LETTER TO THE EDITOR Laparoscopic Retroperitoneal Hepatectomy for a Subcapsular Hepatocellular Carcinoma To the Editor: e read with interest the article by Nguyen et al1 describing various laparoscopic hepatectomy approaches for liver tumors. In the present case, we would like to show another developing laparoscopic technique for an elective liver resection. On March 12, 2013, a 48-year-old woman with a decade’s history of hepatitis B virus infection without cirrhosis came to our hospital for a further treatment of hepatic tumor for 21 months. She had undergone transcatheter arterial chemoembolization therapy at the initial diagnosis in June 2011. Then, a follow-up of every 3 months was conducted, and the patient’s condition was stable shown by the upper abdominal computed tomographic scan until this admission; she was aware of the possibility of a recurrence after the intervention operation. She took no antihepatitis virus drug during the period. The abdominal computed tomographic scan demonstrated a solitary 2.0 × 2.0-cm lesion very close to adrenal gland at the segment VI of the liver, associated with a higher αfetoprotein value (1254 ng/mL) and a ChildPugh A score. Physical examination and routine blood investigations were normal, as were both signs and symptoms of the patient. On April 8, a pure laparoscopic retroperitoneal hepatectomy was performed (Fig. 1; see Supplementary Digital Content video, available at http://links.lww.com/SLA/A538). Similar to retroperitoneal laparoscopic radical nephrectomy of renal carcinoma, the patient was placed in a left lateral position. Retroperitoneal access was obtained, and 3 trocars were placed. A 30-degree laparoscope was inserted and CO2 gas insufflated until the retroperitoneal pressure reached 8 to 9 mm Hg. After
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Disclosure: This study was not supported by any pharmaceutical company or grants; the cost was borne by the authors’ institutions. All authors looked after the patient and wrote the report. Written consent to publish was obtained. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsofsurgery.com). C 2014 Wolters Kluwer Health, Inc. All Copyright rights reserved. ISSN: 0003-4932/14/26202-e0077 DOI: 10.1097/SLA.0000000000000565
FIGURE 1. Patient was placed in a left lateral position (A). Retroperitoneal access was obtained and 3 trocars were placed. Computed tomographic scans showing the lesion at initial admission (B) and at 6 months postoperatively (C). Hepatocellular carcinoma was confirmed by pathological examination with a negative margin (D).
the retroperitoneal space was checked to make sure the peritoneum was undamaged, the kidney was mobilized and the right adrenal gland was identified. Then, the round-shaped lesion located at liver segment VI just above the adrenal gland was detected. The laparoscopic ultrasound guidance was used to define tumor extent, positioned in direct contact with the liver surface. By ultrasonographic guidance, the proposed line of parenchymal incision was circumferentially scored with an electrocautery J-hook, maintaining an approximate 5-mm margin around the tumor. According to surgeon preference, the artery and the vein were occluded or just isolated. The tumor was sharply excised, and a drain was left in the flank. The operation time was 44 minutes, and the blood loss was 30 mL. She was discharged from the hospital within 3 days. Postoperative pathology confirmed the diagnosis of hepatocellular carcinoma with a negative margin. At the patient’s last follow-up in October 2013, she was well and showed no signs of recurrence. A small hepatocellular carcinoma in a noncirrhotic liver is generally initially managed with a resection whenever possible. However, tumor location is always the stumbling block for general surgeons to show their swords. Various approaches have been used in liver surgery; of note is the observation that the anterior approach results in better operative and survival outcomes than the conventional approach, especially for major right
Annals of Surgery r Volume 262, Number 2, August 2015
hepatic resection, whereas it is seldom available even when combined with liver-hanging maneuver within the laparoscopic view.2 In the present case, if conventional approach were decided, major hepatic right resection might be unavoidable, which would be associated with high operative morbidity and mortality, especially in patients with underlying chronic liver disease.3 As a novel approach, laparoscopic retroperitoneal hepatectomy is a rapid and safe method that can be applied to the partial resection of small and superficial tumors of the right posterior segment of the liver.4 We acknowledge that laparoscopic retroperitoneal hepatectomy is not a valid and universal treatment option for all tumors. However, in carefully selected situations, it may be endowed with distinct superiority. Further clinical investigation is eagerly awaited to confirm our conclusion. Zhixiang Jian, MD Haosheng Jin, MD Zi Yin, MD Ye Lin, MD General Surgery Department Guangdong General Hospital Guangdong Academy of Medical Sciences Guangzhou, Guangdong, China [email protected]
Reffereces 1. Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection—2804 patients. Ann Surg. 2009;250:831–841.
