20 Laparoscopic Liver Surgery

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Chapter 19 / Multidisciplinary Approach toLiver Oncology 241

bilobar liver resections in select patients; however, repeat hepatectomy is

associated with higher than average liver morbidity (liver insuciency or

failure) and diminished ability to tolerate additional systemic therapy for

extrahepatic progression postresection. With the emergence of LDTs for

secondary cancers, a clear potential advantage lies in buying potential time

before committing to resection, thereby helping select patients for surgery

who are most likely to benet long term.

Stereotactic Body Radiation Therapy

e data using SBRT in secondary cancers, including metastatic colorectal

cancer, are quite good. e multi-institutional data in secondary cancers from

a number of primary organ sites (lung, colon, breast) showed a 93% 2-year

tumor control rate. Single-institution prospective data in a larger cohort of

patients have corroborated that result. In patients with colorectal lesions

less than 3cm, the 2-year tumor control rate approaches 100%. e eligibility

criteria for these trials were the same as for HCC: solitary lesions up to 6cm

or up to three lesions (none larger than 3cm). SBRT is an excellent choice in

patients with unpredictable disease (synchronous metastatic disease) or sig-

nicant comorbid conditions making resection more risky. Again, its advan-

tage lies in buying considerable time to determine the inherent cancer biology.

Yttrium-90

Y90 is also FDA approved for metastatic colorectal cancer. e response

rates are much lower than with HCC (40% vs. 70%). Some of this decreased

response is most likely due to the tumors being less vascular. However, the

response rate of 40% is higher than the established response rate to second-

line systemic chemotherapy. With current pressure to justify cost of treat-

ment and dene objective measures of benet, clarifying the role of Yttrium

90 in metastatic colorectal cancer will become increasing more important,

more a multidisciplinary liver oncology group. For patients in whom sur-

gical resection is less likely to improve survival (multifocal and/or bilobar

disease), clinical trial data will dene how Y90 therapy integrates into treat-

ment paradigms for secondary colorectal cancer.

Drug-Eluting Beads

e DEB used in metastatic colorectal cancer includes irinotecan. e elu-

tion kinetics are quite variable and, as such, the toxicity is variable as well.

Our experience with irinotecan-eluting beads has been subpar, compared

with Y90, and for this reason, Y90 remains our platform of choice.

Ablation

e results of radiofrequency ablation or microwave ablation in treating

hepatic colorectal cancer metastases are disappointing when compared

to SBRT. However, when used in combination with resection, ablation can

help eliminate all measurable disease in select patients. When used percu-

taneously under image guidance, the recurrence rate in the treated area is

moderately high (20% to 30%).

CONCLUSION

A strong, multidisciplinary panel of invested physicians from HPB surgery,

transplant surgery, hepatology, interventional radiology, radiation oncol-

ogy, medical oncology, nuclear imaging, and abdominal imaging is ideal

to develop, standardize, and continuously evaluate institutional treatment

strategies for primary and secondary liver malignancy.

Section II / Liver242

Laparoscopic Liver Surgery

Juan M. Sarmiento and Edward Lin

Section II / Liver244

By 2007, the majority of the experience came from small case series of

mostly minor liver resections. Koron in 2007 presented the largest series

then from a single institution of 300 cases, with a very good number of

major hepatectomies. is series is probably responsible for changing the

landscape on the feasibility and application of this technique.

e need to standardize this technique came to realization in

2008 after the international conference on laparoscopic liver surgery in

Louisville, KY. is conference brought together expert hepatobiliary sur-

geons, both with and without experience in laparoscopic liver resection,

and produced a document with the following recommendations:

■ e group cautioned on the expansion of the application of the lapa-

roscopic technique for benign lesions that were not oered resection

otherwise.

■ ere was a concern for patient safety due to a rapid and indiscriminate

growth of programs oering this technique without adequate training of

surgeons and paramedical personnel and minimal standards of quality.

