Surg Endosc DOI 10.1007/s00464-014-4048-y
and Other Interventional Techniques
NEW TECHNOLOGY
Modified laparoscopic hepatectomy for hepatic hemangioma Dou-Sheng Bai • Ping Chen • Jian-Jun Qian Jie Yao • Sheng-Jie Jin • Xiao-Dong Wang • Guo-Qing Jiang
•
Received: 11 June 2014 / Accepted: 16 December 2014 Ó Springer Science+Business Media New York 2014
Abstract Background Laparoscopic hepatectomy (LH) using many different surgical techniques has become increasingly popular for the management of hepatic tumors. The performance of surgical procedures involving the least possible impairment is expected increasingly more often by both surgeons and patients. We herein describe a clinical cohort of ten patients with hepatic cavernous hemangioma (HCH) who underwent modified LH (MLH) with a new technique. We herein present the advantages of the low level of impairment during performance of this modified procedure and compare the outcomes of MLH with those of traditional LH (TLH) for HCH. Methods We retrospectively evaluated the treatment outcomes in 24 patients with HCH who underwent MLH (n = 10) or TLH (n = 14) from February 2008 to January 2013. Their demographic, intraoperative, and postoperative variables were compared. Results MLH was successful in all patients. An electromechanical morcellator allowed for easy extraction of the entire HCH without the use of a cumbersome retrieval bag, enlarged incision, or hand-assisted incision. There was no conversion to an open operation or significant perioperative complications. The operation time (P = 0.037), time to removal of the HCH (P \ 0.0001), visual analog scale pain score on the first postoperative day (P = 0.012), time to Dou-Sheng Bai, Ping Chen, and Jian-Jun Qian contributed equally to this work. D.-S. Bai P. Chen J.-J. Qian J. Yao S.-J. Jin X.-D. Wang G.-Q. Jiang (&) Department of Hepatobiliary Surgery, Clinical Medical College of Yangzhou University, 98 West Nantong Rd, Yangzhou 225000, China e-mail: [email protected]
off-bed activity (P = 0.036), and postoperative hospital stay (P = 0.048) were significantly lower in the MLH group than in the TLH group. Conclusions MLH involving the use of an electromechanical morcellator provides expedient recovery and minimal postoperative pain and scarring. It is a feasible, effective, and safe surgical procedure and embodies all of the benefits of minimally invasive surgery for patients with HCH. Keywords Laparoscopy Hepatectomy Hemangioma Morcellator With the recent substantial progress in laparoscopic skills and advances in technical instruments, endoscopic surgery involving improved and advantageous techniques has supplanted traditional open surgery in many areas. However, laparoscopic techniques are much more challenging when performed in patients with hepatic tumors. As experience in laparoscopic hepatectomy (LH) has grown, and surgical techniques have become more advanced, LH has gradually become accepted as a treatment for patients with hepatic tumors. LH will probably become the gold standard technique for left lateral lobectomy and left hemihepatic resection [1, 2]. Many different surgical techniques for removing hepatic specimens during LH are currently performed. These techniques include the use of cumbersome retrieval bags to draw massive hepatic specimens out of the abdomen as well as the creation of enlarged incisions or performance of hand-assisted laparoscopy to morcellate and draw hepatic specimens out of the abdomen [3–10]. Incision-associated impairment should be controlled to ensure faster recovery and fewer complications. We herein report the performance of modified LH (MLH) with a new technique that greatly reduces
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Surg Endosc
impairment in patients with hepatic cavernous hemangioma (HCH). Massive hepatic hemangiomas can be removed from the abdominal cavity through the existing incision using an electromechanical morcellator. To the best of our knowledge, this is the first report of the use of an electromechanical morcellator to extract an entire hepatic hemangioma during LH. The purpose of this article is to report ten patients who underwent MLH with the herein-described new technique and present the feasibility, decreased impairment, and advantages of using an electromechanical morcellator during the procedure. This technique eliminates the need for large, cumbersome retrieval bags and the creation of hand-assisted or enlarged incisions to remove the hepatic hemangioma.
(LC) to treat acute cholecystitis and cholecystolithiasis shown on preoperative ultrasound. All patients had HCH. The longitudinal HCH diameter was 9.7 ± 1.4 cm (range 8–12 cm). No patients had liver cirrhosis. All ten patients had a ChildPugh classification of A. Intraoperative biopsy and frozen section examination of all patients revealed HCH. The preoperative clinical characteristics are listed in Table 1. The results of MLH were compared with those of the 14 patients (5 males, 9 females) who underwent TLH during the same time period. These patients ranged in age from 23 to 69 years (mean 47.93 ± 13.98 years). Two patients had type 2 diabetes mellitus and two had hypertension. All patients had HCH. The longitudinal HCH diameter was 9.61 ± 1.13 cm (range 8–12 cm). No patients had liver cirrhosis. All 14 patients had a Child-Pugh classification of A.
