1. Review of Hepatic Anatomy and Imaging as a Primer for Minimally Invasive Approaches

 

2. Diagnosis & Tissue Sampling - Tools of the Trade

 

3. Laparoscopic Ultrasound Examination of the Liver

 

4. Preoperative Evaluation of Liver Function

 

5. Laparoscopic Management of Benign Liver Disease

 

6. Laparoscopic Liver Resection : Technical Aspects of Left Lateral Segmentectomy

 

7. Minimally Invasive Surgery for Hepatic Malignancy - Endoscopic Liver Resection and Endoscopic Thermal Ablation

 

8. Comparison of Resection vs. Ablative Techniques: Outcomes & Results

Frederick L. Greene, M.D.

Chairman, Department of Surgery, Carolinas Medical Center, P.O. Box 32862
Charlotte, North Carolina 28232

 

The approach and planning of any intraoperative event depends upon utilization of preoperative studies, especially imaging modalities, to allow for adequate planning of operative strategy. This approach, of course, is especially true when minimal access techniques are planned for both malignant and benign hepatic lesions. Understanding of anatomy and the application of studies that fully delineate hepatic and perihepatic anatomy are essential.

 

Surgical Anatomy of the Liver

Anatomic resections, whether performed by laparotomy or minimal access techniques, are based on segmental and lobar branching of the portal triad. The subsegmental anatomy is based on the venous drainage from isolated liver segments and should be completely understood by the surgeon undertaking minimal access segmental liver resection. A right hepatic lobectomy is the removal of the hepatic parenchyma positioned to the right of a plane that extends anteroposteriorly along the gallbladder fossa down to the inferior vena cava. A left hepatic lobectomy is removal of hepatic parenchyma which is positioned to the left of the anatomic mid-plane of the liver extending anteroposteriorly along a plane drawn through the liver extending to the inferior vena cava and slightly to the left of the gallbladder. The most common segment to be removed because of malignant disease is the left lateral segment. This entails the removal of the hepatic parenchyma which resides on the left side of the falciform ligament. A variety of segmental resections was first described by Couinaud in his classic treatise published in 1957. A careful understanding of the labeling of hepatic segmental anatomy is mandatory for appropriate preoperative planning of minimal access liver resection. Currently, especially in patients with cirrhosis, surgeons must assure that only liver parenchyma is removed which allows for complete resection of both benign and malignant lesions. This type of approach includes the proper utilization of imaging techniques to fully define abnormalities in the liver as well as hepatic anatomy.

 

A variety of imaging techniques have been utilized to help in the planning of surgical strategy. For several decades, transabdominal ultrasound has been applied in order to show alterations in anatomic structure, sonographic liver texture and hepatic blood flow. Utilizing the system of Couinaud, the three hepatic veins provide the three major vertical dividing planes resulting in four vertical sections. A horizontal plane defined by the main pedicles of the right and left portal vein branches divides these into eight segments with the caudate lobe forming an additional segment. This method of hepatic division follows functional anatomy whereby each segment retains its own arterial supply, venous drainage, portal circulation and biliary and lymphatic drainage in Couinaud's description. Segment I is the caudate lobe, II and III are the superior lateral and inferior lateral segments of the left lobe, IV is the medial segment of the left lobe, V and VI represent the inferior medial and lateral segments of the right lobe, and VII and VIII the superior lateral and medial segments of the right lobe. The hepatic vasculature and biliary tree are readily visualized by ultrasound. Color flow Doppler imaging is useful when there are issues related to arterial flow and in the identification of the absence of flow which helps to identify biliary ducts.

 

More recently, the use of intraoperative ultrasound has helped greatly in the assessment of liver parenchyma and anatomical landmarks as surgeons begin to apply minimal access techniques to hepatic resection. The application of ultrasound through trocars may identify benign lesions including hepatic hemangiomas, liver cell adenomas and focal nodular hyperplasia. More importantly, in the assessment of hepatic metastases, the ultrasound has been very effective in identifying the margin of tumor involvement which dictates the extent of hepatic resection. Although computerized tomography and magnetic resonance imaging may have better spatial resolution than ultrasound, neither CT nor MRI currently operate in real time.

 

Computed Tomography

For many surgeons, CT remains the imaging modality of choice. With the use of newer contrast agents, focal hepatic diseases can be detected by differences in attenuation between normal and pathologic tissue. CT is especially useful in defining the hepatic vasculature and new subtraction and computer enhancement techniques are making this even more useful. The sequential use of CT also allows the surgeon to assess for growth patterns of liver lesions and to make better assessment between benign and malignant masses. Since metastases are the most common malignant tumor of the liver, the CT scan is especially useful in assessing both the size and number of these lesions as well as the locations within the hepatic parenchyma. Appropriate preoperative planning depends upon the adequate assessment of both the number and size of lesions.

 

Magnetic Resonance Imaging

MRI is an excellent modality to detect and characterize focal liver masses and to evaluate diffuse liver disease. MRI has the greatest advantage over CT in the evaluation of hypervascular malignant lesions such as hepatocellular carcinoma or metastases from hypervascular primary tumors. Benign lesions, such as hepatic adenomas and focal nodular hyperplasia, are outlined appropriately on MRI studies. Features that aid in the distinction between adenomas and focal nodular hyperplasia include the presence of a pseudocapsule, internal hemorrhage, or fat which are features more typical for adenomas, and a central scar that shows delayed enhancement which is more typical for focal nodular hyperplasia. In the evaluation of metastatic disease to the liver, MRI has been used more successfully than CT in detecting multiple lesions in the liver. Both hypovascular and hypervascular metastases to the liver may be imaged appropriately with MRI. Metastases that are commonly hypovascular include colorectal cancer, transitional cell cancer, and carcinoid tumors. Hypervascular liver metastases include renal, islet cell, leiomyosarcoma and melanoma. Hepatocellular carcinoma may have a variety of signal patterns on T1 and T2-weighted images. Early hepatocellular carcinoma is frequently high in signal on T1-weighted images and isointense on T2-weighted images.

 

PET Scanning

The use of the Positron Emission Tomography (PET) scan has grown exponentially over the last three to five years. Medicare beneficiaries have now been allowed to have reimbursement for PET scans in the evaluation of colorectal cancer and carcinoma of the lung as well as melanoma. Comparisons between CT, Magnetic Resonance Imaging and PET have been compared in patients with metastatic colorectal cancer to the liver. PET scanning was successful in identifying up to 85% of the pathologically documented intrahepatic metastases. This compares to a 20% identification rate for CT. As other metastatic lesions in the liver are studied with PET, there may be a greater role for additional primaries when minimal access or ablative techniques are chosen to control hepatic implants.

 

Conclusions

Generally, in accessing patients for minimal access liver resection, several modalities will be employed in order to fully study anatomical, vascular and disease status. The surgeon must be conversant with radiology colleagues in deciding on which modality may be most appropriate for the planned operation. The use of intraoperative ultrasound may take a primary role in final assessment and therefore reduce necessity for costly additional preoperative studies. Imaging is important in characterizing hepatic lesions as either benign or malignant. In dealing with malignancy, the preoperative studies must fully assess the extent of disease as well as the possibility of clinically occult disease. The greatest use of preoperative imaging studies is to make the important decision as to the role of minimal access techniques in the approach to hepatic lesions. In order to avoid unnecessary conversion, especially in patients with malignancy, careful analysis of preoperative studies must be undertaken. For the surgeon performing both open and minimal access hepatic resection and ablative techniques for hepatic malignancy, knowledge of hepatic anatomy, and especially vascular anatomy, is paramount.

 

References

1. Hepatobiliary and Pancreatic Surgery:Imaging strategies and surgical decision making. Evans S and Ascher SM, Eds, Wiley-Liss, Pub, New York, 1998.

2. Couinaud C. Le Foie. In. Etudes Anatomiques et Chirugicales. Masson et Cie, Paris, 1957.

3. Fortner JG, Blumgart LH. A historic perspective of liver surgery for tumors at the end of the millennium. J Am Coll Surg. 2001; 193:210-222.

4. Miller FH, Butler RS, Hoff FL, et al. Using triphasic helical CT to detect focal hepatic lesions in patients with neoplasms. AJR 1998; 171:643-649.

5. Delbeke D, Martin WH, Sandler MP. Evaluation of benign vs malignant hepatic lesions with positron emission tomography. Arch Surg 1998; 133:510-516.

6. Wallace JR, Christians K, Quiroz F, et al. Ablation of liver metastasis: Is preoperative imaging sufficiently accurate? J Gastrointest Surg 2001; 5:98-107.

 

 

2. Diagnosis & Tissue Sampling--Tools of the Trade

David Easter, MD

UCSD Department of Surgery, 9500 Gilman Drive, La Jolla, CA 92023-0987

 

Understanding that laparoscopic survey of the abdominal contents for patients with known or suspected malignancies can be very useful, what are the Tricks and Tools of the Trade? First and foremost, laparoscopy is not an isolated field of abdominal surgery. It is a method of access through the abdominal wall, with most of the potential for diagnosis and therapy that exist with a larger incision. But, the tools are very different. That the tools differ is no reason to alter sound surgical principles or ignore sensible options.

With sound surgical principles in mind, what are the handicaps and limitations to the laparoscopic approach to staging the abdominal cavity for malignancy? There are important tactile, visual, tissue handling, and tissue extraction differences to the laparoscopic approach. While not absent, tactile feedback through long, thin instruments is seriously diminished compared to the gloved fingers of the exploring surgeon. Two-dimensional vision is less appealing than 3-D viewing, but this is not a serious handicap; and, the magnification possibilities with the video imaging equipment more than makes up for this shortfall. Tissue handling and extraction is problematic, and these hurdles are the most serious limitations to laparoscopic techniques.

This session will describe various methods for sampling tissue during laparoscopic exploration of the abdomen. We will use case examples to emphasize the selective application of these Tricks of the Trade.

 

Case #1: Directed cytology and sampling

A 49-year old man presents after a complete and "negative" metastatic survey for resection of his large hepatocellular carcinoma. Though "negative", his work-up has included a CT scan which shows a distinct fluid collection in his lesser sac. You offer him diagnostic laparoscopy with directed tissue sampling separate from a planned partial hepatectomy, knowing that he has either 1) unresectable gross disease, and hence should be considered for palliative or "on study" neoadjuvant chemo-radiation therapy, or 2) no grossly visible disease. If he has no grossly visible disease, the results of cytologic sampling will not be reliable until days after surgery.

At operation, you "run the bowel" and explore all compartments of the abdomen, saving lesser sac exploration for last. You save it for last because it is the most technically challenging, and because it has the highest chance of having microscopic disease, and you don't want to unknowingly spread this throughout the abdomen. Entering the lesser sac- either through the lesser omentum, the greater omentum, or the transverse colon mesentary- you find a thickened posterior gastric wall and scant ascites. You aspirate the fluid into a sterile container for spin-down cytology. Since the stomach wall is thickened and irregular, you provide the pathologist with scrape-cytology samples of the most suspicious areas.

