Laparoscopic Liver Resections

David A. Kooby, MD, FACSAssociate Professor of SurgeryDivision of Surgical Oncology

Emory University School of Medicine

Lap liver

Abbreviations

• OLR; open liver resection

• LLR; laparoscopic liver resection

• mCRC; metastatic colorectal cancer

Lap liver

Overview

• Brief history and technique

• Safety and efficacy (OLR vs LLR)

• Oncologic outcomes• mCRC

History of Lap Liver ResectionHistory of Lap Liver Resection

Open

Lap

1987

2007

2002

1996

1992Lap cholecystectomy

1st report of major LLR

1st large series of LLR

1st large series of major LLRComparative results to OLR

20091st large series comparing cancer outcomes

Lap liver

Laparoscopic hepatic resection of mCRC met.

Lap liver

Technique

Lap liver

Left lateral segmentectomy

Left hepatectomy

Incisions: partial right hepatectomy

Lap liver

Lap liver

Partial right hepatectomy

Lap liver

Laparoscopy for right sided lesions

mCRC – segment IVb

Lap resection

115 minutes

100 ml EBL

LOS 3 days

R0 margins

Lap Ultrasound

Left Hepatectomy - Ports

.

512

12

5

30° scope

Right Hepatectomy - Ports

.

5

12

12

5

30° scope

Right Hepatectomy – Alternative Hand Port

.

Lap liver

Laparoscopic right hepatectomy

VIDEO

Lap liver

Perioperative concerns with LLR

• Hemorrhage• Inadequate inflow/outflow control• Staple line disruption• Inadvertent vascular injury• Difficult parenchymal transection

• Remnant failure• Prolonged inflow occlusion• Major venous thrombosis

• Other injuries• Biliary tract• Intestinal, other• Gas embolus

Lap liver

Literature Review of LLR

• 127 original reports• (1994-2008)

• 2,804 cases

• Mortality 0.3%

• Morbidity 11%

Nguyen and Gellar, Ann Surg, 2009;250:831-841

17% Major resections

Lap liver

LLR for major (>3 segments) hepatectomy

• Pooled data from 6 HPB centers• 3 European, 2 US, 1 Australian

• 210 cases:• 65% right hepatectomies

• 35% left hepatectomies

• 43% total lap

• 12% conversion

• 2 (1%) 30d mortality

• 22% 30d morbidityDagher and Buell, Ann Surg, 2009;250:856-860

Lap liver

LLR vs. OLR

Simillis, Surgery, 2007 141;203-211

Favors LLR Favors OLR

Postoperative morbidity

Lap liver

LLR vs. OLR perioperative outcomes

Reference(Year)

N Estimated blood loss

LOS (days) Complications (%)

L O L O L O L O

Koffron et al (2007)

300 100 - ↑ 1.9 5.4 9.3 22.0

Ito et al (2009)

65 65 - ↑ 4.0 6.0 13.8 44.6

Topal et al (2008)

109 250 - ↑ 6.0 8.0 7.8 28.9

Castaing et al (2009)

60 60 - - 10 11 27.0 28.0

Lap liver

The Louisville Statement, 2008Consensus conference of 45 “experts” on LLR

• Terminology: pure lap, hand-assisted, hybrid

• Technique

• Efficacy and safety

• Conversion

• Benign liver tumors

• Malignant liver tumors

• Live donor hepatectomy

• Randomized trial vs. open registry

• Training and credentialing

Buell et al, Ann Surg, 2008 250;825

Lap liver

Learning curve

Factors A (n=58) B (n=58) C (n=58) P valueProportion lap (%) 18 22 24HCC (%) 18 26 39 <0.05mCRC (%) 0 7 13 <0.05Major LLR (%) 1 9 9 <0.05Conversions (%) 16 10 3 <0.05Op time (min) 210 180 150 <0.05Blood loss (cc) 300 200 200 <0.05Morbidity (%) 17 22 3 <0.05

Vigano et al, Ann Surg, 2009:250;772

Learning curve levels out at 60 cases

Lap liver

LLR for mCRC, largest series

Variables N=109Age (median) 63 yrs (32-88 yrs)

Female 53 (51%)

Site of Primary colon cancer

Sigmoid/rectum 53 (48.6%)

Right colon 23 (21.1%)

Left colon 14 (12.8%)

Transverse colon/splenic flexure 3 (2.8%)

Unknown 16 (14.7%)

Synchronous disease 12 (11.1%)

Interval from primary cancer 12 mos (range 0 – 60)

Chemo prior to LLR 69 (63.3%)

Nguyen et al, Lap. resection mCRC, 6 centers, Ann Surg, 2009; 250:842-848

Lap liver

LLR for mCRC, largest series

Variables N=109Operative approach

Totally laparoscopic 61 (56.0%)

Hand-assisted 44 (40.4%)

Converted to open 4 (3.7%)

Type of resection

Segmentectomy or wedge 37 (33.9%)

Left lateral sectionectomy 29 (26.6%)

Right lobectomy 31 (28.4%)

Left lobectomy 10 (9.2%)

Extended R. hepatectomy 1 (0.9%)

Caudate lobectomy 1 (0.9%)

Nguyen et al, Lap. resection mCRC, 6 centers, Ann Surg, 2009; 250:842-848

Lap liver

LLR for mCRC, largest series

Variables N=109OR time (median) 234 min (60-555 range)

Blood loss (median) 200 ml (200-2500 ml)

Blood transfusion rate 11 (10.1%)

ICU admission rate 34 (31.2%)

Length of stay (median) 4 days (1-22 range)

Mortality 0%

Morbidity 13%

Nguyen et al, Lap. resection mCRC, 6 centers, Ann Surg, 2009; 250:842-848

Lap liver

LLR for mCRC, largest series

Variables N=109Tumor size (median) 30 mm (4 - 152 mm)

Margin positive 5%

Overall survival

1 year 88%

3 year 69%

5 year 50%

Nguyen et al, Lap. resection mCRC, 6 centers, Ann Surg, 2009; 250:842-848

Lap liver

LLR vs. OLR for mCRC

• Matched preoperative characteristics• Demographics and extent of disease: Age, sex, number,

distribution, and size of metastases, CRS, EHD, pre-hepatectomy chemotherapy

• 60 pts in each group• Two separate centers, one for open case, one for laparoscopic

• Extent of liver resection was similar between groups

Castaing, Ann Surg, 2009;250(5):849-855

All LLR were performed by one surgeon!

Lap liver

LLR vs. OLR for mCRC

Castaing, Ann Surg, 2009;250(5):849-855

LLR OLR

Inherent selection bias!

Lap liver

Castaing, Ann Surg, 2009;250(5):849-855

Overall Survival Recurrence-free Survival

p=0.32 p=0.13

LLR vs. OLR for mCRC

Lap liver

Concerns

• Inadequate training, experience, and mentorship

• Missed extrahepatic disease• Render patient unresectable• Hinder R0 resection

• Less parenchymal sparing

Small benign lesions DO NOT need treatment

Malignant Potential Spontaneous Hemorrhage

FNH NO NO

Hemangioma NO RARE

Simple cysts NO YES

Adenoma YES YES

Lap liver

Final judgment

• LLR for mCRC can be performed safely by experienced surgeons and may be appropriate for selected patients.

• Randomized trials for LLR vs. OLR may be impractical due to limited number of experienced surgeons and appropriate surgeons, and registry data may be the most powerful way to assess further questions

Lap liver

Thank you

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