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Annals of Surgery r Volume 262, Number 2, August 2015
Jian et al
2. Liu CL, Fan ST, Cheung ST, et al. Anterior approach versus conventional approach right hepatic resection for large hepatocellular carcinoma: a prospective randomized controlled study. Ann Surg. 2006;244:194–203. 3. Chik BH, Liu CL, Fan ST, et al. Tumor size and operative risks of extended right-sided hepatic resection for hepatocellular carcinoma: implication for preoperative portal vein embolization. Arch Surg. 2007;142:63–69. 4. Hu M, Zhao G, Xu D, et al. Retroperitoneal laparoscopic hepatectomy: a novel approach. Surg Laparosc Endosc Percutan Tech. 2011;21:e245– e248.
Reply: aparoscopic liver resection has gained momentum, and more than 5000 cases have been performed worldwide.1,2 Although early series emphasized nonanatomic resection of benign peripheral hepatic lesions, approximately 50% of laparoscopic liver resections in large series are now undertaken for primary or metastatic malignancy, including resection of hepatocellular carcinoma (HCC) in cirrhotic patients.3 Greater experience has led to major anatomic hepatic resections being successfully performed minimally invasively.4,5 Initial concerns over tumor seeding or adverse oncologic outcomes have not been demonstrated, and numerous studies have reported comparable 5-year overall survival for laparoscopic resection of HCC or metastatic colorectal cancer in case-cohort studies comparing laparoscopic to open liver resection.2 Benefits of laparoscopic resection include smaller incisions, less estimate blood loss and packed red blood cells transfusions, decreased narcotic requirements, shorter length of stay, and diminished postoperative morbidity compared with open hepatic resection.2 Of note, there have been no prospective randomized controlled trials comparing laparoscopic to open hepatic resection, and it is important to recognize that inherent selection bias exists, even in wellmatched case-cohort series. Surgical techniques for laparoscopic hepatectomy include pure laparoscopic, hand-
L
assisted laparoscopic, and laparoscopicassisted “hybrid” approaches where the operation is started laparoscopically and the parenchymal transection is completed through a small open incision. Several reports of robotic liver resection are published, although this approach remains controversial due to the added time and robotic costs.6 A thoracoscopic approach has been described for tumors positioned high in the dome of the right lobe liver segment VIII. A retroperitoneal laparoscopic hepatectomy approach was reported in 2011 for a 2 cm metastatic colorectal cancer tumor located in segment VI.7 In the accompanying Letter to the Editor, Yin and colleagues provide a case report and video of a laparoscopic retroperitoneal hepatectomy for a small 2-cm HCC in a noncirrhotic liver. The patient is positioned in the left lateral decubitus position. Retroperitoneal access is obtained using 3 trocars in a manner similar to a laparoscopic right retroperitoneal adrenalectomy or nephrectomy. In the retroperitoneal space under insufflation, the perinephric fat is dissected and posterior peritoneum reflected to expose the right adrenal gland and the adjacent right posterior hepatic segment VI with visible tumor. Laparoscopic ultrasound is used to confirm tumor borders, and parenchymal transection is accomplished with a bipolar ultrasonic energy device. This laparoscopic retroperitoneal hepatectomy appears to be an excellent technical approach for small subcapsular tumors located superficially in the right posterior hepatic segment VI or at the junction of segments VI/VII. Access to deep right posterior hepatic tumors on the undersurface of segment VI or VI/VII near the inferior vena cava can be very challenging from a conventional laparoscopic transabdominal approach due to limited exposure and visibility. Danger points exist for the variable short hepatic veins that can be encountered along the inferior vena cava. The anatomy of the right retroperitoneal space is relatively straight-forward once the surgeon identifies the right kidney, right adrenal gland, lateral aspect of the inferior vena cava, and the reflected peritoneum.