Materials and methods
Modified laparoscopic procedures
Patients
Laparoscopic hepatectomy
From February 2008 to January 2013, 24 patients were diagnosed with HCH in our department; of these, 10 underwent MLH and 14 underwent traditional LH (TLH). The clinical records of these patients were retrospectively analyzed. The preoperative diagnostic workup, which included B ultrasound and computed tomography or magnetic resonance imaging, confirmed that all patients had HCH. During the preoperative discussion, all patients were informed that although MLH was a minimally invasive procedure, it was in the experimental stage compared with TLH. Selection of the procedure to be performed was based on the patient’s decision. All patients provided written informed consent. The ethics committee of the Clinical Medical College of Yangzhou University, China approved the conduct of the study. The same surgical team performed all operations. The following data were prospectively collected: age, gender, hemangioma size, operative time, time required for removal of the HCH, estimated blood loss, visual analog scale (VAS) pain score on the first postoperative day, time to passage of flatus, time to off-bed activity, length of the postoperative hospital stay, and perioperative complications. The VAS pain score was recorded using a questionnaire that rated pain intensity on a scale of 0–10 [11– 13], with 0 representing no pain and 10 representing very severe pain. The ten patients who underwent MLH comprised three males and seven females with a mean age of 45.5 ± 15.8 years (range 19–64 years). Three patients had type 2 diabetes mellitus, one had hypertension, and one had a history of combined MLH and laparoscopic cholecystectomy
After successful induction of general endotracheal anesthesia, urinary catheters were placed. The patients were first placed in the reverse Trendelenburg position with parted legs. The senior surgeon stood on the right side of the patient. Pneumoperitoneum with a pressure of 13 mmHg was created. A (5 ? 1)-port or 5-port method was used for LH (Fig. 1). Using the Hasson (open) technique, a 10-mm trocar was placed in the umbilicus (port A). A 10-mm, 30° angled laparoscope was then introduced through this trocar. Under direct visualization, 4 ? 1 additional ports were placed: one 5-mm trocar (port B) in the right midclavicular line just below the costal margin, one 10-mm trocar (port C) in the right midclavicular line halfway between the costal margin and the umbilicus, one 12-mm trocar (port D) in the left midclavicular line halfway between the costal margin and the umbilicus, one 5-mm trocar (port E) in the left anterior axillary line below costal margin, and one 10-mm trocar (port F) in the right anterior axillary line halfway between the costal margin and the umbilicus (white line, Fig. 1). Port C was the main port used with monopolar electrocautery, the harmonic scalpel (Ethicon, Cincinnati, OH, USA), and the linear laparoscopic vascular stapler (Ethicon, Hartford, CT, USA). Port D was the main port used with the electromechanical morcellator (TSCS, Hangzhou, China). The necessity of port F was determined based on the surgeon’s preference for the laparoscopic procedure and experience with laparoscopic techniques. Port F was used for the modified Pringle maneuver (with 20-min occlusion and 5-min reopening periods). Performance of the modified Pringle maneuver required an aspirator, a strip of cotton thread about three times the length of the aspirator, and a
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Surg Endosc Table 1 Preoperative clinical characteristics of ten patients who underwent MLH
MLH modified laparoscopic hepatectomy, HCH hepatic cavernous hemangioma
HCH in size (cm3)
Other disorders
II, III, IV
11.5 9 9 9 5
No
III, IV
89595
No
II, III
9 9 8.5 9 7
Diabetes mellitus
No.
Gender
Age (years)
Couinaud’s segments involved
1
Female
23
2
Female
56
3
Male
45
4
Female
47
II, III, IV
8.5 9 7 9 6
Diabetes mellitus
5
Female
64
II, III, IV
11 9 8 9 7
No
6
Female
33
III, IV
9.5 9 6 9 5
Cholecystolithiasis
7
Female
19
II, IV
12 9 11 9 10
No
8
Male
63
II, III, IV
89595
Hypertension
9
Male
56
II, III, IV
99696
No
10
Female
49
II, IV
10 9 7 9 6
Diabetes mellitus
Fig. 2 Modified Pringle maneuver Fig. 1 Port placement for modified laparoscopic hepatectomy for hepatic hemangioma
14-French catheter. After the cotton thread had been passed around the hepatoduodenal ligament, both of its ends were passed through the catheter (which was connected to an aspirator), then all the way through the aspirator (Fig. 2). When inflow occlusion was required, the cotton thread was immediately tightened. Port F was used to prevent bleeding during the first two consecutive modified laparoscopic left hemihepatectomies. With increasing laparoscopic experience, port F was abandoned for utilization in the next consecutive modified laparoscopic left hemihepatectomy. However, port F was routinely used during modified laparoscopic wedge resection. LC was performed only after successful LH had been completed. The three trocars used in LC were port A (inserted by the laparoscope), port C, and port D (as the main port). The laparoscopic procedures were performed as follows. The procedure began after advanced preparation of the device used for the modified Pringle maneuver (if
necessary), which could be used to occlude the inflow in the entire liver when necessary. If the laparoscopic approach was a left hemihepatectomy, we performed left hemihepatic inflow occlusion. Thus, the left branch portal vein and left hepatic artery were separated and occluded with a clip, and the inflow in the remnant liver remained open (Fig. 3). Adhesions and the falciform and triangular ligaments were divided to mobilize the liver. After these manipulations, the blocking zone after left liver ischemia was clearly visible. The hepatic resection line was marked along the blocking zone with the monopolar electrocautery device, which was then used to make an approximately 1.0-cmdeep cut into the liver tissue along the resection line using 80 W output. To locate the biliovascular structures, the senior surgeon used the harmonic scalpel to bite the parenchymal liver tissue, while the assistant surgeon used the aspirator to push, suck, and scratch the tissue. Small biliovascular structures were divided using the harmonic scalpel or endoscopic clips. The left hepatic vein was
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Surg Endosc
Fig. 3 Occlusion of left branch portal vein and left hepatic artery with two clips
divided using an endoscopic stapling device with 2.5-mm staples. If the laparoscopic approach involved a wedge hepatectomy, intraoperative ultrasonography was first performed to assess the boundaries of the hemangioma and its relationship with major vascular structures. The hepatic resection line was then scored with the monopolar electrocautery device. The modified Pringle maneuver was always performed after an approximately 1.0-cm-deep cut was made in the liver tissue by monopolar electrocautery; the aspirator was then used to push, suck, and scratch along the surface of the hepatic hemangioma. Many vessel branches from the hemangioma were thus detected and divided with the clips. The hemangioma was at risk of damage and bleeding during this procedure. Because of the hepatic vascular occlusion, only a slightly greater amount of blood than that sequestered in the hemangioma was discharged. Intraoperative biopsy examination was performed for each patient. During the biopsy examination, hemostasis was mainly carried out by monopolar or bipolar electrocautery. Acute venous or arterial hemorrhage was controlled with sutures. The raw liver surface was irrigated and carefully inspected for bile leakage with white gauze.
D was the main trocar used with the electromechanical morcellator. The hepatic hemangioma was maintained in the ideal location by placing the patient in the reverse Trendelenburg position and using the splenic retractor or the forceps to raise the upper pole of the hepatic hemangioma. The hepatic hemangioma was grasped by the large claw forceps through the motor-driven cutting tube, and the forceps was then pulled back while pressing the hepatic hemangioma against the cutting edge of the rotating tube (Fig. 4); the rotation could be triggered using a hand switch. A cylindrical tissue sample (Fig. 5) could be cut and pulled out from the tube by applying a measured pulling force. This manipulation was repeated until the entire hepatic hemangioma was removed by the electromechanical morcellator. The entrance of the tube remained in view during the entire procedure to prevent damage to the surrounding organs. The entire upper quadrant was irrigated, and the operative field was carefully inspected again for residual tissue, bleeding, and bile leakage. A surgical drainage tube was placed along the liver section and through port C. Traditional laparoscopic procedures After the performance of LH as described as above, TLH for extraction of the hemangioma was performed. Five steps were necessary and were performed in the following order. First, a cumbersome retrieval bag was placed into the abdominal cavity from one 10-mm trocar. Second, the HCH specimens were inserted into the bags. Third, the length of the umbilical incision was enlarged to 3–4 cm along the epigastric linea alba. Fourth, the massive hepatic specimen was drawn out of the abdomen through the enlarged incision. Finally, the enlarged incision was sutured.
