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Minimally invasive liver surgery: indications and contraindications 239
Table 16.1
Institute of Medicine (IOM) quality of care aims.
Conceptual framework of indications and contraindications for minimally invasive approaches to liver resection based on
IOM aim Indications Contraindications
Safe Surgical skill in and experience with hepatobiliary and
minimally invasive surgery
Proper equipment and techniques that provide adequate
patient positioning, exposure, and visualization of operative
planes of dissection
A liver transection strategy that limits bleeding and bile leaks
Ability to progress through the procedure in a timely fashion,
minimizing exposure to transfusion, anesthetic complications,
and surgical team fatigue
Effective An overall patient experience that provides less pain, earlier Inability to identify and/or treat all sites of disease
return to normal activity, and earlier return to intended Inability to achieve adequate oncological margins
adjuvant oncological therapies Inability to perform adequate portal lymphadenectomy
Patient Ability to lessen postoperative pain
centered In selected cases, the ability to provide a cosmetic benefit
Limiting selection of benign tumor patients to those with
malignant potential and/or significant symptoms
Willingness to convert to hybrid or open approach surgery in
cases of perceived or realized issues with patient safety and/or
surgical efficacy
Efficient Ability to solve diagnostic dilemmas, limiting the need for
subsequent follow-up and intervention
Equitable Ability to provide equivalent surgical efficacy with lower Dependence on expensive instrumentation that creates
postoperative care costs excessive intraoperative costs
Timely Ability to provide surgical intervention within an oncologically
appropriate time interval
Tumor locations, patient body habitus, and/or adhesions that
increase the risk of injury to adjacent structures or impair the
ability to obtain vascular control in case of hemorrhage
surgery. Ultimately, however, the surgical principles of
resectability, and in particular the oncological principles
of malignant tumor resection, will remain inviolable.
16.2 General comments
To date, the vast majority of minimally invasive liver
resection cases reported in the literature have been performed for benign indications or for small peripherally
located malignant liver tumors [2–4]. When outcomes for
these cases are compared with the general population of
patients historically and currently treated with open
approach liver surgery, they are favorable [2]. In almost
all of these studies, however, the median magnitude liver
resection is greater in the open approach group, and it is
therefore difficult to separate the morbidity contribution
of case magnitude from that of the surgical approach [5–8]
(Table 16.2). For example, Cannon et al. compared 35
laparoscopic hepatectomy cases with both a historical
open cohort and a contemporary open cohort. In general,
the outcomes in the laparoscopic cohort were superior to
those of the open cohort; however, 83% of patients in the
laparoscopic cohort underwent anatomical hepatectomy
along sectional planes while only 50% of those in the
historical open cohort and 52% of those in the open
contemporary cohort underwent anatomical hepatectomy, potentially explaining differences in blood loss,
bile leak, and other complications [9].
Unfortunately, despite the 20 years that have elapsed
since the introduction of minimally invasive liver surgery [10], we have failed to design and execute a scientifically valid prospective study comparing these
approaches [11]. Left with retrospective comparisons
between larger magnitude and more complex open surgery and smaller magnitude and more straightforward
240 Chapter 16
Table 16.2 Selected reports comparing open to minimally invasive hepatectomy.
