Laparoscopic Hepatobiliary Surgery for Benign and Malignant Lesions – Bringing New Paradigm Into Practice

Daniel Tuvin, Manuel I Rodriguez-davalos, Marcelo E Facciuto, Ashutosh Kaul, Patricia A Sheiner, Michael R Marvin, Sukru Emre. Yale University, Recanati-Miller Transplantation Institute/Mount Sinai NY, New York Medical College

Background: Advances in minimally invasive surgery (MIS) have revolutionized modalities available to patients and clinicians in performing surgical procedures. However, it is only recently that this technique has been introduced for use in hepatobiliary surgery. Laparoscopic liver resections are used for treatment of benign and malignant tumors in many hepatobiliary centers, with growing demand for minimally invasive liver surgery. Evidence on safety and upfront benefits of laparoscopic approach is emerging. Operative time for laparoscopic procedures has been shown to be approaching open ones. Learning curve is described as steep, associated with improving OR time with increased experience.
Methods: A retrospective analysis of patients with potentially resectable liver lesions using minimally invasive techniques (January 2003 to December 2010) was done. Demographics, tumor characteristics, resection technique, and outcomes were evaluated.
Results: 19 laparoscopic liver resections and 20 cyst fenestrations were performed in a group of 39 (30 female, 9 male) patients. All of the mass lesions patients underwent intraoperative ultrasound and biopsy. Two lesions were benign with no malignant potential, and no resection was performed. 7 of 19 were resected for primary hepatocellular carcinoma, 2 for metastases, 2 for hepatic adenoma and 8 for symptomatic benign disease. Mean patient age was 52.1 years (range, 14 to 82). Fifteen of 19 cases were done using hand-assisted techniques. Mean blood loss in liver resection group was 289.8ml (range, 5 to 1500), with 2 patients requiring transfusion. Mean length of stay was 4 days (range, 1 to 13). One patient had to be converted and developed a wound infection in the postoperative course. 5 of 39 patients underwent robotic-assisted procedure.
Conclusions: Laparoscopic hepatic procedures can be accomplished safely and efficaciously by properly trained surgeons familiar with both laparoscopic and hepatobiliary surgery. Advances in technology make the transection of the parenchyma safer, but there is a learning curve in which hand-assisted techniques and robots application may play an important role. Clear understanding of the surgical anatomy of the liver is crucial as is proper utilization of pre- and intraoperative imaging when planning the resection. As with other MIS, laparoscopic hepatic procedures appears to be advantageous over the open technique in select patients; however, further exploration and comparative analysis of new methods is warranted.

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