Introduction

Case Presentation

A 45-year-old woman presented to clinic for evaluation of abdominal pain. Computed tomography (CT) scan showed an 11-cm left liver mass and a possible lesion in her cecum (not shown). Colonoscopy confirmed the presence of a mass in the cecum that was biopsied positive for an adenocarcinoma. Liver biopsy was consistent with metastatic adenocarcinoma of the colon. The patient had a remote history of breast cancer treated with surgery and chemotherapy, and is currently in remission. Metastatic work-up including a positron emission tomography (PET)-CT scan showed disease in the known colon and hepatic sites only (not shown).

Approach to Treatment

For patients with stage IV colorectal carcinoma, multimodality treatment is indicated. In this situation, systemic chemotherapy and biologic therapy are combined with surgical approaches. The potential benefits of the laparoscopic approach are detailed below. Laparoscopic liver resections are technically demanding and require that surgeons have experience in open resection, intraoperative ultrasound, and advanced laparoscopic skills. The major challenges have been to control bleeding during parenchymal transection, achieve adequate margins, and avoid complications such as bile leak and gas embolism. Advances in laparoscopic instruments and ultrasound technology have paved the way for safer approaches in laparoscopic liver resection. Simillis and colleagues[5] conducted a meta-analysis comparing the short-term outcomes for laparoscopic vs open hepatic resections in patients with benign and malignant neoplasms. They reviewed 8 studies published between 1998 and 2005, comprising 403 patients who underwent a total of 409 resections of hepatic neoplasms; 165 were laparoscopic and 244 were open. The authors concluded that laparoscopic hepatic resection can be performed as safely as open hepatic resection in selected patients.

Benefits of Laparoscopic Hepatic Resection

Based on Simillis and colleagues' review,[5] the operative time is comparable between laparoscopic hepatic resection and open hepatic resection, although there is significant heterogeneity among studies. Among all the variables analyzed, only 2 showed consistent significant differences between the techniques: operative blood loss and duration of hospital stay. Thus, reduced blood loss and shorter postoperative hospital stay are associated with the laparoscopic approach. Of note, the ability to achieve oncologic clearance and postoperative adverse events were comparable between the 2 operative techniques. Reduction in postoperative narcotic use and a faster return to normal activities can also be expected in patients undergoing laparoscopic hepatic resection.[5] Other potential advantages of the laparoscopic approach include earlier resumption of systemic adjuvant therapy (eg, chemotherapy)[6] and decreased liver dysfunction in patients with cirrhosis.[7]

 Indications for Laparoscopic Hepatic Resection

The decision to perform hepatic resection is simpler if the patient only requires a wedge resection of superficially or peripherally located masses, compared with those requiring a resection greater than a segmentectomy.[5] Choice D is not indicated for surgery because the patient has a benign lesion that is entirely asymptomatic. The other indications are associated with either malignancy or risk for malignancy and/or rupture, or symptoms.

Several benign lesions, such as simple hepatic cyst, hydatid cyst, FNH, and hemangioma (which rarely requires resection except in the case of symptomatic lesions), can benefit from treatment with a laparoscopic resection. Other benign lesions, such as liver cell adenoma and biliary cystadenoma, have malignant and bleeding potential and should be considered for resection (either open or laparoscopic) especially if they are > 4 cm. HCC is the most common liver malignancy and is often associated with cirrhosis, thus limiting the extent of resection -- but HCC can also be resected laparoscopically. Patients with well-compensated cirrhosis without evidence of portal hypertension can tolerate up to 50% to 60% hepatic resection.[8]

Basic Operative Principles for Laparoscopic Hepatic Resection

Patient and instrument positioning: The patient can be placed in a supine position with the surgeon standing on one side (or a left semi-decubitus position if the liver lesion is in the right side), or the patient can be placed in a lithotomy position with the surgeon standing between the legs of the patient. The majority of clinicians use CO2 pneumoperitoneum, but others prefer the abdominal wall lift method, especially during parenchymal transection given the potential risk for CO2 embolism.[7] However, intraperitoneal pressure created by the pneumoperitoneum is helpful in reducing blood loss stemming from the hepatic venous system. Additionally, in the event of CO2 embolism, the gas is rapidly absorbed, therefore minimizing any significant clinical sequelae.

Liver mobilization: The lesser omentum is checked to verify the presence of a left hepatic artery. If the procedure is not hand-assisted, some surgeons place a tape or vessel loop around the porta hepatis to be used as a tourniquet (Pringle maneuver) if necessary should severe bleeding appear.[9] (A hemi-Pringle, as described by Machado and colleagues,[10] may also be used). The triangular ligament is taken down with cautery or ultrasonic dissection and the suprahepatic inferior vena cava (IVC) is identified as in an open procedure. For a right hepatectomy, additional mobilization is necessary to expose the retrohepatic IVC. Individual caudate branches are dissected cleanly and clipped. Rotation of the liver is usually carried out by hand through a hand-port.