Open
MIS
group
Mala 2002 [59] n = 14 n= 13 7.1% versus 7.6% 500 mL versus 600 mL 0% 8.5 versus 4 days 28% versus 15% 0% versus 0% Retrospective,
Morino 2003 [66] n = 30 n= 30 6.6% versus 13% 479 mL versus 300 mL 0% 8.7 versus 6.4 days 6.6% versus 6.6% 0% versus 0% Retrospective,
Lesurtel 2003 [3] n = 20 n= 18 15% versus 0% 429mL versus 236 mL 11% 10 versus 8 days 15% versus 11% 0% versus 0% Retrospective,
Laurent 2003 [23] n =14 n = 13 28% versus 7.6% 720 mL versus 260mL 15% 12.5 versus 8 days 50% versus 36% 14% versus 0% Retrospective,
Lee 2007 [67] n = 25 n = 25 0% vs. 4% 100 mL versus 250 mL 8% 7 vs 4 days 5.2% versus 5.2% 0% versus 0% Retrospective,
Cai 2008 [31] n =31 n = 31 Not reported 588 mL versus 503 mL 3.2% 12.2 versus 7.5 days 16% versus 0% 0% versus 0% Retrospective,
Castaing 2009 [7] n = 60 n = 60 36% versus 15% Not reported 10% 10 versus 11 days 28% versus 26% 1.7% versus Retrospective
Sarpel 2009 [68] n= 56 n= 20 not reported Not reported 17% Not reported 7.1% versus 5% Not reported Retrospective,
Dagher 2009 [28] n = 50 n= 22 18% versus 14% 735 mL versus 519mL 9% 12.5 versus 8.2 days 34% versus 9% 2% versus 0% Retrospective
Belli 2009 [5] n = 125 n = 54 25% versus 11% 580 mL versus 297 mL 7% Not reported 36% versus 18% 2% in the Retrospective
Tranchart 2009 [8] n = 42 n =42 16.7% versus 9.5% 724 mL versus 364 mL 5% 9.6 versus 6.7 days 11.9% versus 9.5% 2% versus 2% Retrospective,
Cannon 2011 [9] n =140 n = 35 32% versus 17% 385 mL versus 202 mL Not 8.3 versus 4.8 days 49% versus 23% 1.4% versus 0% Retrospective,
Guerron 2012 [41] n= 40 n = 40, 5% versus 20% 753 mL versus 376 mL 5% 6.5 versus 3.7 days 20% versus 15% 0% versus 0% Retrospective,
Doughtie 2013 [12] n = 84 n = 8 31% versus 14% 400mL versus 225 mL 0% 7 versus 3.5 days 60.5% versus 12.5% 9% versus 0% Retrospective,
MIS, minimally invasive surgery.
Transfusion Estimated blood loss Conversion
group
rate
reported case matched
Length of stay Morbidity Mortality Comments
1.7% case matched
laparoscopic
group
case matched
case matched
case–control
case matched
matched pair
matched pair
case matched
matched pair
case matched
case matched
Minimally invasive liver surgery: indications and contraindications 241
minimally invasive surgery, we are forced to constrain
our conclusions regarding the comparative safety and
efficacy of each approach [12].
However, experience with minimally invasive major
hepatectomy is increasingly being reported [9,13–15],
allowing a more precise comparison between outcomes
that are largely dependent only on surgical approach.
Most of the reports on major hepat ectomy come from
specialized and high-volume centers [13,14,16,17].
When considering a discussion about the indications
and contraindications of these approaches, it is therefore critical to take into account the skill and experience
of the operative team. One surgeon/center may be very
proficient and safe at minimally invasive major liver
resection while another surgeon/center would be contraindicated to perform a difficult minimally invasive
liver resection based on a lack of experience, support, or
equipment.
16.3 Aim 1: Safe
In determining the appropriateness of any treatment or
approach, the primary consideration is patient safety.
Surgical experience and skill are baseline requirements
to achieve safe minimally invasive liver resections. Many
have advocated that only the subset of surgeons who are
dually trained in hepatobiliary surgery and minimally
invasive surgery are adequately equipped to safely perform these operations [18]. However, significant numbers of hepatobiliary surgeons have successfully
“retrained” in laparoscopic techniques, largely aided by
a broad experience with laparoscopic cholecystectomy, to
achieve an adequate level of safety with at least minor
minimally invasive liver resection [19]. Given the technical rigor of these cases, one study estimated that the
slope of the learning curve for minimally invasive liver
surgery may not inflect until over 60 cases were performed [20], potentially limiting the indications for major
laparoscopic liver surgery to a small subset of highvolume centers. Of course, it is expected that minor resections would be mastered with a lower number of cases.
