Original article
Risk factors for complications after laparoscopic major hepatectomy T. Nomi1,2 , D. Fuks1 , M. Govindasamy1 , F. Mal1 , Y. Nakajima2 and B. Gayet1 1 Department
of Digestive Disease, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France, and 2 Department of Surgery, Nara Medical University, Nara, Japan Correspondence to: Dr B. Gayet, Department of Digestive Disease, Institut Mutualiste Montsouris, Université Paris Descartes, 42 Boulevard Jourdan, 75014 Paris, France (e-mail: [email protected])
Background: Although laparoscopic major hepatectomy (MH) is becoming increasingly common in
several specialized centres, data regarding outcomes are limited. The aim of this study was to identify the risk factors for postoperative complications of purely laparoscopic MH at a single centre. Methods: All patients who underwent purely laparoscopic MH between January 1998 and March 2014 at the authors’ institution were enrolled. Demographic, clinicopathological and perioperative factors were collected prospectively, and data were analysed retrospectively. The dependent variables studied were the occurrence of overall and major complications (Dindo–Clavien grade III or above). Results: A total of 183 patients were enrolled. The types of MH included left-sided hepatectomy in 40 patients (21⋅9 per cent), right-sided hepatectomy in 135 (73⋅8 per cent) and central hepatectomy in eight (4⋅4 per cent). Median duration of surgery was 255 (range 100–540) min, and median blood loss was 280 (10–4500) ml. Complications occurred in 100 patients (54⋅6 per cent), and the 90-day all-cause mortality rate was 2⋅7 per cent. Liver-specific and general complications occurred in 62 (33⋅9 per cent) and 38 (20⋅8 per cent) patients respectively. Multivariable analysis identified one independent risk factor for global postoperative complications: intraoperative simultaneous radiofrequency ablation (RFA) (odds ratio (OR) 6⋅93, 95 per cent c.i. 1⋅49 to 32⋅14; P = 0⋅013). There were two independent risk factors for major complications: intraoperative blood transfusion (OR 2⋅50, 1⋅01 to 6⋅23; P = 0⋅049) and bilobar resection (OR 2⋅47, 1⋅00 to 6⋅06; P = 0⋅049). Conclusion: Purely laparoscopic MH is feasible and safe. Simultaneous RFA and bilobar resection should probably be avoided. Paper accepted 29 October 2014 Published online 17 December 2014 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9726
Introduction
Since the first successful report1 of laparoscopic liver wedge resection in 1991, laparoscopic liver resection has progressively gained popularity. For minor liver resections, comparative studies2 – 5 between open and laparoscopic procedures have shown that laparoscopic liver resection resulted in decreased intraoperative bleeding, fewer complications and shorter postoperative hospital stays. Moreover, the oncological outcomes are comparable for patients undergoing laparoscopic minor liver resection compared with those having open hepatectomy for hepatocellular carcinoma and colorectal cancer liver metastases2,6 – 8 . In contrast, the progress of laparoscopic major hepatectomy (MH) has been very slow worldwide because of its inherent technical difficulties. Buell and colleagues9 reported © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
at the Louisville Consensus Conference that laparoscopic MH should be performed only by experienced hepatobiliary surgeons with advanced laparoscopic skills. Over the past few years, technological and instrumental improvements have resulted in several centres10 – 13 reporting good results after laparoscopic MH. The present study aimed to identify the risk factors for postoperative complications of purely laparoscopic MH at a single centre. Methods
Data for consecutive patients who had purely laparoscopic MH between January 1998 and March 2014 at the Institut Mutualiste Montsouris, Paris, France, were retrieved retrospectively from a prospectively collected computer database of all patients who had undergone laparoscopic BJS 2015; 102: 254–260
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hepatectomy. MH was defined as the resection of three or more contiguous Couinaud segments. The decision to perform laparoscopic MH was made by the hepatobiliary multidisciplinary team, which included surgeons, pathologists, oncologists, gastroenterologists and radiologists at the authors’ institution.
Preoperative evaluation Preoperative investigations included blood and liver function tests as well as routine cardiorespiratory evaluations. CT and MRI were performed during the later years of the study to assess both underlying liver and tumour characteristics. Initially, a preoperative percutaneous biopsy of the non-tumorous parenchyma was performed on a case-by-case basis. If severe fibrosis or cirrhosis was suspected, patients under consideration for major resection underwent portal vein embolization (PVE)14 when the volume of the future remnant liver was 25 per cent or less in non-cirrhotic livers and 40 per cent or less in cirrhotic livers.
