Repeat laparoscopic anatomical liver resection in a hepatocellular carcinoma patient:a case report

Anatomical resection(AR)has been reported to achieve better long-term outcomes than non-anatomical resection for the treatment of hepatocellular carcinoma(HCC).The surgical feasibility and oncological significance of laparoscopic AR(LAR),especially“subsegment resection”,“cone unit resection”,and repeat LAR for HCC,remain unproven.We present a 67-year-old patient with alcoholic liver cirrhosis and HCC who underwent full LAR three times,focusing on the technical aspects of the Glissonean approach.Repeating LAR for recurrent HCC could be a safe and feasible procedure.However,HCC recurred in the neighboring segment twice,even though pathological vascular invasion and marginal remnants were not confirmed.We should investigate the oncological significance and advancements in subsegmentectomy and cone unit resection,in the future.

Case report of the fourth laparoscopic liver resection and review of repeat laparoscopic resection for recurrent hepatocellular carcinoma in cirrhotic liver

A 73-year-old woman with liver cirrhosis caused by hepatitis C virus(HCV)underwent treatment of three hepatocellular carcinomas(HCCs)in liver segment 4,following three previous laparoscopic liver resections(LLRs)over 73 months.Contrast-enhanced computed tomography showed three 0.5-1.2 cm HCCs deep within the portal territories of subsegments 4a and 4b.The patient underwent laparoscopic resection of 4a and 4b,with the preservation of the portal branch to 4c,after minimal adhesiolysis around segment 4.The operation lasted 284 min,there was 50 mL of intra-operative bleeding and her recovery was uneventful.She was well,had experienced no recurrence and was HCV-negative,after taking oral anti-HCV therapy,21 months later.LLR is associated with fewer adhesions after surgery and requires less adhesiolysis,because the laparoscope and forceps can be used in the small spaces between adhesions.The present patient underwent four LLRs over 6 years without severe deterioration of liver functional reserve.LLR is a useful localized therapy,which can be performed repeatedly and may prolong the survival of patients with multicentric metachronous HCCs.

Pure Laparoscopic Liver Resection for Malignant Liver Tumor： Anatomic Resection Versus Nonanatomic Resection

Background： Laparoscopic liver resection （LLR） has been considered to be safe and feasible. However, few studies focused on the comparison between the anatomic and nonanatomic LLR. Therefore, the purpose of this study was to compare the perioperative factors and outcomes of the anatomic and nonanatomic LLR, especially the area of liver parenchymal transection and blood loss per unit area. Methods： In this study, surgical and oncological data of patients underwent pure LLR procedures for malignant liver tumor were prospectively collected. Blood loss per unit area of liver parenchymal transection was measured and considered as an important parameter. All procedures were conducted by a single surgeon. Results： During nearly 5 years, 84 patients with malignant liver tumor received a pure LLR procedure were included. Among them, 34 patients received anatomic LLR and 50 received nonanatomic LLR, respectively. Patients of the two groups were similar in terms of demographic features and tumor characteristics, despite the tumor size was significantly larger in the anatomic LLR group than that in the nonanatomic LLR group （4.77 ± 2.57 vs. 2.87 ± 2.10 cm, P = 0.001）. Patients who underwent anatomic resection had longer operation time （364.09 ± 131.22 vs. 252.00±135.21 min, P 〈 0.001） but less blood loss per unit area （7.85 ± 7.17 vs. 14.17 ± 10.43 ml/cm2, P = 0.018）. Nonanatomic LLR was associated with more blood loss when the area of parenchymal transection was equal to the anatomic LLR. No mortality occurred during the hospital stay and 30 days alter the operation. Moreover, there was no difference in the incidence of postoperative complications. The disease-free and overall survival rates showed no significant differences between the anatomic LLR and nonanatomic LLR groups. Conclusions： Both anatomic and nonanatomic pure LLR are safe and feasible. Measuring the area of parenchymal transection is a simple and effective method to estimate the outcomes of the liver resection surgery＇. Blood loss per unit area is an important parameter which is comparable between the anatomic LLR and nonanatomic LLR groups.

Anatomic isolated caudate lobectomy: Is it possible to establish a standard surgical flow?

AIM To establish the surgical flow for anatomic isolated caudate lobe resection. METHODS The study was approved by the ethics committee of the Second Affiliated Hospital Zhejiang University School of Medicine(SAHZU). From April 2004 to July 2014, 20 patients were enrolled who underwent anatomic isolated caudate lobectomy at SAHZU. Clinical and postoperative pathological data were analyzed. RESULTS Of the total 20 cases, 4 received isolated complete caudate lobectomy(20%) and 16 received isolated partial caudate lobectomy(80%). There were 4 caseswith the left approach(4/20, 20%), 6 cases with the right approach(6/20, 30%), 7 cases with the bilateral combined approach(7/20, 35%), 3 cases with the anterior approach(3/20, 15%), and the hanging maneuver was also combined in 2 cases. The median tumor size was 5.5 cm(2-12 cm). The median intraoperative blood loss was 600 m L(200-5700 m L). The median intra-operative blood transfusion volume was 250 m L(0-2400 m L). The median operation time was 255 min(110-510 min). The median post-operative hospital stay was 14 d(7-30 d). The 1-and 3-year survival rates for malignant tumor were 88.9% and 49.4%, respectively. CONCLUSION Caudate lobectomy was a challenging procedure. It was demonstrated that anatomic isolated caudate lobectomy can be done safely and effectively.

The APR triangle:A practical zone in the Glissonean approach to laparoscopic anatomical right hepatectomy

Background:An understanding of vascular anatomy is crucial for the safe performance of laparoscopic anatomical liver excision.We discovered a triangular zone during the laparoscopic right liver surgery and termed this zone the APR triangle.The purpose of this study was to determine the probability of the existence of the APR triangle and elucidate its various forms.Methods:Analyzed three-dimensional image reconstructions of 66 individuals who underwent liver surgery and calculated the statistics for various types of APR triangles under various grouping settings.Results:The APR triangle was present in the majority of cases,with right hepatic vein trunk type in 68%and right hepatic vein branch type in 21%,respectively.The angle between the right anterior and right posterior hepatic pedicles(AP&PP)was at most between 45 and 90°(74%).There was a 35%chance that at least one of the AP&PP was longer than 2 cm,and a 39%chance that both were.The right posterior pedicle first branch would appear at the bifurcation of AP&PP in 13%only.Conclusions:The APR triangle is objectively present and may represent a practical zone for performing laparoscopic right hepatic anatomical resection more simply and safely.

The role of minimally invasive surgery in the treatment of HCC

Liver surgery is the first-line treatment for hepatocellular carcinoma(HCC).Minimally invasive liver resection(MILS)has become an attractive option thanks to reduced intraoperative blood losses,shortened length of hospital stay,and similar oncological outcomes when compared to open liver resection.Nonetheless,the safety of MILS is still debated in challenging situations,such as in cirrhotic patients,difficult tumor locations,multiple or large tumors,and repeat resection.The aim of this review is to discuss current indications of laparoscopic liver resection for HCC treatment in the light of its outcomes,focusing on technical aspects of minimally invasive anatomic liver resection and state of the art of MILS in challenging situations.