Original Article

Single incision laparoscopic : Advances in laparoscopic

Tayar Claude1, Subar Daren1,2, Salloum Chady1, Malek Alexandre1, Laurent Alexis1, Azoulay Daniel1 1Digestive, Hepato-Bilio-Pancreatic Surgical and Hepatic Transplantation Service, Henri Mondor Hospital, Creteil, France, 2Department of General and Hepato-Pancreato-Biliary Surgery, Blackburn Royal Hospital, Blackburn, Lancashire, United Kingdom

Address for Correspondence: Prof. Daniel Azoulay, Service Chirurgie Digestive, Hépato-Bilio-Pancréatique et Transplantation Hépatique, Hôpital Henri Mondor, 51 avenue De Lattre De Tassigny, 94010 Créteil, France. E-mail: [email protected]

Abstract without oncological compromise and with favourable cosmetic results. This surgical technique requires relatively advanced BACKGROUND: Laparoscopic liver surgery is now an laparoscopic skills. Further studies are needed to determine established practice in many institutions. It is a safe and the potential advantages of this technique, apart from the better feasible approach in experienced hands. Single incision cosmetic result, compared to the conventional laparoscopic laparoscopic surgery (SILS) has been performed for approach. , nephrectomies, splenectomies and obesity surgery. However, the use of SILS in Key words: Hepatectomy, laparoscopic liver resection, single incision liver surgery has been rarely reported. We report our laparoscopic hepatectomy (SILH), single incision laparoscopic initial experience in seven patients on single incision surgery (SILS) laparoscopic hepatectomy (SILH). PATIENTS AND METHODS: From October 2010 to September 2012, seven patients underwent single-incision laparoscopic liver surgery. The was approached through a INTRODUCTION 25 mm periumbilical incision. No supplemental ports were required. The liver was transected using a combination of Laparoscopic liver surgery is now widely practised in many LigaSureTM (Covidien-Valleylab. Boulder. USA), Harmonic institutions worldwide. In accordance with the Louisville Scalpel and Ligaclips (Ethicon Endo-Surgery, Inc.). RESULTS: Liver resection was successfully completed statement the best indications are for solitary lesions 5 cm or for the seven patients. The procedures consisted of less located in the periphery of the liver and laparoscopic left two partial resections of segment three, two partial lateral lobectomy should be considered the standard of care.[1] resections of segment fi ve and three partial resections The advantages of shorter hospital stay, decreased blood loss of segment six. The mean operative time was 98.3 min as well as the attainment of disease free and overall survival (range: 60-150 min) and the mean estimated blood comparable to open liver resections in laparoscopic liver loss was 57 ml (range: 25-150 ml). The postoperative surgery has been well documented.[2] The natural progress courses were uneventful and the mean hospital stay was 5.1 days (range: 1-13 days). Pathology identifi ed to minimise incisions has seen the development of single three benign and four malignant liver tumours with clear incision laparoscopic surgery (SILS) in a number of surgical margins. CONCLUSION: SILH is a technically feasible subspecialties.[3-6] and safe approach for wedge resections of the liver The use of SILS in single incision laparoscopic hepatectomy (SILH) is still in the early stages of development and little

Access this article online has been published on the matter. SILS and its derivative Quick Response Code: Website: SILH pose a technical challenge to the surgeon due to the www.journalofmas.com acute angle of triangulation and difficulty of manipulation. In contrast, the potential advantage of better cosmesis and shorter hospital stay makes it attractive in a select group DOI: 10.4103/0972-9941.124454 of patients. This advantage must not be at the sacrifice of maintaining oncological principles and low morbidity and mortality rates. We describe here our initial experience

14 Journal of Minimal Access Surgery | January-March 2014 | Volume 10 | Issue 1 Tayar et al.: Single incision laparoscopic hepatectomy with SILH with particular reference to morbidity, oncological Boulder, USA). Haemostasis was achieved with LigaSure, clearance, advantages and challenges. bipolar forceps and Ligaclips (Ethicon Endo-Surgery, Inc.). No Pringle manoeuvre was necessary. No additional ports PATIENTS AND METHODS were needed for any of the procedures.