Modified laparoscopic hepatic hemangioma extraction methods All intraoperative biopsy examinations revealed a hemangioma. All patients’ hepatic hemangiomas were removed from the abdominal cavity using an electromechanical morcellator comprising a motor-driven cutting tube that can be directly inserted into the abdominal cavity through a 12-mm port and a large claw forceps. The surgeon preferred to be positioned between the patient’s legs, and port
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Fig. 4 Extraction of hepatic hemangioma with the electromechanical morcellator
Surg Endosc Fig. 5 Cylindrical sections of hepatic hemangioma tissue and electromechanical morcellator (1 large claw forceps; 2 motordriven cutting tube)
Statistical analysis Statistical analysis was performed using SPSS for Windows, version 12.0 (SPSS, Inc., Chicago, IL). All data are expressed as mean ± SD.
Results Modified laparoscopic left hemihepatectomy was performed for HCH in segments II, III, and IV in five patients; segments II and IV in two patients; and segments III and IV in two patients. Modified laparoscopic wedge resection was performed for HCH in segments II and III in one patient. MLH with the herein-described new technique was successfully performed in all patients. No patients were converted to open surgery, and none required an intraoperative blood transfusion. No patients who underwent modified laparoscopic left hemihepatectomy required inflow occlusion. The one patient who underwent laparoscopic wedge resection developed inflow occlusion using the modified Pringle maneuver. There were no intraoperative or postoperative episodes of massive bleeding. Only one patient developed bile leakage, which resolved after 2 weeks with complete drainage. The operative and postoperative data are shown in Table 2. The baseline demographic and clinical characteristics of the MLH and TLH groups are shown in Table 3. There were no significant between-group differences, including differences in age, gender, diabetes mellitus, longitudinal
diameter of the HCH, or type of procedure. All patients were discharged in good condition. The intraoperative and postoperative details of the MLH and TLH groups are shown in Table 4. The operation time (149.50 ± 18.77 vs. 163.93 ± 13.18 min, P \ 0.05) and time required to remove the HCH (15.90 ± 4.79 vs. 33.93 ± 3.12 min, P \ 0.0001) were significantly shorter in the MLH group than in the TLH group. The VAS score on the first day postoperatively was significantly lower in the MLH group than in the TLH group (2.30 ± 0.95 vs. 3.36 ± 0.93, P \ 0.05). The time to off-bed activity (2.40 ± 0.84 vs. 3.14 ± 0.77 days, P \ 0.05) and the length of the postoperative hospital stay (8.60 ± 2.72 vs. 10.58 ± 1.91 days, P \ 0.05) were significantly shorter after MLH than after TLH.
Discussion Most studies describe the use of cumbersome retrieval bags or the creation of an enlarged incision or hand-assisted incision for extraction of hepatic hemangiomas during LH. Laparoscopic hepatic hemangioma extraction using an electromechanical morcellator during LH has not been previously reported. The spleen was reportedly extracted by an electromechanical morcellator 13 years ago, but this technique was only used during laparoscopic splenectomy for pediatric and adult patients with hematological disorders or other diseases [14–16]. We previously reported the use of an electromechanical morcellator to extract an
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Surg Endosc Table 2 Operative and postoperative data of the MLH group No.
Operative time (min)
HCH removal time (min)
Blood loss (ml)
VAS score
Postoperative stay (days)
Complication
LC
1
125
28
220
2
11
No
No
2
135
20
250
2
5
No
No
3
155
14
290
3
7
No
No
4
140
16
370
2
9
No
No
5
165
12
450
1
10
No
No
6
135
14
280
4
6
No
Yes
7 8
185 170
13 15
320 410
3 1
10 14
No Bile leakage
No No
9
145
14
360
3
7
No
No
10
140
13
350
2
7
No
Yes
MLH modified laparoscopic hepatectomy, HCH hepatic cavernous hemangioma, VAS score visual analog scale score on the first postoperative day, Post-op stay postoperative hospital stay, Conversion conversion to open surgery, LC laparoscopic cholecystectomy
Table 3 Baseline demographic and clinical characteristics of the MLH and TLH groups
Variable
P value
P = 1.000
Male
3
5
Female
7
9
Age, years
45.50 ± 15.81
47.93 ± 13.98
P = 0.107
Diabetes mellitus
3
2
P = 0.671
Longitudinal diameter of HCH, cm
9.65 ± 1.44
9.61 ± 1.13
P = 0.935
Left hemihepatectomy
9
12
P = 1.000
Wedge hepatectomy
1
2
The type of procedure
Table 4 Intraoperative and postoperative characteristics of the MLH and TLH groups
Variable
MLH (n = 10)
TLH (n = 14)
P value
Operation time (min)
149.50 ± 18.77
163.93 ± 13.18
P = 0.037
Estimated blood loss (ml)
330.00 ± 71.80
310.71 ± 57.57
P = 0.473
Time to remove HCH (min) VAS pain score on the first day
15.90 ± 4.79 2.30 ± 0.95
33.93 ± 3.12 3.36 ± 0.93
P \ 0.0001 P = 0.012
Time to passage of flatus (days)
2.60 ± 0.70
3.29 ± 0.99
P = 0.075
Time to off-bed activity (days)
2.40 ± 0.84
3.14 ± 0.77
P = 0.036
Postoperative hospital stay (days)
8.60 ± 2.72
10.58 ± 1.91
P = 0.048
Perioperative complications
1
2
P = 1.000
Surgical site infections
0
1
P = 1.000
Bile leakage
1
1
P = 1.000
extremely enlarged spleen during our modified laparoscopic splenectomy and azygoportal disconnection. We demonstrated that this technique was a feasible, effective, and safe minimally invasive surgical technique for patients with liver cirrhosis with bleeding portal hypertension and hypersplenism [17, 18]. Although HCH is usually asymptomatic, it may be accompanied by symptoms such as abdominal swelling or
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TLH (n = 14)
Gender
MLH modified laparoscopic hepatectomy, TLH traditional laparoscopic hepatectomy, HCH hepatic cavernous hemangioma