Intraoperative tumor assessment: Laparoscopic flexible ultrasound probe is not only useful but also indispensable for assessing anatomic landmarks that define the segmental anatomy (Figure), as well as for determining surgical margins around the tumor(s). In the hand-assisted approach, hand palpation of the tumor is very helpful, and it also provides the ability to retract and compress tissue for hemostasis.

Parenchymal dissection: The intended liver parenchymal transection is marked on the surface using diathermy, microwave, ultrasonic dissection, saline-infused cautery, tissue fusion system device, or radiofrequency ablation device. Then the surgeon can precoagulate the parenchyma using saline-perfused cautery or a radiofrequency ablation device, or can start transecting the liver without performing this maneuver, using endovascular staplers. With repeated "layered" application of the endovascular staplers, both the parenchyma and vascular structures (ie, portal triad, hepatic veins) can be transected.

For hemostasis, one can coagulate small vessels with diathermy, saline-perfused cautery, or radiofrequency ablation device. The use of argon-beam coagulation, while helpful in open procedures, is prohibited during laparoscopy due to an increment in the intra-abdominal pressure that occurs when it is applied. Also because it is an inert gas, it is not absorbed, thus creating a potential risk for argon embolism.[11] Reduction in the blood pressure by up to 25% to 30% in the portal region during laparoscopy has been shown to help achieve better hemostasis during the laparoscopic liver resection.[12] Bleeding from larger vessels can usually be managed by clip application or intracorporeal suturing.

Description of the Operative Technique

The patient is placed in a supine position; heparin (5000 units subcutaneously) and IV antibiotics are administered before the operation. At our center, we elect to use a hand-assist device which provides tactile feedback and allows for retraction and digital compression if bleeding occurs. Additionally, two 12-mm ports for the camera and the stapler, and another 5-mm working port, are placed.

We proceed to identify the lesion and to perform a laparoscopic ultrasound exam, which helps us to plan the resection according to the relationship between the tumor and vascular structures. The plane of resection is marked on the liver surface. The coronary ligament is divided, and the bare area of the liver is mobilized to identify the hepatic veins. We incise Glisson's capsule of the liver using the ultrasonic coagulation device. Then, using the radiofrequency ablation device, we perform the precoagulation of the parenchyma. This is followed by a series of endovascular stapler applications, using 60-mm length to 2.5-mm laparoscopic reticulating stapler until completion of the parenchymal dissection. The specimen is placed into a plastic bag and is extracted through the gel port. Hemostasis is achieved using the radiofrequency ablation device or intracorporeal suturing. A fibrin sealant is applied to the cut surface of the liver. The ports are removed and the incisions are closed. In our experience, most patients do not require ICU admission, and the average length of stay is 3 days.

Postoperative orders include using patient-controlled analgesia, which is later transitioned to oral narcotics, thromboembolism prophylaxis, and antiemetics. Resumption of preoperative oral medications is begun as soon as clear liquids can be tolerated. Routine follow-up is conducted at 2 weeks postoperatively and then every 3 months for the first year.

Complications

The most feared complication of laparoscopic liver resection is hemorrhage during the parenchyma transection or a tear occurring during the dissection of the portal vessels, IVC, or hepatic veins. The majority of conversions are secondary to intraoperative bleeding. Adequate selection of patients, careful technique, and clamping maneuvers (Pringle) can help decrease this complication (intraoperative bleeding).[13]

Biliary leaks are assessed in conjunction with hemostasis and are controlled with coagulation or using fibrin polymers to seal the tissue, as suggested by Buell and colleagues.[14]

Another potential problem associated with laparoscopic liver resection includes the seeding of tumor cells when the specimen is removed. To avoid this problem, the specimen is always placed in a bag before its extraction. There is no definitive evidence in the literature that laparoscopy increases the risk for neoplasm dissemination, and none of the patients in the meta-analysis studies developed any port-site or cutaneous metastases.[1,7]

Gas (CO2) embolism secondary to pneumoperitoneum is a very rare but potential complication of the laparoscopic approach. Biertho and colleagues[15] have reported 2 cases of possible embolism after 186 laparoscopic hepatic resection.

Conclusion

Minimally invasive surgery has transformed the approach of many surgical procedures, reducing associated pain, hospital length of stay, and achieving comparable results with open operations. Skilled surgical teams, with experience in hepatic and laparoscopic surgery, have demonstrated that the laparoscopic approach for liver resection is safe and feasible for a selected group of patients with benign or malignant liver tumors. Additional studies are needed to assess the long-term outcomes following laparoscopic hepatic resection.

Reviewed by Dr. Ramaz Mitaishvili