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Single Incision Laparoscopic Hepatectomy: Advances in Laparoscopic Liver Surgery

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Single Incision Laparoscopic Hepatectomy: Advances in Laparoscopic Liver Surgery Original Article Single incision laparoscopic hepatectomy: Advances in laparoscopic liver surgery 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. cholecystectomies, 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 abdomen 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 cholecystectomy, 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 abdominal surgery 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
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