MLH modified laparoscopic hepatectomy, TLH traditional laparoscopic hepatectomy, HCH hepatic cavernous hemangioma, VAS score visual analog scale score on the first postoperative day
MLH (n = 10)
pain due to pressure on adjacent organs or partial infarction within the tumor [19–22]. Early satiety, nausea, and vomiting have also been reported [22]. Traditionally, when HCH leads to symptoms, is very large, or grows rapidly, surgical resection is the treatment of choice [20, 22]. However, substantial recovery times and high morbidity rates are associated with open hepatectomy or enucleation [21]. The morbidity and mortality rates in such cases are
Surg Endosc
reportedly 15–30 % and up to 5 %, respectively [20, 23]. In the present study, the mean longitudinal diameter of the HCH was approximately 10 cm, the HCH grew rapidly in 13 patients, and the above-mentioned symptoms were seen in 11 patients. The ideal surgical procedure effectively controls bleeding with little impairment, a low complication rate, and rapid recovery. Bleeding is the most critical complication during LH. This problem can be avoided with the use of advanced instruments and a skillful technique. In general, the harmonic scalpel is safe, but the advantages of the electrocoagulator are ingenious. The use of an electrocoagulator with an 80 W output is a competent and effective way to divide small biliovascular structures, especially in limited spaces with few vessels. This instrument reduces the rate of bleeding to a certain extent. All ten patients in this report underwent successful LH with the new technique. We extracted the hepatic hemangioma using the electromechanical morcellator during the LH procedure. In our opinion, this procedure should be performed from exterior to interior, from front to back, and from the lower to the upper pole when the rotating tube is used to extract the hepatic hemangioma. This allows for ordered, convenient, and rapid completion of the procedure. The time required to remove the hepatic hemangioma was 28 min in the first patient, but with mastery of the surgical principals and function of the morcellator, the speed was quickly increased. A left hemiliver specimen with hemangioma tissue can currently be removed with a morcellator within 15 min. The specimen is then collected for analysis, and the pathologist is still able to obtain detailed histological information because the excellent cutting effect prevents damage to the tissue architecture. Several studies on TLH [3–10] have reported two main methods for removing hepatic hemangiomas during LH. One method involves insertion of the hepatic tissue into a retrieval bag followed by removal of one trocar and enlargement of the abdominal entry site to a length of C3 cm. If the specimen is too large, it is fragmented within the bag. In the second method, the specimen is removed through the protractor portion of the hand port during handassisted LH. However, both of these methods induce more tissue damage and pain than does our modified method. In contrast, laparoscopic hepatic hemangioma extraction during MLH does not require enlargement of any incision, and postoperative abdominal pain is rare. In addition to inducing less postoperative pain than TLH, the extremely minimally invasive MLH method is associated with more rapid recovery because of the extremely small incisions required. In the present study, MLH was associated with a shorter time to off-bed activity and a shorter postoperative hospital stay, possibly because of the shorter time required to remove the HCH and shorter operation time. The time to
passage of flatus in patients who underwent MLH was 2.60 ± 0.70 days. In comparison, the time to passage of flatus in those who underwent TLH was 3.29 ± 0.99 days, although the between-group difference was not statistically significant (P = 0.075), probably because of the small sample size. Some surgeons are reluctant to perform LH. The advantages of laparoscopic surgery are obviated because the placement of the hepatic hemangioma into an intracorporeal bag may be difficult and tedious for some surgeons, and the creation of an enlarged incision or handassisted incision is necessary to remove the hepatic hemangioma. These patients are often faced with a high risk of postoperative complications due to the surgical stress and large surgical incision. Postoperative pain is associated with the enlarged incision or hand-assisted incision required in conventional extraction techniques. The use of a morcellator is a feasible way to solve the problems associated with intracorporeal morcellation. The hepatic hemangioma can be safely, efficiently, and rapidly removed using a morcellator without the need for an intracorporeal bag, enlarged incision, or hand-assisted incision. No incision-related complications occurred in the present study. This technique allows for expedient recovery and minimal postoperative pain and scarring. It is easy to learn and will enable and encourage surgeons to perform LH. The trauma associated with open hepatectomy or TLH in patients with benign HCH appears to be equal to that in patients with malignant liver tumors; this level of trauma is too high for patients with HCH. However, MLH only involves the use of several small ports, thus solving the problem of trauma induced by a longer incision. MLH has irreplaceable advantages over open hepatectomy in patients with HCH. MLH with the new technique described herein may become the gold standard for removal of hepatic hemangiomas using an electromechanical morcellator. This technique will extend the advantages of laparoscopic surgery to a number of patients who are likely to benefit the most, namely patients with HCH. Disclosures D.-S. Bai, P. Chen, J.-J. Qian, J. Yao, S.-J. Jin, X.-D. Wang, and G.-Q. Jiang have no conflicts of interest or financial ties to disclose.
