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Print version ISSN 0100-6991
Rev. Col. Bras. Cir. vol.39 no.6 Rio de Janeiro Nov./Dec. 2012
Marcel Autran Cesar Machado, TCBC-SPI; Fábio Ferrari MakdissiII; Rodrigo Cañada Trofo SurjanIII
IFull Professor, Faculty of Medicine, São Paulo State University USP
IIPhD, Faculty of Medicine, São Paulo State University USP
IIIAssistant Physician, Faculty of Medicine, São Paulo State University USP
OBJECTIVE: To analyze our experience after 107 laparoscopic hepatectomies and discuss the technical evolution of
laparoscopic hepatectomy in the last five years.
METHODS: Between April 2007 and April 2012 we performed 107 laparoscopic hepatectomies in 105 patients. The mean age was 53.9 years (17 to 85). Fifty-three patients were male. All interventions were performed by the authors.
RESULTS:from the total of 107 operations, there was need for conversion to open technique in three cases (2.8%). Sixteen patients (14.9%) had complications. Two patients died, a mortality of 1.87%. One death was due to massive myocardial infarction, unrelated to the procedure, which was uneventful and showed no conversion or bleeding. The other death was due to failure of the stapler. Twenty patients (18.7%) required blood transfusion. The most frequent type of hepatectomy was bisegmentectomy of segments 2-3, (33 cases), followed by right hepatectomy (22 cases). Seventy-two procedures (67.3%) were performed by the technique of Glissonian access.
CONCLUSION: The dissemination of results is of utmost importance. The technical difficulties, complications and even death, inherent in this complex type of surgery, need to be clearly disclosed. This procedure should be performed in a specialized center with knowledgeable staff. The technique of laparoscopic Glissonian access, described by our staff, facilitates the realization of anatomical hepatectomies.
Key words: Liver. Techniques. General surgery. Laparoscopy. Hepatectomy.
The development and improvement of new instrumental techniques enabled the performance of laparoscopic liver resections1-3 in the early 1990s. From the 2000s, there was an exponential growth in the number of hepatectomies by this method, reflecting the growing number of publications4-8.
The first laparoscopic hepatectomy in Brazil, a bisegmentectomy of segments 2-3, was performed by Kalil et al.3 in 1997. In 2007, our team performed the first major laparoscopic hepatectomy, a right hepatectomy9. After these pioneering cases, there was a spread of our technique in our country10-12.
The advantages of laparoscopy over open technique include smaller incisions, reduced postoperative pain, shorter recovery time, lower immune and metabolic response, shorter hospital stay, as well as lower morbidity7,8,13.
Today laparoscopic hepatectomy is a reality in Brazil and is now part of the surgical armamentarium in the treatment of liver diseases. Currently major and / or complex hepatic resections, such as right hepatectomy9, right trisegmentectomy14, left hepatectomy15, mesohepatectomy16 and even two-time hepatectomy17 are routinely performed by laparoscopy in Brazil in specialized centers by skilled teams3,9,14-18.
The objective of this study was to analyze our experience with more than a hundred cases and discuss the technical evolution of laparoscopic hepatectomy in the past five years, highlighting our contribution to the development of the laparoscopic Glissonian access technique.
All patients who underwent laparoscopy liver resection between April 2007 and April 2012 were retrospectively analyzed from prospectively collected database.
During this period, 107 laparoscopic hepatectomies were performed in 105 patients. Mean age was 53.9 ± 15.8 years (17 to 85). Fifty-two patients were female and 53 male. Tables 1 and 2 show the types of laparoscopic hepatectomy performed and indications. Of the total of 107 resections, 29 were performed outside our service.
Conversion to laparotomy was required in three cases (2.8%) due to bleeding (1 case), embolism (1 case) and instrumental failure (1 case).
Sixteen patients had complications, a rate of 14.9% morbidity. Major complications were ascites and transient hepatic failure, occurring in cirrhotic patients. One patient with liver metastases, previous chemotherapy, undergoing a right trisegmentectomy without prior portal embolization, presented with prolonged hepatic insufficiency, with gradual improvement and was discharged after 15 days of hospitalization. Two patients had biliary fistula after hepatic resection. One patient was reoperated by laparoscopy for suspected bleeding (sudden drop in hematocrit), but no bleeding focus was found, and evolved to stabilization of the hemoglobin levels after transfusion. Two patients died after surgery, a mortality of 1.87%. These two patients were operated on another service; one death was due to myocardial infarction, unrelated to that laparoscopic hepatectomy, which was uneventful. The other patient died during hepatectomy, due to failure of the stapler that resulted in bleeding, conversion and need for massive transfusion; death occurred on the third day after surgery.
