9 laparoscopic liver surgery for patients with hepatocellular carcinoma

7/31/2019 9 Laparoscopic Liver Surgery for Patients With Hepatocellular Carcinoma

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Laparoscopic Liver Surgery for Patients with

Hepatocellular Carcinoma

Hong-Yaw Chen, MD,1 Chung-Chou Juan, MD, PhD,1

and Chen-Guo Ker, MD, PhD, FACS2

1Department of Surgery, Gastrointestinal Center, Yuan General Hospital, Kaohsiung, Taiwan2Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Kaohsiung Medical University Hospital,

100, Tz-You 1st Rd, Kaohsiung, 80756, Taiwan

Background: Laparoscopic hepatectomy is feasible for hepatocellular carcinoma (HCC)today. This is a retrospective study of the patients with HCC treated by liver resection with atotally laparoscopic approach.

Methods: This study recruited 116 patients (92 male, 24 female) that underwent laparo-scopic liver resection (LR) for HCC. Patients were divided into two groups: group I: ( n = 97,78 male,19 female) those with a volume of resection less than two segments; group II: ( n = 19,14 male, 5 female) those with a volume of resection of more than two segments. The distri-bution of the tumor-nodemetastasis (TNM) stage of patients in the two groups was notsignificantly different.

Results: Patients resumed full diet on the second or third day after the operation, and theaverage length of hospital stay was 6 days. The operation time was 152.4 336.3 min and175.8 57.4 min, while blood loss was 101.6 324.4 mL and 329.2 338.0 ml, for groups

I and II, respectively. Five patients (5.2%

) in group I and three patients (15.8%

) in group IIrequired blood transfusion (p = 0.122). The mortality rate was zero among our patients andcomplication rates were 6.2% and 5.2% for groups I and II, respectively. The 1-year, 3-year,and 5-year survival rates were 85.4%, 66.4%, and 59.4% for group I, and 94.7%, 74.2%, and61.7% for group II, respectively, with no significant difference between two groups(p = 0.1237).

Conclusion: Laparoscopic liver resection is a procedure of significant risk and is moretechnically demanding in comparison with traditional open method. There was no significantdifference in survival rates, based on the volume of resection. Laparoscopic surgery should beperformed in selected patients as the postoperative quality of life of patients is better than thatwith open resection.

Key Words: Liver cancerLaparoscopic surgeryHepatectomy.

Hepatocellular carcinoma (HCC) is a not infre-

quent disease in Taiwan. To date, literature on lap-

aroscopic hepatic surgery is uncommon and we

believe this technique is an innovation.12 In 1998, we

started to apply the laparoscopic approach to liver

surgery for liver cancer.2 The laparoscopic approach

has not yet been well developed for liver resection and

only limited case series have been reported. Besides,

laparoscopic examination and laparoscopic ultraso-

nography are indispensable to guarantee the precise

determination of the segmental tumor location and

the relationship of the tumor to adjacent vascular or

biliary structures.36 Therefore, the tumor location

Published online: December 29, 2007.Address correspondence and reprint requests to: Chen-Guo Ker,

MD, PhD, FACS; E-mail: [email protected]

Published by Springer Science+Business Media, LLC 2007 The Society ofSurgical Oncology, Inc.

Annals of Surgical Oncology 15(3):800806

DOI: 10.1245/s10434-007-9749-1

800


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and its spatial details are important during laparo-

scopic liver dissection in our experience.

With improvements in laparoscopic techniques

and the development of new technology and

equipment, laparoscopic liver resection is safe when

undertaken by experienced surgeons. In 2000, De-scottes et al.7 reported its use for major operations,

such as right liver lobectomy, and believed the use

of this technical approach offers many advantages.

In addition, the caudate lobe alone could be re-

moved without sacrificing other parts of the liver,

as reported by Dulucg.8 Therefore, the laparoscopic

technique has gradually become acceptance for

application to liver resection, worldwide, in some

institutions.

Unlike laparoscopic cholecystectomy, laparoscopic

hepatectomy has been slow to gain acceptance be-

cause of its associated technical difficulties. Theoret-ically, laparoscopic liver surgery has advantages over

the traditional open procedure. Therefore, the aim of

this research is to perform a retrograde study of

laparoscopic procedures for tumor resection in the

patients of HCC.

METHODS

Patient Data

One hundred and sixteen patients (92 male and

24 female) underwent laparoscopic liver resection

between 1998 and 2006. Two groups were created;

group I; (n = 97, 78 male,19 female) patients with

a volume of resection of less than two segments:

group II; (n = 19, 14 male, 5 female) patients with

a volume of resection greater than two segments,

including left lobectomy (removal of segments II

and III) in seven patients, and left hepatectomy

(removal of segments II, III, and IV) in four pa-

tients. The criteria for liver resection were HCC,

with pathological diagnosis before operation, which

was found to be resectable after imaging and clin-

ical studies. The indications for a laparoscopic

procedure were tumor located in the peripheral partof left liver or the anterior sector of right liver, and

the size less than 5 cm in diameter, as shown in

Fig. 1. Basic data regarding the patients are shown

in Table 1.

