Hepatocellular Carcinoma: Targeted Therapy and Multidisciplinary P21

Chapter 12 Laparoscopic Liver Resection for HCC: A European Perspective Luca Viganò and Daniel Cherqui Keywords Laparoscopic liver resection · HCC · Hepatic resection Hepatocellular carcinoma (HCC), the most common primary liver cancer, occurs in >90% of the cases on an underlying hepatic disease [1]. Screening programs allow diagnosis at an early stage where curative treatments can be proposed. These include liver resection, percutaneous radiofrequency ablation, and liver transplantation [1, 2].EveniflivertransplantationisthebesttreatmentforearlyHCCbyremovingboth the tumor and the underlying liver disease, shortage of donor organs and dropout from the waiting list limit its efficacy [3]. In recent years liver resection in cirrhotic patients became safer [4, 5] and achieved a key role in HCC treatment: in advanced tumors it is the only therapeutic option, while in early tumor it can be proposed as an alternative or a bridge to liver transplantation [6–9]. The vast majority of hepatic resections for HCC are stand-alone procedures, without any need for reconstruction, which should make them good candidates for a laparoscopic approach. However, diffusion of laparoscopic liver resection is still limited and few centers worldwide regularly perform it [10]. The reasons for the limited development of such an approach to date are threefold. First, technical prob-lems are anticipated and, indeed, the elementary maneuvers of open hepatic surgery (including manual palpation, organ mobilization, vascular control, and parenchymal transection) are thought to be difficult to reproduce laparoscopically. Second, there are anticipated hazards: hemorrhage may be more difficult to control laparoscopi-cally, especially in cirrhotic livers, and the risk of gas embolism may be increased by the use of pneumoperitoneum. The third problem is a fear of oncological inad-equacy and tumor spread. Although still limited in number of cases, publications about laparoscopic liver resection have increased in recent years and HCC has been one of the most common indications. In this chapter, we will review the various D. Cherqui ( ) Department of Surgery, New York-Presbyterian/Weill Cornell, New York, NY, USA K.M. McMasters, J.-N. Vauthey (eds.), Hepatocellular Carcinoma, 185 DOI 10.1007/978-1-60327-522-4_12, C Springer Science+Business Media, LLC 2011 186 L. Viganò and D. Cherqui aspects of laparoscopic liver resection for HCC, including technical features, short-and long-term results. We will also briefly discuss the impact of laparoscopic liver resection on the treatment strategy of HCC. Feasibility: Technique and Indications In comparison with open hepatectomy series, the number of published papers about laparoscopic liver surgery is very low [10]. At present only 14 studies (includ-ing 1 multicentric) reported 50 or more cases [11–24] (Table 12.1). Interestingly the majority of them have been published in the last 2 years [11, 13, 18–24]. An increasing proportion of malignant diseases have been treated and HCC was the most common indication. The feasibility of laparoscopic liver resection has been the main criterion studied to date. Despite the increasing number of reported series, in expert centers laparo-scopic approach ranges from 5 to 30% [11, 13, 15, 16, 22] and only some recent series reported higher rates, reaching 50–80% [18, 20, 21]. On our part, over the past 12 years (1996–2008), we performed 174 laparoscopic liver resections out of 782 hepatectomies (22.3%) [25]. Considering HCC, the proportion of laparoscopic resection was higher, about 30% (69 of 229) and reached 39.4% in the last 4 years of our experience [25]. Table 12.1 Series of laparoscopic liver resections including more than 50 cases Author Year # Descottes [14]a 2003 87 Mala [15] 2005 53 Kaneko [16] 2005 52 Vibert [12] 2006 89 Cai [17] 2006 62 Dagher [11] 2007 70 Koffron [18]b 2007 273 Chen [19] 2008 116 Topal [13] 2008 109 Buell [20] 2008 253 Cho [21] 2008 128 Sasaki [23] 2008 82 Inagaki [24] 2009 68 Cherqui [25] 2009 174 Proportion of LLR on total LR NR 44% 17% NR NR 15% NR NR 28% NR NR 29% NR 22% Malignant lesions 0% 89% (47) NR 73% (65) 32% (20) 54% (38) 37% (103) 100% (116) 71% (77) 42% (106) 61% (78) 93% (78) 76% (52) 63% (110) HCC 0% 2% (1) 77% (40) 18% (16) 29% (18) 34% (24) NR 100% (116) NR 14% (36) 45% (57) 45% (37) 43% (36) 40% (69) amulticentric study bonly pure laparoscopic and hand-assisted laparoscopic hepatectomies included NR: data not reported; LLR: laparoscopic liver resection; LR: liver resection 12 Laparoscopic Liver Resection for HCC 187 Surgical Technique State-of-the-art equipment is required. The use of two monitors is recommended. Although some groups use 0◦ laparoscopes [11, 12], 30◦ laparoscopes are preferred by most authors. Patient Positioning We suggest two different positions according to lesion site. For lesions located in segments 2 through 5 (the majority of cases), the patient is placed in the supine position, with lower limbs apart (Fig. 12.1). The surgeon stands between the legs with one assistant on each side. For patients with lesions of segment 6 scheduled for atypical resection or segmentectomy, the left lateral decubitus position may be used in order to expose the lateral and posterior aspect of the right liver (Fig. 12.2). In this case the surgeon is on the ventral side of the patient. In case of laparoscopic right hepatectomy, supine position with lower limbs apart is preferred. Some authors prefer supine position with the surgeon stand on patient side and the assistant on the opposite one [18]. Pneumoperitoneum A problem concerning laparoscopic liver surgery is the pneumoperitoneum itself. The risk of gas embolism due to hepatic vein lesions during parenchymal Fig. 12.1 Port placement for resection of lesions located in segments 2–5 and for right hepatectomy. The patient is in supine position with lower limbs apart and the surgeon between the legs. Numbers shown represent trocar sizes in millimeters 188 L. Viganò and D. Cherqui Fig. 12.2 Port placement for resection of lesions located in segment 6. The patient is in left lateral decubitus for right lobe mobilization and posterior exposure. The table can be turned to the right to reapplytherightlobeandgainanterioraccess.Numbersshownrepresenttrocarsizesinmillimeters transection has been suggested. Transesophageal echocardiography study in animal model demonstrated gas embolism in almost all animals undergoing laparoscopic liver resection with cardiac arrhythmia in two-thirds of cases [26]. In order to avoid it, gasless laparoscopy has been proposed [27]. However, gas embolism occurrence in clinical practice is extremely low [28]. In 2002, Biertho et al. reviewed published laparoscopic liver resections and reported only 2 cases of possible gas embolism over about 200 procedures [29]. In recent series [11, 18, 20, 30] and in our expe-rience [22], few cases of transient mild cardiovascular alteration due to embolism occurred without clinical consequences. Carbon dioxide pneumoperitoneum mini-mizes risk of gas embolism as compared to air and low pneumoperitoneum pressure further reduces its incidence [31]. Electronic monitoring of intra-abdominal pres-sure is required and should be maintained at less than 14 mm Hg. Gas embolism occurrence has been also related to argon beam coagulation which increases endo-abdominal pressure leading to increased risk of gas embolism [32]. To date CO2 pneumoperitoneum is considered safe and gasless laparoscopy is no longer in use. Port Sites Positioning and Hand Assistance Positioning of port sites is different according to tumor site and it is shown in Figs. 12.1 and 12.2. Many variants have been described. The position of trocar for the laparoscope can be higher on the midline or more lateral on the right side in case of right liver resection [11, 12]. Hand-assisted laparoscopy is used by several authors [18, 33–35]. It consists in the placement through an 8-cm incision of a gas-tight port permitting the introduc-tion of a hand in the abdomen. The assisting hand allows tactile feedback while palpating the liver and it may help in abdominal exploration, mobilizing the liver, provides gentle retraction, and helps during parenchymal transection. In addition, 12 Laparoscopic Liver Resection for HCC 189 in case of bleeding hand compression allows easier hemostasis. For its proponents, this technique may render laparoscopic liver resection safer and more accessible. Koffron et al. recently proposed a wide use of hand assistance in order to increase the proportion of patients that can benefit from laparoscopic-assisted approach [18]. In our experience, hand assistance has been used in selected cases (about 10%) of right hepatectomies or limited resections of posterior right segments to facilitate when liver mobilization or parenchymal transection can be difficult. Pedicle Clamping Intermittent clamping (15-min clamping and 5-min release periods) can be per-formed whenever necessary. Our group demonstrated that in patients with normal cardiac function laparoscopic pedicle clamping is safe and well tolerated [36, 37]. However, it is used less often and the majority of recent resections have been performed without any clamping even in cirrhotic patients [25]. Liver Mobilization and Inflow/Outflow Control Several techniques have been described which cannot be detailed here. Our usual technique is briefly depicted. In left lateral sectionectomy, the round, falciform, and left triangular ligaments and the lesser omentum are divided. Dissection of the falciform ligament is con-tinued to the level of the inferior vena cava and the insertions of the hepatic veins. Parenchymal transection is carried out until the portal pedicles of segments 2 and 3 are exposed. The pedicles are then divided using linear staplers. Left hepatic vein is divided at the end of parenchymal transection by linear stapler [38]. In limited resections, parenchymal transection is carried out along decided tran-sectionlines.Portalpediclesandhepaticveinsarecontrolledastheyareencountered during transection. In limited right-sided resections, the right triangular ligament is divided, taking advantage of the lateral position of the patient. Parenchymal transection is then carried out. Laparoscopic right hepatectomy includes dorsal decubitus position, initial divi-sion of the right portal pedicle, right liver mobilization, taping of right hepatic vein if feasible and transection. Hand assistance can be used. Hand port is introduced through a right iliac or flank transverse incision. Surgeon’s left hand or assistant’s right hand helps mobilizing the liver and compresses in case of bleeding. Parenchymal Transection The main technical challenge of laparoscopic liver resection remains hemorrhage during parenchymal transection, especially in cirrhotic patients. Several devices havebeendeveloped withtheaimtoperformmorebloodlessandaccurateparenchy-mal transection. These devices have not proved to be indispensable during open resections.However,inlaparoscopicsurgery,thesimpleprinciplesoftransectionare more difficult to apply and some of the newly designed technologies are required. ... - tailieumienphi.vn