If metastatic disease is encountered, you consider placing a laparoscopic-assisted feeding jejunostomy catheter. This option should be considered well in advance of the procedure, depending on adjuvant therapy concerns and a full informed consent.

Though adding an "extra step" to his surgical management, the patient and family are reassured that 1) a more extensive and fruitless operation was avoided (when metastatic disease is encountered), or that 2) his surgical resection is likely to be uncomplicated and potentially curative (with negative findings provided by the directed laparoscopic sampling.

 

Case #2: Directed Fine Needle Aspiration (FNA) of liver lesions

A 35-year old woman presents on metastatic survey for a melanoma with two indistinct liver lesions. Multiple imaging studies, including CT, MRI, Ultrasound, and PET imaging are suggestive of benign cysts, but are too small to be fully characterized, i.e., "cannot exclude malignancy." Intending to re-excise her close surgical margins and perform sentinel node biopsy, you also know that metastatic disease would make these efforts meaningless. With a full informed consent that describes the sequence of events and intraoperative decision making, she elects for diagnostic laparoscopy with ultrasonography and sampling or excision of the liver lesions.

At operation, the two lesions are clearly simple cysts. You aspirate both for cytology, and complete the abdominal survey with ultrasound of the liver parenchyma. Quick-stain cytology confirms that no malignant cells are recovered, so you re-drape for the re-excision and sentinel node biopsy. The patient, family, and all concerned clinicians are relieved of long-term worrying over these otherwise indeterminate lesions.

Case #3. Directed core needle sampling of post-treatment liver lesions.

A 52-year old female presents after chemotherapy for metastatic breast cancer with a residual liver lesion. Her medical oncologist doesn't know if she has remaining active disease, or if this represents residual scarring from a fully treated metastasis. Though the lesion has shrunk with therapy, it has not disappeared. Live tumor cells means a change to 2nd line chemotherapy, but scarring with no recognizable tumor cells means a changeover to hormonal therapy. With a full discussion of the decision making algorithm, that includes the patient and all relevant treating physicians, she elects for diagnostic laparoscopy with directed biopsy.

At laparoscopy, no other lesions exist. The mass in question looks like a fibrotic, retracted scar that is concave to the liver surface. Regardless of the visual assurances, you make multiple passes with an 18-gauge core needle "biopsy gun." Though potentially resectable, you know that systemic therapy best treats breast cancer metastases, as other distant disease very likely exists if this is positive for cancer.
The multiple core samples yield no viable tumor cells. You have just spared this patient six more cycles of "dose escalated" chemotherapy! Plus, the emotional worry over this lesion is all but gone.

 

Case #4. Incisional sampling biopsy for peritoneal-based lesions.

A 72-year old man presents with vague abdominal symptoms, weight loss, malaise, fatigue, and an exhaustive search for the cause of his problems that has yielded no clear diagnosis. Endoscopy, CT scans, ultrasonography, and other seemingly low-yield studies have been fruitless. You are asked to consider an operative biopsy of a "slightly thickened omentum."

Knowing that peritoneal-based disease is hard to image on all non-operative studies, you suggest laparoscopic exploration and directed biopsies. You suspect the unusual, i.e., mesothelioma. You expect to solve this riddle with laparoscopic means alone, but consent the patient for possible exploratory laparotomy.

At laparoscopy, the diagnosis is clear. This is mesothelioma. Large biopsies are required for material to secure an accurate pathologic diagnosis. You use the "big bertha scoop" to cup large samples of peritoneal tumor, and use a stapling-cutting device to remove a large piece of involved omentum. All samples are removed through a shielded trocar assembly, or within a specimen retrieval bag.

Since the incisions were all small, his recovery is uneventful. He is able to consider systemic therapy within the shortest of intervals.

 

Case #5. Excisional biopsy of suspicious lymph nodes.

A 28 year old HIV (+) male presents with night sweats, weight loss, malaise, and a CT which shows isolated abdominal lymphadenopathy. The interventional radiologists have been consulted, but no safe biopsy route is found. The differential diagnosis includes reactive nodes, tuberculous adenopathy, and and immunosuppression-associated lymphoma. Directed therapy requires directed biopsies.

You offer and he consents to diagnostic laparoscopy with lymph node biopsies. At operation, you find enlarged nodes throughout his small bowel mesentery. Using clips to ligate their vascular and lymphatic pedicles, you completely excise the two most suspicious nodes. Upon retrieval, you coordinate sending the nodes fresh for microbiology, touch prep cytology, histopathology, and if indicated, flow cytometry. You bring the pathologist into the operating room if necessary to ensure proper tissue handling.

The diagnosis is lymphoma, and the appropriate systemic therapy is begun shortly after laparoscopic lymph node sampling.

 

Case #6. Staging operation for Hodgkin's Lymphoma

A 26 year-old female presents with localized cervical lymphadenopathy due to Hodgkin's Disease, but, she has confusing systemic symptoms, i.e., night sweats. Her image-based staging is "clear." Keen to avoid chemotherapy, but alert to the value of complete staging of her disease, she is referred for staging laparotomy. Even at laparotomy, you know that involved pelvic nodes will be a clear indication for systemic therapy. You consider lymphangiography, in order to direct your sampling efforts.

Knowing that many intraoperative decisions will likely be required, you spend significant time orienting the patient and her family to the unknowns of this procedure. Will a splenectomy be performed? (Yes, if no other disease is encountered.) What about the liver? (Biopsies will be taken.) Will she be able to have children in the future? (Hopefully, and especially since you plan to relocate the ovaries to the midline, away from potential radiotherapy fields.) Can this all be performed laparoscopically? (Yes, all but the easy removal of the intact spleen.)

You coordinate the specimen handling with the pathologist du jour. If all biopsies are negative leading up to the splenectomy, you already know if the pathologist will tolerate "minced spleen", versus a whole organ retrieval. As this is one of the most demanding laparoscopic procedures currently performed, you make sure that you have your favorite 1st assistant, and the most capable operating room team lined up for this 3-4 hour adventure. You are quick to consider converting this to an open operation if you feel youself compromising on the goals of the operation.

The good struggle is had, and all has turned out well. All biopsies show no sign of Hodgkin's Disease, and the patient is comforted with this knowledge. No recovery time is needed prior to starting the radiation therapy.

 

Summary of the Tricks of the Trade

Mindset: what would happen in the open operation? Have the same goals for the laparoscopic counterpart.

Think ahead: will the findings at laparoscopy matter to the eventual treatment or prognosis?

Tissue needs: Have all your sampling and excisional biopsy options available.

Extra toys: Ask the interventional radiology technicians for their latest gadgets, e.g., spring-loaded biopsy guns.

Staging vs. resection: Consider separating the laparoscopic sampling from the intended resection, for the clarity of further thought and permanent pathology results.

Specimen retrieval: Shield all suspect tissue from contaminating the abdominal wall wherever possible.

Adjunctive tools: Consider adding intraoperative laparoscopic ultrasonography to assist in solid organ inspection. This may help replace the utility of being able to directly palpate organs. Also consider inviting the ultrasound radiologist into the room to assist with interpretations- it's billable and novel to these valuable colleagues!

Anesthesia: General anesthesia is usually preferred. If the patient is too sick for a general anesthetic, it is doubtful that anything more than symptom palliation is warranted.

Tough cases: Remember that hand-assisted laparoscopy is a natural intermediary between open and laparoscopic explorations.

Ascites: Close all incisions with extra care, and in layers. Place ports obliquely through abdominal musculature, to minimize the chance of a postoperative leak.

 

Conclusion

Laparoscopy is a method of access through the abdominal wall, not a significantly restricted set of diagnostic and therapeutic surgical options.

 

References

1. Easter, DW. Tissue harvesting techniques in laparoscopic surgery. Seminars Lap Surg 1(1):62-71, 1994.

2. Pratt BL, Greene FL. Role of laparoscopy in the staging of malignant disease. Surg Clin NA 80(4):1111-1126, 2000.

3. Easter, DW. Potential for abdominal wall implantation after laparoscopic procedures of the hepatobiliary tract. Seminars Lap Surg, 2(3):163-6, 1995.

4. Goudas LA, Brams DM, and Birkett DH. The use of laparoscopic ultrasonography in staging abdominal malignancy. Seminars Lap Surg 7(2): 78-86, 2000.

5. Saber AA, et al. Part I. Laparoscopic approach to abdominal malignancies. Curr Probl Cancer 25(5):311-26, 2001.

6. Miller CE. Methods of tissue extraction in advanced laparoscopy. Curr Opin Obstet Gynecol 13(4):399-405, 2001.

7. Saeian K, et al. Staging laparoscopy: a peek may save a cut. Endoscopy 31(5):389-91, 1999.

8. Ramshaw BJ, et al. Laparoscopy for the diagnosis and staging of malignancy. Semin Surg Oncol 16(4):279-83, 1999.

9. Rozycki GS. Surgeon-performed ultrasound- its use in clinical practice. Am Surg 228(1):16-28, 1998.

 

 

 

3. Laparoscopic Ultrasound Examination
of the Liver

Desmond H. Birkett, MD

Department of General Surgery, Lahey Clinic Medical Center, Burlington, MA

 

Introduction

The negative resection rate for patients with hepatic tumors who have been determined on preoperative work up by the non-invasive methods of percutaneous ultrasound, CT scanning or MRI to be respectable is approximately 49%. Laparoscopic ultrasound has been determined to be more accurate at assessing hepatic lesions and their respectability than the non-invasive methods of percutaneous ultrasound, CT scanning or MRI.

 

Equipment

Laparoscopic ultrasound probes

• Sector scan which has the transducer on the end of the instrument giving a wedge or pie shape image forward looking image
• linear array transducers with the transducers placed on the side of the tip of the probe giving an image at right angles to the probe
• Rigid probes
• Movable probes with

Two way movement, up and down

Four way movement, up and down, and side to side

Color Doppler is useful for visualizing and assessing vascular structures

 

The use of laparoscopic ultrasound has significant advantages over percutaneous ultrasound examination.

• The distance the ultrasound has to pass through tissue is less and as a result transducers of a higher frequency can be used.
• The higher the frequency of the ultrasound transducer used, the higher the image resolution.
• There is no ring down effect. A distortion that is caused by the sound waves passing through the layers of the abdominal wall.