From October 2010 to September 2012, seven patients Haemostasis was secured after the transection. The specimen were selected by a consensus of senior surgeons to undergo was then retrieved in an endoscopic bag (Memo Bag, Teleflex SILH in our unit. These patients were otherwise considered medical, Park, Athlone, Ireland) and extracted from the suitable for laparoscopic liver resection. All patients had abdomen via the umbilical port. In two patients who each superficial lesions. Patient demographics, clinical history, had a concurrent , a 10 Fr drain was inserted. preoperative diagnosis, laboratory examinations, radiological After checking for haemostasis and biliary leak, the incision images, operating time, blood loss, hospital stay and was closed with number 1 polydioxanone suture (PDS) histopathological results were reviewed from a prospective (Ethicon Inc.) to the rectus sheath and a subcuticular 3/0 database. The patients’ preoperative demographics are listed undyed monocryl (Ethicon Inc.) to the skin. Postoperatively, in Table 1. all patients were admitted to the ward.

Surgical Technique RESULTS Preoperative assessment and anaesthesia was routine as for all liver resections in our department. The patients were There were four males and three females in our case series placed in the supine position with 20° reverse Trendelenberg with a median age of 58 years (range: 31-71 years). All seven position which is standard for all laparoscopic liver surgery patients had peripheral lesions demonstrated on preoperative at our institution. A 25 mm periumbilical skin incision was imaging and underwent non-anatomical resections. Three made and either a SILSPORT (Covidien-Valleylab. Boulder. lesions were located in segment VI and two lesions were USA.) or a Gelpoint (Applied Medical. Rancho Santa Margarita, located in segment III and V each. Two of the seven patients CA. USA) was inserted under direct vision after breaching had previous for resection of colorectal the peritoneal cavity. A pneumoperitoneum to 12 mmHg cancer. Successful resection of the hepatic lesion via the was created using carbon dioxide via the insufflation port SILSPORT was achieved in all patients without the need for on the SILSPORT system. The SILSPORT system has three the insertion of additional ports or conversion to an open 5 mm operating ports. One port was used to introduce a procedure in any of the cases. Three of the patients had 5 mm 30° laparoscope (Karl Storz, Tuttlingen, Germany) and resections for a preoperative diagnosis of suspicious lesions the two other 5 mm ports were used as the working ports on imaging which were histologically reported as adenomas. to introduce various instruments during the procedure. In Four patients had resections for malignancy, including two one patient a high definition (HD) flexible tip laparoscope each for hepatocellular cancer (HCC) with underlying cirrhosis (Olympus, Center Valley, PA, USA) was used. The transection and metastatic colorectal cancer (CRLM). The two patients line was marked on the liver surface with bipolar and liver with HCC each had a Child-Pugh score of A and early B. One parenchymal transection was done with Harmonic Scalpel patient had a synchronous resection of a colorectal liver (Ethicon Endo-Surgery, Inc.) and LigaSure (Covidien-Valleylab, metastasis via SILH and a pulmonary wedge resection via a thoracotomy for a lung metastasis. The median operating time was 110 minutes (range: 60-150 minutes). Median blood Table 1: Demographics of seven patients who had single port loss was 50 ml (range: 25-150 ml). The median size of the liver resection for isolated liver lesions resected lesion was 20 mm (range: 20-47 mm). All operative Age/Sex Diagnosis Segment Tumour Previous location of size abdominal margins were clear with a median resection margin of 2.5 mm lesion (mm) surgery (range: 2-8 mm) [Table 2]. In the two patients who had drains 44/Female FNH III 20 None inserted at the time of the operation, these were removed 58/Female CRLM V 22 Rectal Resection on postoperative day 2. 58/Male HCC V 22 None 47/Female HA VI 47 None 63/Female CRLM VI 20 Rectal Resection Postoperatively all patients had uncomplicated recoveries 31/Male HCC VI 20 None with a median hospital stay of 5 days (range: 1-13 days). 71/Male LH III 20 None Normal diet was resumed on the day of surgery. The patient FNH: Focal nodular hyperplasia, CRLM: Colorectal liver metastases, HCC: Hepatocellular carcinoma, HA: Hepatic adenoma, LH: Haemangioma of the who had synchronous pulmonary and liver resection had liver the longest hospital stay of 13 days. This delayed discharge