The contribution of adequate equipment to the safety
of minimally invasive liver surgery cannot be overestimated. As with any surgical approach, adequate exposure
and visualization are paramount in performing safe minimally invasive surgery. Liver surgery poses unique challenges with regard to these two attributes. The location of
the liver in the right upper quadrant of the abdomen, with
over half of the liver parenchyma below the horizon of a
typical laparoscopic view, makes visualization of the
relevant anatomy difficult. Both the porta hepatis and
the vena cava are, likewise, obscured over the visual
horizon of the colon and duodenum, creating the need
to position the camera and working ports in a more
cephalad/subcostal orientation than is the case in general
abdominal laparoscopy. Obesity may pose additional
challenges to visualization of certain tumor locations
within the liver. In some cases and locations, however,
visualization with angled lens laparoscopes may be superior to that with open anterior incisions. Irrespective of
this variability, failure to adequately visualize the transection plane and/or critical vascular and other surrounding structures is an absolute contraindication to minimally
invasive liver resection.
There is a growing body of literature that defines
several additional factors that contribute to the safe application of minimally invasive approaches to liver surgery.
With regard to patient safety, a primary objective of open
and minimally invasive liver surgery is the ability to avoid
hemorrhage and/or to be able to recover from a vascular
injury [14]. Traditionally, with regard to bleeding, the
main component of liver surgery safety has been the
magnitude of resection, with larger magnitude resections
engendering more risk for vascular injury. To avoid these
risks, the minimally invasive liver surgeon requires the
ability to expose and control adjacent vascular structures
within the porta hepatis and retrohepatic/vena caval
areas [21].
Even in the most skilledhands, laparoscopic approaches
to liver resection may be associated with an impaired
ability to recover quickly from a major vascular injury.
Although conversion rates are not well documented for
minimallyinvasive liver surgery, ranging from 0% to 15%
(see Table 16.2), bleeding is clearly the most frequent
indication for conversion [2,7,16,22,23]. Likewise, the
ability to rapidly control vascular structures, particularly
in teaching environments, is a perceived advantage of
hybrid and hand-assisted approaches to major hepatic
resection [4,24–27].
The hemostatic issues with open and minimally invasive liver surgery fall into two categories: sudden largevolume blood loss from vascular injury and general
hemostasis along the cut surface of the liver. On the
whole, catastrophic bleeding events have been infrequently described in minimally invasive liver surgery.
242 Chapter 16
This is likely due to disincentives to self-report such
complications as well as a historical avoidance of major
resections that would risk significant vascular injury. As
indications are extended to larger and more complex
resections, however, a persistent contraindication to minimally invasive approaches will be tumor locations and
resections that create situations with either high likelihood of vascular injury and/or limited ability to rapidly
control hemorrhage.
With regard to subcatastrophic bleeding, typically from
the parenchymal transection surface, both the technique
of transection and the availability of topical thermal and
nonthermal coagulants need to be considered. Although
expensive, there are an ever increasing number of devices
and agents to serve this purpose, almost all of which are
only supported by preclinical evidence of efficacy. In the
reported literature to date, dominated by nonchemotherapy-treated patients and minor hepatectomy procedures,
rates of estimated blood loss (EBL) and perioperative
transfusion in minimally invasive liver resection are
low [2]. In the limited series from the most advanced
centers reporting on minimally invasive major hepatectomy, the median blood transfusion rates acceptably
range from 14% to 17% [6,7,13,14,28]. One point to
note is that a catastrophic hemorrhage will frequently not
be reflected in reported median EBL and transfusion
numbers. These events in minimally invasive liver surgery are likely rare but important reminders of the narrow
therapeutic index of liver resection regardless of
approach [29–31].
In many cases, the size and location of the tumor may
increase the risk of a vascular injury or impede access to
vascular control to a degree that completely contraindicates
a minimally invasive approach. For bulky liver tumors, a
frequent issue is difficulty in laparoscopic mobilization of
the liver. Unlike general abdominal laparoscopy, the ribcage does not allow the pneumoperitoneum to significantly enlarge the volume of work space for liver surgery.
