Ashkan Moazzez, MD, Rodney Mason, MD, Namir Katkhouda, MD
Since the introduction of laparoscopic cholecystectomy, laparoscopy has become the approach of choice for many abdominal operations including some of those pertinent to hepatobiliary surgery. Katkhouda et al first reported a laparoscopic laser resection of a liver hydatid cyst in 1992,1 that was subsequently followed by descriptions of a number of laparoscopic non-anatomical and anatomical hepatectomies.2,3 Since these initial reports, there have been a number of reports of major liver lobectomies and trisegmentectomies in the literature.4 However, most of these procedures have been performed in centers with a large experience and volume in these types of surgeries, subjecting the recommendations to a possible bias due to the lack of publication of negative results.5
For optimal outcome, laparoscopic liver operations must conform to the same standards used in open liver surgery. Appropriate laparoscopic and hepatobiliary surgical skills, in addition to equipment technology should be available. This can be achieved with the collaboration and presence of 2 surgeons, one experienced in liver surgery and the other in laparoscopic surgery or one surgeon experienced in both.
Anatomy and Technical Considerations
Familiarity with liver anatomy and Couinaud’s segments is mandatory for successful laparoscopic liver surgery. Patients with solitary liver lesions less than 5 cm located in segments 2-6 are good candidates for laparoscopic resections. Although performed in some centers, large lesions (>5 cm), central, multiple, bilateral or close proximity to liver hilum or IVC are relative contraindications for laparoscopic resection.5 On the other hand, laparoscopic left lateral sectionectomy can be considered the standard of care in experienced hands.
The patient is positioned in the supine split legs position, with the surgeon standing between the legs and his assistants at the sides. A total of 4-6 trocars are used with the camera trocar placed above the umbilicus. In a "four-hand" laparoscopic approach, two surgeons work simultaneously; the first surgeon performs an instrumental fracture of the liver parenchyma, exposing all bile ducts and vessels, while the second surgeon controls all the vasculobiliary pedicles with clips or other hemostatic tools. This approach reduces the operative time and reduces the risk of hemorrhage and carbon dioxide gas embolism.
The four-hand laparoscopic technique is used for benign solid tumor resections such as adenomas and focal nodular hyperplasia. The resection begins with division of the right or left triangular ligament for lesions located in the corresponding lobe. Glisson's capsule is scored 2 cm away from the lesion using electrocautery. The first surgeon uses the harmonic shears (Ethicon Endosurgery, Inc., Cincinnati, OH) to dissect the parenchyma, while retracting the exposed liver surface. Simultaneously, the second surgeon divides all exposed larger vascular and biliary pedicles between large hemostatic clips. Hemostasis and control of any bile leak from raw liver surfaces can be achieved by wide application of fibrin sealant. Clips are used for hemostasis of larger vascular structures, and linear endovascular cutters are reserved for the hepatic veins. A flexible laparoscopic sonography probe is useful for locating anatomic landmarks or vasculobiliary structures.6
Specific Disease Entities and Role of Laparoscopy
Solitary Giant Hepatic Cyst
Non-parasitic hepatic cysts are usually asymptomatic with no hepatic function abnormalities. However, as the cysts grow in size, they may become symptomatic. Rupture, infection and intracystic hemorrhage are potential complications of these cysts.7
Since simple aspiration results in 100% recurrence, laparoscopic “unroofing” of the cyst wall has become the therapeutic option of choice.8 The open “unroofing” technique was originally introduced by Lin et al in 1968 for the treatment of patients with Polycystic Liver Disease. The goal is to decompress the cyst and avoid recurrence.9 Cystic neoplasms of the liver should be excluded with appropriate imaging studies prior to the operation. In addition, intraoperative examination of the cyst for septations or irregularities is mandatory, since if a neoplasm is suspected, a total cyst excision should be performed instead.
Katkhouda et al reported their results of laparoscopic “unroofing” with minimal morbidity and no recurrences, which concurred with other published results.10,11,12,13 The laparoscopic approach should become the treatment of choice for this liver disease entity.
Polycystic Liver Disease
PLD is classified into two groups according to the number, distribution, and location of cysts.13
1- Type 1: characterized by a limited number of large cysts predominantly located in the anterior segments of the liver.
2- Type 2: characterized by multiple small cysts that are distributed throughout the liver, including posterior segments (Swiss cheese).
Patients with type 1 disease are amenable to laparoscopic management. Patients with type 2 disease, however, have deep cysts that communicate with superficial cysts through a thin parenchymal wall, which are difficult to reach laparoscopically and are hard to differentiate from hepatic venous structures.