■ ere was clarity in dening laparoscopic surgery (“pure laparoscopy”)

and hand-assisted ( for obvious reasons) and hybrid technique (laparos-

copy for mobilization and dissection but transection performed via an

open approach).

■ ere was a denition for the ideal candidate for laparoscopic hepatec-

tomy: patients with solitary small (<5 cm) lesions, located peripherally

(segments II through VI). Also, it was stated that left lateral sectionec-

tomy should be done laparoscopically as the standard of practice.

■ Need for expeditious recognition of conversion to an open approach due

to safety or lack of progress.

■ Need for a cooperative registry for all laparoscopic liver resections to

monitor outcomes, especially in high-risk resections (major hepatec-

tomy, living donors). A randomized trial was probably impractical, and

this registry would serve as an alternate source of information and

follow-up.

■ Denition that resection, either open or laparoscopic, is the gold stan-

dard for the treatment of colorectal metastases. Caution was given to the

need of keeping comparable rates of negative-margin resections and the

avoidance of missing occult lesions.

■ Denition of how laparoscopic resection is still a valuable tool in the

treatment of hepatocellular carcinoma (HCC), and no specic distinc-

tion was made between ablation and transplantation.

One of the realities in dealing with laparoscopic liver resections

is the great variance of operations tting the denition. If we somewhat

simplify the term, and call it major resection, we can describe at least ve

operations that t this term: right lobectomy, extended right lobectomy, left

lobectomy, extended left lobectomy, and central hepatectomy. If we add the

caudate lobe, technically a minor liver resection but operatively demand-

ing, and also add combined liver and biliary resection, there is a whole

spectrum of “major” resections to be mastered laparoscopically. Other sub-

specialized areas like Whipple procedures or colectomies really encompass

two to three operations that are more reproducible and amenable to stan-

dardization. Like any other operation, the surgeons’ comfort grows with

experience in the procedure; laparoscopic wedge resections are tackled at

rst, then progressing to the laparoscopic left lateral sectionectomy, and

then to subsegmentectomy/segmentectomy II to VI. With the progressive

experience, the condence of the surgeon and dexterity will increase, and

at some point, the surgeon will be ready to take on laparoscopic major

hepatectomy, resembling the learning process of the open liver resection.

Chapter 20 / Laparoscopic Liver Surgery 245

e hand-assisted technique could even bridge that transition as it applies

principles of both the open and the laparoscopic approach. e hand is par-

ticularly useful for the mobilization of the liver, the palpation of structures,

the compression of the liver parenchyma for hemostatic purposes, as well

as the rapid and secure control of bleeding from major vascular structures.

In addition, the hand port is used for specimen extraction, an incision that

is unavoidable for major liver resection. Along the same lines, rapid conver-

sion to an open approach early in the experience and implementation of the

hybrid technique are also valid strategies to reach the degree of condence

necessary to achieve competence in laparoscopic liver resections.

As Cherqui points out, laparoscopic liver resection should be based upon

the foundation of open liver surgery, being that laparoscopy is most dicult

of the two major skill sets necessary for this technique. e surgeon collabo-

ration is mutually enriching and, based on the maturity of the surgeons, will

serve as the basis for independent criticism of their own technique and the

development of prociency and standardization of these cases. Doubling the

experience to two surgeons with a single case is another perk in a eld with

limited number of cases. Finally, the application of production quality mea-

surement tools adopted from the manufacturing industry has helped w ith the

renement of the nal product, in this case laparoscopic hepatectomy.