 

Technique

• Laparoscopy under general anesthesia
• 10 mm trocar at the umbilicus for the camera
• 10 mm trocar on the right side of the abdomen at the level of the umbilicus for the ultrasound probe
• Abdomen examined laparoscopically examining the liver surface and the peritoneal surface
• Use picture in picture video mixing technique to monitor position of probe inside abdominal cavity
• Extra 10 mm trocar on the left side of the abdomen also for the ultrasound probe may be needed to enhance visualization of the lateral segment of the left lobe
• Window in the falciform ligament to aid visualization of the posterior aspect of the left lateral segment
• Examine superior and inferior aspects of liver

 

Difficulties encountered with laparoscopic ultrasound

• Adhesions from previous operations may limit the examination of the liver if they cannot be taken down
• Segments IVA, VII, and VIII may be difficult to visualize, but the problem can be helped by filling the upper abdomen with saline, or using a steerable probe

 

Advantages of laparoscopy of the liver

• Increased sensitivity of laparoscopic ultrasound examination of the liver

Advanced cirrhosis not recognized pre-operatively

Small intra-hepatic lesions, 1 cm in diameter or less not found on pre-operative workup by non-invasive studies such as CT scan, MRI or transcutaneous ultrasound

Detection of peritoneal deposits

• Assessment of tumor proximity, compression, and invasion of lesions to vascular structures
• Assessment of portahepatic lymph nodes
• The ability to take accurate and directed biopsies
• The ability to accurately direct injection treatment
• Avoidance of a negative laparotomy in patients with an unresectable lesion
• Detection of small lesions that are too small

 

Disadvantages of Laparoscopic Ultrasound

• Lack of tactile feedback
• Need for minimal access laparoscopy

 

Results

John et al showed that in 50 patients with operative lesions determined by preoperative workup, laparoscopy precluded curative treatment in 23 patients (46%), with laparoscopic ultrasound identifying liver tumors not visible during laparoscopy in 14 patients (33%), and providing staging information in 18 of 43 patients (42%). The respectability rate was found to be 93% with laparoscopy and ultrasound compared to 58% with laparotomy alone. Therefore preventing a significant number of negative laparotomies, reducing cost and returning patients home for the start of other therapeutic options at an earlier stage.

 

Bibliography

1. Schirmer B. Laparoscopic ultrasonography. Ann Surg 1994 220:709-10

2. John TG, Greig JD, Crosbie JL et al. Superior staging of liver tumors with laparoscopy and laparoscopic ultrasound. Ann Surg 1994 220:711-9

3. Babimeau TJ, Lewis WD, Jenkins RL, et al. Role of staging laparoscopy in the treatment of hepatic malignancy. Am J Surg 1994 167:151-05

4. Eubanks S. The role of laparoscopy in the diagnosis and treatment of primary or metastatic liver cancer. Semin Surg Oncol 1994 10:404-10

5. Brady PG, Pebbles M, and Goldschmid S. Role of laparoscopy in the evaluation of patients with suspected hepatic or peritoneal malignancy. Gastrointest Endosc 1991 37:27-30

6. Callery MPO, Strasberg SV, Doherty GM, Soper NJ, Norton JA. Staging laparoscopy with laparoscopic ultrasonography optimizing respectability in hepatobiliary and pancreatic malignancy J Am Coll Surg 1997 185:33-39

7. Montorsi M, Santambrogio R, Bianchi P, Opocher E, Cornalba GP, Dapri G, Bonavina L, Zuin M, Podda M. Laparoscopy with laparoscopic ultrasound for pretreatment staging of hepatocellular carcinoma: a prospective study J Gastrointest Surg 2001 5:312-315

 

 

4. Preoperative Evaluation of Liver Function

Paul Hansen, MD

Director of Research and Educatio, Department of Minimally Invasive Surgery

Legacy Health System, Portland, Oregon

 

Better understanding of hepatic anatomy, improvements in operative technique, and advances in perioperative care have allowed surgeons to become increasingly aggressive in the surgical management of liver tumors. As technical challenges are overcome, we increasingly push up against a new limit to our success, our inability to accurately access functional hepatic reserve, and thereby to determine the volume of hepatic parenchyma which can be safely resected in a given patient. Though we have a number of laboratory tests available to us which reflect individual facts about liver injury, synthetic capability, or pre-existing disease, we do not have readily available and accurate tests which will identify patients with marginal liver function who will not tolerate a planned resection. The final decision to resect or not in marginal cases should be based on existing laboratory data, the surgeon's clinical experience, and the patient's willingness to accept risk.

 

The introduction of techniques and technologies such as laparoscopic liver surgery and tumor ablation bring new complexities to this decision making process. The laparoscopic approach to liver resection is technically feasible, but introduces a new set of physiologic alterations which may play a role the outcome of marginal cases. CO2 pneumoperitoneum has been shown to decrease overall liver blood flow, reduce indocyanine green clearance, and reduce tissue oxygen tensions. The role that these alterations may play in tolerance of resection in marginal cases is currently unclear. Similarly, liver ablation technologies such as radiofrequency ablation are taking on an increasing role in the management of hepatic malignancies. These procedures have the advantage of eradicating the tumor while limiting the degree of injury to surrounding parechnyma. Parenchymal sparing procedures may extend the patient pool to which surgical treatment of liver tumors is offered, and undoubtedly, as experience and success with ablations grows, more difficult cases will push the limits of the technique.

 

Patients with healthy livers may tolerate resections of nearly 80% of their original hepatic volume. Extended right and left hepatectomies will leave the patients with two functional segments of their liver. The majority of regeneration will occur within two weeks and the process is often complete by 6 to 8 weeks. The limitations of resection in patients with a healthy liver are more frequently related to the patients overall health and the presence of co-morbid conditions. Cirrhotic patients on the other hand, have a very limited capacity both to tolerate surgical stress and little ability to regenerate the functional hepatic volume lost in resection. Morbidity and mortality in cirrhotic patients is generally related to liver dysfunction.

 

Our preoperative ability to test liver reserve can be broken down into markers of hepatocyte injury, cholestasis, synthetic capability, viral infection, autoimmune or metabolic dysfunction, or to a very limited degree quantitative functional reserve. Qualitative studies such as ICG clearance may be used as a general guide to overall liver function. Finally, a number scoring systems exist which are based on a combination of laboratory tests and clinical factors and assist in presurgical assessment.

 

 

Test	Disease Process	Comment
AST/ALT	Hepatic Necrosis	ALT is liver specific, AST is more sensitive. General markers of hepatocyte injury.
Alk phos GGT	Cholestatis	Non-tissue specific, but both increase markedly with biliary obstruction.
Bilirubin	Obstruction Cirrhosis	May indicate structural injury to the liver, diffuse or focal obstruction.
PT/INR	Clotting Synthesis	The liver is the primary site of synthesis of clotting factors
Albumen	Synthesis	Measures synthetic capability and nutrition

 

Indocyanine green is an anionic organic dye which is given intravenously. It is extracted from the blood by a carrier-mediated mechanism, and the rate of extraction is a rough guide to hepatic functional reserve. It remains an imperfect test because it depends both on hepatic blood flow and on functional capacity of the liver. These two variables cannot be reflected individually. Several authors have quantitated extraction rates with survival following progressively larger resections. Retention of less than 15% at 15 minutes suggests that formal resections may be undertaken. Retention rates between 20% - 30% will allow more limited resection, while retention rates greater than 40% should have nothing more than tumor enucleation.

 

The Child's-Pugh classification of liver disease has generally been accepted as the most reliable predictor of survival for cirrhotic patients following liver resection. This scoring system uses serum albumin, serum bilirubin, PT, the presence of ascites, and the presence of encephalopathy. Patients with a Child's-Pugh score of greater than 6 are not candidates for surgical resection. Many surgeons will exclude patients with single marker findings, such as a serum bilirubin greater than 2.0mg/dL, a PT greater than 4 seconds above normal, or the presence of ascites or encephalopathy.

 

The ability to determine functional hepatic reserve, and therefore the ability of a patient to tolerate surgical resection of hepatic parenchyma remains an imperfect science. A combination of serum blood tests, clinical findings, and a qualitative assessment of function capacity give us the best estimation currently available. We have preliminary data suggesting that a laparoscopic approach to liver resection must be viewed cautiously in marginal patients, as impairments in liver blood flow and decreased oxygen tension may further compromise the tolerance of the procedure. There may be some hope, however, of increasing the overall pool of patients who are candidates for surgical intervention through the utilization of parenchymal sparing, ablative techniques. As always, more research is needed to help us define the appropriate utilization of these procedures.

 

References

1. Decailliot F, Cherqui D, Leroux B, et al. "Effects of portal triad clamping on haemodynamic conditions during laparoscopic liver resection." Br J Anaesth 2001 Sep; 87(3): 493-6

2. Lau W, Leung K, Leung TW, et al. "A logical approach to hepatocellular carcinoma presenting with jaundice." Annals of Surgery. 1997b; 225: 281-5.

3. Makuuchi M, Kosuge T, Takayama T, et al. "Surgery for small liver cancers." Seminars in Surgical Oncology. 1993; 298-304.

4. Miyagawa S, Makuuchi M, Kawaski S, et al. "Changes in serum amylase level following hepatic resection in chronic liver disease." Archives of Surgery. 1994; 129: 634-8.

5. Noguchi T, Imai T, Mizumoto R. "Preoperative estimation of surgical risk of hepatectomy in cirrhotic patients." Hepatogastroenterology. 1997; 37: 165-71.

6. Pastor CM, Morel DR, Clergue F, et al. "Effects of abdominal CO2 insufflation on renal and hepatic blood flows during acute hemorrhage in anesthetized pigs." Critical Care Medicine. May 2001; 29(5): 1017-22

7. Richter S, Olinger A, Hildebrandt U, et al. "Loss of physiologic hepatic blood flow control ("hepatic arterial buffer response") during CO2 pneumoperitoneum in the rat." Anesth Analg 2001 Oct; 93(4): 872-7.

8. Sato K, Kawamura T, Wakusawa R. "Hepatic blood flow and function in elderly patients undergoing laparoscopic cholecystectomy." Anesthesia & Analgesia. May 2000; 90(5): 1198-202.

9. Schager M, Krahenbuhl L. "Effect of laparoscopy on intra-abdominal blood flow." Surgery. Apr 2001; 129(4): 385-9.

10. Suehiro T, Sugimachi K, Matsumata T, et al. "Protein induced by vitamin K absence or antagonist II as a prognostic marker in hepatocellular carcinoma. Comparison with alpha-fetoprotein." Cancer. 1994; 73: 2464-71.

11. Tunon MJ, Gonzalez P, Jorquera F, et al. "Liver blood flow changes during laparoscopic surgery in pigs. A study of hepatic indocyanine green removal." Surgical Endoscopy. Jul 1999; 13(7): 668-72.

12. Zimmerman H, Reichen J. "Assessment of liver function in the surgical patient." In: Surgery of the Liver and Biliary Tract 3rd Edition; W.B. Saunders 2000; 34-63.

Namir Katkhouda, MD, FACS*, and Eli Mavor, MD+

* Professor of Surgery, Chief, Division of Emergency Non Trauma and Minimally Invasive Surgery, Department of Surgery, University of Southern California School of Medicine, Los Angeles, CA.

