Recommendations for Laparoscopic Liver Resection
Recommendations for Laparoscopic Liver Resection
Q8. Current Spread of LLR. The number of LLRs reported has steadily increased, especially since 2009, with the increase marked by greater proportions of major and anatomic LLRs, although minor resections still comprise the vast majority of procedures in clinical practice. East Asia, North America, and Europe seem to be witnessing the greatest diffusion of LLR. The number of hepatocellular carcinoma (HCC) cases to which LLR is applied has increased steeply over the past 5 years, especially in Asia and Europe, and the rate of conversion to OLR is gradually decreasing.
Q9. A Difficulty Scoring System for LLR. In an effort to estimate the difficulty of LLR easily before surgery, a novel difficulty scoring system was created for discussion at the ICCLLR. The difficulty of LLR is determined by various factors, such as the tumor size, the extent of liver resection, the tumor location, the proximity to major vessels, and the severity of fibrosis. The difficulty scoring system can be used to predict the difficulty of LLR from preoperative variables and to appropriately select patients according to the surgeons' skill level, ranked as low, intermediate, advanced, or expert. In addition, to these factors, it was suggested that the use of hand-assisted laparoscopic surgery (HALS) and the hybrid method (in which the operation is begun laparoscopically and completed through a small open incision) are likely to reduce certain difficulties associated with pure LLR and should be taken into account in future difficulty scorings.
Q10. The Role of HALS and Hybrid Procedures in LLR. Although pure laparoscopy is the most commonly used technique worldwide, there are geographical differences, and many centers use a combination of pure laparoscopic, HALS, and the hybrid technique in selected cases. Although there are no data that suggest any of these 3 approaches is superior to the others, HALS and the hybrid method are claimed by their proponents to be beneficial for large lesions, posterior lesions, donor hepatectomy and for the training of surgeons in major LLR techniques. HALS and the hybrid method can be used to manage intraoperative difficulties that are encountered, and they can in theory decrease the frequency of conversion to a full open incision.
Q11. Conceptual Changes. The caudal approach is the main conceptual change in LLR. The caudal approach, which relies on visual magnification, offers improved exposure around the right adrenal gland and the vena cava and greatly facilitates identification of the Laennec's capsule and the Glissonian pedicle at the hilar plate. Furthermore, meticulous caudal-cranial transection of the hepatic parenchyma with magnification results in better identification of intraparenchymal structures for optimal transection of the liver. Compared to the anterior approach, which has been described for the resection of large tumors with liver parenchymal transection before right lobe mobilization, the caudal approach can be applied efficiently to expose the inferior vena cava from caudal to cranial with division of the short hepatic veins before parenchymal transection. In addition, CO2 pneumoperitoneum is likely to reduce bleeding from hepatic veins. Placement of the patient in the reverse Trendelenburg position should help decrease the venous pressure and improve exposure by gravitationally shifting visceral structures away from the liver hilum. Other conceptual changes include the superior and lateral approaches with or without the use of intercostal or transthoracic trocars. For these approaches, the patient is placed in the left lateral decubitus position. The left lateral decubitus position or even the prone position offers better exposure of the right posterior segments and lifts the right hepatic vein higher than the vena cava to reduce hepatic venous bleeding. However, there are some inherent drawbacks to LLR, such as lack of tactile sensation and restricted maneuvers that can lead to challenges in treating bleeding.
Q12. Essentials in Bleeding Control. The CO2 pneumoperitoneum is generally established at 10 to 14 mm Hg, and this provides for fairly good control of back-bleeding during liver transection. Low central venous pressure (<5 mm Hg) should be used during LLR, as in open surgery. Selective control of the inflow during laparoscopy may be more efficient than during open surgery (possible effect of the pneumoperitoneum). In cases of severe bleeding, increasing the pneumoperitoneum pressure and decreasing the airway pressure by a brief pause in the artificial ventilation are maneuvers that can be used to decrease back-bleeding. Although there were no data as to what pneumoperitoneum pressure should be used to decrease back-bleeding when encountered, the range used by some members of the expert technical panel was 16 to 20 mm Hg. Careful inspection after decreasing the pneumoperitoneum pressure should be performed routinely, along with selective bipolar coagulation or suture at the bleeding point. Suturing skills are needed for all LLR.