LAPAROSCOPIC MAJOR HEPATECTOMY

Dagher et al. published an international registry study collecting informa-

tion on 210 patients undergoing laparoscopic major hepatectomy, 57%

being hand-assisted approaches. ey reported a mortality of 1% and a

morbidity of 8% with a conversion rate of 12%. Experience over time showed

that operative time, blood loss, portal triad clamping time, conversion

rate, and length of stay were improved. Martin et al. from the University of

Louisville more recently showed in a matched study of laparoscopic major

liver resection a mortality of 1% with a morbidity of 23% and a conversion

rate of 4%. Blood loss, use of the Pringle maneuver, length of stay, compli-

cation rate, operative time, and blood transfusion were signicantly better

than the matched open group. ese two studies show that laparoscopic

major liver resection can be achieved with acceptable results in terms of

complications and, that with enough experience, all the feared events (i.e.,

hemorrhage, increased operative time, need for transfusion) not only are

manageable but result in better outcomes.

Two recent meta-analyses (including both minor and major laparo-

scopic liver resections) have shown similar results to the two studies men-

tioned above, with the exception that operative time was longer with the

laparoscopic method. However, blood loss, morbidity rate, and length of

stay were signicantly better for the laparoscopic group with similar mar-

gin-negative rates. Taking into account the inherent bias in the selection of

patients submitted to laparoscopic resection, there is at least a comparable

outcome prole for the laparoscopic technique, with a trend toward lower

blood loss and decreased hospital stay.

ONCOLOGIC APPLICATIONS

Colorectal Metastases

e fact that no randomized trial has been done for liver resection as the

treatment of colorectal metastases basically denes the impossibility of

doing one for laparoscopic versus open resection. After the COST trial for

surgical resection of colorectal cancer, where no oncologic dierences were

found between the two approaches (laparoscopic vs. open), there is su-

cient approval of laparoscopy as a technique for resection, if feasible, for

Section II / Liver246

colorectal cancer. e other issue is that most of these patients have prior

abdominal operations (colectomy) and adhesions could be dicult to over-

come for a denitive liver resection. An international multicenter study of

109 patients was reported by Nguyen et al. in 2009. Almost 40% of the resec-

tions were a full lobectomy; 95% of patients had negative margins with a

5-year disease-free survival of 43% and an overall survival at 5-year of 50%.

Another study from Europe of about 150 patients showed a 93% margin-

negative rate, though major resection accounted for less than 20% of the

patients in that series. Although the follow-up was short, the disease-free

survival was similar to that seen in open resection. e above-cited studies

were descriptive in nature and basically, they both justify per se the lapa-

roscopic approach, when feasible, for resection of colorectal metastases to

the liver. Another important article from France was done with case–con-

trol methodology, including 60 patients in each group and having compara-

ble incidence of major hepatectomy (about 40% in each group). Important

dierences shown in this paper include a higher R0 resection rate (87% vs.

72%) in the laparoscopic group. In terms of survival, the 5-year recurrence

free rate was similar (35% laparoscopic vs. 27% open) as well as the over-

all survival (64% laparoscopic vs. 56% open). It is perfectly valid to assume

after studying all these series that the oncologic safety of the laparoscopic

procedure is acceptable and that the administration of pneumoperitoneum

does not increase the recurrence of the tumor in these patients.

Hepatocellular Carcinoma

e higher number of studies in laparoscopic resection for HCC prob-

ably speaks more of the higher incidence of this condition than the com-

fort of the surgeons with this technique. Ninety percent of HCC patients

have accompanying cirrhosis, and the implications of this association are

diverse. First, the manipulation of the liver with cirrhosis is more complex,

with a higher tendency to tear and bleed, and also the hard consistency of

the brotic liver complicates parenchymal transaction. Second, pneumo-

peritoneum increases the abdominal pressure creating ischemia to the liver

and the kidneys, with a further decrease of glomerular ltration (a common

occurrence in cirrhosis) and possible renal decompensation. ird, portal

hypertension and coagulopathy, again a common occurrence in cirrhotic

patients, increase intraoperative bleeding and obscure the limited laparo-

scopic eld; this coupled with the fact that manual compression/manip-

ulation is not readily available theoretically could alert the surgeon to be

more cautious when submitting these patients to laparoscopy. In spite of

the above considerations, there are more data on HCC than on colorectal

metastases, although for obvious reasons, the rate of major hepatectomy

is consistently low for the HCC series. Two matched studies (Belli et al.

and Sarpel et al.) have shown comparable results between laparoscopic

and open techniques for resection of HCC. e rst one shows a similar

mortality rate but a lower morbidity rate for the laparoscopic approach.