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14. Hebra A, Walker JD, Tagge EP, Johnson JT, Hardee E, Othersen HB Jr (1998) A new technique for laparoscopic splenectomy with massively enlarged spleens. Am Surg 64:1161–1164 15. Hashizume M, Migo S, Tsugawa K, Tanoue K, Ohta M, Sugimachi K (1998) Laparoscopic splenectomy with the newly devised morcellator. Hepatogastroenterology 45:554–557 16. Hashizume M, Tanoue K, Akahoshi T, Morita M, Ohta M, Tomikawa M, Sugimachi K (1999) Laparoscopic splenectomy: the latest modern technique. Hepatogastroenterology 46:820–824 17. Jiang G, Qian J, Yao J, Wang X, Jin S, Bai D (2013) A new technique for laparoscopic splenectomy and azygoportal disconnection. Surg Innov. doi:10.1177/1553350613492587 18. Bai DS, Qian JJ, Chen P, Yao J, Wang XD, Jin SJ, Jiang GQ (2014) Modified laparoscopic and open splenectomy and azygoportal disconnection for portal hypertension. Surg Endosc 28:257–264 19. Fan RF, Chai FL, He GX, Wei LX, Li RZ, Wan WX, Bai MD, Zhu WK, Cao ML, Li HM, Yan SZ (2006) Laparoscopic radiofrequency ablation of hepatic cavernous hemangioma. A preliminary experience with 27 patients. Surg Endosc 20:281–285 20. Zagoria RJ, Roth TJ, Levine EA, Kavanagh PV (2004) Radiofrequency ablation of a symptomatic hepatic cavernous hemangioma. AJR Am J Roentgenol 182:210–212 21. Cui Y, Zhou LY, Dong MK, Wang P, Ji M, Li XO, Chen CW, Liu ZP, Xu YJ, Zhang HW (2003) Ultrasonography guided percutaneous radiofrequency ablation for hepatic cavernous hemangioma. World J Gastroenterol 9:2132–2134 22. Tak WY, Park SY, Jeon SW, Cho CM, Kweon YO, Kim SK, Choi YH, Chung JM (2006) Ultrasonography-guided percutaneous radiofrequency ablation for treatment of a huge symptomatic hepatic cavernous hemangioma. J Clin Gastroenterol 40:167–170 23. Livraghi T, Solbiati L, Meloni MF, Gazelle GS, Halpern EF, Goldberg SN (2003) Treatment of focal liver tumors with percutaneous radiofrequency ablation: complications encountered in a multicenter study. Radiology 226:441–451
and Other Interventional Techniques
NEW TECHNOLOGY
Modified laparoscopic hepatectomy for hepatic hemangioma Dou-Sheng Bai • Ping Chen • Jian-Jun Qian Jie Yao • Sheng-Jie Jin • Xiao-Dong Wang • Guo-Qing Jiang
•
Received: 11 June 2014 / Accepted: 16 December 2014 Ó Springer Science+Business Media New York 2014
Abstract Background Laparoscopic hepatectomy (LH) using many different surgical techniques has become increasingly popular for the management of hepatic tumors. The performance of surgical procedures involving the least possible impairment is expected increasingly more often by both surgeons and patients. We herein describe a clinical cohort of ten patients with hepatic cavernous hemangioma (HCH) who underwent modified LH (MLH) with a new technique. We herein present the advantages of the low level of impairment during performance of this modified procedure and compare the outcomes of MLH with those of traditional LH (TLH) for HCH. Methods We retrospectively evaluated the treatment outcomes in 24 patients with HCH who underwent MLH (n = 10) or TLH (n = 14) from February 2008 to January 2013. Their demographic, intraoperative, and postoperative variables were compared. Results MLH was successful in all patients. An electromechanical morcellator allowed for easy extraction of the entire HCH without the use of a cumbersome retrieval bag, enlarged incision, or hand-assisted incision. There was no conversion to an open operation or significant perioperative complications. The operation time (P = 0.037), time to removal of the HCH (P \ 0.0001), visual analog scale pain score on the first postoperative day (P = 0.012), time to Dou-Sheng Bai, Ping Chen, and Jian-Jun Qian contributed equally to this work. D.-S. Bai P. Chen J.-J. Qian J. Yao S.-J. Jin X.-D. Wang G.-Q. Jiang (&) Department of Hepatobiliary Surgery, Clinical Medical College of Yangzhou University, 98 West Nantong Rd, Yangzhou 225000, China e-mail: [email protected]
off-bed activity (P = 0.036), and postoperative hospital stay (P = 0.048) were significantly lower in the MLH group than in the TLH group. Conclusions MLH involving the use of an electromechanical morcellator provides expedient recovery and minimal postoperative pain and scarring. It is a feasible, effective, and safe surgical procedure and embodies all of the benefits of minimally invasive surgery for patients with HCH. Keywords Laparoscopy Hepatectomy Hemangioma Morcellator With the recent substantial progress in laparoscopic skills and advances in technical instruments, endoscopic surgery involving improved and advantageous techniques has supplanted traditional open surgery in many areas. However, laparoscopic techniques are much more challenging when performed in patients with hepatic tumors. As experience in laparoscopic hepatectomy (LH) has grown, and surgical techniques have become more advanced, LH has gradually become accepted as a treatment for patients with hepatic tumors. LH will probably become the gold standard technique for left lateral lobectomy and left hemihepatic resection [1, 2]. Many different surgical techniques for removing hepatic specimens during LH are currently performed. These techniques include the use of cumbersome retrieval bags to draw massive hepatic specimens out of the abdomen as well as the creation of enlarged incisions or performance of hand-assisted laparoscopy to morcellate and draw hepatic specimens out of the abdomen [3–10]. Incision-associated impairment should be controlled to ensure faster recovery and fewer complications. We herein report the performance of modified LH (MLH) with a new technique that greatly reduces
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impairment in patients with hepatic cavernous hemangioma (HCH). Massive hepatic hemangiomas can be removed from the abdominal cavity through the existing incision using an electromechanical morcellator. To the best of our knowledge, this is the first report of the use of an electromechanical morcellator to extract an entire hepatic hemangioma during LH. The purpose of this article is to report ten patients who underwent MLH with the herein-described new technique and present the feasibility, decreased impairment, and advantages of using an electromechanical morcellator during the procedure. This technique eliminates the need for large, cumbersome retrieval bags and the creation of hand-assisted or enlarged incisions to remove the hepatic hemangioma.
(LC) to treat acute cholecystitis and cholecystolithiasis shown on preoperative ultrasound. All patients had HCH. The longitudinal HCH diameter was 9.7 ± 1.4 cm (range 8–12 cm). No patients had liver cirrhosis. All ten patients had a ChildPugh classification of A. Intraoperative biopsy and frozen section examination of all patients revealed HCH. The preoperative clinical characteristics are listed in Table 1. The results of MLH were compared with those of the 14 patients (5 males, 9 females) who underwent TLH during the same time period. These patients ranged in age from 23 to 69 years (mean 47.93 ± 13.98 years). Two patients had type 2 diabetes mellitus and two had hypertension. All patients had HCH. The longitudinal HCH diameter was 9.61 ± 1.13 cm (range 8–12 cm). No patients had liver cirrhosis. All 14 patients had a Child-Pugh classification of A.