Although reports of minimally invasive liver resection for
large liver tumors are emerging [12], bulky tumors that
can be mobilized and manipulated through an open
incision can at times completely obscure laparoscopic
transection planes and critical structures. Visualization
issues may be compounded by body habitus, adhesions,
and intra-abdominal obesity. Ultimately, the safety value
of the surgical principles of positioning, exposure, and
lighting remain constant for minimally and maximally
invasive surgery.
Another unanswered issue regarding the safety of
minimally invasive liver surgery is the ability to prevent
postoperative bile leak. Despite better understanding of
liver anatomy and transection techniques, postoperative
bile leak continues to be a frequent and significant complication in liver surgery [32]. As this is largely related to
magnitude of resection, observational studies addressing
mainly minor laparoscopic liver resections have reported
low rates of this complication (1.4%) [2]. As minimally
invasive liver surgery is expanded to more substantial
resections with broad transection surface areas and division of larger bile ducts deeper within the liver parenchyma, it is anticipated that the bile leak rate would rise.
For minimally invasive major hepatectomy, most surgeons use a vessel sealing device, endovascular staplers or
a combination to transect the liver parenchyma. Few
reports exist comparing biliary complications after major
transections using these devices and techniques [33]. In
practice, the bile leak rate should be less than 5% for
major resection. Given the significant impact that postoperative bile leak has on related morbidity, including
venous thromboembolism, delayed discharge, delayed
recovery, need for additional procedures, and costs of
care, minimally invasive techniques that result in a bile
leak rate in excess of this number may signal a contra-
indication to these approaches on a center-by-center
basis [32,34].
16.4 Aim 2: Effective
After the safety of the operation, the efficacy of the
operative approach is the next most important factor
that should inform the discussion of surgical indication
or contraindication. In contrast to patient safety (the
avoidance of a negative outcome, typically a short-term
consideration), the effectiveness or quality of liver surgery (achievement of a positive outcome) is measured on
a longer time scale across several different domains.
With regard to liver resection, the most important
domain of efficacy of the minimally invasive approach
is freedom from recurrence of malignant disease. Intraoperative factors that directly contribute to this domain
include identification and oncological resection of all
tumor sites. To this end, technical ability with intraoperative ultrasound and availability of appropriate laparoscopic ultrasound probes and consoles are necessary
to assist in the identification of small, previously
Minimally invasive liver surgery: indications and contraindications 243
undiagnosed tumors. Although several studies have
suggested that intraoperative ultrasound may identify
previously underappreciated lesions in 3–50% of
patients [35,36], it is unclear what percentage of these
findings were aided by liver palpation and complete
visualization that subsequently directed the ultrasound
to small subcapsular lesions [24,37–39]. As totally laparoscopic approaches are limited in their ability to visualize
and, in particular, palpate subtle liver tumors, a higher
premium must be placed on preoperative imaging and
intraoperative ultrasound to detect occult disease and
avoid early “recurrence” from undetected lesions after
laparoscopic resection. Whenever there is concern for
additional malignant disease that is not laparoscopically
accessible, a conversion to open surgery is indicated [7].
Frequently in hepatobiliary cancer surgery, nodal
recovery is critical to staging and prognosis, as well as
providing the indication for postoperative therapies. As
such, the ability to perform a minimally invasive portal,
aortocaval, and celiac node dissection is often comparably
as important as the ability to perform the liver tumor
resection. In contrast to liver transection, which can be
performed in the linear plane of the typically rigid instruments used in laparoscopic liver surgery, portal lymphadenectomy requires a perpendicular set of angles of attack
with a more vertical orientation. This necessitates creativity, unique technical skills, and, at times, additional port
sites and special instrumentation, all of which may be
necessary to consider a laparoscopic approach indicated for
resection of liver malignancy [40].