Interestingly, overall survival at 3 years was similar (67% lap, 62% open) as

well as the disease-free survival (52% lap, 59% open). Furthermore, the sur-

vival statistics are in accordance with traditional series on survival for the

open approach. e second matched study conrmed the similar rates of

overall survival and disease-free survival as the rst study, without dier-

ence in perioperative results but a lower hospital stay favoring the laparo-

scopic group. Hence, matched studies show again the oncologic safety of

the laparoscopic approach.

A meta-analysis of nine studies performed by Fancellu in 2011 com-

piled 600 patients, 40% of them performed laparoscopically. Among the

dierences found, the laparoscopic group had a higher R0 resection rate,

Chapter 20 / Laparoscopic Liver Surgery 247

shorter hospital stay, lower operative blood loss and need for transfusions,

lower rates of liver failure and ascites, and a trend for lower perioperative

mortality without increase in operative time.

A last point is worth mentioning: When the liver resection is used as a

bridge to transplantation or the patient needs a rescue liver transplant, the

laparoscopic approach has proved to create fewer adhesions and decreases

the complexity of the procedure as demonstrated by lower operative time,

blood loss, and need for transfusion during the hepatectomy phase of the

liver transplant.

Overall, all the results of the laparoscopic technique are at least

comparable to the open approach in managing HCC and do not alter the

recurrence and survival rates compared to open resection. Obviously, these

operations are more challenging due to the reasons explained above but

experienced laparoscopic HPB surgeons can approach these patients with

condence in both perioperative and long-term results.

ANATOMIC RESECTIONS

In an eort to make comparisons more realistic, as all the series mentioned

above contain a great range of the type of liver resections, it is important

to include in this analysis a direct comparison of patients undergoing both

techniques for the same type of hepatectomy.

Left Lateral Sectionectomy

In an analysis by Cherqui’s group in 2003, which includes patients with any

type of disease, operative blood loss and hospital stay were lower in the lapa-

roscopic group, with no dierences in morbidity but an increase in operative

time. is study was presented early in the development of the laparoscopic

technique. Another study performed at Pittsburgh compared 29 laparo-

scopic cases with 40 open; again, the length of stay was lower in the lapa-

roscopic group, and the morbidity rate was also lower. Interestingly, adding

these two factors to an economic model, they determined that laparoscopy

saved between 1,500 and 3,000 US dollars per patient. Overall, as determined

by the international conference in 2008, this specic type of liver resection

should now be approached laparoscopically as the primary option.

Right Hepatectomy

is is the most common major hepatectomy done, and it is probably the

best model to establish the standard results and also to compare with the

open approach. Right hepatectomy is very well dened traditionally, is done

routinely in major centers, and is the most common major resection of the

liver. On the other hand, as surgeons become facile with the laparoscopic

approach while other experienced members of the team continue perform-

ing the traditional open approach, this creates a setting for comparative

studies over the same time period. e two largest published studies rep-

resent that scenario. Even in that setting, laparoscopic right hepatectomy

accounted for 22 patients in a French study and 36 in another. In the rst

study by Dagher et al., patients were matched by demographics and risk

factors (comorbidities). e results showed similarity in operative times

(an improvement, as traditionally laparoscopic cases take longer) and liver-

specic complications, but lower blood loss, shorter hospital stay, and lower

overall morbidity rate for laparoscopy. In the second paper by Hilal et al.,

also case-matched, operative times were longer in the laparoscopic group,

with similar morbidity rates and blood loss, but with a signicantly shorter

hospital stay. e authors of this review also have shown with a comparative

study of about 50 laparoscopic right hepatectomies that all the

erioperative

Section II / Liver248

parameters are improved including operative time (unpublished data). Also,

we found a signicantly lower morbidity rate and a signicantly shorter

hospital stay for the laparoscopic cases. Even though operative costs were

increased, they were compensated by early dismissal and lower complica-

tions resulting in a similar overall cost for both procedures.