Q13. Parenchymal Transection. Transection of the superficial layer of the liver parenchyma can be done with an energy device. Deeper transection should be performed meticulously by exposing intraparenchymal structures with an ultrasonic aspirator (Cavitron ultrasonic surgical aspirator or equivalent), the clamp-crushing technique, or similar parenchymal dissection technique. Hemostasis is usually achieved with bipolar cautery for vessels of 2 mm or less, and with vessel sealing devices or clips for vessels of 3 to 7 mm. Locked clips or staplers are used for vessels of more than 7 mm. As in open surgery, some authors recommend the use of staplers for parenchymal transection. This is an efficient and expeditious technique. However, many consider it lacks precision and identification of divided structures. Almost all authors have reported using staplers to secure and divide major vessels such as the main hepatic veins or portal vein branches as well as the segmental Glissonian pedicles. Therefore, multiple surgical implements are frequently chosen and, as in OLR, it is difficult to specify the best technique and device for laparoscopic hepatic parenchymal transection, which is mainly dependent on surgeon's preference.
Q14. Energy Device. Unlike open surgery in which liver resection can be performed without any specific technology outside of regular cautery (eg, the crush-clamp technique), LLR typically involves the use of some kind of energy device. No specific energy device has emerged as superior over another. The argon beam coagulator is not generally recommended due to the risk of gas embolism.
Q15. Hilar Approach. In the case of right or left hepatectomy, hilar dissection with individual vessel preparation is a standard practice. It requires caution and planning by preoperative imaging to identify anatomical variations. Hilar dissection cannot be performed distal to the first bifurcation of the portal branch (ie, the right anterior and posterior sectional branches). The Glissonian approach serves as an important alternative if it is applied appropriately. A discussion ensued about the potential "pitfalls" of stapling the right or left hilar pedicle via Glissonian approach with potential risk of injury or stenosis to the contralateral hepatic duct. It was agreed that only surgeons experienced with this technique should use it.
Q16. Anatomical Resection. Remnant liver volume and tumor clearance are important issues in LLR, as they are in OLR. Two basic surgical techniques are commonly used to reduce disease recurrences: anatomical resection for HCC and margin-negative parenchyma-sparing resection for colorectal cancer liver metastasis. Anatomical resection refers to parenchymal preserving resections of portal territories including sectionectomy, segmentectomy, and subsegmentectomy. These are complex resections that require identification of anatomical boundaries. These boundaries rely on external landmarks, intraoperative ultrasound, and selective clamping using the Glissonian approach. Superficial resection can be performed nonanatomically according to a parenchyma-sparing strategy, but care must be taken to secure an adequate resection margin due to the lack of tactile sensation during LLR. The use of intraoperative ultrasound either for accuracy of clear margins or to avoid injuries of major pedicles is recommended during LLR.
Q17. Simulation, Navigation. Preoperative simulation is useful for measuring the remnant liver volume, visualizing the anatomy and tumor location, and defining the resection plane. Further study is needed to evaluate the effect of simulation and navigation on clinical outcomes in terms of both short-term and long-term results.
Expert Recommendations
Spread, Difficulty, Alternatives
Q8. Current Spread of LLR. The number of LLRs reported has steadily increased, especially since 2009, with the increase marked by greater proportions of major and anatomic LLRs, although minor resections still comprise the vast majority of procedures in clinical practice. East Asia, North America, and Europe seem to be witnessing the greatest diffusion of LLR. The number of hepatocellular carcinoma (HCC) cases to which LLR is applied has increased steeply over the past 5 years, especially in Asia and Europe, and the rate of conversion to OLR is gradually decreasing.
Q9. A Difficulty Scoring System for LLR. In an effort to estimate the difficulty of LLR easily before surgery, a novel difficulty scoring system was created for discussion at the ICCLLR. The difficulty of LLR is determined by various factors, such as the tumor size, the extent of liver resection, the tumor location, the proximity to major vessels, and the severity of fibrosis. The difficulty scoring system can be used to predict the difficulty of LLR from preoperative variables and to appropriately select patients according to the surgeons' skill level, ranked as low, intermediate, advanced, or expert. In addition, to these factors, it was suggested that the use of hand-assisted laparoscopic surgery (HALS) and the hybrid method (in which the operation is begun laparoscopically and completed through a small open incision) are likely to reduce certain difficulties associated with pure LLR and should be taken into account in future difficulty scorings.
Q10. The Role of HALS and Hybrid Procedures in LLR. Although pure laparoscopy is the most commonly used technique worldwide, there are geographical differences, and many centers use a combination of pure laparoscopic, HALS, and the hybrid technique in selected cases. Although there are no data that suggest any of these 3 approaches is superior to the others, HALS and the hybrid method are claimed by their proponents to be beneficial for large lesions, posterior lesions, donor hepatectomy and for the training of surgeons in major LLR techniques. HALS and the hybrid method can be used to manage intraoperative difficulties that are encountered, and they can in theory decrease the frequency of conversion to a full open incision.
