Hepatocellular Carcinoma: Targeted Therapy and Multidisciplinary P22

12 Laparoscopic Liver Resection for HCC 195 our series of 174 laparoscopic resections, mortality was nil and morbidity occurred in 14.4% of cases [25]. Considering the 69 patients affected by HCC morbidity rate was 21.7%, but it significantly decreased in the second half of our series (lower than 10%) [25]. Two complications are commonly feared in laparoscopic liver surgery: gas embolism and bleeding. As previously discussed, gas embolism is rarely reported and is usually without any clinical consequences, except for transient cardiovas-cular alterations. On the other side, hemorrhagic complications can occur during parenchymal transection and may lead to urgent conversion. In the literature some severe hemorrhagic complications have been reported, mainly related to hepatic veins injuries [11, 12, 22, 64]. These have been usually managed either laparoscopi-cally or by conversion to laparotomy without reported consequences except for two cases: one brain death [12] and one hypovolemic shock with postoperative renal failure requiring hemodialysis for 4 months [64]. No intraoperative death has been reported. In the published series, hemorrhagic risk was not increased in cirrhotic patients. In the literature, reported conversion rate is about 5–15% [11–13, 15, 22, 65]. Similar data have been reported in HCC cases [19, 21, 23, 25, 45, 57–61]. The rea-sons for conversion are essentially two. The first reason is, of course, bleeding. The second is a technical one, a composite association of difficult exposure, insufficient or poor quality view, fragile tumor with risk of rupture or uncertainty about the dis-tance between the tumor and the transection plane. In our series, the conversion rate was 9.8% in the whole series and 13% in HCC cases, with two-thirds for technical reasons and one-third for bleeding [25]. In our experience, massive bleeding requir-ing rapid conversion never occurred; they were rather situations that were difficult to control by laparoscopy and that, by their persistence, hampered the progress of the operation and were leading to a significant blood loss. Comparison with Open Liver Resections Three case–control studies (one from our group) [44, 60, 66] compared outcomes of laparoscopic and open liver resections in cirrhotic patients. Two comparative studies without any matching criteria compared laparoscopic and open resections for HCC [45, 57]. The outcomes of these studies are summarized in Table 12.3. Reduced morbidity, especially rare occurrences of postoperative ascites, was observed in patients operated through a laparoscopic approach [44, 66]. Operative time of laparoscopic resections was longer in two studies [45, 66], while a trend toward reduced blood loss has been reported [44, 45, 66]. Hospital stay was shorter in laparoscopic group [40, 45, 60]. Learning Curve In surgical procedures the so-called learning curve effect has been described, demonstrating improvement in results along with experience [67, 68]. In laparo-scopic liver surgery series, some authors reported reduced operative times, blood 196 L. Viganò and D. Cherqui 12 Laparoscopic Liver Resection for HCC 197 loss, and conversion rate when comparing early and late cases of their series [11, 16, 38, 69]. Our group recently studied the learning curve effect along our experi-ence of laparoscopic liver resections [25]. We split our series of 69 laparoscopic liver resections for HCC into three groups of 23 consecutive cases. Conversion rate progressively decreased (26.1, 8.7, and 4.3%). A significant decrease of pedicle clamping rate (from 100 to 17.4%), clamping duration when used (60 to 20 min), operative time (240 to 150 minutes), and blood loss (400 to 100 cc) was observed. Morbidity decreased from 43.5 to 13.0 and 8.7% and hospital stay passed from 9 to 7 and 6 days, respectively. Left Lateral Sectionectomy Left lateral sectionectomy has a privileged place in laparoscopic resections (Fig. 12.5). Our group demonstrated by a case–control study that, despite longer operative times, laparoscopy is associated with reduced blood loss and morbid-ity, especially in cirrhotic patients [70]. A further analysis on 36 laparoscopic left lateral sectionectomies reported no mortality and no liver-specific morbidity, low blood loss, and no transfusion [38]. Conversion occurred only in one patient during our experience. In addition a clear learning curve effect was demonstrated: opera-tive time, use of Pringle maneuver, and hospital stay were significantly reduced in the last 18 patients. All these data have been confirmed by further recent studies [71–73]. Laparoscopy can be recommended as the routine approach to left lateral sectionectomy. Fig. 12.5 Laparoscopic left lateral sectionectomy for HCC. (a) Preoperative CT scan. (b) The surgical field at the end of parenchymal transection. (c) The specimen 198 L. Viganò and D. Cherqui Other Minor Resections Antero-lateral liver segments (segments 2–6) are the so-called laparoscopic liver segments. Their non-anatomical resections are commonly reported in the literature and are associated with excellent outcomes [11–20, 22, 23] (Fig. 12.6). Even if no studies specifically compared their results with those of open counterparts, equiva-lence between the two procedures can be postulated and advantages of laparoscopic approach can be hypothesized. In fact, together with left lateral sectionectomies, they represent the majority of cases included in case–control studies comparing open and laparoscopic liver surgery. Fig. 12.6 Laparoscopic segmentectomy 4b for HCC. (a) Preoperative CT scan. (b) The surgical field at the end of parenchymal transection As mentioned above, non-anatomical resections of segments 7, 8, and 1 have been usually excluded from laparoscopic approach because of difficult visualiza-tion of surgical field. Similarly right liver segmental anatomic resections present many problems, mainly related to adequate exposure, the need for two transec-tion planes, and the difficulties to check margin adequacy [40]. Increased risk of intraoperative bleeding and positive surgical margin can be feared. Recently feasi-bility of these procedures has been reconsidered and successful laparoscopic cases have been reported, especially applying hand assistance [19, 21, 34, 74] (Fig. 12.7). Laparoscopic right posterior sectionectomies and caudate lobectomies have been performed with good outcomes [18, 20, 21, 43, 74]. Cho et al. compared outcomes of laparoscopic approach for lesion in antero-lateral segments vs. postero-superior ones and they did not report any differences, except for longer operative time and higher transfusion rate in the second group [21, 43]. Despite these positive results, little data are presently available and further studies are necessary to validate outcome of these procedures. Major Hepatectomy An increasing number of laparoscopic major hepatectomies have been reported in the literature [11–13, 18, 20–22, 56, 69, 75–77], including large series in the past 12 Laparoscopic Liver Resection for HCC 199 Fig. 12.7 Laparoscopic atypical resection of segment 8 for HCC. (a) Preoperative MRI. (b) Liver transection performed with harmonic scalpel. (c) Specimen is placed in a plastic bag. (d) Specimen extraction through a separate incision. (e) The surgical field at the end of parenchymal transection. (f) The specimen 2 years [11, 13, 18, 20–22, 75]. The majority of procedures were right or left hepate-ctomies. However, few specific data about these procedures are available and only a limited number of cases have been performed in patients with HCC [19–21, 25, 58, 60] (Table 12.2). Even if some authors suggest feasibility of right hepatectomy by ... - tailieumienphi.vn