Laparoscopic Liver Resection: an Early Experience in a Resource Limited Country

Tsiiregzen Enkh-Amgalan, MD, Jigjidsuren Chinburen, MD, Katie M Wells, MD, Erdenebileg Taivanbaatar, MD, Gurbadam Unenbat, MD, Dagvadorj Munkhbat, MD, Erdene-Ochir Dulguun, MD, Raymond Price, MD. National Cancer Center of Mongolia, University of Utah Center for Global Surgery, Intermountain Health Care.

Introduction: Mongolia has the highest mortality rate of liver cancer in the world (six times the global average). While open liver resections are currently being preformed safely in Mongolia, many patients seeking access to minimally invasive approaches to hepatic resection are traveling abroad to receive laparoscopic surgical care. Recognizing the economic burden of traveling abroad for surgical care, Mongolia has been building advanced laparoscopic surgical capability to address hepatobiliary disease through a multinational cooperative capacity building initiative. A single institutional experience of the implementation of laparoscopic hepatic resection in a resource poor country is reviewed.

Methods/Procedure: A retrospective chart review was conducted of 39 patients who underwent laparoscopic liver resections by the Hepato-Pancreatic-Biliary Surgical Department at the National Cancer Center of Mongolia between October 2010 and August 2013. Prior to the initiation of laparoscopic hepatic resection the Mongolian hepatobiliary surgeons, underwent multiple basic and advanced laparoscopic training courses ranging from two days to six months over a ten-year period, including courses in Japan, the United States, Switzerland, Taiwan, and South Korea. These courses included experiences with didactic lectures and animal labs including laparoscopic liver resections and nephrectomies. A harmonic scalpel generator donated by a private non-governmental organization along with important disposables provided key equipment facilitating laparoscopic liver resection.

Results: There were 39 laparoscopic hepatic resections preformed. Male/female ratio: 14/25. Twenty-two cases were left lateral sectionectomy, and 17 cases of small isolated tumor resection. Pathology included: Hepatocellular carcinoma- 28; cholangiocarcinoma-1; hepatic adenoma-3; Hydatid cyst and cystadenoma-1; hemangioma-3; high grade dysplastic nodule, and CRLM-1. The mean duration of surgery was 134.75 min (60-240 minutes). Mean blood loss was 91.41 mL (30-300mL). There were 2 intraoperative complications, which were bleeding, and a left diaphragm injury, and one conversion from a laparoscopic to an open procedure because of bleeding. Postoperative complications: bile leak-1; re-operation-1; wound infections-7; liver failure and ascites-2; postoperative bleeding-1, with no documented cases of perioperative mortality. The mean hospital length of stay was 7.97 days (4-29 days), with two patients requiring re-admission.

Conclusion: Laparoscopic hepatic resection is now available to address the large burden of hepatic disease in Mongolia. The implementation of an advanced laparoscopic procedure requires a significant amount of training and resource assistance. As developing economies grow, so does the demand for advanced surgical techniques. To address this demand, and to continue to further strengthen surgical capacity, Mongolian surgeons are working to give their patients the highest standard of quality surgical care through modern surgical techniques locally. Laparoscopic hepatic resection for left lateral resection and small right-sided liver neoplasms can be preformed safely and effectively in a resource-poor country.

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