To date, we have few data regarding long-term oncological outcomes in patients treated with minimally invasive hepatectomy. There are several recently published
studies documenting longer term survivals in patients
with laparoscopically resected metastatic and primary
liver malignancies that suggest acceptable midterm outcomes (Table 16.3). It should be noted that the median
follow-up intervals in these reports rarely exceed
24 months, statistically limiting the validity of benchmark
five-year survival estimates [6,7,16,29,41,42]. Also, none
of these studies report early recurrence rates that may
reflect “missed” disease in the operating room. This having been noted, there is no reason to expect that wellperformed minimally invasive liver surgery for malignant
indications would result in any decrement in long-term
recurrence rates and overall survivals. Indeed, data
regarding modulation of the immunosuppressive effects
of surgery associated with minimally invasive approaches
may provide an oncological advantage to these
patients [43,44]. Further correlative clinical studies are
required to determine the realization of this theoretical
benefit.
In the absence of data comparing long-term oncological
outcomes, the only available surrogate oncological quality indicator is pathological margin status. Although the
adequate oncological width of the margin of resection is
debated based on tumor histology, preoperative therapy,
and other anatomical and technical factors, in general it is
clear that patients with metastatic disease have lower
recurrence rates after R0 resection [45,46] and patients
with hepatocellular carcinoma (HCC) have lower recurrence rates with anatomical resections that entirely
remove the segments of liver that contain tumor [47,48].
Based on these concepts, the inability to achieve adequate
oncological margins is one of the strongest contraindica-
tions to minimally invasive surgery.
The vast majority of minimally invasive liver resections
reported in the literature are for benign indications and/
or small tumors requiring minor liver resection [2,49,50].
In both of these scenarios, adequate margins are fairly
simple to obtain, as reflected in the modest margin-positive rates for minimally invasive liver resection ranging
from 0% to 18%, with rates of margins less than 1 cm
ranging from 0% to 43% [2,11,26] (see Table 16.3). As
minimally invasive approaches extend to involve larger
magnitude resections, it may be anticipated that margin
status will become a major focus of outcomes analyses [51]. Certainly, the long-term outcomes of minimally
invasive liver surgery need to be thoroughly studied, as a
marginal difference in short-term length of stay cannot be
considered more valuable than a lower recurrence rate in
oncological surgery.
The nature of the current instrumentation for minimally invasive liver surgery imposes some limitations to
access and exposure of liver tumors, placing surgeons at
higher risk of obtaining inadequate oncological margins.
As almost all visualization ports are placed anterior and
caudal to the liver, segments II, III, IVb, V, and VI are the
most accessible for resection [26,52,53]. Segments I, IVb,
VIII, and particularly segment VII are difficult to visualize
adequately [38,54,55]. The fixed planar orientation of
laparoscopic instruments creates further obstacles to margin-negative tumor removal in these difficult locations.
When tumor location justifies an intended line of liver
division on a sectional plane (i.e. right hepatectomy,
left hepatectomy, left lateral bisegmentectomy), the
244 Chapter 16
Table 16.3 Selected reports of oncological outcomes after minimally invasive liver resection for cancer.