+ Research Fellow, Division of Emergency Non Trauma and Minimally Invasive Surgery, Department of Surgery, University of Southern California School of Medicine, Los Angeles, CA.

 

Proof and reprints to: Namir Katkhouda, MD

USC Department of Surgery, Healthcare Consultation Center

1510 San Pablo Street, Suite 514, Los Angeles, CA 90033-4612

TEL#: (323) 442-6279, FAX#: (323) 442-5709, e-mail: nkatkhouda@surgery.usc.edu

 

 

Despite recent advances in laparoscopic techniques and instrumentation, laparoscopic liver surgery has remained uncharted territory. Laparoscopic fenestration of solitary giant liver cysts has been reported4, 6, 8, 10, 18, but few studies have included management of larger numbers of patients with polycystic liver disease (PLD)8, 12, 24 or benign solid tumors3, 7, 13, 26. The feasibility of effective laparoscopic management of echinococcal liver disease is still unclear5. Liver cases are traditionally sent to academic liver centers that focus on transplantation and resection of liver cancer, but lack sometimes advanced laparoscopic expertise. The complexity of the laparoscopic techniques and undefined inclusion criteria are additional contributing factors. The aim of this review is to analyze the technical feasibility and safety of laparoscopic liver surgery, and to evaluate its role in the management of two types of benign lesions: hepatic cysts and solid tumors.

 

INDICATIONS

Benign liver tumors and cysts are relatively rare lesions, but because of improvements in imaging modalities and the wide spread use of ultrasound as a screening tool in patients with abdominal symptoms, they are diagnosed more frequently today. Surgery is indicated when they become symptomatic or complicated or demonstrate rapid growth23, 27.

In order to embark upon safe laparoscopic liver surgery, a combined extensive experience in advanced laparoscopic and hepatobiliary surgery are mandatory. For optimal results, the following rules must be strictly adhered to: laparoscopic operations must conform to standards employed in open surgery; only lesions favorably located should be approached; and, appropriate laparoscopic skills and technology should be available.

For patients with benign solid tumors and hydatid cysts, only lesions located in anterolateral segments 2 through 6 (Couinaud classification) should be considered for laparoscopic treatment. All solitary liver cysts, regardless of their size and anatomic location, are suitable for laparoscopic management. In patients with polycystic liver disease, only dominant cysts located in anterior segments should be approached laparoscopically. Cholangitis resulting from communication of a hydatid cyst with the intrahepatic biliary tree, cirrhosis and poor cardiac function are contraindications to laparoscopy.

Despite isolated reports of laparoscopic resection of malignant hepatic lesions9, 26, laparoscopic management of intraabdominal cancer is controversial11. It is not inconceivable that wedge resection of limited liver metastases could be an acceptable alternative to an open metastasectomy, pending trials assessing the safety and efficacy of laparoscopic management of intraabdominal malignancy.

 

TECHNIQUE

The patient is positioned in the inverted-Y position with the surgeon standing between the legs and the assistants at the sides. A 30° videolaparoscope (Karl Storz, Tutlingen, Germany) is introduced at the umbilicus via a 10- to 12-mm trocar (Ethicon Endo Surgery Inc., Cincinnati, OH). Two 10-mm ports surround the umbilicus in a 90° triangulated fashion, and a subxiphoid trocar is used for a fan retractor or the irrigation/suction device. For resection of solid tumors, this basic technique can be modified to a "four-hand" approach, where two additional trocars allow two surgeons to work simultaneously. The first surgeon performs with the laparoscopic ultrasonic dissector an instrumental fracture of the liver parenchyma, exposing all bile ducts and vessels, while the second surgeon controls all the vasculobiliary pedicles with clips or other hemostatic tools. This speeds up the operation and reduces the risk of hemorrhage and carbon dioxide gas embolism.

The "four-hand" technique is used to resect benign solid tumors such as adenomas and focal nodular hyperplasia. The resection begins with division of the round ligament and the right or left triangular ligament for lesions located in the corresponding lobe. Glisson's capsule is scored 2 cm away from the lesion using electrocautery. The Harmonic shears ( LCS, Ethicon Endosurgery,Cincinatti,OH )is one of the key instrument in laparoscopic liver surgery.It can be used to mimick a "Kelly fracture technique"while achieving hemostasis and biliostasis of all small radicles .Its action is based on the denaturation of proteins through a heat induced coagulation proccess by the oscillations of the blades at 55,000 cycles /sec. Those shears are used by the first surgeon to dissect the parenchyma, while the left hand retracts the exposed liver surface. Simultaneously, the second surgeon divides all exposed larger vascular and biliary pedicles between large hemostatic clips. Hemostasis and control of bile leak from raw liver surface are achieved by wide application of fibrin sealant. Fibrin Sealant ( Tisseel?, Hyland/Immuno Div., Baxter Corp., Deerfield, IL) has been approved for clinical use in the US in 1998 and is currently commercially available. It is achieved by a combination of 2 main products: human derived fibrinogen mixed with an antifibrinolytic agent (aprotinin) and thrombin activated by calcium chloride. The vials are heated at 37°C on a specially designed plate (Fibrinotherm, Baxter Corp., Deerfield, IL) and agitated. The end product (fibrin glue) duplicates natural human polymerized fibrin chains.

It is reconstituted in the clinical setting by combining the two seringes containing fibrinogen on one hand and activated Calcium chloride on the other hand via a laparoscopic applicator (Duplocath *, Baxter healthcare,Inc ).

Fibrin sealant has several interesting properties that makes it appealing in laparoscopic liver surgery.

First, it is a powerful hemostatic agent .Reproducing the last step of the coagulation cascade,it will stop venous oozing from the liver surface.It is best applied in a thin layer using the Tissumat * device .It is recommended during application to monitor the intraabdominal pressure to avoid a surge that could lead to a state of mechanical hyperinflation .The excess CO2 should be released through the opening of the trocar valve.

It is obvious that the use of Tisseel will not replace excellent surgical technique.

Argon beam coagulation is an alternative hemostatic option but our preference goes to the use of fibrin sealant as it will avoid the charring effect that accompanies the use of the argon technology.

Second, fibrin sealant will occlude exposed small biliary radicles thus minimizing the risk of postoperative biliary fistulas.

Clips are used for hemostasis of large structures, and linear endovascular cutters are reserved for the hepatic veins. A flexible laparoscopic ultrasound probe is useful in locating anatomic landmarks or vasculobiliary structures.

If left lateral segmentectomy is indicated, it is commenced by dividing the falciform and left triangular ligaments until the inferior vena cava is identified. The liver is displaced inferiorly using a fan retractor, and the junction between the left hepatic vein and the inferior vena cava is carefully exposed using the right-angled and peanut dissectors to gain extrahepatic control of the vein. This maneuver should not be attempted if the retrohepatic course of the hepatic vein is too short. The hepatoduodenal ligament is dissected and a rubber tourniquet is passed around the porta hepatis to prepare for a Pringle maneuver in the event of massive hemorrhage. An 0 silk tie is placed around the hepatic vein and the vein is ligated using intracorporeal knot-tying technique but is not divided. The liver capsule is then scored on the anterior and inferior surface 1 cm to the left of the falciform ligament. Using the "four hand" approach, the liver parenchyma is fractured with long atraumatic forceps or the ultrasonic dissector in a technique similar to the open finger-fracture method. The vasculobiliary pedicles of segments 2 and 3 are identified and serially ligated using hemostatic clips, and divided. The pretied left hepatic vein is divided within the liver parenchyma using a vascular endolinear cutter. Drains are placed in the residual space. The specimen is placed in a puncture-resistant bag (Cook Surgical, Bloomington, IN), sliced into two or three fragments and brought out through the enlarged umbilical port.

Constant monitoring of hemodynamic status and end tidal CO2 and O2 saturation are essential for early diagnosis and correction of CO2 embolism, which may pose at least a theoretical risk during surgery, particularly in the presence of divided parenchyma or hepatic venotomies.

Solitary nonparasitic liver cysts are fenestrated. The blue dome of the cyst is opened using scissors, and the cyst content is aspirated. The cavity is thoroughly examined for the presence of indentations indicating neoplastic changes that would prompt an open resection of the lesion. The wall of the cyst is excised to within 3 mm of the liver parenchyma and is sent for pathology. Careful hemostasis of the cyst edge is performed with electrocautery. The presence of bile at the cystic edge, indicating an injury to septal bile ducts, is assessed, and a hemostatic clip or a tie is applied when needed.

The application of fibrin sealant will alliveate the need of placement of a drain thus reducing the risk of postoperative serous leaks by exudation of the remaining cyst wall.

In inferiorely located cysts, no marsupialasation with omentum is needed .

In cysts located on the dome of the liver, Way advocated stuffing the unroofed cyst with omentum to prevent a recurrence by reformation of the wall .the use of Fibrin sealant alliviates the need for this maneuver.

In PLD, deeper cysts which appear blue must be distinguished from portal or hepatic veins before transcystic fenestration. Laparoscopic ultrasound with color Doppler is helpful to delineate cysts from vascular structures. No drains are placed. Fascia of all wounds must be carefully closed to prevent leakage of cystic fluid.

Small, partially calcified hydatid cysts favorably located in an anterior hepatic segment can be managed by total pericystectomy. It consists of sequential vascular control of all the pedicles, using the pericystic layer as the plane of dissection.

Management of larger hydatid cysts proceeds in three stages. First, cholecystectomy is performed and transcystic cholangiography is done to identify possible intrahepatic biliary fistula or the presence of parasitic debris in the common duct (despite the absence of cholangitis). Next, the parasitic content is sterilized with 10 to 20 cc of hypertonic saline instilled for 10 minutes via a percutaneous spinal needle. The sterilized parasitic debris is aspirated with a large-bore trocar. Care is taken to prevent the spillage of parasitic material to avoid secondary echinococcal infestation or anaphylactic shock. Two 4x4" pieces of gauze marked with a radiopaque strip and Prolene suture for easy retrieval are soaked with hypertonic saline and placed around the cyst, and the cyst is opened and inspected for biliary leaks. These can be further demonstrated by the injection of methylene blue through the transcystic catheter, and closed laparoscopically. Finally, the residual cavity is filled with omentum.

Fibrin sealant is applied when the cyst has been removed totally (pericystectomy).

Collagen fleeces can also be used as an addon to the sealant.

All patients are given perioperative albendazole to help prevent recurrence of echinococcal disease in the event of an unrecognized spillage of hydatid debris.

 

RESULTS

We have recently reported our results of laparoscopic management of benign liver disease in 43 patients operated upon between September1990 and October 1997 15. There were 11 men and 32 women with a median age of 47 years (range, 22 to 88 years). Of patients with cystic disease of the liver, pathology included solitary giant liver cyst in 16 patients, PLD in 9 and hydatid cysts in 6 patients (Table 1.). Solid tumors consisted of adenoma in 9 patients and focal nodular hyperplasia (FNH) in 3 patients.