Laparoacopic Approach Procedures

The patient was in supine position under general

anesthesia and the trocar insertion sites depended on

the site of tumor. Usually, it was necessary to insert

four trocars to have optimal operative manipulation.

The abdominal pressure was maintained at the low

level of 812 mmHg, in addition to abdominal lifting

if necessary.

The general condition of the liver could be evalu-

ated directly from the laparoscopic examination, and

then used to decide on the following procedure. The

site and extension of the tumor, and its relationship

to the vasculature, were confirmed by laparoscopic

ultrasonography. The line of intended resection, tu-

mor feeding vessels, and hepatic veins, were marked

on the liver surface using diathermy. Microwave

coagulation along the resection line was performed,

before dissection of the liver parenchyma as shown in

Fig. 2. With this technique, the risk of bleeding dur-

ing dissection is reduced. All of the resection lines

were punctured with laparoscopic microwave tissue

coagulator to minimize bleeding during the liver

dissection. Then, an ultrasonic dissector system

(CUSA) was used, and branched vessels and ducts

were clipped and then transected, as is commonlydone in our patients, as shown in Fig. 3. The surgical

field was irrigated and checked for bleeding or bile

leak, and residual fluid was removed by suction. The

electric coagulator was applied in order to ensure

hemostasis of the resection surface. After dissecting

the resected part of liver, the specimen was be re-

moved by widening of the epigastric port wound.

Finally, a drainage tube was placed to allow post-

operative drainage.

FIG. 1. Schema of the location of tumors removed with totallylaparoscopic liver resection or the hand-port-assisted technique.

LAPAROSCOPIC LIVER SURGERY 801

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Postoperative Evaluation

The surgical procedure, postoperative course, and

follow-up were evaluated periodically. The following

data were collected prospectively, including duration

of surgery, blood loss, perioperative transfusions,

surgical events, postoperative complications, hospital

stay, and survival rate of patients.

TABLE 1. Preoperative clinical data regarding the patients with hepatocellular carcinoma

Variable Group I (n = 97) Group II (n = 19) P-value

Sex Male 78 14 0.540Female 19 5

Age Total 57.6 12.6 61.6 13.1 0.219

Male 55.9 12.5 63.1 8.4 0.043*Female 64.7 10.8 57.4 22.7 0.520

Body mass index (kg/m2) 25.0 3.4 24.8 3.5 0.806HBsAG No 31 11 0.059

Yes 66 8Anti-HCV No 64 11 0.681

Yes 33 8Alpha-fetoprotein (ng/ml)


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creased and unnecessary laparotomy may be avoi-

ded.13 Despite significant improvements in preoper-

ative tumor staging, due to sophisticated new imaging

and interventional techniques, peritoneal tumor

spread and occult liver and lymph node metastases

are only detected during surgery in some patients.Therefore, those patients could be given postopera-

tive adjuvant therapy if occult tumor spread was

found with the aid of diagnostic laparoscopy.14

Therefore, preventing patients with advanced tumors

from undergoing unnecessary laparotomy is an

important guiding principle in the staging of the

cancer patient.15 In some situations, patients with

potentially resectable hepatobiliary malignancy are

found to have unresectable tumors at laparotomy.

DAngelica et al. report that laparoscopic inspection

could be completed in 291 (73%) patients, and 153

patients (38%

) were found to have unresectable dis-ease, 84 of whom were identified laparoscopically,

increasing resectability from 62% to 78%.16 There-

fore, laparoscopic liver resection is feasible in hepa-

tocellular carcinoma if the tumor is singular, smaller

than 5 cm, and located in the left lateral segments, or

in the anterior or inferior sector of the right liver.

Postoperative morbidity is low and long-term results

seem to be similar to those of traditional laparotomy,

based on our experience. Hence, we and Champault

et al.17 believe that the laparoscopic surgery could be

used as a procedure for staging and determining

resectability in surgical oncology. Our experience

strongly suggests that lesions of the left liver lobe(segments II and III), and the anterior sector (seg-

ments IVa, V, and VI), constitute a good indication

for laparoscopic approach, whereas lesions of the

posterior and superior liver segments (segment VII,

VII, IVc, and I) are technically demanding and

should only be approached with extreme caution or

hand-port assisted procedures. Another important

factor in laparoscopic surgery was the small tumor

size (average diameter less than 5 cm) found in the

most of the reported series.

