Laparoscopic liver resection safe, feasible in the hands of highly skilled surgeons
Laparoscopic liver resection (LLR) is safe and effective when performed by expert laparoscopic surgeons, a recent study found.
“LLR is associated with a low morbidity and mortality rate [and] adoption of LLR by liver surgeons with expertise in laparoscopy is safe and feasible,” said lead author Associate Professor Brian Goh, senior consultant at the Department of Hepatopancreatobiliary and Transplantation Surgery, Singapore General Hospital.
In this single-centre retrospective study, major postoperative morbidity (Clavien-Dindo grades III-V) and mortality (within 90 days of surgery or during the same hospitalization) occurred in just 5.6 (n=11) and 0.5 percent (n=1) of subjects, respectively. [Singapore Med J 2016;doi:10.11622/smedj.2016188]
Of the 195 patients (median age 60 years) who underwent LLR between 2006 and 2014, 12.3 percent (n=24) required open conversion surgery mostly due to bleeding, 34.9 percent (n=68) underwent resection of tumours in difficult posterosuperior segments, and 6.2 percent (n=12) required major hepatectomies involving more than three segments.
“Bleeding is a major complication of liver surgery and this may be more difficult to control via laparoscopy over the open approach if one does not have the necessary training or expertise. However, when performed by expert surgeons many studies have shown that LLR is associated with less blood loss over the open approach,” said Goh.
Subjects were limited to those who underwent liver lesion resections, thus excluding patients who underwent laparoscopic hepatic cyst fenestration, abscess drainage, excision biopsy, and local ablation. The most common reason for LLR was hepatocellular carcinoma (52.3 percent).
The study periods were divided into three time frames: 2006–2008 (period 1), 2009–2011 (period 2), and 2012–2014 (period 3). Results showed that the number of LLRs performed increased with time (22 in period 1 vs 154 in period 3).
Over time, the likelihood of LLR being performed for malignant lesions also increased (54.5 percent in period 1 vs 81.8 percent in period 3; p=0.011), as did the likelihood of LLR being performed for difficult posterosuperior segments (13.6 percent in period 1 vs 40.3 percent in period 3; p=0.009), which the authors suggested pointed to an expansion of indications for LLR.
Median operation time also increased (180, 200, and 215 minutes in periods 1, 2, and 3, respectively; p=0.027), which the authors attributed to an increase in the number of “more technically challenging procedures” carried out, while the rates of open conversion surgery reduced (22.7 percent in period 1 vs 9.1 percent in period 3; p=0.028).
“LLR is highly technically demanding and surgeons need to perform a relatively large number of cases to overcome the learning curve. This may not be feasible in low volume centres or surgeons,” said Goh.
“There is a real risk of complications such as major intraoperative bleeding if not performed by technically competent surgeons. More established and experienced open liver surgeons may not have the necessary laparoscopic skills to perform these procedures safely. To start performing LLR, one must be both an experienced liver surgeon and technically competent in advanced laparoscopic surgery,” he said.