Median size was 4 cm for solid nodules (range, 2 to 7 cm) and 14 cm for solitary liver cysts (range, 7 to 22 cm). Patients with PLD had a median of 8 cysts (range, 6 to 12 cysts) with a median diameter, as measured on CT scan, of 8 cm (range, 4 to 16 cm).

41 patients were symptomatic. 2 asymptomatic patients had 6 and 7 cm solid masses excised and shown on pathology to be adenoma and FNH. Presenting complaints included right upper quadrant pain (68%), symptoms related to compression of adjacent organs (22%), sepsis (6%) and refractory pleural effusion (4%).

The operative procedures are shown in Table 1. In three patients (7.1%), the operation was converted to laparotomy. In two patients, conversion was to control bleeding, during fenestration of a polycystic liver, and during total pericystectomy of a hydatid cyst. Both hemorrhagic events resulted from injury to hepatic venous branches. A left lateral segmentectomy for adenoma was converted electively after intraoperative ultrasound showed the mass to be impinging on the inferior vena cava.

Median operative time was 179 minutes (range, 45 to 325 minutes). All solitary liver cysts were fenestrated in less than 1 hour.

There were no deaths. Three patients received blood transfusions. Complications occurred in 6 cases (14%): pleural effusion in two patients with PLD, one empyema after total pericystectomy for hydatid disease which required drainage, recurrent ascites in a patient with PLD that was managed conservatively, and 2 abscesses, which were drained under CT scan guidance. No complications occurred after completed laparoscopic resection of 11 solid tumors. Diet was resumed on the first postoperative day. The median length of stay was 4.7 days (range, 1 to 17 days).

Median follow-up was 30 months (range, 3 to 78 months). All patients underwent a routine CT scan 6 months after surgery. CT scan of patients with solid tumors showed no residual lesions, and they remained asymptomatic on follow-up. One patient with PLD had recurrent right upper quadrant pain; CT scan showed an increased size of preexisting posterior cysts. He subsequently underwent an uneventful open cyst fenestration. Four patients with hydatid disease remained symptom-free on the last follow-up. The other two returned to their country of origin and were lost to follow-up.

 

Solitary Giant Liver Cyst

Non-parasitic hepatic cysts are usually asymptomatic and are not associated with hepatic function abnormalities. However, as they expand, they may become symptomatic. Complications such as rupture, infection or intracystic hemorrhage can occur27.

Simple aspiration results in 100% recurrence and has been abandoned25. The goal of surgical treatment of giant solitary cysts is to decompress the cyst and avoid recurrence. The current management involves cyst fenestration, a technique introduced by Lin et al in 1968 for treatment of PLD21, 22 and now performed laparoscopically6, 8, 18. The cystic wall should always be examined intraoperatively for possible septations or irregularities that might indicate neoplastic changes (e.g., cystadenoma). An open total cyst excision would be indicated in this situation. Our results show minimal morbidity and no recurrence and concur with published results8, 20, 24. Laparoscopic approach should become the treatment of choice for this indication.

 

PLD

Surgical management of polycystic liver disease is more complex because proliferating cysts can affect a significant portion of the hepatic parenchyma. The surgical approach is determined by the stage of the disease. PLD may be classified into two groups according to the number, distribution and location of cysts as defined by Morino et al24. Type 1 is characterized by a limited number of large cysts predominantly located in the anterior segments of the liver. Type 2 is characterized by multiple small cysts which are distributed throughout the liver, including posterior segments ("Swiss cheese"). Patients with type 1 disease are amenable to laparoscopic management. Deep cysts that communicate with superficial cysts through a thin parenchymal wall are difficult to reach laparoscopically and moreover are difficult to differentiate from hepatic venous structures.

The rate of recurrence depends on patient selection. In Morino's series24, recurrence rate was 60% at 6 months, but included predominantly type 2 lesions. Our low recurrence rate of 11% may reflect the inclusion of patients with only type 1 cysts. We believe that laparoscopic fenestration in this instance is the preferred method of treatment. Open fenestration with liver resection should be reserved for type 2 lesions.

 

Hydatid Cysts

The management of hydatid cysts is challenging even for surgeons with extensive open surgical experience and laparoscopic expertise2, 14, 16. Two surgical techniques are advocated for treatment of hydatid cysts: unroofing the sterilized cyst and omentoplasty, which is reserved for large cysts or cysts in contact with venous branches of the inferior vena cava; or total pericystectomy, which is indicated for anterior cysts19. Dissection may prove quite difficult due to the inflammatory response of the liver parenchyma to the parasitic cyst, the increased risk of intraabdominal complications by spilled parasitic debris, the possibility of anaphylactic shock and the complex anatomy of biliary fistulas.

Our series of six laparoscopically treated hydatid cysts resulted in two hemorrhagic and two infectious complications. Anaphylactic shock after laparoscopic fenestration of a hydatid cyst has been reported recently17. Despite the small number of cases included in our study, we cannot advocate routine laparoscopic management of echinococcal disease.

 

Benign Solid Tumors

The coordinated dissection offered by the "four hand" approach that we have described for resection of solid liver tumors increases the visibility, safety, and expediency of the procedure7. The goal of the operative technique is to reproduce the open surgery finger-fracture technique, which bluntly exposes vascular and biliary structures. For each liver resection, we used an ultrasonic dissector, which is precise but has an unwieldy handpiece. Experience with division of the short gastric vessels during laparoscopic fundoplication and splenectomy, as well as laboratory work in the liver parenchyma, has proven the efficacy of the harmonic shears. It achieved satisfactory vascular control and biliostasis during left lateral segmentectomy.

Following the proven efficacy of fibrin sealant in controlling bleeding in hepatic and splenic trauma28, we used it liberally to control raw surface oozing and for sealing of biliary leaks. In addition to its hemostatic effect, it has the properties of enhancing tissue healing by serving as a network for fibroblast proliferation and by the creation of soft adhesions, thus promoting closure of dead spaces.

Our data support the literature1, 7, 13, 26 and suggest that laparoscopic resection of small benign tumors in selected patients is safe, provided the lesions are located in the left lobe (segments 2, 3 and 4) or in the anterior segments of the right lobe (segments 5 and 6). We attempted three laparoscopic left lateral segmentectomies for benign tumors, converting one deliberately because of the proximity of the lesion to the inferior vena cava. The two other cases were completed laparoscopically without complications.

 

CONCLUSION

Minimally invasive techniques may be used for treating a variety of benign hepatic lesions in selected patients. The size of the lesions is less important than the anatomic location in safe anterolateral regions. Laparoscopic unroofing of solitary liver cysts is the procedure of choice for this indication. The laparoscopic management of polycystic liver disease should be reserved for patients with a limited number of large, anteriorly located symptomatic cysts. Active hydatid cysts present technical difficulties due to their complex biliovascular connections and the inherent nature of the parasite. Our results do not support widespread use of laparoscopy in these cases. Uncomplicated benign liver tumors located in the left lobe or in the anterior segments of the right lobe can be resected safely using a "four hand" technique. Open surgery should remain the treatment of choice when tumors are malignant, are located posteriorly, or are in proximity to major hepatic vasculature.

The use of fibrin sealant now routinely available has proven to be a useful adjunct in laparoscopic liver surgery minimizing the need for omental patching,improving hemostasis and finally and most importantly,allowing for a very low morbidity provided the indication is appropriate and the technique flawless.

 

REFERENCES

1. Azagra JS, Georgen M, Gilbert E, et al: Laparoscopic anatomical (hepatic) left lateral segmentectomy - technical aspects. Surg Endosc 7:758, 1996

2. Bickel A, Loberant N: The feasibility of safe laparoscopic treatment of hydatid cysts of the liver. Surg Endosc 9:934, 1995

3. Cunningham JD, Katz LB, Brower ST, et al: Laparoscopic resection of two liver hemangiomata. Surg Laparosc Endosc 4:277, 1995

4. Diez J, Decoud J, Gutierrez L, et al: Laparoscopic treatment of symptomatic cysts of the liver. Br J Surg 85:25, 1998

5. Ertem M, Uras C, Karahasanoglu T, et al: Laparoscopic approach to hepatic hydatid disease. Dig Surg 15:333, 1998

6. Fabiani P, Katkhouda N, Iovine L, et al: Laparoscopic fenestration of biliary cysts. Surg Laparosc Endosc 1:162, 1991

7. Gugenheim J, Mazza D, Katkhouda N, et al: Laparoscopic resection of solid liver tumours. Br J Surg 83:334, 1996

8. Hansen P, Bhoyrul S, Legha P, et al: Laparoscopic treatment of liver cysts. J Gastrointest Surg 1:53, 1997

9. Hashizume M, Takenaka K, Yanaga K, et al: Laparoscopic hepatic resection for hepatocellular carcinoma. Surg Endosc 9:1289, 1995

10. Hauser CJ, Poole GV: Laparoscopic fenestration of a giant simple hepatic cyst. Surg Endosc 8:884, 1994

11. Johnstone PAS, Rohde DC, Swartz SE, et al: Port site recurrences after laparoscopic and thoracoscopic procedures in malignancy. J Clin Oncol 14:1950, 1996

12. Kabbej M, Sauvanet A, Chauveau D, et al: Laparoscopic fenestration in polycystic liver disease. Br J Surg 83:1697, 1996

13. Kaneko H, Takagi S, Shiba T: Laparoscopic partial hepatectomy and left lateral segmentectomy: technique and results of a clinical series. Surgery 120:468, 1996

14. Katkhouda N, Fabiani P, Benizri E, et al: Laser resection of a liver hydatid cyst under videolaparoscopy. Br J Surg 79:560, 1992

15. Katkhouda N, Hurwitz M, Gugenheim J, et al: Laparoscopic management of benign solid and cystic lesions of the liver. Ann Surg 229:460, 1999

16. Khoury G, Geagea T, Hajj A, et al: Laparoscopic treatment of hydatid cysts of the liver. Surg Endosc 8:1103, 1994

17. Khoury G, Jabbour-Khoury S, Soueidi A, et al: Anaphylactic shock complicating laparoscopic treatment of hydatid cysts of the liver. Surg Endosc 12:452, 1998

18. Krahenbuhl L, Baer HV, Renzulli P, et al: Laparoscopoic management of non-parasitic symptom producing solitary hepatic cysts. J am Coll Surg 183:493, 1996

19. Langer JC, Rose DB, Keystone JS, et al: Diagnosis and management of hydatid disease of the liver: a 15-year North American experience. Ann Surg 199:412, 1984

20. Libutti SK, Starker PM: Laparoscopic resection of a nonparasitic liver cyst. Surg Endosc 8:1105, 1994

21. Lin TY, Chen CC, Wang SM: Treatment of non-parasitic cystic disease of the liver: a new approach to therapy with polycystic liver. Ann Surg 168:921, 1968

22. Litwin DEM, Taylor BR, Greig P, et al: Nonparasitic cysts of the liver: the case of conservative surgical management. Ann Surg 205:45, 1987

23. Malt RA: Surgery for hepatic neoplasms. N Engl J Med 313:1591, 1985

24. Morino M, De Giuli M, Festa V, et al: Laparoscopic management of symptomatic nonparasitic cysts of the liver: indications and results. Ann Surg 219:157, 1994

25 Saini S, Mueller PR, Ferrucci JT, et al: percutaneous aspiratrion of hepatic cysts does not provide definitive therapy. AJR 141:559, 1983

26 Samama G, Chiche L, Brefort JL, et al: Laparoscopic anatomic resection. Report of four lobectomies for solid tumors. Surg Endosc 12:76, 1998

27 Sanchez H, Gagner M, Rossi R, et al: Surgical management of nonparasitic cystic liver disease. Am J Surg 161:113, 1991

28. Spotnitz WD, Falstrom JK, Rodeheaver GT: The role of sutures and fibrin sealant in wound healing. Surg Clin North Am 77:651, 1997

 

Synopsis

Laparoscopic liver surgery can be accomplished safely in selected patients with benign liver lesions, provided appropriate laparoscopic skills and technology are available. The size of the lesions is less important than the anatomic location in anterolateral regions. Small benign solid tumors located in the anterior liver segments and giant solitary cysts can be managed safely and effectively using the laparoscopic approach. The laparoscopic management of polycystic liver disease should be reserved for patients with a limited number of large, anteriorly located cysts. Because of the complex nature of hydatid disease of the liver, it is best treated through an open approach.