n= Anatomical/
Mala 2002 [59] 21 6/15 0/21 R0 = 95%, 29% <1 cm Not reported 2/21 Not reported
Gigot 2002 [69] 27 24/3 2/25 R1 = 7% 53% at 2 years 100% at 2 years Mean: 14 months
Laurent 2003 [3] 13 Not reported 0/13 R0 = 92%, 23% <1 cm 44% at 3 years 9% at 3 years Not reported
O’Rourke 2004 [70] 33 27/5 24/9 3.5% positive, mean 9 recurred/22, 67% at 15 recurred/22, 75% at 20 months
Keneko 2005 [71] 30 10/20 0/30 Not reported 31% at 5 years 61% at 5 years Not reported
Vibert 2006 [62] 65 Not reported 32/33 Median 5 mm (CRM), 51% at 3 years 87% at 3 years Mean: 30 months
Poultsides 2007 [39] 28 Not reported Not R0 = 100% 13% at 2 years 61% at 2 years Mean: 24 months
Lee 2007 [67] 19 11/16 19/0 Median 1.41 cm (0–3 cm) DFS = 24 months 2 deaths/19 11 months
Chen 2008 [72] 116 11/105 4/112 Not reported Not reported 62% at 5 years Mean: 94months
Dagher 2008 [22] 32 26/6 4/28 Not reported 55% at 3 years 72% at 3 years Mean: 26 months
Robles 2008 [38] 21 21/0 2/19 R0 = 100% 5 recurred/21 80% at 3 years Mean: 32 months
Cai 2008 [31] 31 14/17 28/3 >1 cm in all patients 11 recurred/31 60% at 3 years Mean: 30 months
Sarpel 2009 [68] 20 Not reported Not Not reported 70% at 2 years 100% at 2 years 21 months
Belli 2009 [5] 54 33/21 3/51 R0 = 100% 52% at 3 years 67% at 3 years 24 months
Castaing 2009 [7] 60 35/25 29/31 R0 = 87% RFS: 30% at 3 years 82% at 3 years 30 months
Sasaki 2009 [42] 76 10% 76/0 R0 = 91%
Nguyen 2009 [16] 109 70/39 67/42 R0 = 94.5% 50% at 5 years 20months
Kazaryan 2010 [29] 139 total, 110/38 141/7 R0 = 94% NR 46% at 5 years 19 months
Guerron 2012 [41] 40 16/24 35/5 R0 = not reported Median: Median DFS: 98% at 2 years 16 months
Cannon 2012 [6] 35 29/6 19/16 R0 = 97% 15% at 5 years 36% at 5 years Not reported
Doughtie 2013 [12] 8 8/0 1/7 R0 = 100% DFS = 14.4 months 87% at 1 year Not reported
DFS, disease-free survival; HCC, hepatocellular carcinoma.
113 malignant
nonanatomical
Minor/
major
reported
reported
Margins Recurrence Overall survival Follow-up
1.1 cm 2 years 2 years
10 mm (HCC) (only 17 patients
Not reported 64% at 3 years 22 months
1.0 cm 23 months
at risk
at 3 years)
Minimally invasive liver surgery: indications and contraindications 245
overlapping orientation of the transection line with the
plane of the laparoscopic instruments increases the ability
to achieve an oncologically effective operation, explaining the overrepresentation of these anatomical transections in reported series of minimally invasive
hepatectomies (see Table 16.2) and the rapidity with
which the minimally invasive approach is becoming a
standard for these resections [6,9,13,56–58].
This point is highlighted in several recent multicenter
reports. In one report, 210 minimally invasive major
hepatectomies were described, including 114 malignant
tumor resections, with the majority being solitary lesions
and all treated with anatomical resections on sectional
planes [14]. Only three of these were associated with a
positive margin of resection (2.6%). Likewise, a comparative study that included 60 minimally invasive liver
resection patients with malignant indications, with
58% treated with anatomical resections including 52%
major resections, reported a microscopic margin-positive
rate of only 8% [7]. Unfortunately, straightforward anatomical resections for malignant indications (where
patients frequently present with bilateral, multifocal disease and/or underlying liver disease) are the exception
rather than the rule. More frequently, the liver surgeon is
called upon to perform resections across multiple angles
and to create curvilinear planes of transection. Somewhat
paradoxically, the limitations on transection curvature
imposed by laparoscopic liver surgery’s fixed planar
angles of approach actually mandate a less parenchyma-sparing technique to achieve adequate margins
in some cases [4]. In either a nonanatomical or anatomical resectional setting, when the limitations of the laparoscopic instrumentation impair the surgeon’s ability to
achieve an adequate margin of resection, this becomes a
contraindication to a minimally invasive approach.
It is anticipated that future improvements in instrumentation, with the ability to angulate instruments,
either manually or via robotic manipulation, will progressively overcome these barriers, making more difficult
intrahepatic locations accessible and widening the ability
to achieve adequate oncological margins when nonanatomical transection planes are required.
