but no difference in postoperative complications or overall cost.CONCLUSIONLH is safe and cost-effective in overweight and obese patients. Furthermore, LH is significantly associated with fewer postoperative complications and reduced hospital stay compared to OH in these patients.

Hepatectomy had a high mortality rate in the previous decade because of inadequate techniques, intraoperative blood loss, liver function reserve misdiagnoses, and accompanying postoperative complications. However, the development of several modalities, including intraoperative ultrasonography (IOUS), has made hepatectomy safer. IOUS can provide real-time information regarding the tumor position and vascular anatomy of the portal and hepatic veins. Systematic subsegmentectomy, which leads to improved patient outcomes, can be performed by IOUS in open and laparoscopic hepatectomy. Although three-dimensional (3D) computed tomography and gadoxetic acid-enhanced magnetic resonance imaging have been widely used, IOUS and contrast-enhanced IOUS are important modalities for risk analyses and making decisions regarding resectability and operative procedures because of the vital anatomical information provided and high sensitivity for liver tumors, including "disappearing" liver metastases. Intraoperative color Doppler ultrasonography can be used to delineate the vascular anatomy and evaluate the blood flow volume and velocity in hepatectomy patients and recipients of deceased- and living-donor liver transplantation after vessel reconstruction and liver positioning. For liver surgeons, IOUS is an essential technique to perform highly curative hepatectomy safely, although recent advances have also been made in virtual modalities, such as real-time virtual sonography with 3D visualization.

Background/aim To evaluate the complication rates and risk factors associated with transumbilical wounds and investigate the usefulness of an incision for organ removal in laparoscopic hepatectomy (Lap-H). Patients and methods We enrolled 42 patients who underwent Lap-H excluding a small partial resection in our hospital between 2013 and 2018. The occurrences of superficial surgical site infection (SSI) and transumbilical port-site incisional hernia were recorded. Results SSI was not observed, and hernia occurred in 3 patients (7.14%). Univariate analysis revealed that body mass index (BMI) (p=0.004) was significantly associated with the risk of hernia formation. Conclusion High BMI is a risk factor for hernia formation in patients undergoing Lap-H with transumbilical incision; hence, wound closure should be performed carefully. The construction of the transumbilical wound for organ removal was feasible with rationality, with no need to create a new wound.

BACKGROUND Hepatic lymphangioma, a malformation of the liver lymphatic system, is a rare benign neoplasm and usually coexists with other visceral lymphangiomas. Solitary hepatic lymphangioma is much more rarely seen and could cause a clinical misinterpretation as malignancy. CASE SUMMARY A 50-year-old woman with a liver mass of approximately 3.5 cm was initially diagnosed with hepatocellular carcinoma given the risk factors for liver cancer that she presented with, including Schistosome japonicum infection and jaundice, and also together with imaging results, which showed the mass enhanced quickly in the arterial phase and faded fast in the venous phase. The patient did not have the surgery first but received three rounds of transarterial chemoembolization because of her anxiety and fears for operation. Finally, the patient underwent laparoscopic liver segment 4b resection and cholecystectomy and was discharged from the hospital only 10 d after the operation. The pathological examination indicated the mass as hepatic lymphangioma. The patient has been followed up for 30 mo without recurrence. To raise the awareness of this misdiagnosed case and to better diagnose and treat this rare disease in future, we reviewed the published literature of solitary hepatic lymphangioma for its clinical symptoms, imaging presentation, operative techniques, histology features and prognosis. CONCLUSION Solitary hepatic lymphangioma mimicking malignancy makes diagnosis difficult. Complete surgical resection is the first choice to treat solitary hepatic lymphangioma.