Laparoscopic right hepatectomy should also serve as a tool to estab-

lish standards of quality for major HPB centers. is operation is easily

deconstructed in steps, amenable to measurement (each one of them), and

is done frequently enough to produce data from each center. We have done

this structured comparison and have found consistency for each of the

steps (i.e., low standard deviation) except for the parenchymal transaction.

We have observed that liver-specic features such as size and presence of

steatosis or cirrhosis (all of them beyond the surgeon’s control) account for

some of these variances. By dening these steps and identifying the vari-

ance, we can measure costs associated with these dierences and predict

complication rates and associated costs.

Overall, laparoscopic right hepatectomy and, by extension, major

hepatectomy in general are associated with shorter hospital stay and com-

parable blood loss/transfusion rates. e morbidity is probably lower as

well, and operative times, which tend to improve with experience and stan-

dardized protocols, will be amenable to improvement with this technique.

We predict that laparoscopic major hepatectomy will become as routine

as left lateral sectionectomy is today and certainly could potentially be the

main indication for laparoscopic liver resection.

Other Major Resections

ere is interest for other types of anatomic resections but with sparse data.

Living donor left lateral sectionectomy was reported in the last decade for

17 cases with overall good results. Some data have been included also on

donor right hepatectomy (this one mostly with the hybrid approach), again

with comparable results to the open technique. e authors of this chap-

ter have presented a small series of caudate resection and combined major

hepatectomy with bile duct resection/reconstruction, which are techni-

cally demanding but are almost unexplored in the eld of laparoscopic

resections. ese patients so far have had good results and show promise as

this technique is further developed.

ROBOTIC LIVER SURGERY

Robotic surgery is an extension of minimally invasive liver resection.

rough the experience in prostatectomy and other abdominal opera-

tions, there has been a proven benet with emphasis on shorter hospital

stay, better cosmetic results, and lower postoperative pain. Advantages of

tridimensional view (resembling the human eye), greater articulation, and

overall resemblance of the surgeon’s physical approach to these opera-

tions engender enthusiasm toward applying this technique to liver surgery.

However, the learning curve, the high level of dexterity needed, and the

overall enhanced technical skills make the robotic technique less available

for widespread use. With better devices to control bleeding and approach

parenchymal transactions, some centers are starting to reexplore the

robot’s use in liver surgery. e robotic technique is so young that it was not

discussed at the international conference in 2008.

It is important to point out certain potential benets of robotic liver

surgery. Biliary reconstructions are theoretically ideal for the dexterity and

“wrist” articulation of the robot. ere are case reports of robotic Kasai

procedures, choledochal cyst resection, and biliary reconstruction. It oers

Chapter 20 / Laparoscopic Liver Surgery 249

advantages in this setting over laparoscopy in terms of better ergonomics,

increased dexterity, and higher degree of needle rotation. is improve-

ment for biliary anastomosis is also applied to combined liver/biliary resec-

tions, even if the liver resection only uses laparoscopy and not the robot.

e addition of the third robot arm is critical here to set-up the anastomo-

sis, to keep gentle retraction (i.e., the base of segment IV), and to facilitate

the formation of the anastomosis or even facilitate hemostasis.

ere is also interest in combined robotic abdominal resections. Since

rectal surgery is really going in the direction of robotics, and about 20% of

the patients present with simultaneous liver metastases, there is a renewed

interest in combining these two resections robotically. Like in any other

cancer operation, the hope with this technique is to improve the recovery

of the patient and make the patient t for timely start of chemotherapy.

ere is no question that robotic liver surgery is in its infancy. Most

series are very low in number and mostly done by single surgeons who

developed focused interest in this practice. e dicult learning curve and

the challenge of new instruments will select the surgeons who want to take

advantage of the robot platform. Even after conquering the laparoscopic

phase of liver surgery, few surgeons will be prepared to advance to the robotic

phase. We must remember that there was also fear that came at the beginning

of the laparoscopic era, but laparoscopy is the standard of practice for many

abdominal procedures nowadays. With the improved ergonomics of the

robot and the incorporation of haemostatic and transecting devices to the

robot platform, the challenges of hepatic surgery are ready to be conquered.