16.5 Aim 3: Patient centered
When evaluating the utility of minimally invasive liver
surgery, it is critically important to objectively assess the
true benefits of the approach from the patient’s
perspective. Early studies comparing minimally invasive
and open approach liver surgery demonstrated a shorter
length of hospital stay (LOS) and improvements in postoperative pain associated with the minimally invasive
strategy [59,60]. Although inpatient LOS is an important
indicator of recovery, more specific midterm recovery
metrics may be better indicators of the quality of the
surgical approach from the patient’s point of view. These
include the time to return to normal/baseline performance status and, very importantly for patients with hepatobiliary malignancy, the time to return to intended
adjuvant oncological therapies. Also, the implementation
of fast-track enhanced recovery pathways is significantly
closing the gap in terms of the patient experience with
recovery between minimally invasive and open approach
liver surgery [61].
The other often quoted patient-centered benefitof
minimally invasive approaches is cosmesis. Although
this factor may play a role for a subset of younger patients,
it is not consistently rated as a decision-making factor for
cancer patients desiring curative resection. As surgeons,
therefore, we must be careful to evaluate the approach to
liver resection from the patient’s point of view, choosing
the best oncological operation independent of approach.
Likewise, surgeons need to maintain a patient-centered
view on the issue of conversion of laparoscopic resection
to open surgery whenever there is a perceived or realized
safety or quality issue. Unfortunately, particularly in the
United States, there is a significant stigma associated with
conversion of a minimally invasive procedure to an open
procedure. Many surgeons have been formally and
informally “trained” to view conversion of minimally
invasive to open surgery as a personal technical failure.
In this setting, some surgeons may persist with unsafe
laparoscopic situations, considering their own motivations and ego over the patient’s best interests. From a
patient-centered point of view, this must be avoided. To
this end, the liver surgical community has a responsibility
to de-emphasize both ends of the conversion spectrum
(not overlauding reports of low conversion rates and not
criminalizing reports of high conversion rates), particularly during the long learning phase of acquisition of
competency [14].
It has been well documented that the early era of
minimally invasive surgery was characterized by an overrepresentation of benign tumor resections [2]. Despite
benign tumors accounting for less than 20% of indications for liver resection overall, only recently have large
series begun to report on histological distributions with
246 Chapter 16
less than 50% of the minimally invasive resections done
for benign indications [14,17,39,42,62]. Clearly, patients
with symptomatic benign tumors and those at risk for
malignant degeneration or rupture benefit from minimally invasive surgical approaches. Although the question of whether the ability to perform minimally invasive
liver resection should expand the indications for benign
tumor resection was initially debated, there is currently
clear consensus that this should not be done [18,63,64].
However, there is certainly a subset of patients who
present with indeterminate or minimally suspicious liver
tumor imaging findings that, prior to the availability of
minimally invasive liver surgery, would have been recommended for observation instead of incurring the risks
and disability of open surgery but who now are indicated
for minimally invasive diagnostic/therapeutic procedures [63]. Given the advances in imaging accuracy, these
cases are becoming more rare, but as discussed below, the
ability of minimally invasive liver resection to resolve
diagnostic dilemmas should be considered an indication
for this approach.
16.6 Aim 4: Efficient
In terms of the IOM aim of efficiency, the ability to obtain
adefinitive diagnosis of indeterminate liver pathology
lends a significant indication to minimally invasive
approaches to liver surgery. Simultaneous increases in
the number and type of abdominal imaging procedures
have improved the detection of indeterminate and incidental liver lesions. Although the accuracy of computed
tomography (CT) and magnetic resonance imaging (MRI)
has improved, the sensitivity of lesion detection has outpaced the specificity of lesion characterization, leaving a
small number of patients with radiological diagnoses of
indeterminate or atypical lesions. These lesions are frequently difficult to biopsy and/or the amount of pathological material available via fine needle or core biopsy is
inadequate to provide a definitive diagnosis.