Xiaoyun Lu1,2 *,* Ping Yu1,2 *,* Chaopeng Ou1,2 *,* Junchao Wang,1,2 Zhongguo Zhou,1,3 Renchun Lai1,2 1Collaborative Innovation Center for Cancer Medicine, State Key Laboratory of Oncology in South China, Sun Yat-Sen University Cancer Center, Guangzhou, Guangdong, People’s Republic of China; 2Department of Anesthesiology, Sun Yat-Sen University Cancer Center, Guangzhou, Guangdong, People’s Republic of China; 3Department of Liver Surgery, Sun Yat-Sen University Cancer Center, Guangzhou, Guangdong, People’s Republic of China*These authors contributed equally to this work.Correspondence: Zhongguo Zhou; Renchun Lai Email zhouzhg@sysucc.org.cn; lairench@sysucc.org.cnBackground: Our aim was to investigate the postoperative analgesic effect of ultrasound (US)-guided bilateral transversus abdominis plane (TAP) blocks combined with rectus sheath blocks (RSBs) in laparoscopic hepatectomy.Patients and Methods: A total of 126 patients were allocated into two groups for analysis. Group 1 (n = 63) did not receive any local anesthetics. Group 2 (n = 63) received US-guided bilateral TAP blocks and RSBs using 20 mL 0.25% ropivacaine in each block. Postoperative pain scores, the dose of intraoperative remifentanil, 24 h consumption of oxycodone, adverse events such as postoperative dizziness, nausea and vomiting, and the length of postoperative hospital stay were recorded.Results: In the postanesthesia care unit, patients in group 2 had significantly lower pain visual analog scale (VAS) scores at rest than those in group 1 (P < 0.001). The VAS scores both at rest and during movement were significantly lower in group 2 than in group 1 at 2, 4 and 6 h postoperatively (all P < 0.001). There was no difference in VAS scores between the two groups at rest 24 h postoperatively (P = 0.477). However, the VAS score during movement at 24 h in group 2 was significantly lower than that in group 1 (P < 0.001). No significant differences in the incidence of adverse events or the dose of intraoperative remifentanil were observed between the two groups (all P > 0.05). Patients in group 2 had a significantly lower 24 h consumption of oxycodone than patients in group 1 (P < 0.001). The mean length of postoperative hospital stay of group 2 was shorter than that of group 1 (P = 0.032).Conclusion: US-guided bilateral TAP blocks combined with RSBs provide effective postoperative analgesia for laparoscopic hepatectomy, and they could shorten the postoperative hospital stay without increasing the incidence of adverse events from opioids.Keywords: laparoscopic hepatectomy, analgesia, transversus abdominis plane block, rectus sheath block, ultrasound

Introduction Laparoscopic hepatectomy (LH) is very difficult to perform in patients with cirrhosis because of the haemorrhagic and fibrotic nature of the liver, although there are various advantages to laparoscopic surgery. Aim To investigate the surgical outcomes, and efficacy and safety of LH versus open hepatectomy (OH) for hepatocellular carcinoma (HCC) resection. Material and methods A total of 112 patients with cirrhosis, who underwent hepatectomy, were analysed retrospectively. We investigated the safety and efficacy of LH for HCC with cirrhosis. Student's t and χ2 tests, Mann-Whitney's U test, Wilcoxon's signed-rank test, and Fisher's exact test were used in the statistical analysis. Results Seventy-one patients underwent LH, and 41 underwent OH. The conversion rate from LH to OH was 12.7%. After propensity score matching, the estimated blood loss was significantly lower in the LH group than in the OH group (25 vs. 310 ml; p < 0.001), and there was a significant difference between the groups in the operative time (p = 0.091). The LH group had complication rates of 3.6% and 0% for refractory ascites and pleural effusion, respectively, while those were 17.9% and 10.7%, respectively, in the OH group (p = 0.019 and p = 0.005, respectively). The LH group had no mortality, whereas the OH group had a mortality rate of 10.7% (p = 0.038). The postoperative length of stay was significantly longer in the LH group than in the OH group (9 days vs. 14 days) (p = 0.002). Conclusions LH can be performed safely for HCC with cirrhosis. More favourable results are achieved with LH than with OH in terms of surgical outcomes.