Given the scant number of case reports, laparoscopic retroperitoneal hepatectomy seems to have a role in highly selected cases. Tumors should be limited to less than 3 cm, in the posterior subcapsular portions of segments VI or VI/VII, without invasion or adherence to the inferior vena cava. The tumors need to be superficial in the right posterior liver and amenable to nonanatomic resection that does not require vascular control. Further investigation is needed to define the limits of this technique. Major hepatectomy or right hepatic lobectomy should not be done using a retroperitoneal approach and should be accomplished with a laparoscopic or open peritoneal approach. Mohammad Khreiss, MD David A. Geller, MD, FACS Department of Surgery University of Pittsburgh Pittsburgh, PA [email protected]
REFERENCES 1. Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection—2,804 patients. Ann Surg. 2009;250:831–841. 2. Nguyen KT, Marsh JW, Tsung A, et al. Comparative benefits of laparoscopic versus open hepatic resection: a critical appraisal. Arch Surg. 2011;146:348–356. 3. Cherqui D, Laurent A, Tayar C, et al. Laparoscopic liver resection for peripheral hepatocellular carcinoma in patients with chronic liver disease: midterm results and perspectives. Ann Surg. 2006;243:499– 506. 4. Dagher I, O’Rourke N, Geller DA, et al. Laparoscopic major hepatectomy: an evolution in standard of care. Ann Surg. 2009;250:856–860. 5. Lin NC, Nitta H, Wakabayashi G. Laparoscopic major hepatectomy: a systematic literature review and comparison of 3 techniques. Ann Surg. 2013;257:205–213. 6. Tsung A, Geller DA, Sukato DC, et al. Robotic versus laparoscopic hepatectomy: a matched comparison. Ann Surg. 2014;259:549–555. 7. Hu M, Zhao G, Xu D, Ma X, Liu R. Retroperitoneal laparoscopic hepatectomy: a novel approach. Surg Laparosc Endosc Percutan Tech. 2011;21:e245– e248.
Disclosure: The authors declare no conflicts of interest. 10.1097/SLA.0000000000000566
e78 | www.annalsofsurgery.com
C 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
W
Disclosure: This study was not supported by any pharmaceutical company or grants; the cost was borne by the authors’ institutions. All authors looked after the patient and wrote the report. Written consent to publish was obtained. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.annalsofsurgery.com). C 2014 Wolters Kluwer Health, Inc. All Copyright rights reserved. ISSN: 0003-4932/14/26202-e0077 DOI: 10.1097/SLA.0000000000000565
FIGURE 1. Patient was placed in a left lateral position (A). Retroperitoneal access was obtained and 3 trocars were placed. Computed tomographic scans showing the lesion at initial admission (B) and at 6 months postoperatively (C). Hepatocellular carcinoma was confirmed by pathological examination with a negative margin (D).
