Totally Laparoscopic and Hand-assisted Laparoscopic Major Liver Resection: An 8-year Single Institution Experience

Edwin O Onkendi, MBChB, John A Stauffer, MD, Steven P Bowers, MD, Justin H Nguyen, MD, Horacio J Asbun, MD. Mayo Clinic

Introduction: Minimally invasive major liver surgery (MIMLS) in increasingly being performed in tertiary centers. Two main approaches utilized are hand-assisted laparoscopic surgery (HALS) and totally laparoscopic surgery (TLS). Our aim was to review our 8-year experience with MIMLS and associated perioperative outcomes.

Methods and Procedures: At our institution, MIS liver resection was formally introduced in January 2007, initially using the HALS approach. Since then, the use of TLS approach has increased. We retrospectively reviewed our prospectively maintained hepatobiliary resection database to assess our 8-year experience with MIS liver resection thus far, focusing on major liver resection defined as resection of ≥3 liver segments. The TLS and HALS approaches were comparatively analyzed, specifically assessing the effect of totally laparoscopic major liver resection on outcomes.

Results: From 1/2007 to 12/014, 387 patients underwent open and MIS liver surgery. Of these, 262 patients (68%) underwent MIS major and minor liver surgery. From this latter group, 55 patients (21%) who underwent MIMLS comprised our study group. Mean age was 60.2±13.6 years, with 27 patients (49%) being male. Forty-three patients (78%) had malignant disease, with colorectal cancer metastases being the most common malignant tumor resected (51%). Overall, 64% of patients underwent MIS right hepatectomy, 29% had left hepatectomy, and 7% underwent central and extended right hepatectomy. Use of TLS approach significantly doubled (51.9% from 25%, p=0.029) over the two halves of the 8 years, with an associated decrease in the HALS approach (75% to 48%, p=0.029). Overall conversion rate to open resection was 20%, with need for complex biliary reconstruction being the commonest reason for conversion from laparoscopic to open.  Median operating time was 270 minutes (105-839). Median estimated blood loss was 600 (0-13300), with 29% of patients requiring pRBC transfusion in the OR and 15% requiring transfusion postoperatively. Mean malignant tumor size was 6.5±4.2 cm. R0 resection margin rate was 100%, with average closest negative margin of 7 ± 5 mm. Mean hospital stay was 6.4 ± 3.5 days; reoperation rate was 1.8%. Overall major morbidity (Clavien grade III-V) was 18.2%. Liver-specific morbidity was 20%; including bile leak in 11%, post-hepatectomy hemorrhage in 9% and post-hepatectomy liver failure in 3.6%. Overall 90-day mortality was 3.6%.

Conclusions: MIMLS is feasible and safe with an adequate R0 resection. A tendency to a totally laparoscopic approach was present in the second half of the study period without a significant change in the outcomes.

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