 

 

6. Laparoscopic Liver Resection : Technical Aspects of Left Lateral Segmentectomy

Hironori Kaneko, M.D.

 

Despite the continuing evolution of laparoscopic surgery and the advanced techniques of open hepatectomy, the application to laparoscopic hepatectomy, especially resection of large pieces of parenchyma, has not been actively performed because of technical difficulties, such as hemostasis from the transection plane, controlling hemorrhaging from intrahepatic vessels and exploration of deep regions. In the past few years, however, a variety of laparoscopic instruments and devices have been developed, leading us to establish to perform a series of 10 patients received clinical left lateral segmentectomy of the liver. Results of a clinical series of 10 patients with hepatic malignant tumor are reported.

Patients: In 34 cases of laparoscopic hepatectomy, Left lateral segmentectomy was performed in 10 patients. The indications were hepatocellular carcinoma in 6 cases, isolated metastatic tumor in 3 cases and benign tumor in one case. The underlying liver diseases was liver cirrhosis in 2 cases and chronic hepatitis in 4 cases.

Surgical procedure: Seven cases were laparpscopy alone and laparo-assisssted hepatectomy was performed in three cases. A microwave tissue coagulator was used in combination with an ultrasonic surgical aspirator or a laparoscopic coagulating shears to divide hepatic parenchyma by using abdominal wall lift without pneumoperitoneum. Branched vessels and ducts were clipped and transected. The endoscopic linear stapler was used to transect the Glisson's pedicle, left hepatic vein and liver tissue transection in resent cases.

Result: The all procedures were performed safely. There were notable difference in blood loss compared with open hepatectomy and no operative mortality. Operating time has been getting shorter by improvement technique in recent cases and no difference compared with open hepatectomy. The postoperative recovery was faster and pain was minimal.

Indication: The preoperative assessment of liver function for laparoscopic and open hepatectomy is the same. Tumors smaller than 5 cm, and nodular types, especially extrahepatic growth types, are the best candidates for laparoscopic resection. Concerning location, tumors in the lower segment and left lateral segment were good indication.

Conclusion: The laparoscopic hepatectomy, especially partial or left lateral segmentectomy, appears to be a viable surgical alternative in selected patients. Left lateral segmentectomy is considered to be feasible and less invasive laparoscopic operation in the anatomical liver resection.

 

References

1) Kaneko H, et al: Experimental laparoscopic hepatectomy of left lateral lobe in pig models. J Jpn Coll Surg 21:83-86, 1996

2) Kaneko H, et al :Laparoscopic partial hepatectomy and left lateral segmentectomy: technique and results of a clinical series. Surgery 120:468-475, 1996

3) Kaneko H: Laparoscopic partial hepatectomy. Edited by Current Surgical Therapy. six edition. Mosby, Philadelphia, 1998, p1217-1222

4) Takagi S: Hepatic and portal vein blood flow during carbon dioxide pneumoperitoneum for laparoscopic hepatevtomy. Surg Endosc 12:427-431, 1998

5) Cherqui D et al : Laparoscopic liver resections: A feasibility study in 30 patients. Ann Surg 232:753-762, 2000

 

 

7. Minimally Invasive Surgery for Hepatic Malignancy - Endoscopic Liver Resection and Endoscopic Thermal Ablation

Go Wakabayashi, Masaki Kitajima

Department of Surgery, Keio University School of Medicine,

35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan

go@med.keio.ac.jp

 

Abstract

This paper deals with the practice and usefulness of endoscopic hepatectomy and endoscopic thermal ablation as minimally invasive surgical techniques for the treatment of liver cancer. We have, until now, treated small liver cancers (up to about 3 cm diameter) by minimally invasive surgery and obtained favorable results. Endoscopic hepatectomy is primarily indicated in protruding or superficial type tumors, which are confined to the lateral segment or the marginal area of the inferior segment of the liver. Endoscopic thermal ablation would be indicated for other non-superficial liver cancers. Endoscopic hepatectomy is now a safe and simple technique if it is performed while keeping the hepatic and portal blood flow obstructed, and using either an automated suturing machine or a computer-aided surgical device. Endoscopic thermal ablation allows for safe and reliable tumor necrosis, since it is performed under endoscopic and ultrasound guidance. Endoscopic hepatectomy and endoscopic thermal ablation are complementary to each other in terms of the areas of the liver to which they can be applied. Combined use of these two techniques would allow for radical local treatment of hepatic malignant tumors, while causing minimal distress to the patient.

 

Introduction

In recent years, diverse approaches, including various non-operative methods that have been developed, have been used for the treatment of hepatocellular carcinoma (HCC). The basic principle underlying these approaches is minimization of distress to the patient. The success in effecting local radical treatment, however, seems to vary among the methods. Surgeons specialized in the management of gastrointestinal cancers tend to feel rather uneasy if any cancer is left unresected. However, it would be reasonable to discuss the appropriateness of invasive surgical treatment of liver cancer on the basis of the incidence of cancer recurrence in the non-resected portion of the liver with underlying disease other than cancer.

Endoscopic surgery has advanced remarkably over the past several years. Its indications have expanded markedly following advances in operative techniques. Concerning surgery for liver diseases, endoscopy can now be utilized for various operations, ranging widely from liver cyst fenestration (1) or thermal ablation of malignant tumors (2), to hepatectomy (3-9). Laparoscopic hepatectomy allows for radical resection of tumors, similar to conventional open hepatectomy via a celiotomy, with minimization of distress to the patient.

Endoscopic surgery for liver diseases has just recently begun to be used, and there is still a lot of scope for modification of the various operative procedures. Techniques of endoscopic surgery for liver diseases that are used relatively frequently include liver cyst fenestration and endoscopic thermal ablation. The use of laparoscopic hepatectomy is still confined to a small number of medical facilities. This paper will present two minimally invasive surgical procedures for liver cancer (endoscopic hepatectomy and endoscopic thermal ablation), and discuss their usefulness and future perspectives.

 

History of endoscopic surgery for liver cancer

We first began to perform laparoscopic cholecystectomy in July 1990. Since then, we have actively introduced endoscopic surgery for the diagnosis and treatment of liver diseases (Table 1). In regard to the surgical treatment of liver diseases, the first laparoscopic liver cyst fenestration at our facility was performed in June 1992. After accumulation of experience in endoscopic surgery, we performed the first laparoscopic hepatectomy in July 1995, in a patient with a metastatic liver tumor in the lateral segment of the liver, originating from a colorectal cancer (3). From Western countries, while several reports have been published on laparoscopic hepatectomy since 1991 (4,5), all of these reports pertain to cases with benign liver diseases. In Japan, case reports of laparoscopic hepatectomy for the treatment of liver cancer have been published since 1995 (6,7). Since then, an increasing number of reports on laparoscopic hepatectomy have also been published from all around the world, but primarily from European countries and Japan (8,9).

A method for thoracoscopic resection of subphrenic liver cancer that cannot be resected under laparoscopic guidance has been developed. With this method, the diaphragm is incised under thoracoscopic guidance, and protruding or superficial type of liver cancer below the dome can be resected. Since 1999, we have performed thoracoscopic hepatectomy in 3 cases with protruding or superficial type of liver cancer confined to the S8 area.

Microwave coagulo-necrotic therapy utilizes the effect of directly applied microwaves (originally used for dissecting the parenchyma during hepatectomy) for inducing tumor necrosis. Japanese liver surgeons are by now rather familiar with this mode of therapy, because it has been developed originally in Japan (10). Percutaneous ethanol injection therapy (PEIT) is also now widely used in Japan for treating primary HCC, and favorable long-term results of local therapy for HCC have been obtained. After PEIT became a widely accepted method of therapy, microwave coagulo-necrotic therapy as a means of local therapy for liver cancer has also been performed percutaneously (PMCT) or endoscopically (LMCT/TMCT) (11). Microwave coagulation therapy developed in Japan, and radiofrequency coagulation therapy often used in Western countries, can be basically classified as belonging to the same class of therapy. Both are designed to achieve radical local treatment of tumors by inducing tumor necrosis.

In 1997, we first performed microwave coagulation therapy via the diaphragm under thoracoscopic guidance, in a case with small hepatocellular carcinoma confined to the subphrenic S8 area. Later, an ultrasound probe for insertion of a thermal coagulation needle during endoscopic surgery was developed, which made the above-mentioned surgery much easier. Furthermore, thermal ablation of a tumor under both ultrasound and endoscopic guidance allowed complete tumor necrosis to occur in a reliable manner, thus tumor ablation became radical resection of the tumor. Subsequent to this finding, the number of patients undergoing endoscopic thermal ablation for liver cancer (including laparoscopic thermal ablation) at our facility has increased significantly.

At present, we determine the indications for endoscopic hepatectomy and endoscopic thermal ablation of tumor (both minimally invasive surgical techniques for small liver cancer) on the basis of the location and distribution of the tumor. A large proportion of patients with small liver cancer treated at our facility are treated using these procedures. The two procedures, both aimed at radical resection of liver cancer, are complementary to each other. Technically, the procedures have become relatively routine. Further refinement of the techniques is expected in the near future.