the retroperitoneal space was checked to make sure the peritoneum was undamaged, the kidney was mobilized and the right adrenal gland was identified. Then, the round-shaped lesion located at liver segment VI just above the adrenal gland was detected. The laparoscopic ultrasound guidance was used to define tumor extent, positioned in direct contact with the liver surface. By ultrasonographic guidance, the proposed line of parenchymal incision was circumferentially scored with an electrocautery J-hook, maintaining an approximate 5-mm margin around the tumor. According to surgeon preference, the artery and the vein were occluded or just isolated. The tumor was sharply excised, and a drain was left in the flank. The operation time was 44 minutes, and the blood loss was 30 mL. She was discharged from the hospital within 3 days. Postoperative pathology confirmed the diagnosis of hepatocellular carcinoma with a negative margin. At the patient’s last follow-up in October 2013, she was well and showed no signs of recurrence. A small hepatocellular carcinoma in a noncirrhotic liver is generally initially managed with a resection whenever possible. However, tumor location is always the stumbling block for general surgeons to show their swords. Various approaches have been used in liver surgery; of note is the observation that the anterior approach results in better operative and survival outcomes than the conventional approach, especially for major right
Annals of Surgery r Volume 262, Number 2, August 2015
hepatic resection, whereas it is seldom available even when combined with liver-hanging maneuver within the laparoscopic view.2 In the present case, if conventional approach were decided, major hepatic right resection might be unavoidable, which would be associated with high operative morbidity and mortality, especially in patients with underlying chronic liver disease.3 As a novel approach, laparoscopic retroperitoneal hepatectomy is a rapid and safe method that can be applied to the partial resection of small and superficial tumors of the right posterior segment of the liver.4 We acknowledge that laparoscopic retroperitoneal hepatectomy is not a valid and universal treatment option for all tumors. However, in carefully selected situations, it may be endowed with distinct superiority. Further clinical investigation is eagerly awaited to confirm our conclusion. Zhixiang Jian, MD Haosheng Jin, MD Zi Yin, MD Ye Lin, MD General Surgery Department Guangdong General Hospital Guangdong Academy of Medical Sciences Guangzhou, Guangdong, China [email protected]
Reffereces 1. Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection—2804 patients. Ann Surg. 2009;250:831–841.
www.annalsofsurgery.com | e77
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Annals of Surgery r Volume 262, Number 2, August 2015
Jian et al
2. Liu CL, Fan ST, Cheung ST, et al. Anterior approach versus conventional approach right hepatic resection for large hepatocellular carcinoma: a prospective randomized controlled study. Ann Surg. 2006;244:194–203. 3. Chik BH, Liu CL, Fan ST, et al. Tumor size and operative risks of extended right-sided hepatic resection for hepatocellular carcinoma: implication for preoperative portal vein embolization. Arch Surg. 2007;142:63–69. 4. Hu M, Zhao G, Xu D, et al. Retroperitoneal laparoscopic hepatectomy: a novel approach. Surg Laparosc Endosc Percutan Tech. 2011;21:e245– e248.
Reply: aparoscopic liver resection has gained momentum, and more than 5000 cases have been performed worldwide.1,2 Although early series emphasized nonanatomic resection of benign peripheral hepatic lesions, approximately 50% of laparoscopic liver resections in large series are now undertaken for primary or metastatic malignancy, including resection of hepatocellular carcinoma (HCC) in cirrhotic patients.3 Greater experience has led to major anatomic hepatic resections being successfully performed minimally invasively.4,5 Initial concerns over tumor seeding or adverse oncologic outcomes have not been demonstrated, and numerous studies have reported comparable 5-year overall survival for laparoscopic resection of HCC or metastatic colorectal cancer in case-cohort studies comparing laparoscopic to open liver resection.2 Benefits of laparoscopic resection include smaller incisions, less estimate blood loss and packed red blood cells transfusions, decreased narcotic requirements, shorter length of stay, and diminished postoperative morbidity compared with open hepatic resection.2 Of note, there have been no prospective randomized controlled trials comparing laparoscopic to open hepatic resection, and it is important to recognize that inherent selection bias exists, even in wellmatched case-cohort series. Surgical techniques for laparoscopic hepatectomy include pure laparoscopic, hand-