Surgical procedures All resections were performed with curative intent, and were performed by a single surgeon. The operative procedure, including the position of trocars, has been described previously10,15 – 18 . Briefly, for all right-sided hepatectomies, including right hemihepatectomy, right hemihepatectomy with resection of segment I and right trisectionectomy (right hemiliver plus left medial section)19 , the patient was placed in the supine position, in a slightly reverse-Trendelenburg orientation. Intra-abdominal pressure was maintained at 12 mmHg. Resectability was always confirmed by intraoperative ultrasonography. The cystic duct and artery were divided but the gallbladder was not removed, to allow for its use as a handle for retraction. Starting from the junction of the cystic and common hepatic duct, the portal vein was dissected in a cephalic direction with routine lymphadenectomy of the hepatoduodenal ligament. Following the common bile duct to the confluence of the right and left hepatic ducts, Glisson’s capsule was incised. The biliary convergence was then gently retracted medially to expose the right hepatic artery, which was clipped and divided. The portal vein was mobilized up to the bifurcation of the right and left portal veins. The right trunk was dissected for 1–2 cm; the portal vein to the other side was clearly identified and then the right portal vein was either clipped or stapled. The hilar plate was lowered to allow safe dissection and division of the right hepatic duct above the biliary © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
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convergence. The right hepatic duct was either clipped or suture-ligated before transection, if visualized clearly. Parenchymal division was initiated along the demarcated line. For all procedures, tissue dissection and haemostasis were performed using an ultrasonic dissector, primarily SonoSurg® or Thunderbeat® (Olympus, Tokyo, Japan) or HARMONIC™ (Ethicon Endo-Surgery, Cincinnati, Ohio, USA); the Gayet bipolar forceps (MicroFrance CEV134; Medtronic, Minneapolis, Minnesota, USA) provided retraction and rescue haemostasis. Bleeding from small holes in the hepatic veins was usually controlled by instantaneous bipolar coagulation and/or compression. The branches of the middle hepatic vein from segment V to segment VIII were ligated when exposed. In the anterior approach, the inferior vena cava was dissected in a caudal to cephalic direction. The right hepatic vein was dissected free and then sectioned with an endoscopic vascular stapler. Finally, the resection specimen was extracted in a plastic retrieval bag through a suprapubic incision. Drains were used only if there was concern about intraoperative control of biliary tree radicals or adequacy of haemostasis. In principle, a left-sided hepatectomy was done using the same procedure as the right-sided hepatectomy described above, except for the mobilization. Methylene blue injection through the cystic drain was not performed routinely. All intraoperative parameters, including type and duration of vascular clamping, blood loss with subsequent intraoperative blood transfusion and duration of surgery, were recorded.
Postoperative outcomes Postoperative complications after laparoscopic MH were compared with those observed after MH performed by upfront laparotomy during the study period. These complications were stratified according to the Dindo–Clavien classification20 ; major complications were defined as those with grade III or above. If a patient had two or more complications, the most severe was taken into account. Liver-specific complications commonly encountered after major liver procedures were detailed as follows: liver failure was defined according to the ‘50–50 criteria’ on postoperative day 521 ; ascites was defined as abdominal drainage output of more than 10 ml per kg per day after the third postoperative day22 ; and biliary leakage was defined by a bilirubin concentration in the drainage fluid more than threefold that in serum23 . Complications and operative mortality considered were those that occurred within 90 days of surgery, or at any time during the postoperative hospital stay. The pathological surgical margin was defined as either microscopically positive (R1) or negative (R0). www.bjs.co.uk
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Statistical analysis Baseline patient characteristics were expressed as median (range) for continuous data and as numbers with percentages for categorical data. Preoperative, operative and postoperative characteristics were compared according to the presence of a complication or major complication. Fisher’s exact test was used to compare differences in categorical variables, and the Wilcoxon rank sum test for continuous variables. Variables with statistical significance at the 0⋅100 level in univariable analysis were considered for multivariable analysis. A backward variable procedure was used to identify the independent predictive factors. Because of the small number of events, a multivariable analysis of risk factors for mortality was not conducted. All statistical analyses were performed using SPSS® for Windows® version 18.0 (IBM, Armonk, New York, USA), and statistical significance was accepted at the 0⋅050 level. Results
Among the 183 patients enrolled in the study, there were 107 men (58⋅5 per cent) and 76 women (41⋅5 per cent) with a median age of 64 (range 24–86) years (Table 1). Thirty-six patients (19⋅7 per cent) wese classified as having American Society of Anesthesiologists fitness grade III. The indication for hepatectomy was malignancy in 166 patients (90⋅7 per cent) and benign disease in 17. Some 114 patients (62⋅3 per cent) had undergone previous abdominal surgery, including 31 (16⋅9 per cent) with a previous hepatectomy. Preoperative portal vein embolization was performed in 32 patients (17⋅5 per cent) because of anticipated insufficient volume of the future remnant liver. Of 123 patients treated for colorectal liver metastases, 80 (65⋅0 per cent) had received preoperative chemotherapy.