Techniques
Q11. Conceptual Changes. The caudal approach is the main conceptual change in LLR. The caudal approach, which relies on visual magnification, offers improved exposure around the right adrenal gland and the vena cava and greatly facilitates identification of the Laennec's capsule and the Glissonian pedicle at the hilar plate. Furthermore, meticulous caudal-cranial transection of the hepatic parenchyma with magnification results in better identification of intraparenchymal structures for optimal transection of the liver. Compared to the anterior approach, which has been described for the resection of large tumors with liver parenchymal transection before right lobe mobilization, the caudal approach can be applied efficiently to expose the inferior vena cava from caudal to cranial with division of the short hepatic veins before parenchymal transection. In addition, CO2 pneumoperitoneum is likely to reduce bleeding from hepatic veins. Placement of the patient in the reverse Trendelenburg position should help decrease the venous pressure and improve exposure by gravitationally shifting visceral structures away from the liver hilum. Other conceptual changes include the superior and lateral approaches with or without the use of intercostal or transthoracic trocars. For these approaches, the patient is placed in the left lateral decubitus position. The left lateral decubitus position or even the prone position offers better exposure of the right posterior segments and lifts the right hepatic vein higher than the vena cava to reduce hepatic venous bleeding. However, there are some inherent drawbacks to LLR, such as lack of tactile sensation and restricted maneuvers that can lead to challenges in treating bleeding.
Q12. Essentials in Bleeding Control. The CO2 pneumoperitoneum is generally established at 10 to 14 mm Hg, and this provides for fairly good control of back-bleeding during liver transection. Low central venous pressure (<5 mm Hg) should be used during LLR, as in open surgery. Selective control of the inflow during laparoscopy may be more efficient than during open surgery (possible effect of the pneumoperitoneum). In cases of severe bleeding, increasing the pneumoperitoneum pressure and decreasing the airway pressure by a brief pause in the artificial ventilation are maneuvers that can be used to decrease back-bleeding. Although there were no data as to what pneumoperitoneum pressure should be used to decrease back-bleeding when encountered, the range used by some members of the expert technical panel was 16 to 20 mm Hg. Careful inspection after decreasing the pneumoperitoneum pressure should be performed routinely, along with selective bipolar coagulation or suture at the bleeding point. Suturing skills are needed for all LLR.
Q13. Parenchymal Transection. Transection of the superficial layer of the liver parenchyma can be done with an energy device. Deeper transection should be performed meticulously by exposing intraparenchymal structures with an ultrasonic aspirator (Cavitron ultrasonic surgical aspirator or equivalent), the clamp-crushing technique, or similar parenchymal dissection technique. Hemostasis is usually achieved with bipolar cautery for vessels of 2 mm or less, and with vessel sealing devices or clips for vessels of 3 to 7 mm. Locked clips or staplers are used for vessels of more than 7 mm. As in open surgery, some authors recommend the use of staplers for parenchymal transection. This is an efficient and expeditious technique. However, many consider it lacks precision and identification of divided structures. Almost all authors have reported using staplers to secure and divide major vessels such as the main hepatic veins or portal vein branches as well as the segmental Glissonian pedicles. Therefore, multiple surgical implements are frequently chosen and, as in OLR, it is difficult to specify the best technique and device for laparoscopic hepatic parenchymal transection, which is mainly dependent on surgeon's preference.
Q14. Energy Device. Unlike open surgery in which liver resection can be performed without any specific technology outside of regular cautery (eg, the crush-clamp technique), LLR typically involves the use of some kind of energy device. No specific energy device has emerged as superior over another. The argon beam coagulator is not generally recommended due to the risk of gas embolism.
Q15. Hilar Approach. In the case of right or left hepatectomy, hilar dissection with individual vessel preparation is a standard practice. It requires caution and planning by preoperative imaging to identify anatomical variations. Hilar dissection cannot be performed distal to the first bifurcation of the portal branch (ie, the right anterior and posterior sectional branches). The Glissonian approach serves as an important alternative if it is applied appropriately. A discussion ensued about the potential "pitfalls" of stapling the right or left hilar pedicle via Glissonian approach with potential risk of injury or stenosis to the contralateral hepatic duct. It was agreed that only surgeons experienced with this technique should use it.
Q16. Anatomical Resection. Remnant liver volume and tumor clearance are important issues in LLR, as they are in OLR. Two basic surgical techniques are commonly used to reduce disease recurrences: anatomical resection for HCC and margin-negative parenchyma-sparing resection for colorectal cancer liver metastasis. Anatomical resection refers to parenchymal preserving resections of portal territories including sectionectomy, segmentectomy, and subsegmentectomy. These are complex resections that require identification of anatomical boundaries. These boundaries rely on external landmarks, intraoperative ultrasound, and selective clamping using the Glissonian approach. Superficial resection can be performed nonanatomically according to a parenchyma-sparing strategy, but care must be taken to secure an adequate resection margin due to the lack of tactile sensation during LLR. The use of intraoperative ultrasound either for accuracy of clear margins or to avoid injuries of major pedicles is recommended during LLR.
