Laparoscopic Liver Surgery
Hepatocellular Carcinoma
The world's greatest experience in laparoscopic liver surgery with an oncological indication is in patients with hepatocellular carcinoma (HCC). On the one hand, this reflects the widespread use of minimally invasive liver surgery in Asian countries, with a high proportion of patients with liver tumors. On the other hand, laparoscopy seems to promise advantages in these patients.
Use of Laparoscopic Needle Driver is a prudent choice for Training.
The indisputably lower access trauma in laparoscopic surgery with the resulting lower need for painkillers, earlier mobilization and shorter hospital stays significantly reduces the risk of complications in patients with liver cirrhosis. Less blood loss, the reduced need for fluid administration, earlier bowel movements and the possibility of repeated resections with only minor adhesion formation also contribute to the better overall result of laparoscopic liver surgery in patients with HCC and liver cirrhosis. Laparoscopic resection should therefore prefer to open resection in this patient group.
Metastasis Of Colorectal Carcinomas
In contrast to the indication for liver tumors, the proportion of laparoscopic operations for metastatic colorectal carcinoma is significantly lower worldwide. Reasons must sees here in the frequently bilobular occurrence of metastases with the need for complex resections, the previous operation of the primary tumor (colon resection, rectum resection), but also in the significantly lower prevalence of laparoscopic liver surgery in the western world. In stark contrast to this are the excellent results achieved in studies on the laparoscopic resection of colorectal metastases.
In almost all series, with oncological equivalence, it shows that minimally invasive liver surgery reduces morbidity and length of stay in hospital. Some studies have even described an oncological advantage. Early recovery of the patient after laparoscopic liver resection also allows earlier access to adjuvant chemotherapy, if needed, like what describes for other indications. Taken together, the laparoscopic approach for liver resection also considers in this patient group.
Technical Aspects
Technical Requirements
The surgical technique and the associated technical requirements and the instruments used in minimally invasive liver surgery often correspond to those used in open surgery. Nevertheless, there are some special features that should not go unmentioned here. Intraoperative ultrasound examination is of particular importance in laparoscopic surgery.
In our opinion, if bimanual palpation is not possible, it is always necessary to examine the liver intraoperatively using ultrasound when exploring the patient, which requires a corresponding sonography unit with a laparoscopic probe. This not only serves to verify the preoperative cross-sectional image diagnostics, but also to determine and adjust the resection planes intraoperatively about important anatomical structures.
Further technical prerequisites are laparoscopic instruments for parenchymal transection. Energy devices, ultrasonic dissection devices, stapling devices, clip applicators and coagulation instruments use here. Intraoperative ultrasound examination to check the position of the tumors and to determine the resection planes.
Storage And Access
Due to the clearly limited intra-abdominal space, the positioning of the patient and the access in laparoscopic surgery are more important than in the open procedure. Depending on the operation, the patient positions with the upper body upright in such a way that the operating table rotates and thus better exposure of the operating area is possible. In our clinic, we mostly use vacuum mattresses to ensure that the patient fixes.
The trocars arrange in such a way that the best possible view of the operating area provides. The most used positioning with the placement of 4 to 5 trocars in a crescent shape under the right costal arch allows excellent access to the hepatic porta, the anterior liver segments, and the vena-cava. Therefore, with little variation, this positioning is suitable for resection of the anterior segments and right and left sided hemi-hepatectomy.
Positioning the patient on the left side with the trocar positioned far laterally and transdiaphragmatic trocar positioning may allow better access to the posterior and cranial segments of the liver. In this respect, preoperative imaging with the corresponding operation and positioning planning is of great importance.
Dissection, Bleeding Control and Parenchymal Section
While the Pringle maneuver initially uses routinely, increased centers are doing without this possibility of influence control. Nevertheless, the control of the porta hepatis offers an important possibility of influence control also in laparoscopic surgery, e.g., B. in hemi-hepatectomy. The transection of the large vascular structures (portal vein branches, hepatic veins, pedicles) carries out in most working groups using a vascular stapler. The Ultrasonic Aspirator Allows Subtle Visualization of Vascular Structures.