Materials and methods
Modified laparoscopic procedures
Patients
Laparoscopic hepatectomy
From February 2008 to January 2013, 24 patients were diagnosed with HCH in our department; of these, 10 underwent MLH and 14 underwent traditional LH (TLH). The clinical records of these patients were retrospectively analyzed. The preoperative diagnostic workup, which included B ultrasound and computed tomography or magnetic resonance imaging, confirmed that all patients had HCH. During the preoperative discussion, all patients were informed that although MLH was a minimally invasive procedure, it was in the experimental stage compared with TLH. Selection of the procedure to be performed was based on the patient’s decision. All patients provided written informed consent. The ethics committee of the Clinical Medical College of Yangzhou University, China approved the conduct of the study. The same surgical team performed all operations. The following data were prospectively collected: age, gender, hemangioma size, operative time, time required for removal of the HCH, estimated blood loss, visual analog scale (VAS) pain score on the first postoperative day, time to passage of flatus, time to off-bed activity, length of the postoperative hospital stay, and perioperative complications. The VAS pain score was recorded using a questionnaire that rated pain intensity on a scale of 0–10 [11– 13], with 0 representing no pain and 10 representing very severe pain. The ten patients who underwent MLH comprised three males and seven females with a mean age of 45.5 ± 15.8 years (range 19–64 years). Three patients had type 2 diabetes mellitus, one had hypertension, and one had a history of combined MLH and laparoscopic cholecystectomy
After successful induction of general endotracheal anesthesia, urinary catheters were placed. The patients were first placed in the reverse Trendelenburg position with parted legs. The senior surgeon stood on the right side of the patient. Pneumoperitoneum with a pressure of 13 mmHg was created. A (5 ? 1)-port or 5-port method was used for LH (Fig. 1). Using the Hasson (open) technique, a 10-mm trocar was placed in the umbilicus (port A). A 10-mm, 30° angled laparoscope was then introduced through this trocar. Under direct visualization, 4 ? 1 additional ports were placed: one 5-mm trocar (port B) in the right midclavicular line just below the costal margin, one 10-mm trocar (port C) in the right midclavicular line halfway between the costal margin and the umbilicus, one 12-mm trocar (port D) in the left midclavicular line halfway between the costal margin and the umbilicus, one 5-mm trocar (port E) in the left anterior axillary line below costal margin, and one 10-mm trocar (port F) in the right anterior axillary line halfway between the costal margin and the umbilicus (white line, Fig. 1). Port C was the main port used with monopolar electrocautery, the harmonic scalpel (Ethicon, Cincinnati, OH, USA), and the linear laparoscopic vascular stapler (Ethicon, Hartford, CT, USA). Port D was the main port used with the electromechanical morcellator (TSCS, Hangzhou, China). The necessity of port F was determined based on the surgeon’s preference for the laparoscopic procedure and experience with laparoscopic techniques. Port F was used for the modified Pringle maneuver (with 20-min occlusion and 5-min reopening periods). Performance of the modified Pringle maneuver required an aspirator, a strip of cotton thread about three times the length of the aspirator, and a
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Surg Endosc Table 1 Preoperative clinical characteristics of ten patients who underwent MLH
MLH modified laparoscopic hepatectomy, HCH hepatic cavernous hemangioma
HCH in size (cm3)
Other disorders
II, III, IV
11.5 9 9 9 5
No
III, IV
89595
No
II, III
9 9 8.5 9 7
Diabetes mellitus
No.
Gender
Age (years)
Couinaud’s segments involved
1
Female
23
2
Female
56
3
Male
45
4
Female
47
II, III, IV
8.5 9 7 9 6
Diabetes mellitus
5
Female
64
II, III, IV
11 9 8 9 7
No
6
Female
33
III, IV
9.5 9 6 9 5
Cholecystolithiasis
7
Female
19
II, IV
12 9 11 9 10
No
8
Male
63
II, III, IV
89595
Hypertension
9
Male
56
II, III, IV
99696
No
10
Female
49
II, IV
10 9 7 9 6
Diabetes mellitus
Fig. 2 Modified Pringle maneuver Fig. 1 Port placement for modified laparoscopic hepatectomy for hepatic hemangioma
14-French catheter. After the cotton thread had been passed around the hepatoduodenal ligament, both of its ends were passed through the catheter (which was connected to an aspirator), then all the way through the aspirator (Fig. 2). When inflow occlusion was required, the cotton thread was immediately tightened. Port F was used to prevent bleeding during the first two consecutive modified laparoscopic left hemihepatectomies. With increasing laparoscopic experience, port F was abandoned for utilization in the next consecutive modified laparoscopic left hemihepatectomy. However, port F was routinely used during modified laparoscopic wedge resection. LC was performed only after successful LH had been completed. The three trocars used in LC were port A (inserted by the laparoscope), port C, and port D (as the main port). The laparoscopic procedures were performed as follows. The procedure began after advanced preparation of the device used for the modified Pringle maneuver (if
necessary), which could be used to occlude the inflow in the entire liver when necessary. If the laparoscopic approach was a left hemihepatectomy, we performed left hemihepatic inflow occlusion. Thus, the left branch portal vein and left hepatic artery were separated and occluded with a clip, and the inflow in the remnant liver remained open (Fig. 3). Adhesions and the falciform and triangular ligaments were divided to mobilize the liver. After these manipulations, the blocking zone after left liver ischemia was clearly visible. The hepatic resection line was marked along the blocking zone with the monopolar electrocautery device, which was then used to make an approximately 1.0-cmdeep cut into the liver tissue along the resection line using 80 W output. To locate the biliovascular structures, the senior surgeon used the harmonic scalpel to bite the parenchymal liver tissue, while the assistant surgeon used the aspirator to push, suck, and scratch the tissue. Small biliovascular structures were divided using the harmonic scalpel or endoscopic clips. The left hepatic vein was
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Fig. 3 Occlusion of left branch portal vein and left hepatic artery with two clips
divided using an endoscopic stapling device with 2.5-mm staples. If the laparoscopic approach involved a wedge hepatectomy, intraoperative ultrasonography was first performed to assess the boundaries of the hemangioma and its relationship with major vascular structures. The hepatic resection line was then scored with the monopolar electrocautery device. The modified Pringle maneuver was always performed after an approximately 1.0-cm-deep cut was made in the liver tissue by monopolar electrocautery; the aspirator was then used to push, suck, and scratch along the surface of the hepatic hemangioma. Many vessel branches from the hemangioma were thus detected and divided with the clips. The hemangioma was at risk of damage and bleeding during this procedure. Because of the hepatic vascular occlusion, only a slightly greater amount of blood than that sequestered in the hemangioma was discharged. Intraoperative biopsy examination was performed for each patient. During the biopsy examination, hemostasis was mainly carried out by monopolar or bipolar electrocautery. Acute venous or arterial hemorrhage was controlled with sutures. The raw liver surface was irrigated and carefully inspected for bile leakage with white gauze.