Simulation, Navigation
Q17. Simulation, Navigation. Preoperative simulation is useful for measuring the remnant liver volume, visualizing the anatomy and tumor location, and defining the resection plane. Further study is needed to evaluate the effect of simulation and navigation on clinical outcomes in terms of both short-term and long-term results.
Summary of JURY Recommendations
MINOR LLR is confirmed to be a standard practice in surgery but is still in an assessment phase (IDEAL 3) as it is adopted by an increasing proportion of surgeons. Judged as a whole available literature studies indicated that some outcomes such as certain postoperative complications and length of stay were superior to open procedures and no outcomes were inferior. Unfortunately, the quality of studies is generally designated as LOW. Thus, additional higher quality studies are suggested to define its role and benefits in relation to open surgery.
MAJOR LLR is an innovative procedure. It is still in an exploration or learning phase (IDEAL 2b) and has incompletely defined risks. It should continue to be introduced cautiously. Judged as a whole available literature studies indicated that length of stay is superior to open procedures and other outcomes were not inferior. Blood loss is also reported to be less but questions remain regarding the methodology used. Again the quality of studies is generally designated as LOW. Therefore, there are strong recommendations for additional higher quality studies including registries to define its role and benefits in relation to open surgery.
METHODOLOGIC PROBLEMS resulted in a number of additional recommendations including the reporting of 90-day mortality, reporting of complications based on available standard classification systems, and standardization of methods of evaluating blood loss.
MAJOR ROBOTIC SURGERY: Very little data available for evaluation. Thus at this time the procedure fits IDEAL 2a best. Advisable to be done within institutional review board–approved registry.
LAPAROSCOPIC DONOR SURGERY: Pediatric donor surgery: as for major laparoscopic liver surgery is IDEAL 2b. Adult to adult donor surgery is an innovative procedure in a development phase (IDEAL 2a). At this time, the recommendation is that it be performed under institutional ethical approval and reporting registry.
EDUCATION: A major focused effort is required to determine how the laparoscopic skills needed for MAJOR LLR should be obtained by trainees and hepatopancreatobiliary surgeons in practice.
Summary of Expert Technical Recommendations
GENERAL AGREEMENT is achieved that experience in both open liver surgery and advanced laparoscopy is mandatory and surgeons must begin with minor laparoscopic resections.
A GLOBAL SPREAD of LLR has occurred after the first international consensus conference in 2008. Overall, LLR is utilized in a small percentage of liver resections (range: 5%–30%), although some groups have reported higher rates, reaching 50% to 80%. The vast majority of data arise from minor resections but the proportion of major resections is increasing.
THE SCORING SYSTEM is proposed for estimating the difficulty of LLR preoperatively.
HALS AND HYBRID TECHNIQUE can help overcome certain difficulties associated with pure LLR and may be useful in minimizing conversions.
CONCEPTUAL CHANGES include
The caudal approach that optimizes hilar dissection and transection of the liver parenchyma for major and/or anterior resections.
The lateral approach (left lateral decubitus position) that optimizes access to posterior segments.
A CO2 PNEUMOPERITONEUM of 10 to 14 mm Hg is generally used along with low central venous pressure and allows a good control of the bleeding during LLR.
LAPAROSCOPIC PARENCHYMAL TRANSECTION requires specific instruments. Several are available including a variety of energy devices and staplers. It is essential that the surgeons have a concrete understanding of the advantages and limitations of available instruments to conduct safe and effective LLR.
ENERGY DEVICES are efficient and reliable but cannot replace the acquisition of basic skills of hepatic surgery such as meticulous dissection, direct visualization, and sealing of the vascular structures. Caution should be made with the use of argon beam coagulator.
HILAR APPROACH includes individual hilar dissection and Glissonian approach. Although individual hilar dissection is the standard technique, Glissonian approach is feasible and can be useful for anatomical liver resection, especially hemihepatectomy, sectionectomy, or less. It can reduce the operative time but needs expertise, skills, and knowledge of liver anatomy.
ANATOMICAL RESECTION for HCC and margin-negative parenchyma-sparing resection for colorectal cancer liver metastasis are standard of care procedures, but the laparoscopic versions of these techniques need to be standardized to increase propagation.
PREOPERATIVE SIMULATION seems accurate in measuring volumetrics and surgical margins. Current studies lack intraoperative real-time navigation.