Journal of Minimal Access Surgery | January-March 2014 | Volume 10 | Issue 1 15 Tayar et al.: Single incision laparoscopic hepatectomy

Table 2: Operative details with postoperative hospital stay and study by Aldrighetti et al. suggests that there is no difference histological margins in outcome between SILH and conventional laparoscopic Age/Sex Operating Blood Resection Duration Complications surgical resection of the left lateral lobe. time loss margin of hospital (mins) (ml) (mm) stay (days) In SILH (laparoscopic liver surgery with SILS), cosmesis may 44/Female 110 25 3 5 None have to be a compromise as the port site scar is not truly well 58/Female 150 50 2 5 None 58/Male 60 50 2 1 None hidden if it is above umbilicus. However, this technique does 47/Female 118 150 8 3 None minimise the number of ports. In addition, for , 63/Female 120 50 2.5 13 None the use of SILS has highlighted some technical challenges. 31/Male 70 50 5 3 None 71Male 60 25 2 6 None These include the lack of adequate triangulation with difficulty in manipulation of the instruments and a parallel field of vision.[16] To overcome this, Tan et al. described a was a result of the decision made by the thoracic surgeons natural evolution in their technique for laparoendoscopic who performed the pulmonary resection and not due to any single site surgery in which they used longer bariatric complication of the hepatic resection. Excluding this patient, instruments to compensate for overcrowding.[17] In our series all other patients had a hospital stay of 6 days or less. we used standard laparoscopic instruments for all procedures and we concur that there are issues with overcrowding and DISCUSSION lack of manipulative capabilities. The use of curved and articulating instruments as well as flexible endoscopes have Laparoscopic liver surgery is now the mainstay of left helped to overcome some of these problems.[22,23] lateral lobectomy and peripherally located lesions in many centres.[7] In addition, in experienced hands laparoscopic Our series demonstrates that SILH is a safe, feasible and major hepatectomies have been shown to be feasible and safe oncologically acceptable technique for liver resection with with good oncological resection margins.[8-10] Laparoscopic results comparable to standard laparoscopic liver resection in hepatectomy has demonstrated a decreased hospital stay,[11] published series. However, patient selection is of paramount less blood loss[12] with mortality, morbidity and oncological importance and we think that the Louisville statement should outcomes comparable to that of open resections.[2] Recent be adopted for SILH. Although others have reported SILH for interest in “scarless” surgery and the theoretical advantage left lateral lobectomy,[17,24] we think that in the learning phase of better preservation of collateral veins on the anterior SILH should only be attempted by experienced laparoscopic abdominal wall in patients with underlying liver disease liver surgeons on tumours ≤5 cm located on the periphery has seen some centres develop an interest in SILS.[13-15] In of the liver. addition, in laparoscopic wedge resections of the liver one of the trocar sites usually needs to be enlarged to extract Although cosmetic and postoperative recovery advantages the specimen. The advantage of SILH in this setting is the of SILS in colorectal surgery has been reported,[25] it ability to perform the same resection through the same size remains to be seen if this holds true for SILH. Continued incision as that which would be necessary for specimen development of laparoscopic instruments for SILS to improve extraction without the need for an additional three or four manipulation will likely see further progress in this technique. ports. This, in theory, makes the procedure less invasive In conclusion, SILH appears safe and feasible. Larger studies in these circumstances. Our outcome data appears to be are needed, in particular, a randomised study comparing it comparable with other published literature on SILH.[16,17] In to conventional laparoscopic techniques to demonstrate any addition, the results are also comparable to published data potential advantages. on conventional laparoscopic minor hepatectomies (≤2 Couinaud segments)[18,19] supporting the view that SILH is REFEREN CES as safe and as feasible as conventional laparoscopic liver resection.[20] In contrast, both Tan et al.[17] and Aldrighetti 1. 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