D was the main trocar used with the electromechanical morcellator. The hepatic hemangioma was maintained in the ideal location by placing the patient in the reverse Trendelenburg position and using the splenic retractor or the forceps to raise the upper pole of the hepatic hemangioma. The hepatic hemangioma was grasped by the large claw forceps through the motor-driven cutting tube, and the forceps was then pulled back while pressing the hepatic hemangioma against the cutting edge of the rotating tube (Fig. 4); the rotation could be triggered using a hand switch. A cylindrical tissue sample (Fig. 5) could be cut and pulled out from the tube by applying a measured pulling force. This manipulation was repeated until the entire hepatic hemangioma was removed by the electromechanical morcellator. The entrance of the tube remained in view during the entire procedure to prevent damage to the surrounding organs. The entire upper quadrant was irrigated, and the operative field was carefully inspected again for residual tissue, bleeding, and bile leakage. A surgical drainage tube was placed along the liver section and through port C. Traditional laparoscopic procedures After the performance of LH as described as above, TLH for extraction of the hemangioma was performed. Five steps were necessary and were performed in the following order. First, a cumbersome retrieval bag was placed into the abdominal cavity from one 10-mm trocar. Second, the HCH specimens were inserted into the bags. Third, the length of the umbilical incision was enlarged to 3–4 cm along the epigastric linea alba. Fourth, the massive hepatic specimen was drawn out of the abdomen through the enlarged incision. Finally, the enlarged incision was sutured.
Modified laparoscopic hepatic hemangioma extraction methods All intraoperative biopsy examinations revealed a hemangioma. All patients’ hepatic hemangiomas were removed from the abdominal cavity using an electromechanical morcellator comprising a motor-driven cutting tube that can be directly inserted into the abdominal cavity through a 12-mm port and a large claw forceps. The surgeon preferred to be positioned between the patient’s legs, and port
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Fig. 4 Extraction of hepatic hemangioma with the electromechanical morcellator
Surg Endosc Fig. 5 Cylindrical sections of hepatic hemangioma tissue and electromechanical morcellator (1 large claw forceps; 2 motordriven cutting tube)
Statistical analysis Statistical analysis was performed using SPSS for Windows, version 12.0 (SPSS, Inc., Chicago, IL). All data are expressed as mean ± SD.
Results Modified laparoscopic left hemihepatectomy was performed for HCH in segments II, III, and IV in five patients; segments II and IV in two patients; and segments III and IV in two patients. Modified laparoscopic wedge resection was performed for HCH in segments II and III in one patient. MLH with the herein-described new technique was successfully performed in all patients. No patients were converted to open surgery, and none required an intraoperative blood transfusion. No patients who underwent modified laparoscopic left hemihepatectomy required inflow occlusion. The one patient who underwent laparoscopic wedge resection developed inflow occlusion using the modified Pringle maneuver. There were no intraoperative or postoperative episodes of massive bleeding. Only one patient developed bile leakage, which resolved after 2 weeks with complete drainage. The operative and postoperative data are shown in Table 2. The baseline demographic and clinical characteristics of the MLH and TLH groups are shown in Table 3. There were no significant between-group differences, including differences in age, gender, diabetes mellitus, longitudinal
diameter of the HCH, or type of procedure. All patients were discharged in good condition. The intraoperative and postoperative details of the MLH and TLH groups are shown in Table 4. The operation time (149.50 ± 18.77 vs. 163.93 ± 13.18 min, P \ 0.05) and time required to remove the HCH (15.90 ± 4.79 vs. 33.93 ± 3.12 min, P \ 0.0001) were significantly shorter in the MLH group than in the TLH group. The VAS score on the first day postoperatively was significantly lower in the MLH group than in the TLH group (2.30 ± 0.95 vs. 3.36 ± 0.93, P \ 0.05). The time to off-bed activity (2.40 ± 0.84 vs. 3.14 ± 0.77 days, P \ 0.05) and the length of the postoperative hospital stay (8.60 ± 2.72 vs. 10.58 ± 1.91 days, P \ 0.05) were significantly shorter after MLH than after TLH.
Discussion Most studies describe the use of cumbersome retrieval bags or the creation of an enlarged incision or hand-assisted incision for extraction of hepatic hemangiomas during LH. Laparoscopic hepatic hemangioma extraction using an electromechanical morcellator during LH has not been previously reported. The spleen was reportedly extracted by an electromechanical morcellator 13 years ago, but this technique was only used during laparoscopic splenectomy for pediatric and adult patients with hematological disorders or other diseases [14–16]. We previously reported the use of an electromechanical morcellator to extract an
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Surg Endosc Table 2 Operative and postoperative data of the MLH group No.