In comparing our results with the report of Mori-

no,18

the mean postoperative hospital stay was 6.4days (range, 216 days) in the laparoscopic group, 5.7

days for non-cirrhotic patients and 12.6 days for

cirrhotic ones. In general, the hospital stay was

shorter in those patients treated by a laparoscopic

approach in our series and on literature review.1819

The mean operating time was 160.5 minutes and the

conversion rate to open surgery was 8%, as reported

by the National Registry in Spain20, and 5.2% in our

series. We believe that the laparoscopic approach

reduces blood loss and postoperative hospital stay, as

well. Intraoperative bleeding is a topic of great con-

cern in laparoscopic liver resection. In our series,

eight patients (8/108), in total, needed blood trans-

fusion. As in open surgery, management of bleeding

during dissection of liver parenchyma requires tech-

nical experience, and adequate preoperative evalua-tion is important and offers the best guarantee. The

microwave coagulator and CUSA were proved useful

during laparoscopic resection, because they can

coagulate and divide the hepatic parenchyma during

dissection. However, one should be given enough

time to operate, in order to achieve adequate

homeostasis. In addition, the potential risk of gas

embolism led some authors to use gasless suspension

laparoscopy. When CO2, which is highly soluble, is

used, this complication is rare. However, precautions,

such as low abdominal pressure, monitored at the

level of 68 mmHg, are warranted.

2122

In the studyof Belli et al., they suggest that laparoscopy was

performed with a CO2 pneumoperitoneum at the le-

vel of 1214 mmHg.23 In our experience, it was safe if

the pneumoperitoneum was set at a level of 610

mmHg. No port-site metastases were observed in

patients of malignant disease, either in our series, or

in the literature.24

Laparoscopic liver resection for peripheral or

subcapsular hepatocellular carcinoma, in patients

with chronic liver disease, is associated with lower

morbidity than open resection.18,2527 However,

based on our experience, the postoperative compli-

cation rate was 6.0%, in total, for laparoscopic liverresection, which was better than that observed in

patients who underwent traditional resection in our

department (unpublished data).

A retrospective study was performed in 11 surgical

centers in Europe, looking at their experience with

laparoscopic resection of liver malignancies, and 37

patients with HCC were included.28 During a mean

follow-up period of 14 months, the 2-year disease-free

survival was 44% for patients with HCC. The 3-year

overall and disease-free survival rates for patients

with HCC (mean follow-up, 40 months) were 85%

and 68%, respectively, as reported by Vibert27

, and93% and 64%, respectively, as reported by Cherqui.29

The 5-year overall cumulative survival rate for the 69

patients was 63.9%. 5 five-year overall survival rate

for patients with well differentiated HCC was 78.9%,

whereas patients with moderately or poorly differ-

entiated HCC had a 5-year overall survival rate of

38.9%. The 5-year cumulative survival rate for pa-

tients with HCCs of up to 2.0 cm in diameter was

76.0%, and 56.3% for patients with HCCs larger than

2.0 cm.29 To some extent, this shows that laparo-

H.-Y. CHEN ET AL.804



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scopic procedures are best suited to the treatment of

well-differentiated HCC.2930 In our series, the 5-year

survival rates were found to be 59.7% and 61.7% for

laparoscopic liver resection in groups I and II,

respectively, and differences between the groups were

nonsignificant (p = 0.1237).Due to the accumulation of experience and

improvement of instruments, laparoscopic surgery is

more frequently applied to right hepatectomy.31

Ultrasonically activated scissors and blades could

decrease the blood loss during laparoscopic or open

liver resections. The surgical technique is an impor-

tant factor in preventing intraoperative and postop-

erative complications. Various techniques have been

developed for safe and careful dissection of the liver

parenchyma. Therefore, hand-assisted laparoscopic

liver resection is a safe and feasible procedure for

removal of two segments of liver.

32

Although we havelimited experience of hand-port procedure, direct

feeling with the surgeons fingers makes possible a

procedure that is almost identical to open surgery, in

which there is better visualization of the surgical field

and transected margin, and immediate homeostasis is

also achieved by manually depressing the bleeding

point. From these reports, laparoscopic liver resec-

tion using the hand-port system is feasible in selected

patients with lesions in the posterior portion of the

right hepatic lobe requiring limited resection.3334

Individuals with small tumors may benefit, because a

large abdominal incision is not required, and the

wound-related complication rate might be reduced.In conclusion, laparoscopic hepatectomy could

avoid some of the disadvantages of open hepatec-

tomy and is beneficial for patient quality of life, as a

minimally invasive procedure. Evolution of laparo-

scopic hepatectomies will probably continue and is

worthy of encouragement, depending on the devel-

opment of new techniques and instruments.

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9 laparoscopic liver surgery for patients with hepatocellular carcinoma

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