Background Several randomized controlled trials (RCTs) compared the effects of laparoscopic hepatectomy (LH) and radiofrequency ablation (RFA) for the treatment of hepatocellular carcinoma (HCC), but the results have remained inconsistent. Hence, a meta-analysis and a systematic review of these treatment modalities are necessary to evaluate their efficacy and safety for HCC treatment. Methods From the inception of this meta-analysis and review until August 31, 2019, we searched Medline, PubMed, EMBASE, Cochrane Library, China National Knowledge Infrastructure, Wanfang Database, and China Biomedical Literature Database for RCTs involving LH and RFA treatments of patients with HCC. The studies were screened and the data from these articles were extracted independently by two authors. Summary odd ratios (OR) or mean differences (MD) with 95% confidence intervals (CI) were calculated for each outcome with a fixed- or random-effect model. The outcomes for effectiveness evaluations included duration of surgery, estimated bleeding volume, incidence of blood transfusion during surgery, duration of hospital stay, and the outcome for safety included the incidence of cancer recurrence. Results Seven RCTs with a total of 615 patients were identified, 312 and 303 of which underwent RFA and LH treatments, respectively. The duration of surgery (MD = −99.04; 95% CI: −131.26–−66.82), estimated bleeding volume (MD = −241.97; 95% CI: −386.93–−97.02), incidence of blood transfusion during surgery (OR = 0.08; 95% CI: 0.02–0.37), and duration of hospital stay (MD = −3.4; 95% CI: −5.22–−1.57) in RFA treatment were significantly lower than those of LH treatment. However, the incidence of cancer recurrence was significantly higher for RFA treatment compared with LH treatment (OR = 2.68; 95% CI: 1.72–4.18). Conclusions LH treatment is preferred over RFA treatment with a better radical effect, but RFA treatment is more beneficial with smaller trauma, development of less complications, and shorter operating time when compared with HCC treatment.

Jun Zhang, Tieshuai Liu, Haiyan Zhou, Yue Fei, Xin Yu Department of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of ChinaCorrespondence: Xin YuDepartment of Anesthesiology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, 3 Qingchun Road East, Jianggan District, Hangzhou 310016, Zhejiang, People’s Republic of ChinaTel +86 13588708514Fax +86 0571-86006662Email xinxin_yu@zju.edu.cnPurpose: Postoperative pain management for patients undergoing hepatic resection is still a challenge due to the risk of perioperative liver dysfunction. The transversus abdominis plane (TAP) block is a promising regional analgesic technique. However, the correct guidelines regarding the dose and regimen of local anesthetics in patients undergoing hepatic resection have yet to be established completely. This study aimed to evaluate the safety and efficacy of ultrasound-guided BD-TAP block with a large dose of ropivacaine in laparoscopic hepatectomy.Patients and Methods: This prospective, blinded, randomized, controlled study was conducted with 50 patients who were scheduled for selective laparoscopic hepatectomy. Patients who received a BD-TAP block (3 mg/kg of ropivacaine diluted to 60 mL) with general anesthesia were categorized into the BD-TAP block group (n = 25), and those who received general anesthesia were categorized into the control group (n = 25). The primary outcomes were consumption of sufentanil within 48 hours post-operation and plasma ropivacaine concentration. The secondary outcomes were the severity of pain (at rest and upon coughing), nausea and/or vomiting, and quality of recovery.Results: Compared with the control group, the patients in BD-TAP block group had a significant reduction of postoperative sufentanil consumption at 2 hours (P = 0.019), 24 hours (P = 0.001), and 48 hours (P = 0.001), and the visual analog scale (VAS) scores on coughing were significantly lower at postoperative 2 hours (P = 0.004). There were no statistically significant differences in postoperative nausea and/or vomiting, flatus, catheter removal, off-bed activity, liver function, or postoperative hospital stay. The mean peak total ropivacaine concentration was 1,067.85 ng/mL, which occurred 1 hour after administering the block, and mean free ropivacaine concentration was 52.32 ng/mL. The highest individual peak plasma concentration was 2,360.90 ng/mL at 45 min postinjection, and the free ropivacaine concentration was 139.29 ng/mL.Conclusion: Ultrasound-guided BD-TAP block provides effective postoperative analgesia after laparoscopic hepatectomy. This study also confirms that ultrasound-guided BD-TAP blocks with 3 mg/kg ropivacaine during laparoscopic hepatectomy almost never results in the plasma ropivacaine concentrations associated with neurotoxicity.Keywords: ropivacaine, laparoscopic hepatectomy, BD-TAP block, neurotoxicity

Minimally invasive hepatectomy has been shown to be associated with improved outcomes when compared with open surgery. However, data comparing laparoscopic and robotic hepatectomy is lacking and limited to single-center studies. Patients undergoing major (≥ 3 segments) or partial (≤ 2 segments) hepatectomy were identified in the 2014–2017 ACS-NSQIP hepatectomy targeted database. Patients undergoing laparoscopic and robotic approaches were compared, and propensity score matching was utilized to adjust for bias. Of 3152 minimally invasive hepatectomies (MIHs), 86% (N = 2706) were partial and 14% (N = 446) were major. The laparoscopic approach was utilized in 92% of patients (N = 2905) and 8% were performed robotically (N = 247). The percentage of MIHs increased over time (p