Surgical procedures and pathological specimen The intraoperative characteristics of the patients are summarized in Table 1. The types of MH included left-sided hepatectomy in 40 patients (21⋅9 per cent), right-sided hepatectomy in 135 (73⋅8 per cent) and central hepatectomy in eight (4⋅4 per cent). Intermittent vascular inflow clamping was required in 19 patients (10⋅4 per cent). Additional wedge resection in the contralateral liver was performed in 40 patients (21⋅9 per cent), and 19 (10⋅4 per cent) had intraoperative radiofrequency ablation. Median duration of surgery was 255 (range 100–540) min. Concomitant extrahepatic resection was performed in 20 patients (10⋅9 per cent). Transfusion was required during surgery in 19 patients (10⋅4 per cent). There were 21 (11⋅5 per cent) © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
T. Nomi, D. Fuks, M. Govindasamy, F. Mal, Y. Nakajima and B. Gayet
Preoperative and intraoperative characteristics of 183 patients undergoing major laparoscopic liver resection
Table 1
No. of patients (n = 183) Age (years)* Sex ratio (M : F) Body mass index (kg/m2 )* ASA fitness grade I II III Co-morbidities Diabetes mellitus Cardiopulmonary Hypertension Hyperlipidaemia Hepatitis B or C Alcohol abuse Smoking Diagnosis HCC Cholangiocarcinoma Colorectal carcinoma metastases Non-colorectal carcinoma metastases Benign Extent of liver resection Left hepatectomy Right hepatectomy Left trisectionectomy Right trisectionectomy Central hepatectomy Bilobar resection Combined resection of adjacent organs Diaphragm Common bile duct Inferior vena cava Adrenal gland Kidney Colon Pancreas Duodenum Blood loss (ml)* Drain
64 (24–86) 107 : 76 24⋅3 (15⋅9–35⋅5) 42 105 36 13 (7⋅1) 33 (18⋅0) 45 (24⋅6) 32 (17⋅5) 8 (4⋅4) 33 (18⋅0) 51 (27⋅9) 20 (10⋅9) 18 (9⋅8) 123 (67⋅2) 5 (2⋅7) 17 (9⋅3) 29 (15⋅8) 122 (66⋅7) 11 (6⋅0) 13 (7⋅1) 8 (4⋅4) 41 (22⋅4) 20 (10⋅9) 7 (3⋅8) 6 (3⋅3) 2 (1⋅1) 1 (0⋅5) 1 (0⋅5) 1 (0⋅5) 1 (0⋅5) 1 (0⋅5) 280 (10–4500) 42 (23⋅0)
Values in parentheses are percentages unless indicated otherwise; *values are median (range). ASA, American Society of Anesthesiologists; HCC, hepatocellular carcinoma.