The recurrence rates are variable and depend on patient selection. Morino et al reported a recurrence rate of 60% at 6 months but included predominantly type 2 lesions.13 By contrast, Katkhouda et al showed a low recurrence rate of 11%, which may reflect the inclusion of only type 1 polycystic liver disease patients.10
The laparoscopic management of hydatid cysts of the liver can be challenging.1,14,15 The two surgical techniques are:
1) “Unroofing“ of a sterilized cyst and omentoplasty. This technique is reserved for large cysts or cysts in contact with venous branches of the IVC. All patients are given perioperative albendazole. Two 4x4 gauzes soaked in hypertonic saline are placed around the cyst. First, a cholecystectomy is performed together with a cholangiogram to exclude any possible biliary fistulas. The cyst contents are then sterilized with hypertonic saline and drainage. The cyst is subsequently unroofed and the residual cavity filled and packed with omentum.
2) Total pericystectomy. This is indicated for partially calcified anterior cysts. This consists of sequential vascular control of all the pedicles, using the pericystic layer as the plane of dissection.6 However, with this technique the dissection is often difficult because of the inflammatory response of the liver parenchyma to the parasitic cyst, and consequently the risk of intra-abdominal complications by spillage of cyst contents, anaphylactic shock, and biliary fistulas is increased.
Katkhouda et al reported a series of six laparoscopically treated hydatid cysts that resulted in two hemorrhagic and two infectious complications.10 Consequently, routine laparoscopic management of patients with echinococcal disease cannot be advocated, especially when the surgeon has had no previous experience managing hydatid disease through an open approach.
Studies have shown that many patients with colorectal metastasis to liver can benefit from laparoscopic liver resection. Preoperative staging studies should be performed, to minimize the risk of missing small lesions and for determining resectablility.5
Castaing et al reported comparable oncologic results between laparoscopic and open liver resection for colorectal metastasis. The morbidity and mortality were similar, while transfusion rates were significantly less in the laparoscopic group (15% vs. 36% with p=0.007). The overall and recurrence-free survivals were similar in both groups.16
Although Radio-frequency ablation is an option for non-resectable lesions, for resectable metastasis, resection is the gold standard due to a high recurrence rate that exceeds 30% in patients treated with RFA.17
Hepatocellular Cancer (HCC)
HCC is associated with hepatitis C and non-Alcoholic steatohepatitis. With the rise in these two diseases, there has been a concomitant increase in the incidence of HCC. Resection is the treatment of choice for patients with well-compensated cirrhosis.5 It has been shown that laparoscopic liver resection for small HCC has a lower morbidity in cirrhotic patients compared to open surgery and has decreased formation of postoperative ascites.18,19,20
Complications and Rescue Strategies
The major complication of liver surgery is bleeding. Bleeding can be divided into minor and major bleeds. Minor bleeding can usually be controlled with unipolar or bipolar atraumatic forceps. The coagulating spatula is also very useful. With more serious arterial bleeding where there is clearly spurting of blood, the camera should be pulled back to prevent obscuring the scope lens with blood, and then the artery should be grasped, dissected and clipped. Often the constant oozing makes management of venous bleeding in hepatic surgery more complicated and the achievement of hemostasis difficult. Temporary compression with a 4x4 gauze can stabilize the situation, however sometimes laparoscopic placement of a suture is necessary. If the venous injury is more extensive, such as to the hepatic vein or a branch of the portal vein, one should not hesitate to convert to an open procedure to allow for precise action and enable the operation to be concluded safely.
Bile leakage from the raw surface of the liver is a well-known complication after laparoscopic liver surgery and occasionally needs further therapeutic intervention. In addition to excellent surgical technique, application of fibrin sealant (Tisseel, Baxter Corp., Deerfield, IL) is one of the techniques used to decrease this risk. Tisseel is a combination of 2 main coagulation factors: human derived fibrinogen and thrombin. These 2 components can be administered through a laparoscopic applicator and when they mix and contact the raw surface of liver, they form a clot. Although Tisseel is a mainly a hemostatic agent, it will also occlude the exposed small biliary branches and minimize the risk of postoperative biliary leaks. In addition, it has the benefit of enhancing tissue growth by serving as a network for fibroblast proliferation and by creating soft adhesions that promotes closure of dead space.
Argon beam coagulation is another option for small bleeding but carries the risk of Argon gas embolization (see below).
In case of a major bile duct leak from the raw surface of the liver, laparoscopic application of a clip or placement of a figure-of-eight suture should be performed.
The probability of CO2 embolism is low during most laparoscopic procedures. However, in laparoscopic liver surgery the risk is slightly increased due to the exposed liver tissue with its hepatic vein branches. Constant control of CO2 pressure, continuous monitoring of the patients hemodynamic status, end-tidal CO2 and O2 are essential for the early diagnosis and correction of CO2 embolism. Transesophageal echocardiogram can diagnose the gas embolism. Due to high solubility of CO2, the hemodynamic instabilities associated with it are less significant than with air embolism.
Argon gas embolization, on the other hand, can be a life threatening complication of laparoscopic liver surgery and its use is controversial.5 Some experts are against using it, while others have used it safely for years. It is recommended however that it should be used only for minor bleeding while one of the ports is left open for desufflation of excessive gas and prevention of increased intra-abdominal pressure.
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