TECHNIQUE OF LAPAROSCOPIC LIVER RESECTION

is technique should follow both the indications and the initial steps of

the open procedure. e surgeon should master laparoscopic intraopera-

tive ultrasound and should follow the initial inspection of the abdominal

cavity as the rst stages of the operation. For wedge resections, the surgeon

should triangulate as three trocars usually suce: the camera being placed

in direct (“perpendicular”) view of the segment to resect and the other two

ports at a variable distance that allows for freedom of movement with com-

fortable distance to the target area. Most wedges can be done with regular

hemostatic devices like bipolar energy, ultrasonic scalpel, and radiofre-

quency ablation. Use of staplers is not necessary for the most part.

Laparoscopic left lateral sectionectomy is very straightforward. e

camera is placed in the umbilicus or slightly higher. en the other two

ports are placed above the level of the umbilicus, close to the midclavicular

line (Fig. 20.1). We use 10- to 12-mm trocars in all the ports to exchange sta-

pling devices and large graspers on both sides of the midline. e transec-

tion is started to the left of the umbilical ssure with any hemostatic device

after “hanging” the liver from the round ligament (approached from the

right trocar). After thinning out the liver parenchyma and identifying the

portal pedicles, an endovascular stapler is red from the left trocar; usually

two loads are necessary to take both the pedicle for segment 3 and the one

for segment 2. e rest of the transection is done with the energy device,

and care must be taken in the posterior area to avoid an injury to the left

hepatic vein. Upon identication of the left hepatic vein, dissection is done

around it, and then, the stapler is red this time from the right-sided trocar.

en, parenchymal transaction is completed, and the triangular ligament is

transected as the last step of the resection. e specimen is removed via an

extended incision over the umbilical trocar.

Laparoscopic Right Hepatectomy. We follow the same technique as the

open approach. e advantages of laparoscopy are better visualization,

Section II / Liver250

especially of the areas behind the liver, over the inferior vena cava (IVC),

over the right hepatic vein, etc. Also, the increased pressure of the pneu-

moperitoneum keeps the operative eld relatively bloodless as small

venules on the transection line are collapsed. Since the patient will need

an incision for specimen extraction, a hand-assisted technique has been

developed with an additional advantage for liver mobilization, compres-

sion, and urgent management of major vascular bleeding. We place the

trocars as shown in Figure 20.2. No mobilization of the liver is done after

the ultrasound, and the gallbladder is kept in situ for traction. e right

hepatic artery is visualized after taking the cystic artery and is ligated and

transected. e right portal vein is transected with endovascular staplers.

is is important as the space to the area of the right portal pedicle “opens

up” with traction and moves away allowing for a more lateral transection,

thus avoiding injury to the contralateral bile duct (orthe common hepatic

duct). e right bile duct is transected within the liver. Mobilization is

done all the way up to the right hepatic vein, and then we use energy

devices to take all the small vessels of the anterior surface of the IVC until

identication of the IVC ligament, which is taken with staplers. After this,

the right hepatic vein is dissected and stapled. With the line of demarca-

tion now present, we score the capsule of the liver and then start tran-

secting with energy devices, which is done blindly for the rst 2to 3 cm

in depth as the vessels lying in that area are within the hemostatic capa-

bilities of these devices. With further dissection, we take smaller bites on

FIGURE 20.1 Trocar placement for left lateral sectionectomy.

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