The pneumoperitoneum and the associated intra-abdominal pressure play a special role in controlling bleeding during parenchymal transection. Despite the lack of the possibility of manual bleeding control, the venous return flow can minimize and blood contamination reduces by lowering the central venous pressure with a simultaneous stable, positive pressure of the pneumoperitoneum.
Parenchymal Section
Various technical solutions known from open surgery uses for the actual cutting of the parenchyma: energy devices, staplers, ultrasonic aspirators, but also modified "crush-clamp techniques". From our own experience, we prefer the use of energy devices for mobilization and the parenchymal section close to the capsule.
Use Of Ultrasonic Aspirator
For deeper sections of parenchyma, we prefer to use an ultrasonic aspirator with the possibility of subtle visualization of the vascular structures. Such a procedure allows the representation of the segmental vascular architecture, which means that anatomical segment resections can also carries out. The vessel then transects after clip application or after bipolar coagulation. Large vessels (e.g., intra-parenchymatous transection of the hepatic veins) transects using a vascular stapler.
Trifurcation Of the Portal Vein
Laparoscopic preparation of the portal vein coming from the right. trifurcation of the portal vein. Transection of the central branch of the portal vein with the vascular stapler during the liver split Parenchymal transection using an ultrasonic aspirator. Smaller vessels coagulate or severed after clip application.
Postoperative Course and Fast Track
The principles of perioperative treatment of the patient according to a "fast-track" concept, initially develops for colorectal surgery, have increasingly found their way into liver surgery. The recovery time, which already significantly reduces by the laparoscopic operation, can further reduces by appropriate anesthetic procedures with epidural catheters, early mobilization and nutrition, and the early removal of all invasive accesses.
It remains unclear whether the hospital discharges achieved in studies on the second postoperative day after laparoscopic liver resection in an unselected, real patient collective are sustainable and reasonable. Nevertheless, patients with smaller liver resections without major parenchymal loss seem to benefit from laparoscopy.
Current Developments
Even if the technical development is far from complete, laparoscopic liver surgery in experienced centers has almost reached the complexity and extent of open liver surgery. Thus, current developments keep pace with innovations and improvements in open liver surgery.
In particular, the expansion of the indication for liver surgery in the case of borderline residual liver tissue (future liver remnant, FLR) should mention here. By integrating multimodal therapeutic procedures (chemotherapy, local ablative procedures, interventional procedures, etc, attempts make to safely conduct liver surgery in patients primarily classified as non-rejectable.
Two-Stage Surgical Procedures
Two-stage surgical procedures such as the ALPPS procedure (“associating liver partition and portal vein ligation” ;) should also mentions here. While the technique developed as an open surgical procedure, both surgical steps can also safely perform laparoscopically (see additional material online: video). The less surgical trauma, the smaller extent of adhesions after the hypertrophy-inducing step and the faster recovery of the patient may speak in favor of laparoscopic surgery.
Further developments in minimally invasive liver surgery go hand in hand with the development of robotic systems. Here the meaning is not yet foreseeable. A great opportunity here could lie in the expansion of reconstructive possibilities in complex liver surgery (bile duct and vascular reconstruction, construction of biliodigestive anastomoses), which has so far continued to be the domain of open surgery.
Opening of the split plane during the second step of the ALPPS (associating liver partition and portal vein ligation) procedure for laparoscopic extended right hemi-hepatectomy. After the laparoscopic implementation of the first step, there are only a few adhesions.
Conclusion
After initially slow development, laparoscopic liver surgery has taken its place in the treatment of liver tumors. Due to the advantages for the patient in the short and long term, the number of centers with experience in laparoscopic liver surgery has increased sharply in recent years and the complexity of the interventions has almost reached the level of open surgery. Minor resections on the anterior liver segments are now a standard procedure performed by many surgeons.
This development, with a further spread of minimally invasive liver surgery, expects to continue in the coming years. The results of prospective randomized studies comparing open and laparoscopic liver surgery also expects to be an important milestone. If the results obtained so far confirms, this will lead to a further upsurge in laparoscopic liver surgery.
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