Carbon dioxide embolism is a rare but severe complication of laparoscopic hepatectomy. We reported a case of massive carbon dioxide embolism that developed into a rare paradoxical gas embolism during laparoscopic hepatectomy and resulted in reduced muscular power of the left upper extremity, severe pleural effusion and hypoalbuminemia after surgery. Fortunately, the patient fully recovered with positive prevention and postoperative treatment. This case report highlights that the surgeon and anaesthesiologist must be aware of the risks and the importance for prompt treatment when massive carbon dioxide embolism occurs.

Purpose: The current study aims to investigate the effect of tumor suppressor LHPP-associated microRNA (miR)-765 on the prognosis of laparoscopic hepatectomy (LH) or open hepatectomy (OH) for hepatocellular carcinoma (HCC). Materials and Methods: A total of 160 patients with HCC were enrolled and randomly divided into the LH or OH group. According to the operation time, these patients were followed up for 12 months, and the number of deaths and the corresponding death time during the follow-up period were counted. Results: The authors found that the LHPP gene levels in HCC tissues were lower than that in adjacent normal tissues, whereas miR-765 was overexpressed in HCC tissue. Overexpression of miR-765 promoted the epithelial-mesenchymal transition and proliferation and inhibited apoptosis of HCC through directly downregulating LHPP expression. Serum miR-765 expression level was significantly associated with lymph node metastasis and histologic grading. Survival analysis showed that the overall survival rate in 12 months after the operation was significantly lower in the OH-high miR-765 group (P

Introduction The efficacy of laparoscopic simultaneous resection of primary colorectal cancer and synchronous colorectal liver metastases (SCRLM) remains unclear. Methods We retrospectively evaluated data from 258 patients who had undergone simultaneous curative resection of the primary tumor and SCRLM from 2006 to 2017. We compared surgical outcomes between open, hybrid (laparoscopic colorectal resection and open hepatectomy), and pure laparoscopic approaches. Surgical outcomes were also evaluated between the open hepatectomy (OH) group (ie, open/hybrid surgery) and the laparoscopic hepatectomy (LH) group (ie, pure laparoscopic surgery) in 141 patients later in the study period (2013-2017), when the clinical indications for laparoscopic hepatectomy were restricted to simple wedge resection and/or left lateral sectionectomy in our center. Results The pure laparoscopic approach was associated with significantly less intraoperative blood loss and a significantly shorter postoperative hospital stay than the open and hybrid approaches. Late in the study period, operative outcomes in the LH group (n = 37) were more favorable than for the OH group (n = 104) in terms of intraoperative blood loss and postoperative hospital stay. In patients with rectal cancer, however, earlier postoperative recovery in the LH group did not differ significantly from the OH group. Conclusion Laparoscopic simultaneous resection of SCRLM with the primary tumor by simple hepatectomy is safe and may enhance patients' postoperative recovery, especially in patients with colon cancer.

Both radiofrequency ablation (RFA) and laparoscopic hepatectomy (LH) are minimally invasive approach for hepatocellular carcinoma (HCC) at early stage. This study aimed to compare the efficacy of RFA and LH for treating HCC with a large cohort.From March 2014 to July 2016, 477 patients who underwent RFA (n = 314) or LH (n = 163) for HCC tumors meeting the criteria were included. Overall survival (OS) and recurrence-free survival (RFS) were compared. Propensity score matching (PSM) was performed to balance for the factors that may affect the choice of treatment.Collectively, the 1-, 2- and 3-year OS rates were significantly greater after LH than RFA, as well the corresponding RFS rates, before and after PSM by 2:1. However, the RFA group had fewer major complications (P=0.004), shorter postoperative stays (P=0.023) and lower hospital charges (P0.001) than the LH group. In the subgroup analysis, RFA demonstrated comparable RFS in treating less than 3 cm tumor (P=0.22) located in noncentral bisection (SII, SIII, SVI, SVII) and tumor between 3 cm and 5 cm (P=0.07) located in central bisections (SIV, SV, SVIII). The female, HBV infection, and RFA are factors of worse OS, and the latter two factors also indicated higher RFS.Though, LH possessed superior intrahepatic control rate than RFA in most condition of tumor smaller than 5 cm, the RFA could be an optimal approach achieved comparable outcomes in patients with centrally located HCC, with fewer major complications, shorter postoperative stays and lower hospital charges.