 

Indications for endoscopic hepatectomy

Table 2 lists the requirements we consider before performing endoscopic hepatectomy. Patients who satisfy these requirements and in whom this procedure is rated as optimal for the treatment of the primary disease are judged as suitable candidates for endoscopic hepatectomy. The indications for endoscopic hepatectomy in the treatment of HCC have been determined by comparing this method with other methods of treatment, as discussed later in this paper. Considering that this procedure is technically complex, factors such as the experience and level of skill of the surgeons in endoscopic surgical techniques can also significantly influence the indications for this surgery.

There is no doubt that the procedure is minimally invasive. However, caution must be exercised in patients with a low hepatic reserve. In patients with a poor hepatic reserve due to liver cirrhosis, we consider that this procedure is indicated only when the patient satisfies the requirements for open hepatectomy via a celiotomy. Thus, the indications for hepatectomy using this procedure must still be based on the presence of a hepatic reserve that is considered adequate for endoscopic liver surgery, in general.

At present, the indications for endoscopic hepatectomy at our facility are quite limited. We confine ourselves to performing the procedure only in patients in whom the tumor is located in the lateral segment, or in the vicinity of the liver margin of the lower segment, or on the very surface of the liver (protruding or superficial type) (Fig. 1 and Fig. 2). We perform this surgery only when the volume of the liver that must be resected for the treatment of liver cancer is relatively small. The maximum number of sites resected at a time should be no greater than two (a case of metastatic liver cancer where three lesions were present). This is based on our judgment that performance of endoscopic hepatectomy requires a high level of skill, and that we are still on the learning curve for this procedure.

Although it is difficult to say that endoscopic hepatectomy is being performed widely, it has been reported that about 50 medical facilities in our country have experience of this surgery in several or more cases. If the procedure were covered by the National Health Insurance, its use will probably spread to the level of the widely performed laparoscopic splenectomy. We estimate that about 5-10% of all patients undergoing hepatectomy are suitable candidates for this procedure.

 

Practice and modification of endoscopic hepatectomy

The procedure of laparoscopic hepatectomy currently used at our facility is outlined in Table 3. Although our technique is more or less the same as that reported from other facilities, it is unique with respect to the step of raising the abdominal wall. This is aimed at avoiding the risk of pulmonary gas embolism that may be caused by the CO2 used for abdominal insufflation. In animal experiments, the entry of air bubbles into hepatic veins during hepatectomy after abdominal insufflation has been revealed ultrasonographically (12).

For laparoscopic hepatectomy to become widely accepted, the procedure needs to be improved and simplified. At our facility, endoscopic surgery has frequently been used to treat liver diseases. To date, we have performed the procedure in 92 cases (endoscopic hepatectomy in 27, endoscopic thermal ablation in 25, laparoscopic liver cyst fenestration in 17, and laparoscopic liver wedge biopsy in 23). Of these, 24 underwent endoscopic hepatectomy for the treatment of liver cancer (the details of these cases undergoing laparoscopic hepatectomy are shown in Table 4). The operative results are shown in Table 5. The following are the special procedures we have introduced to improve the technique of endoscopic hepatectomy, based on our experience.

(1) Obstruction of hepatic and portal blood flow

We obstruct hepatic and portal blood flow in order to ensure good control of bleeding during laparoscopic hepatectomy (Fig. 3). Among all the cases in which we performed laparoscopic hepatectomy, bleeding requiring blood transfusion never developed in any case, and the procedure could be performed extremely safely, if the extent of hepatectomy was relatively small. However, depending on the location of the tumor, hepatectomy may be needed at a site close to the main trunk of the hepatic vein, and, in such cases, massive bleeding (blood loss of around several hundred ml) can occur if the blood vessels are not manipulated appropriately. To deal with bleeding from hepatic veins, it is essential to precisely determine the location of the major hepatic veins by intraoperative ultrasonography, and to effect hemostasis adequately using an automated suturing machine, or clipping/ligation.

(2) Hepatectomy using an automated suturing machine

As described above, resection of narrow peripheral areas of the liver constitutes the major indication for laparoscopic hepatectomy at present. An automated suturing machine is applicable in some cases during hepatectomy. We used an automated suturing machine during laparoscopic hepatectomy in 13 out of 24 cases (this count also includes cases in which the automated suturing machine originally designed for open hepatectomy was used, i.e., cases where the machine was used via a small incision). In one of the 13 cases, an automated suturing machine designed for endoscopic surgery was used throughout the procedure of hepatectomy (Fig. 3). We believe that the use of an automated suturing machine makes it easier for the surgeon to manipulate the hepatic veins and Glisson's sheath, leading to simplification of the procedure of laparoscopic hepatectomy.

(3) Thoracoscopic hepatectomy with a Da Vinci

Thoracoscopic hepatectomy is performed in cases with a protruding or superficial type of liver tumor confined to the S8 area (Fig. 2). Incision and suturing of the diaphragm after tumor resection and ensuring the safety margin of the tumor bottom in the longitudinal direction are beset with technical difficulties. With the development of computer-aided devices, suturing of the diaphragm and manipulations of the tumor bottom have become easier than ever. We used a Da Vinci (a device for computer-aided surgery manufactured by Intuitive Surgical) while performing a thoracoscopic hepatectomy. This device allows for very smooth performance of thoracoscopic hepatectomy, since it allows the surgeon to conduct suturing within a relatively narrow operative field of the thoracic cavity, and to remove the tumor in a longitudinal direction.

 

Indications for endoscopic thermal ablation

It is believed that microwave coagulo-necrotic therapy or radiofrequency ablation may yield more radical local treatment than PEIT. However, while these techniques may be used to induce tumor necrosis during a single session of treatment, they require complex manipulations. Considering the pain caused to the patient during the performance of these procedures, they need to be performed under general anesthesia to ensure satisfactory results. It is recommended that thermal ablation of a tumor under general anesthesia be performed under endoscopic guidance, since bleeding from the hole created by puncturing with the coagulation needle can be controlled better if ablation is performed under ultrasound and endoscopic guidance, and because the endoscope would also allow for checking of the severity of the liver cirrhosis. The development of an ultrasound probe for aiding in the puncture of tissue with a thermal coagulation needle during endoscopic surgery has made it possible for tumor puncture to be performed as precisely as that using extracorporeal ultrasonography, and also for tumor ablation to be performed safely and reliably even when the tumor is located in areas that are difficult to detect by extracorporeal ultrasonography.

We use a laparoscope when performing endoscopic surgery for tumors in the inferior segment of the liver (Fig. 4), and a thoracoscope when performing surgery for tumors in the superior segment of the liver (Fig. 5). In both cases, the punctured site is monitored under endoscopic and ultrasound guidance. When percutaneous thermal ablation is performed for protruding or superficial type of tumors, adequate tumor ablation is often difficult because of tumor burst or thermal injury to the peritoneum. However, if tumor ablation is performed endoscopically, it is possible to burn the tissue around the tumor first and then to safely perform hepatectomy. At our facility, tumor resection after adequate thermal ablation of the surrounding tissue was performed in three cases.

Generally, tumors situated deeper than superficial tumors, and tumors located distal to the third Glisson's branch are considered suitable for endoscopic thermal ablation. Endoscopic thermal ablation is sometimes possible even in cases where the hepatic reserve is not large enough to allow endoscopic hepatectomy. We believe that thermal ablation performed under endoscopic and ultrasound guidance would allow for radical treatment comparable in efficacy to hepatectomy. In fact, none of the cases who have undergone endoscopic thermal ablation of liver tumors at our facility have developed local recurrence until now. The operative results of endoscopic thermal ablation are shown in Table 6.

 

Practice and skill for endoscopic thermal ablation

Thoracoscopic thermal ablation is performed in cases where the liver cancer is about 3 cm in diameter, is located in the superior segment of the liver below the diaphragm (S8, S7 and S4b), and is of a type other than a protruding or superficial type of cancer (Fig. 4). Usually, a reasonable operative field in the thoracic cavity is ensured by inducing collapse of the right lung by unilateral ventilation, and a trocar is inserted between the fourth and fifth intercostal spaces, followed by insertion of the thoracoscope and an ultrasound probe. The ultrasound probe is placed at an appropriate site under the endoscope tip to check for intrahepatic lesions through the diaphragm. Blood vessels and the bile duct around the tumor are confirmed, and tumor vessels are identified. Then, a third trocar is inserted to allow insertion of the thermal ablation needle from an optimum point.

A thermal coagulation needle is inserted towards the center of the tumor, aided by an ultrasound probe, designed specifically for this use, jointly by our facility and Aloca Inc.. During each session, coagulation of up to about 2 cm of the tumor is possible with a deep microwave needle, and of up to about 3 cm is possible with a radiofrequency needle. To ensure adequate tumor necrosis, it is essential to have a relatively wide safety margin when performing the coagulation.

Laparoscopic thermal ablation is used for liver cancers that are about 3 cm in diameter, are located in the inferior segment of the liver (S5, S6 and S4a), and are of a type other than the protruding or superficial type (Fig. 5). The laparoscope is inserted while maintaining abdominal insufflation. Usually, cholecystectomy is performed first, as there is a risk of cholecystitis developing when the hepatic artery may need to be occluded in the future for the management of HCC. Adequate prophylactic cholecystectomy allows satisfactory occlusion of the hepatic artery, and allows safer thermal ablation of the tumor near the liver and gallbladder bed. Then, the ultrasound probe is inserted from an optimum point (determined according to the location of the tumor), the blood vessels and the bile duct around the tumor are confirmed, and the tumor vessels are identified before the thermal ablation needle is inserted towards the center of the tumor.

One of the greatest cautions that must be exercised during laparoscopic thermal ablation is to avoid thermal injury of the major Glisson's sheath. During thoracoscopic thermal ablation, the needle is inserted along Glisson's sheath from the periphery (liver surface), and thermal injury of the major Glisson's sheath is relatively unlikely. However during laparoscopic thermal ablation, the needle is inserted vertically to the direction of the arrangement of the fibers of Glisson's sheath, and thermal injury can occur in the vicinity of the anteroposterior segmental branches of the right lobe even when the tumor is located distal to the third Glisson's branch. Adequate care is therefore needed.

 

Significance of minimally invasive surgery for liver cancer

In the Japanese people, HCC is often secondary to viral hepatitis. Because of a high incidence of recurrence after surgical resection, percutaneous ethanol injection therapy (PEIT) and transarterial embolization therapy (TAE) have been employed more frequently than surgery in recent years when dealing with this cancer. Microwave coagulo-necrotic therapy (MCT) and radiofrequency coagulo-necrotic therapy (RFA) are new alternatives that have been developed for the treatment of HCC. We have combined such thermal coagulation therapy with endoscopy and ultrasonography to develop an endoscopic surgical technique that can be used as a minimally invasive surgical procedure in cases of liver cancer not suitable for endoscopic hepatectomy.

Our efforts to develop this therapy are based on the fact that conventional laparoscopic hepatectomy, although minimally invasive and effective for radical local treatment, cannot be performed in many cases of liver cancer, and that endoscopic thermal ablation is also a minimally invasive procedure that allows for efficient radical local treatment.