The estimated blood loss, as well as operative time and length of hospitalization, varied according to the type of resection. Twenty patients (18.7%) required transfusion (1-6 units) during or after hepatectomy. Most patients requiring transfusion had undergone major hepatectomies.
The most common type of hepatectomy was bisegmentectomy of segments 2-3, followed by right hepatectomy (Table 1) and the main indication was hepatic metastasis (Table 2). Seventy-two operations (67.3%) were performed by the Glissonian access technique, previously described11,12. The remaining 35 (32.7%) were performed by dissection of the hepatic hilum or were non-anatomic dissections (Table 3). In ten cases, the hemi-Pringle technique19 was used to perform non-anatomic resections. In four cases, we decided to use the technique of intermittent Pringle, after preconditioning (ten minutes by clamping the hepatic hilum followed by ten minutes of release of hepatic perfusion). In two cases we used the aid of the hand and in the other two we used the hybrid technique. One patient with hilar cholangiocarcinoma underwent a left hepatectomy with totally laparoscopic lymphadenectomy, but the intrahepatic hepatic-jejunal anastomosis was performed by a hybrid method due to the location and caliber of the biliary tree that did not permit a safe anastomosis. Of the total of 107 operations, except for conversions (3 cases) and hybrid operations (2 cases) or with the aid of the hand (2 cases), 100 were performed completely laparoscopically (93.5%).
In four cases of liver metastasis, hepatectomy was concurrently performed with laparoscopic colorectal surgery, two being right hepatectomies and one bisegmentectomy of segments 5-8, associated with rectosigmoidectomy for low rectal tumor and diverting ileostomy. In one case there were concomitant right hepatectomy and right colectomy, with ileal-transverse anastomosis.
Three patients with hepatic metastases from neuroendocrine tumors underwent resection of the primary tumor during surgery, two being enterectomies and a body-tail pancreatectectomy. In all these procedures, the associated operation was also performed laparoscopically.
Other procedures performed at the same time of laparoscopic hepatectomy (resection of segment 4 and right hepatectomy, respectively) were a laparoscopic right nephrectomy and thoracoscopic pulmonary metastatic excision (performed by other teams).
In 33 operations (30.8%) the type of hepatectomy was major, ie there was resection of three or more segments in the same operation. Although highly complex and with large raw area, bisegmentectomies (segments 6-7, 7-8 and 5-8) were considered minor hepatectomies (Table 4).
The annual number of laparoscopic resections performed during the study period is shown in figure 1.
The development of the technique of laparoscopic liver resection requires technical training in advanced laparoscopic surgery and liver surgery7,8,13,20,21. The lack of such knowledge can lead to mistakes, which, when dealing specifically with laparoscopic liver resection, may result in intraoperative bleeding with risk of severe complications and mortality.
With this in mind, the authors initiated a training program in mid-sized animals (dogs and pigs), deeming possible the use and development of various instruments. This program resulted in the description of a useful experimental model22, because the experience of situations, such as poor positioning of trocars and intraoperative bleeding, caused the authors to gain experience in this complex type of procedure.
The application in humans began gradually, with segmental resections of the liver with the use of the hemi-Pringle technical19. The initial results in humans, the continuous technical improvement and the continuous exchange of information with surgeons from other centers made authors able to perform major liver resections successfully.
After the initial success of the first cases of right hepatectomy9,10,23, the authors have organized various courses of training and teaching of laparoscopic surgery in midsize animals after technical capacitation and development of experimental models. Performing operations in other hospitals was important for seeding the technique throughout Brazil, and enabled a rapid increase in our series. The disclosure of our experience in several congresses and medical events in recent years, as well as access to our edited videos available on websites for public access and educational, helped spread the art in Brazil. Today laparoscopic hepatectomy is a reality in our midst.
Our experience with the Glissonian access technique via laparotomy, employed since 2001 in more than 400 cases, prompted us to also use this technique in laparoscopic surgery11,12. Indeed, knowledge of anatomical points, useful for the location of segmental pedicles, and experience with laparotomy procedures, facilitated this task and we quickly abandoned the technique of dissection of the hepatic hilum in patients without anatomic alteration. The only exception was in one case of Klatskin tumor, where the dissection of the hilum was mandatory.
A new strategy of hepatic parenchymal section24 during right hepatectomy resulted in reduced bleeding and operative time. The section of the posterior part of the liver before inserting the stapler for parenchymal transection reduces bleeding from the accessory hepatic veins draining directly to the retro-hepatic vena cava.