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.

Laparoscopic hepatectomy has rapidly evolved and has become a viable alternative to open hepatectomy. However, the dissection of liver parenchyma via the laparoscopic caudal approach (parenchymal transection from the caudal to cranial direction under a laparoscopic caudal view) has several limitations. To avoid these limitations in anatomical hepatectomy along the hepatic vein with the caudal approach, it is important to recognize the “tenting sign of the hepatic vein,” which helps to identify the running of the main trunk of the hepatic vein. In the bifurcation of the hepatic vein, there is a possibility of splitting of the hepatic vein branch or disorientation between the main trunk and branch. Therefore, it is vital that when the branch is pulled, the main trunk of the hepatic vein appears to be toward the direction of the branch. As a result, the main trunk appears in the direction from the original route to the pseudo route. In the caudal approach, this phenomenon is called “tenting sign of the hepatic vein.” Therefore, liver dissection should be performed in the contralateral and cranial sides of the main trunk, with the “tenting sign of the hepatic vein” in mind. This report describes specific cases of the “tenting sign of the hepatic vein.” The “tenting sign of the hepatic vein” from the caudal approach is essential knowledge for safe and reliable anatomical laparoscopic hepatectomy and can lead to expansion of indications in the future.

Background: The incidence of hepatocellular carcinoma (HCC) in elderly patients is increasing worldwide. Although open hepatectomy (OH) yields acceptable outcomes, high morbidity rate is concerned. Laparoscopic hepatectomy (LH) has evolved to improve perioperative outcomes. However, comparative study between both techniques for elderly patients with HCC is scarce. Objective: This study aimed to compare outcomes between LH and OH specifically. Methods: HCC patients aged ≥70 years after hepatectomy (2003–2018) were included. The propensity score matching (PSM) and comparative analyses between groups were performed. Results: After PSM, there were 41 patients in each group with similar demographics, radiographic tumor characteristics, cirrhotic status, and extent of resection. The LH group had a shorter hospital stay (7 vs. 11 days, p = 0.002) compared with the OH group. The completeness of resection and complication rates were not statistically different between groups. The 5-year overall survival and recurrence-free survival rates were 86.7 and 43.4% in the LH group and 62.2 and 30.8% in the OH group (p = 0.221 and 0.500). Conclusion: Our study confirmed the operative and oncological safety of LH in elderly HCC patients with improved perioperative outcomes compared with OH.

Introduction: The Iwate Score (IS) have not been well-validated for specific procedures, especially for right posterior sectionectomy (RPS). In this study, the utility of the IS was determined for laparoscopic (L)RPS and the effect of tumor location on surgical outcomes was investigated. Methods: Post-hoc analysis of 647 L-RPS performed in 40 international centers of which 596L-RPS cases met the inclusion criteria. Baseline characteristics and perioperative outcomes of patients stratified based on the Iwate score were compared to determine whether a correlation with surgical difficulty existed. A 1:1 Mahalanobis distance matching was utilized to investigate the effect of tumor location on L-RPS outcomes. Results: The patients were stratified into 3 levels of difficulty (31 intermediate, 143 advanced, and 422 expert) based on the IS. When using a stepwise increase of the IS excluding the tumor location score, only Pringle’s maneuver was more frequently used in the higher surgical difficulty level (35.5%, 54.6%, and 65.2%, intermediate, advanced, and expert levels, respectively, Z = 3.34, p = 0.001). Other perioperative results were not associated with a statistical gradation toward higher difficulty level. 80 of 85 patients with a segment VI lesion and 511 patients with a segment VII lesion were matched 1:1. There were no significant differences in the perioperative outcomes of the two groups including open conversion, operating time, blood loss, intraoperative blood transfusion, postoperative stay, major morbidity, and mortality. Conclusion: Among patients undergoing L-RPS, the IS did not significantly correlate with most outcome measures associated with intraoperative difficulty and postoperative outcomes. Similarly, tumor location had no effect on L-RPS outcomes.

