Reuters Health Information (2013-01-03): Major laparoscopic hepatectomy safe in selected patients
Major laparoscopic hepatectomy safe in selected patients
Last Updated: 2013-01-03 15:15:17 -0400 (Reuters Health)
NEW YORK (Reuters Health) - Three different types of laparoscopic major hepatectomy, and traditional open liver resection, all yielded similar results in a systematic literature review by Japanese surgeons.
"We believe laparoscopic liver resection is the way to go and most liver surgeons should become familiar with the techniques," senior author Dr. Go Wakabayashi from Iwate Medical University told Reuters Health by email.
Aside from the open operations, cases were done either with pure laparoscopy, hand-assisted laparoscopy, or laparoscopy assisted techniques.
In pure laparoscopy, all of the dissection is done laparoscopically, and the specimen is removed via a Pfannelstiel incision. Hand-assisted surgery involves the use of a hand port to help with the dissection and specimen removal through the hand port incision. In laparoscopy assisted resection, the liver is mobilized laparoscopically, and the liver parenchyma is transected and removed through a 10 cm to 12 cm incision.
None of the 29 papers included in the study were randomized trials or direct comparisons of one method to another, the authors reported online December 20 in Annals of Surgery.
At the time of the literature search - more than a year ago - 1,161 major laparoscopic hepatic resections had been reported, mainly for hepatocellular carcinoma, metastatic disease, and benign tumors.
Operations lasted from 126 to 388 minutes on average. The rate of transfusions ranged from 0% to 33%, and conversions to open surgery occurred in 0% to 26%. Complication rates ranged from 11% to 23%, with three postoperative deaths.
Dr. Wakabayashi believes that blood loss is limited by the pressure exerted by the pneumoperitoneum and the meticulous dissection used in laparoscopic liver surgery. He said the mortality rate is so low because the patients were highly selected and the centers reporting these procedures were quite sophisticated.
Four papers included matched controls; these generally showed that laparoscopic hepatectomy had comparable results to open surgery, with shorter hospital stays and fewer complications in the laparoscopic groups.
In an email to Reuters Health, Dr. David A. Geller, Co-Director of the Liver Cancer Center at the University of Pittsburgh, said, "Overall this is a thorough review of the literature to date on laparoscopic major hepatectomy."
The learning curve was about 15 to 60 cases, and the paper suggests that surgeons who want to learn the technique start by doing simple peripheral lesions at first. Dr. Wakabayashi said it takes about 30 cases to achieve a competence for minor hepatectomy and fewer cases after that for major hepatectomy.
The data on long-term outcomes for cancer surgery are limited, with only 148 cases reported.
Living donor resections appear to be safe, but just 87 cases have been reported. Dr. Geller and Dr. Wakabayashi both mentioned that a living donor died recently in Boston due to bleeding after a laparoscopic hand-assisted hepatectomy.
According to Dr. Geller, many transplant surgeons feel living donor right lobectomies should not be done laparoscopically. Dr. Wakabayashi, however, believes more data are needed from centers that do laparoscopic liver donor hepatectomies before concluding whether they're safe or not.
Few studies addressed costs of open and laparoscopic procedures, and results were mixed due to longer case durations for patients done early in some series and exclusion of outliers.
The authors concluded that each of the three types of laparoscopic major hepatectomy has advantages in certain situations. They write, "The pure laparoscopic method is suitable for experienced surgeons to achieve better cosmetic outcomes, whereas the hand-assisted laparoscopic method was associated with better perioperative outcomes; the laparoscopy-assisted method is used by surgeons for unique resections such as resection of cirrhotic livers, laparoscopic resection of tumors in unfavorable locations, and living donor hepatectomies."
At this point, however, more research is necessary to define their roles of the various approaches. "The biggest factor for choice of technique is still surgeon preference," Dr. Geller said.
Based on his experience and this literature review, Dr. Wakabayashi said, "Although laparoscopic major hepatectomy sounds dangerous, it might not be such dangerous as we imagine."
But Dr. Geller pointed out, "The majority of right hepatic lobectomies worldwide are still being done with an open approach." At his center, 35% of liver resections in 2012 were done with a minimally invasive approach. But for major resections, the laparoscopic technique was used in less than 20% of cases.
Ann Surg 2012.