Another important change in the art, introduced in recent cases, was the reduction in the number and size of the trocars 24. Initially we used five trocars for a right hepatectomy, three being 12mm. Currently, we use only one 12mm trocar to introduce the stapler, a 10mm for the optics and other two 5mm. The introduction of flexible staplers allowed this change. Previously, for each angle of parenchymal section, a trocar 12mm was necessary. Another change was the systematic removal of the surgical specimen through a suprapubic incision, replacing the use of previous incisions or extended ports. The reason for this change was the minor pain with Pfannenstiel incision25.
The use of laparoscopy results in clear benefits for the patient, such as less postoperative pain, preservation of the abdominal wall, shorter hospitalization, better cosmetic effect, less bleeding, earlier return to professionals activities and others7,8,13,20,21,26. With this in mind, we increased the indication for laparoscopy use. The use of the laparoscopic technique requires special instruments such as laparoscopic stapler with vascular load. This can result in increased procedure costs, but that may be offset by less blood loss, shorter hospital stay and earlier return to work. The cost analysis was not the object of this study. However, as occurred with the use of staplers in open surgery and in other laparoscopic surgery, the cost tends to fall with increasing number of cases. The type and amount of material needed will vary greatly according to the type of surgery. A right hepatectomy needs more stapler loads, while a simple enucleation can be performed without any special material.
In patients for whom we anticipate a technical difficulty for the exclusive use of laparoscopy, we apply hybrid techniques with the use of an assisting hand or laparoscopic liver dissection followed by section through a small incision27-29.
The use of hand-assisted technique facilitates exposure of the liver parenchyma and section, especially in cirrhotic livers, and also gives the surgeon the tactile feel lost in laparoscopy27. We believe that the systematic use of this technique is not required and, together with four other authors, the use it as a step prior to complete conversion to laparotomy or in cases of anticipated difficulties for carrying out an entirely laparoscopic technique.
The literature review shows an exponential growth in the number and indications of laparoscopic hepatectomy. In a review of all published cases of laparoscopic hepatectomy8, held in 2009, 2804 cases were found. In this study mortality was only 0.3% and morbidity 10.5%. Nevertheless, 45% of cases were wedge resections, and nearly half of cases in patients with benign tumors. Only 9% of the cases were right hepatectomies, ie there was case selection. When analyzing data from multicenter trials with only major resections30, we find significantly greater morbidity and mortality; moreover, the conversion rate remained at 12.4%.
To the extent that this procedure was inserted in the therapeutic arsenal permanently and with no selection, findings tended to reflect the actual results of the method: lower morbidity, bleeding and mortality than open surgery. No mortality, present in the initial series, reflects selection of patients1,2,5. Series with a large number of patients with benign lesions and minor resections show selection and should not be a parameter for comparison with open surgery. Randomized prospective studies have never been done, perhaps given the great diversity of liver procedures and the obvious preference of patients for minimally invasive surgery and, therefore, probably will not be carried out. Therefore, in the presence of impending hepatectomy, provided there are no contraindications to the method, laparoscopy must be the technique of choice.
Complex hepatic interventions, such as hepatectomy for Klatskin tumors and even the technique of "Associated Liver Partition and Portal vein ligation for Staged Hepatectomy " (ALPPS) (first case in the world) could be performed completely by laparoscopy31.
The criteria for performing a liver resection in this way include experience in hepato biliopancreatic surgery and advanced laparoscopy. But the indication of laparoscopy cannot and should not prevail over the surgical and oncological principles.
The dissemination of results after five years of use of laparoscopy in performing hepatic resections is of utmost importance. The results, including technical difficulties, complications and even death, inherent of this complex type of surgery, need to be clearly disclosed.
The laparoscopic hepatectomy is a reality in Brazil, but there is still no method of teaching this procedure in major academic centers and universities. This procedure, therefore, should be performed in a specialized center by knowledgeable staff. The technique of laparoscopic Glissonian access, described by our team, now used in major world centers, facilitates the realization of anatomic resections, which have a lower risk of complications and bleeding.
New techniques and instrumental improvements have continually been described and now, according to our experience, the proportion of patients amenable to laparoscopic liver resection is about 50% of cases.
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Address for correspondence:
Marcel Autran C. Ax
Received on 01/06/2012
Accepted for publication 27/07/2012
Conflict of interest: none
Source of funding: no
Work performed in the Syrian-Lebanese Hospital, São Paulo, Brazil.