L
assisted laparoscopic, and laparoscopicassisted “hybrid” approaches where the operation is started laparoscopically and the parenchymal transection is completed through a small open incision. Several reports of robotic liver resection are published, although this approach remains controversial due to the added time and robotic costs.6 A thoracoscopic approach has been described for tumors positioned high in the dome of the right lobe liver segment VIII. A retroperitoneal laparoscopic hepatectomy approach was reported in 2011 for a 2 cm metastatic colorectal cancer tumor located in segment VI.7 In the accompanying Letter to the Editor, Yin and colleagues provide a case report and video of a laparoscopic retroperitoneal hepatectomy for a small 2-cm HCC in a noncirrhotic liver. The patient is positioned in the left lateral decubitus position. Retroperitoneal access is obtained using 3 trocars in a manner similar to a laparoscopic right retroperitoneal adrenalectomy or nephrectomy. In the retroperitoneal space under insufflation, the perinephric fat is dissected and posterior peritoneum reflected to expose the right adrenal gland and the adjacent right posterior hepatic segment VI with visible tumor. Laparoscopic ultrasound is used to confirm tumor borders, and parenchymal transection is accomplished with a bipolar ultrasonic energy device. This laparoscopic retroperitoneal hepatectomy appears to be an excellent technical approach for small subcapsular tumors located superficially in the right posterior hepatic segment VI or at the junction of segments VI/VII. Access to deep right posterior hepatic tumors on the undersurface of segment VI or VI/VII near the inferior vena cava can be very challenging from a conventional laparoscopic transabdominal approach due to limited exposure and visibility. Danger points exist for the variable short hepatic veins that can be encountered along the inferior vena cava. The anatomy of the right retroperitoneal space is relatively straight-forward once the surgeon identifies the right kidney, right adrenal gland, lateral aspect of the inferior vena cava, and the reflected peritoneum.
Given the scant number of case reports, laparoscopic retroperitoneal hepatectomy seems to have a role in highly selected cases. Tumors should be limited to less than 3 cm, in the posterior subcapsular portions of segments VI or VI/VII, without invasion or adherence to the inferior vena cava. The tumors need to be superficial in the right posterior liver and amenable to nonanatomic resection that does not require vascular control. Further investigation is needed to define the limits of this technique. Major hepatectomy or right hepatic lobectomy should not be done using a retroperitoneal approach and should be accomplished with a laparoscopic or open peritoneal approach. Mohammad Khreiss, MD David A. Geller, MD, FACS Department of Surgery University of Pittsburgh Pittsburgh, PA [email protected]
REFERENCES 1. Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection—2,804 patients. Ann Surg. 2009;250:831–841. 2. Nguyen KT, Marsh JW, Tsung A, et al. Comparative benefits of laparoscopic versus open hepatic resection: a critical appraisal. Arch Surg. 2011;146:348–356. 3. Cherqui D, Laurent A, Tayar C, et al. Laparoscopic liver resection for peripheral hepatocellular carcinoma in patients with chronic liver disease: midterm results and perspectives. Ann Surg. 2006;243:499– 506. 4. Dagher I, O’Rourke N, Geller DA, et al. Laparoscopic major hepatectomy: an evolution in standard of care. Ann Surg. 2009;250:856–860. 5. Lin NC, Nitta H, Wakabayashi G. Laparoscopic major hepatectomy: a systematic literature review and comparison of 3 techniques. Ann Surg. 2013;257:205–213. 6. Tsung A, Geller DA, Sukato DC, et al. Robotic versus laparoscopic hepatectomy: a matched comparison. Ann Surg. 2014;259:549–555. 7. Hu M, Zhao G, Xu D, Ma X, Liu R. Retroperitoneal laparoscopic hepatectomy: a novel approach. Surg Laparosc Endosc Percutan Tech. 2011;21:e245– e248.
Disclosure: The authors declare no conflicts of interest. 10.1097/SLA.0000000000000566
e78 | www.annalsofsurgery.com
C 2014 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2014 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