Operative time (min)
HCH removal time (min)
Blood loss (ml)
VAS score
Postoperative stay (days)
Complication
LC
1
125
28
220
2
11
No
No
2
135
20
250
2
5
No
No
3
155
14
290
3
7
No
No
4
140
16
370
2
9
No
No
5
165
12
450
1
10
No
No
6
135
14
280
4
6
No
Yes
7 8
185 170
13 15
320 410
3 1
10 14
No Bile leakage
No No
9
145
14
360
3
7
No
No
10
140
13
350
2
7
No
Yes
MLH modified laparoscopic hepatectomy, HCH hepatic cavernous hemangioma, VAS score visual analog scale score on the first postoperative day, Post-op stay postoperative hospital stay, Conversion conversion to open surgery, LC laparoscopic cholecystectomy
Table 3 Baseline demographic and clinical characteristics of the MLH and TLH groups
Variable
P value
P = 1.000
Male
3
5
Female
7
9
Age, years
45.50 ± 15.81
47.93 ± 13.98
P = 0.107
Diabetes mellitus
3
2
P = 0.671
Longitudinal diameter of HCH, cm
9.65 ± 1.44
9.61 ± 1.13
P = 0.935
Left hemihepatectomy
9
12
P = 1.000
Wedge hepatectomy
1
2
The type of procedure
Table 4 Intraoperative and postoperative characteristics of the MLH and TLH groups
Variable
MLH (n = 10)
TLH (n = 14)
P value
Operation time (min)
149.50 ± 18.77
163.93 ± 13.18
P = 0.037
Estimated blood loss (ml)
330.00 ± 71.80
310.71 ± 57.57
P = 0.473
Time to remove HCH (min) VAS pain score on the first day
15.90 ± 4.79 2.30 ± 0.95
33.93 ± 3.12 3.36 ± 0.93
P \ 0.0001 P = 0.012
Time to passage of flatus (days)
2.60 ± 0.70
3.29 ± 0.99
P = 0.075
Time to off-bed activity (days)
2.40 ± 0.84
3.14 ± 0.77
P = 0.036
Postoperative hospital stay (days)
8.60 ± 2.72
10.58 ± 1.91
P = 0.048
Perioperative complications
1
2
P = 1.000
Surgical site infections
0
1
P = 1.000
Bile leakage
1
1
P = 1.000
extremely enlarged spleen during our modified laparoscopic splenectomy and azygoportal disconnection. We demonstrated that this technique was a feasible, effective, and safe minimally invasive surgical technique for patients with liver cirrhosis with bleeding portal hypertension and hypersplenism [17, 18]. Although HCH is usually asymptomatic, it may be accompanied by symptoms such as abdominal swelling or
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TLH (n = 14)
Gender
MLH modified laparoscopic hepatectomy, TLH traditional laparoscopic hepatectomy, HCH hepatic cavernous hemangioma
MLH modified laparoscopic hepatectomy, TLH traditional laparoscopic hepatectomy, HCH hepatic cavernous hemangioma, VAS score visual analog scale score on the first postoperative day
MLH (n = 10)
pain due to pressure on adjacent organs or partial infarction within the tumor [19–22]. Early satiety, nausea, and vomiting have also been reported [22]. Traditionally, when HCH leads to symptoms, is very large, or grows rapidly, surgical resection is the treatment of choice [20, 22]. However, substantial recovery times and high morbidity rates are associated with open hepatectomy or enucleation [21]. The morbidity and mortality rates in such cases are
Surg Endosc
reportedly 15–30 % and up to 5 %, respectively [20, 23]. In the present study, the mean longitudinal diameter of the HCH was approximately 10 cm, the HCH grew rapidly in 13 patients, and the above-mentioned symptoms were seen in 11 patients. The ideal surgical procedure effectively controls bleeding with little impairment, a low complication rate, and rapid recovery. Bleeding is the most critical complication during LH. This problem can be avoided with the use of advanced instruments and a skillful technique. In general, the harmonic scalpel is safe, but the advantages of the electrocoagulator are ingenious. The use of an electrocoagulator with an 80 W output is a competent and effective way to divide small biliovascular structures, especially in limited spaces with few vessels. This instrument reduces the rate of bleeding to a certain extent. All ten patients in this report underwent successful LH with the new technique. We extracted the hepatic hemangioma using the electromechanical morcellator during the LH procedure. In our opinion, this procedure should be performed from exterior to interior, from front to back, and from the lower to the upper pole when the rotating tube is used to extract the hepatic hemangioma. This allows for ordered, convenient, and rapid completion of the procedure. The time required to remove the hepatic hemangioma was 28 min in the first patient, but with mastery of the surgical principals and function of the morcellator, the speed was quickly increased. A left hemiliver specimen with hemangioma tissue can currently be removed with a morcellator within 15 min. The specimen is then collected for analysis, and the pathologist is still able to obtain detailed histological information because the excellent cutting effect prevents damage to the tissue architecture. Several studies on TLH [3–10] have reported two main methods for removing hepatic hemangiomas during LH. One method involves insertion of the hepatic tissue into a retrieval bag followed by removal of one trocar and enlargement of the abdominal entry site to a length of C3 cm. If the specimen is too large, it is fragmented within the bag. In the second method, the specimen is removed through the protractor portion of the hand port during handassisted LH. However, both of these methods induce more tissue damage and pain than does our modified method. In contrast, laparoscopic hepatic hemangioma extraction during MLH does not require enlargement of any incision, and postoperative abdominal pain is rare. In addition to inducing less postoperative pain than TLH, the extremely minimally invasive MLH method is associated with more rapid recovery because of the extremely small incisions required. In the present study, MLH was associated with a shorter time to off-bed activity and a shorter postoperative hospital stay, possibly because of the shorter time required to remove the HCH and shorter operation time. The time to
passage of flatus in patients who underwent MLH was 2.60 ± 0.70 days. In comparison, the time to passage of flatus in those who underwent TLH was 3.29 ± 0.99 days, although the between-group difference was not statistically significant (P = 0.075), probably because of the small sample size. Some surgeons are reluctant to perform LH. The advantages of laparoscopic surgery are obviated because the placement of the hepatic hemangioma into an intracorporeal bag may be difficult and tedious for some surgeons, and the creation of an enlarged incision or handassisted incision is necessary to remove the hepatic hemangioma. These patients are often faced with a high risk of postoperative complications due to the surgical stress and large surgical incision. Postoperative pain is associated with the enlarged incision or hand-assisted incision required in conventional extraction techniques. The use of a morcellator is a feasible way to solve the problems associated with intracorporeal morcellation. The hepatic hemangioma can be safely, efficiently, and rapidly removed using a morcellator without the need for an intracorporeal bag, enlarged incision, or hand-assisted incision. No incision-related complications occurred in the present study. This technique allows for expedient recovery and minimal postoperative pain and scarring. It is easy to learn and will enable and encourage surgeons to perform LH. The trauma associated with open hepatectomy or TLH in patients with benign HCH appears to be equal to that in patients with malignant liver tumors; this level of trauma is too high for patients with HCH. However, MLH only involves the use of several small ports, thus solving the problem of trauma induced by a longer incision. MLH has irreplaceable advantages over open hepatectomy in patients with HCH. MLH with the new technique described herein may become the gold standard for removal of hepatic hemangiomas using an electromechanical morcellator. This technique will extend the advantages of laparoscopic surgery to a number of patients who are likely to benefit the most, namely patients with HCH. Disclosures D.-S. Bai, P. Chen, J.-J. Qian, J. Yao, S.-J. Jin, X.-D. Wang, and G.-Q. Jiang have no conflicts of interest or financial ties to disclose.
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