Chapter 125: Minimally Invasive Techniques and Outcomes in Hepatic Resection

INTRODUCTION

The safety of liver surgery made great strides in the last half of the twentieth century thanks to an improvement in the knowledge of hepatic anatomy, perioperative care, and preoperative imaging techniques.¹ Combined with increased operative experience and technological advancements, minimally invasive surgery (MIS) of the liver has been shown to be safe and feasible with over 3000 cases done worldwide.^1-4 Laparoscopic hepatic surgery was first reported in the early 1990s, and since that time the literature in this field has expanded in an exponential fashion.² The acceptance of MIS hepatic resections has progressed to the point where it is the recommended approach for certain hepatic resections⁵ and as our experience broadens, as do the potential indications. Increasingly complex procedures are being safely performed and achieving excellent results with less morbidity. In the present chapter, we provide an overview of laparoscopic liver resection including some technical aspects, and outcomes of minimally invasive hepatic resection for cancer.

OVERVIEW OF MIS HEPATIC RESECTIONS AND THEIR INDICATIONS

For the purpose of this chapter, an MIS hepatic resection is a general term that includes purely laparoscopic, hand-port assisted laparoscopic, hybrid, and robotic-assisted approaches. Purely laparoscopic is the most commonly reported approach, followed by hand-assisted resections.² Hybrid resection refers to laparoscopic-assisted open resections, where a portion of the procedure is performed laparoscopically, typically the mobilization of the liver, followed by the parenchymal transection done through a small open incision, typically the extension of the hand-port incision, if present.^6,7 While infrequently reported in the literature, this approach may be an attractive option for surgeons wishing to adopt laparoscopic hepatic resections into their practice⁶ and is potentially associated with improved perioperative outcomes.⁸ Robotic resections are restricted by the increased cost of the procedure, but confer some advantages to the operating surgeon including improved dexterity and visualization.^9-11 Other reported approaches include gasless laparoscopic as well as thoracoscopic hepatic resections. As there aren’t any prospective trials comparing the different techniques in MIS liver surgery, the approach is individualized based on tumor characteristics as well as surgeon preference and experience.

The indications for MIS hepatic resections have evolved as our experience grows. While initially described for small nonanatomical resections, major hepatic resections have been reported with increasing frequency and trisectionectomies have been described in certain specialized centers.^8,12–15 As the application of MIS techniques to liver surgery has expanded, a consensus conference was convened in 2008 and involved the leading experts on the topic in order to address the developing questions and issues around the subject. The International Position on Laparoscopic Liver Surgery was published, and recommended that current acceptable indications for laparoscopic resections included solitary lesions of 5 cm or less located in segments 2 to 6.⁵ While it is generally accepted that these lesions are the most amenable to ...