Endoscopic hepatectomy is expected to have a therapeutic efficacy comparable to that of open hepatectomy (hepatectomy via a celiotomy), as it allows for efficient local treatment and tissue removal. In view of its low invasiveness, the usefulness of this therapy seems to be intermediate between that of PEIT and TAE (Fig. 6). However, the number of medical facilities where this procedure has been adopted is still small, and the long-term results still remain to be studied. Endoscopic thermal ablation is advantageous as compared to percutaneous thermal ablation, in that it allows for reliable and safe coagulation of a tumor under endoscopic and ultrasound guidance, and also allows observation of the liver surface and prophylactic cholecystectomy. Endoscopic hepatectomy may be performed even for tumors located at sites where the tumors may not be amenable to endoscopic thermal ablation. On the other hand, endoscopic thermal ablation can be performed for some tumors that may not lend themselves to treatment by endoscopic hepatectomy. Thus, the two techniques are complementary to each other. We therefore combine these two procedures into a single minimally invasive procedure for the treatment of liver cancer in suitable cases (Table 7 and Table 8). Data concerning the tumor locations in patients who underwent minimally invasive surgery for liver cancer at our facility illustrate clearly that endoscopic hepatectomy has been combined successfully with endoscopic thermal ablation at our facility (Fig. 2-4).

 

Conclusion

Endoscopic hepatectomy and endoscopic thermal ablation are complementary to each other when used as minimally invasive radical surgical procedures for the treatment of liver cancer. We believe that their use will become widespread in the near future. In order for the procedures to be used widely, it is essential to improve the skills of surgeons in the techniques of endoscopic surgery for the treatment of liver cancer, and for a system of treatment using these procedures to be established. The greatest advantage of minimally invasive surgery for liver cancer is that it allows for sufficient tumor resection or tumor necrosis for radical treatment, with minimal distress to the patient. Minimally invasive surgery for liver cancer deserves to be adopted at many facilities. We believe that its important role in dealing with HCC will become established in the near future.

 

Tables

 

1. Endoscopic Surgery for the Liver
   (1992.4 - 2001.10 at Keio Univ.)

Laparoscopic Hepatectomy	24 cases
Thoracoscopic Hepatectomy	3 cases
Laparoscopic Thermal Ablation	10 cases
Thoracoscopic Thermal Ablation	15 cases
Laparoscopic Cyst De-roofing	17 cases
Laparoscopic Wedge Biopsy	23 cases
	92 cases

 

1. Requirements for Endoscopic Hepatectomy
   (at the Department of Surgery, Keio University)

1. Endoscopic surgery is possible (considering systemic risks, history of epigastric surgery, etc.)

2. The area to be resected is relatively marginal.

3. The amount of the liver to be resected is relatively small.

4. Informed consent can be obtained from the patient or his/her family.

 

1. Procedure of Laparoscopic Hepatectomy
   (at the Department of Surgery, Keio University)

1. Insertion of an electronic laparoscope by open laparoscopy Abdominal insufflation 2. Exposure of the part of the liver to be resected 3. Intraoperative ultrasonography 4. Determining the resection line 5. Microwave coagulation of the resection line (this step can be omitted) Raising the abdominal wall 6. Preparing for Pringle's maneuver 7. Starting resection of the liver parenchyma 8. Completion of liver resection 9. Collection of the resected liver tissue (into a plastic bag) 10. Hemostasis of the resected plane (spraying fibrin glue) 11. Insertion of a drain

 

1. Details of Patients undergoing Endoscopic Hepatectomy
   (1995.7 - 2001.10 at Keio Univ.)

Hepatocellular carcinoma: 16 cases Metastatic liver cancer: 8 cases Folecular Nodular Hyperplasia: 1 case Malignant lymphoma: 1 case Multiple liver cysts: 1 case

 

1. Operative Results of Endoscopic Hepatectomy
   (1995.7 - 2001.10 at Keio Univ.)

· Resected Liver Weight · Blood Loss · Resection Time · Post-operative Hospital Stay · Complications (bleeding, bile leakage, etc)

6 - 233 g Max. 860 g 36 - 268 min. 4 - 8 days Non

 

1. Operative Results of Endoscopic Thermal Ablation
   (1995.7 - 2001.10 at Keio Univ.)

· Tumor Diameter · Blood Loss · Local Recurrence · Post-operative Hospital Stay · Complications

0.8 - 4.0 cm 0 - 120 g Non (2 - 62 mon.) 6 -107 days Persistent Pleural and/or Abdominal Effusion in 2 cases

 

1. Minimally Invasive Surgery for Liver Cancer
   Type of Malignancy
   (1995.7 - 2001.10 at Keio Univ.)

	Endoscopic Hepatectomy	Endoscopic Thermal Ablation
Primary Liver Cancer	16 cases	18 cases
Metastatic Liver Cancer	8 cases	7 cases
	24 cases	25 cases

 

1. Minimally Invasive Surgery for Liver Cancer
   Type of Tumor Existence
   (1995.7?2001.10 at Keio Univ.)

	Endoscopic Hepatectomy	Endoscopic Thermal Ablation
Protruding or Superficial Type	13 cases	4 cases
Other than Protruding or Superficial Type	11 cases	21 cases
	24 cases	25 cases

 

 

 

Fig. 1:Tumor Location for Laparoscopic Hepatectomy (21 cases)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

1) Z'graggen K,Metzger A,Klaiber CH.Symptomatic simple cysts of the liver:treatment by laparoscopic surgery. Surg Endosc 1991;5:224-225.

2) Saitsu H,Nakayama T,Isomura T,et al:New endoscopic surgical treatment-thoracoscopic microwave coagulo-necrotic therapy for small hepatocellular carcinoma. J Microwave Surg 1994;12:1-8.

3) Wakabayashi G, Ohgami M, Shimazu M, et al:Laparoscopic liver resection with Pringle's manuever. Gold Medal Video Olympic at The 4th World Congress of Endoscopic Surgery, 1996

4) Reich H, McGlynn F, De Caprio J, Budin. Laparoscopic excision of benign liver lesions. Obstet Gynecol. 1991;78:956-8.

5) Gagner M, Rheault M, Dubuc J. Laparoscopic partial hepatectomy for liver tumor. Surg Endosc 1992;6:97-98.

6) Hashizume M, Takenaka K, Yanaga K, et al:Laparoscopic hepatic resection for hepatocellular carcinoma. Surg Endosc 1995;912:1289-91

7) Kaneko H?Takagi S, Shiba T. Laparoscopic partial hepatectomy and left lateral segmentectomy: Technique and results of a clinical series. Surgery 1996;120:468-475.

8) Yamanaka N, Tanaka T, Tanaka W, Yamanaka J, Yasui C, Ando T, Takada M, Maeda S, Okamoto E. Laparoscopic partial hepatectomy.. Hepatogastroenterology. 1998;45:29-33.

9) Cherqui D, Husson E, Hammoud R, Malassagne B, Stephan F, Bensaid S, Rotman N, Fagniez PL. Laparoscopic liver resections: a feasibility study in 30 patients. Ann Surg. 2000;232:753-62.

10) Tabuse K. Basic knowledge of a microwave tissue coagulator and its clinical applications. J Hepatobiliary Pancreat Surg. 1998;5:165-72.

11) Sato M, Watanabe Y, Ueda S, Iseki S, Abe Y, Sato N, Kimura S, Okubo K, Onji M. Microwave coagulation therapy for hepatocellular carcinoma. Gastroenterology. 1996 110:1507-14.

12) Takagi S. Hepatic and portal vein blood flow during carbon dioxide pneumoperitoneum for laparoscopic hepatectomy. Surg Endosc 1998;12:427-31

 

 

 

 

 

8. Comparison of Resection vs. Ablative Techniques: Outcomes & Results

Alan T. Lefor, MD MPH

Cedars-Sinai Medical Center Professor of Surgery
8700 Beverly Blvd Suite 8215 UCLA School of Medicine
Los Angeles CA 90048 Los Angeles CA
Email:alan.lefor@cshs.org

 

 

1. Resection of liver metastases by open surgical techniques

a. Consider as a "standard"

i. What patients should undergo resection?

b. How well do patients do with regard to cancer treatment?

c. How well do patients do in other terms?

 

2. Resection of liver metastases by laparoscopic techniques

a. Benefits to patients: Real and Theoretical

b. Is this an adequate "cancer operation"?

i. Should the indications change?

c. What technologies are available?

d. Where do we go next?

 

3. Ablative techniques for the treatment of liver metastases: Open techniques

a. Consider as a "standard"

i. What patients should undergo ablative therapy instead of resection therapy?

ii. What technologies are available for ablation?

1. Cryosurgical ablation

2. Radiofrequency Ablation

b. How well do patients do in regard to cancer treatment?

c. How well do patients do in other terms?

 

4. Ablative techniques for the treatment of liver metastases: Laparoscopic techniques

a. Benefits to patients: Real and Theoretical

b. Is this an adequate "cancer operation"?

i. Should the indications change?

c. Where do we go next?

 

5. References

a. Cuschieri A. Minimally invasive surgery: hepatobiliary-pancreatic and foregut. Endoscopy 32:331 (2000).

b. Montorsi M, Santambrogio R, Bianchi P et al. Laparoscopic radiofrequency of hepatocellular carcinoma (HCC) in liver cirrhosis. Hepatogastroenterol. 48:41 (2001)

c. Iannitti DA and Dupuy DE. Minimally invasive management of hepatic metastases. Semin Laparosc Surg 7:118 (2000).

d. Hansen P, Ludemann R and Swanstrom LL. Hepatogastroenterol 48:37 (2001)

e. Bilchik AJ, Rose DM, Allegra DP et al. Radiofrequency ablation: A minimally invasive technique with multiple applications. Cancer J Sci Am 5:356 (1999).

f. Siperstein A, Garland A, Engle K et al. Local recurrence after laparoscopic radiofrequency thermal ablation of hepatic tumors. Ann Surg Oncol. 7:106(2000).

g. Bilchik A, Wood TF, Allegra D et al. Cryosurgical ablation and radiofrequency ablation for unresectable hepatic malignant neoplasms: a proposed algorithm. Arch Surg 135:657 (2000)

h. Cherqui D, Husson E, Hammond R, et al. Laparoscopic live resections: a feasibility study in 30 patients. Ann Surg. 232:753 (2000).

i. Schmidbauer S, Hallfeldt K, Sitzman G et al. Experience with ultrasound scissors and blades in open and laparoscopic resection. Ann Surg. 235:27 (2002).

 

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B

Birkett, Desmond H. 10

E

Easter, David 6

G

Greene, Frederick L. 4

H

Hansen, Paul 12

K

Kaneko, Hironori 27

Katkhouda, Namir 20

Kitajima, Masaki 28

L

Lefor, Alan T. 40

M

Mavor, Eli 20

W

Wakabayashi, Go 28