Advances in Minimally Invasive Liver Surgery

By T. Peter Kingham and Vinod P. Balachandran,

Monday, December 14, 2015

Over the past two decades, minimally invasive techniques have been increasingly adopted in multiple surgical specialties including colorectal, gynecologic, urologic, and thoracic. (1), (2), (3), (4), (5) Minimally invasive techniques provide patients with significant benefits, including reduced postoperative pain, reduced morbidity, decreased length of hospital stay, improved cosmesis, and improved overall cost-effectiveness, all without compromising oncologic outcomes.

The initial application of minimally invasive techniques in liver surgery proved challenging given the complex vascular and biliary anatomy, difficult exposure of the liver, risk of bleeding from the liver parenchyma, and limitations of the early forms of the technology. Surgeons at Memorial Sloan Kettering Cancer Center (MSK) have performed more than 4,000 liver resections for malignancies over the past 19 years, and we continue to develop and expand our ability to perform complex hepatopancreatobiliary surgery using minimally invasive techniques.

Laparoscopic Liver Surgery

Laparoscopic liver resections were initially reserved for single, small, peripherally located tumors. Now, we utilize laparoscopy in all aspects of liver surgery and have performed a total of 170 laparoscopic liver resections at MSK.

In a case-control study of 65 laparoscopic liver resections individually paired to comparable cases performed by open surgery, our team, led by Michael I. D’Angelica, MD, found that laparoscopy was associated with significantly reduced estimated blood loss, transfusion frequency, frequency of Pringle maneuver, postoperative morbidity, recovery time, length of hospital stay, and incidence of incisional hernia. (6) Furthermore, we found no positive surgical margins and no local recurrence in either group, and the overall pattern of recurrence was similar. Overall, laparoscopic liver surgery was shown to have similar oncologic outcomes and decreased postoperative morbidity in well-selected patients.

Current recommendations for laparoscopic liver surgery

Based on our work and that of others, the current consensus recommendations regarding indications for laparoscopic liver resection are as follows: (7)

(1) solitary lesions, 5 cm or less, located in peripheral liver segments 2 to 6 are most suited for laparoscopic surgery; and

(2) the laparoscopic approach to left lateral sectionectomy should be considered standard practice; and

(3) major liver resections (right or left hepatectomy) should be reserved for experienced surgeons already skilled at more complex laparoscopic hepatic resections.

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Robotic Liver Surgery

We recently expanded our application of minimally invasive techniques to include robotic liver surgery. Robotic technology offers enhanced instrumentation due to the wristed motion of the robotic instruments and superior three-dimensional visualization, enabling more natural movements of the surgeon’s hands than conventional laparoscopy. Our group, led by T. Peter Kingham, MD, has performed a total of 65 robotic liver resections to date (see Figure 1). In a case-matched comparison of these operations with 65 open liver resections, we found shorter operative time, decreased blood loss, and shorter hospital stay (unpublished results). Therefore, robotic surgery appears safe.

The future of minimally invasive liver surgery is exciting. With rapid technological advances, our ability to apply minimally invasive techniques to liver surgery continues to grow. With more than 300 hepatic resections performed annually by the Hepatopancreatobiliary Service at MSK, we are optimally poised to apply these new techniques to perform safe and effective surgery on this complex anatomical organ, with concurrent preservation of oncologic outcomes.

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  1. The Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopically assisted and open colectomy for colon cancer. N Engl J Med 2004; 350(20):2050-2059.

  2. Guillou PJ, Quirke P, Thorpe H, et al; MRC CLASICC trial group. Short-term endpoints of conventional versus laparoscopic-assisted surgery in patients with colorectal cancer (MRC CLASICC trial): multicentre, randomised controlled trial. Lancet 2005; 365(9472):1718-1726.

  3. Ghezzi F, Cromi A, Ditto A, et al. Laparoscopic versus open radical hysterectomy for stage IB2-IIB cervical cancer in the setting of neoadjuvant chemotherapy: a multi-institutional cohort study. Ann Surg Oncol 2013; 20(6):2007-2015.

  4. Trabulsi EJ, Hassen WA, Touijer AK, Saranchuk JW, Guillonneau B. Laparoscopic radical prostatectomy: a review of techniques and results worldwide. Minerva Urol Nefrol 2003; 55(4):239-250.

  5. Luketich JD, Pennathur A, Awais O, et al. Outcomes after minimally invasive esophagectomy: review of over 1000 patients. Ann Surg 2012; 256(1):95-103.

  6. Ito K, Ito H, Are C, et al. Laparoscopic versus open liver resection: a matched-pair case control study. J Gastrointest Surg 2009; 13(12):2276-2283.

  7. Buell JF, Cherqui D, Geller DA, et al. The international position on laparoscopic liver surgery: The Louisville Statement, 2008. Ann Surg 2009; 250(5):825-830.