Previously, these patients had two choices: observation, with multiple subsequent scans and a possibility of
disease progression in the rare case of unrecognized
malignancy, or open surgical incisional or excisional
biopsy, which in most cases was overly invasive given
the likelihood of a benign diagnosis. The advent of minimally invasive liver surgery has provided an alternative
option that is significantly more efficient [62,63]. The
ability to obtain adequate tissue for diagnosis, with
minimal physiological impact to the patient, and the
potential freedom from anxiety-producing and time-consuming subsequent imaging and follow-up make these
cases a prime indication for minimally invasive liver
surgery.
16.7 Aim 5: Equitable
In the current healthcare environment, on a population
basis, liver surgeons do need to be sensitive to cost issues.
Unfortunately, the lack of head-to-head comparisons of
laparoscopic versus open liver resection clinical outcomes
has impeded determination of the comparative costeffectiveness of these approaches. In general, the cost
structure of minimally invasive liver surgery is thought to
parallel the paradigm of other minimally invasive
approaches, where there are more charges incurred in
the operating room compared with those incurred in
open techniques [17,65]. This differential is largely attributed to the need for additional expensive and mainly
disposable instruments and to longer operative times.
Similar to other areas within minimally invasive surgery,
these additional intraoperative costs may be counterbalanced by lower postoperative care charges, mainly related
to shorter length of inpatient hospitalization [65]. However, few cost comparison studies have been able to
control well for case magnitude. With enhanced recovery
and other perioperative initiatives lowering all liver surgical LOS numbers, the validity of future cost analyses will
be heavily dependent on separately comparing minor
open resection to minor minimally invasive resection
and major open hepatectomy to major minimally invasive hepatectomy.
16.8 Aim 6: Timely
Of course, the availability of minimally invasive surgery
within a region or an individual hospital should be time
sensitive. Particularly for patients with malignant diagnoses, access to expeditious operative therapy is important and should not be delayed based on a lack of
availability of a certain approach, piece of equipment
or technique. Likewise, with increasing numbers of
patients benefiting from multimodality approaches to
their tumors, appropriate timing of surgical intervention
within the larger treatment strategy should not be sacrificed for surgical approach considerations. Continued
Minimally invasive liver surgery: indications and contraindications 247
careful and responsible training and dissemination of
laparoscopic techniques are anticipated to make these
approaches more widely available over time.
outcomes for these procedures demonstrate safety and
efficacy. Only a handful of highly specialized centers
have reported succes s with minimally invasive atypical,
major, and/or radical resections. Ba sed on these data,
this chapter emphasizes the need for safe and oncolog-
16.9 Conclusion
ically sound operations, regardless of approach. Also,
patient-centered, efficient, equitable, and timely care
This chapter describes a co nceptual framework for the
indications and contraindications for minimally invasive approaches to liver resection. Critical review of the
literature indicates that the majority of minimally invasive liver resections that have been successfully performed have been for solitary tumors in anterior
segments of the liver with either wedge resection or
resection on sectional planes. In gen eral, the reported
may variably support or contraindicate the expansion
of indicatio ns for minimally invasive approaches . It is
hoped that this conceptual framework will serve to
establish standards across a highly variable set of pro-
cedures, surgical skill sets, a nd technological advances.
Ultimately, it will require introspective professionalism
and oversight to carefully monitor exact indications on
a case-by-case basis.
KEY POINTS
• Reported outcomes demonstrate that laparoscopic liver surgery as practiced today is safe and effective.
• Quality control is important to ensure safe expansion of minimally invasive liver resection to more advanced resection.
• The goals of advanced laparoscopic liver resection align with the Institute of Medicine healthcare goals of Safe, Effective, Patient-
Centered, Timely, Efficient, and Equitable Care.
• Most resections today are performed for solitary tumors in anterior segments of the liver with either wedge resection or resection
on sectional planes, with only a handful of highly specialized centers performing advanced resections.
• Introspective professionalism and oversight to carefully monitor exact indications on a case-by-case basis are needed to safely
expand advanced minimally invasive liver surgery.
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