Introduction Reduced port surgery (RPS) has been garnering interest as a novel minimally invasive surgery lately. Aim The authors examined the relationship between the number of ports and surgical outcomes after laparoscopic hepatectomy (LH). Materials and methods Between January 2012 and April 2019, 209 patients who underwent laparoscopic partial resection and lateral sectionectomy were retrospectively analyzed with respect to operative variables and surgical outcomes. Patients were divided into 5 groups by the number of ports used. Student's t test, the χ test, the likelihood-ratio test, Fisher exact test, or Mann-Whitney U test were used to analyze the data. Results Operative duration was significantly longer in patients with a larger number of ports than in those with a smaller number of ports. Chronological pain scores according to the visual analog scale (VAS) on postoperative days 1, 2, 4, and 7 were not associated with the number of ports and wound length in the umbilical region. The frequency of using additional analgesic agents was not significantly different between the groups. VAS scores and the number of additional analgesic agents used were smaller in patients in whom non-steroidal anti-inflammatory drugs were regularly administered postoperatively than in those in whom the drug was not regularly administered postoperatively. LH had a 3.4% complication rate (Clavien-Dindo classification >IIIA); however, this was not significantly different between the groups. Conclusions No significant difference in postoperative pain was observed between RPS and conventional methods, although operative durations were shorter with RPS. However, RPS for LH may be associated with excellent cosmetic results compared with conventional methods.

Diaphragmatic hernias may be either congenital or acquired. Acquired diaphragmatic hernias generally develop in association with blunt or penetrating thoraco-abdominal injuries. Iatrogenic diaphragmatic hernias are rare in the literature. Traumatic diaphragmatic ruptures are diagnosed during the imaging tests performed due to accompanying organ injuries or during surgery. However, acquired diaphragmatic hernias developing in the late postoperative period are uncommon, and the difficulties in diagnosis may result in increased mortality and morbidity. The use of electrocautery and other electric devices during the release of hepatic ligaments is thought to result in diaphragmatic hernias in the late period of diaphragmatic injuries that are missed during surgery. We describe the diagnosis and the therapeutic course of a case undergoing laparoscopic right hepatectomy due to hepatic alveolar echinococcosis and taken for emergency surgery with diagnoses of diaphragmatic hernia and intestinal obstruction approximately 20 months subsequently in the light of the current literature.

Laparoscopic hepatectomy brings many physiologic advantages over open hepatectomy and adheres to all oncologic principles. It is currently considered the standard of care. However, these are technically difficult operations to perform. Consequently, the expertise may not be universally available for all patients to benefit from laparoscopic hepatectomy. We report a unique situation where remote mentoring was used to guide bariatric surgeons in Jamaica to complete a laparoscopic hepatectomy.

Objective: To compare the effectiveness and safety of enhanced recovery after surgery (ERAS) in patients with hepatocellular carcinoma (HCC) undergoing laparoscopic hepatectomy.Methods: From September 2016 to June 2019, 282 patients were enrolled, and ERAS was implemented since March 2018. All indicators related to surgery, liver function, and postoperative outcomes were included in the analysis. Propensity score matching (PSM) identified 174 patients for further comparison.Results: After PSM, the clinicopathological baselines were well-matched. The group showed significantly less intraoperative blood loss (100.00 [100.00–200.00] vs. 200.00 [100.00–300.00] ml, P = 0.001), fewer days before abdominal drainage tube removal (4.00 [3.00–4.00] days vs. 4.00 [3.00–5.00] days, P = 0.023), shorter hospital stay after surgery (6.00 [5.00–6.00] days vs. 6.00 [6.00–7.00] days, P < 0.001), and reduced postoperative morbidity (18.39 vs. 34.48%, P = 0.026). The proportion of patients with a pain score ≥ 4 was significantly lower in the ERAS group within the first 2 days after surgery (1.15 vs. 13.79% and 8.05 vs. 26.44%, P = 0.002 and P = 0.001, respectively). Pringle maneuver was performed more frequently in the ERAS group (70.11 vs. 18.39%, P < 0.001), and a significantly higher postoperative alanine aminotransferase level was also observed (183.40 [122.85–253.70] vs. 136.20 [82.93–263.40] U/l, P = 0.026). The 2-year recurrence-free survival was similar between the two groups (72 vs. 71%, P = 0.946).Conclusions: ERAS programs are feasible and safe and do not influence mid-term recurrence in HCC patients undergoing laparoscopic hepatectomy.