conversions to an open procedure, for intraoperative bleeding in 12 patients. None of the 183 patients had evidence of gas embolism. Based on pathology evaluation of the specimens, the median number of tumours was 2⋅0 (range 1–25), and the median size of resected tumours was 40⋅1 (5–170) mm. The median surgical margin was 5 (0–5) mm. R0 resection was achieved in 177 patients (96⋅7 per cent), and six (3⋅3 per cent) had microscopically incomplete resection. No patient had macroscopically incomplete resection. www.bjs.co.uk
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Table 2
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Postoperative results for patients undergoing purely open versus laparoscopic major hepatectomy Open major hepatectomy (n = 28)
Laparoscopic major hepatectomy (n = 183)
P*
1 (4) 16 (57) 8 (29) 2 (7) 1 (4) 3 (11) 1 (4) 1 (4) 8 (29) 1 (4) 0 (0) 4 (14) 1 (4) 0 (0) 2 (7) 7 (25) 1 (4) 1 (4) 2 (7) 0 (0) 1 (1) 2 (7) 0 (0) 0 (0) 0 (0) 7 4 0 2 1
5 (2⋅7) 100 (54⋅6) 62 (33⋅9) 20 (10⋅9) 6 (3⋅3) 24 (13⋅1) 10 (5⋅5) 2 (1⋅1) 38 (20⋅8) 6 (3⋅3) 3 (1⋅6) 13 (7⋅1) 1 (0⋅5) 3 (1⋅6) 12 (6⋅6) 43 (23⋅5) 4 (2⋅2) 3 (1⋅6) 23 (12⋅6) 4 (2⋅2) 2 (1⋅1) 3 (1⋅6) 1 (0⋅5) 1 (0⋅5) 2 (1⋅1) 43 23 4 6 10
0⋅579 0⋅841 0⋅699 0⋅745 1⋅000 1⋅000 1⋅000 0⋅349 0⋅336 1⋅000 1⋅000 0⋅252 0⋅248 1⋅000 1⋅000 0⋅815 0⋅512 0⋅436 0⋅102 1⋅000 0⋅349 0⋅131 1⋅000 1⋅000 1⋅000 1⋅000 1⋅000 1⋅000 0⋅309 1⋅000
Mortality Morbidity Liver-specific morbidity Liver failure Ascites Biliary leakage Intra-abdominal abscess Intra-abdominal bleeding General morbidity Fever Leucocytosis Pulmonary Cardiac Neurological Other Major morbidity (Dindo–Clavien grade ≥ III) Liver failure Ascites Biliary leakage Intra-abdominal abscess Intra-abdominal bleeding Pleural effusion Small bowel obstruction Septic shock Patient positioning complications Treatment of major complications Percutaneous drainage Interventional endoscopy Reoperation (open) Other
Values in parentheses are percentages. *Fisher’s exact test.
Postoperative mortality
Postoperative morbidity
Five patients (2⋅7 per cent) died in the postoperative period (Table 2). The indication for hepatic resection had been HCC in two patients who died, hilar cholangiocarcinoma in one, colorectal cancer metastases in one, and gallbladder cancer in one. Three patients had underlying liver disease (1 cirrhosis, 1 steatosis, 1 cholestasis). One patient with cirrhosis and inferior vena cava injury underwent conversion to an open procedure, and died 8 days after surgery from a massive cerebral infarction secondary to hypotension. One patient died from massive intra-abdominal bleeding due to a slipped clip on the right branch of the portal vein on postoperative day 6, despite reoperation. One patient died 16 days after operation from liver failure following right trisectionectomy with en bloc resection of segment I and the common bile duct for hilar cholangiocarcinoma. Two patients died from septic complications following endoscopic retrograde cholangiopancreatography (ERCP) for persistent bile leakage. Although all patients (except 1) who died had undergone right-sided hepatectomy and extended resection, no risk factor for mortality could be identified in the univariable analysis.
One hundred patients (54⋅6 per cent) experienced postoperative complications after laparoscopic MH, compared with 16 (57 per cent) in the open group (Table 2). Major complications occurred in 43 patients (23⋅5 per cent) after laparoscopic MH, including biliary leakage in 23 (12⋅6 per cent), liver failure in four (2⋅2 per cent), intra-abdominal abscess in four (2⋅2 per cent), ascites in three (1⋅6 per cent) and intra-abdominal bleeding in two (1⋅1 per cent). Two patients (1⋅1 per cent) had complications related to patient positioning (dropping foot, cervicobrachial neuralgia). Among patients undergoing laparoscopic MH who experienced postoperative major complications, four (2⋅2 per cent) with liver failure were transferred to the intensive care unit (ICU) and three with ascites had percutaneous abdominal paracentesis. Four patients (2⋅2 per cent) underwent ERCP for persistent biliary leakage, and 19 others (10⋅4 per cent) were treated with percutaneous drainage of a postoperative biloma. Two patients (1⋅1 per cent) with intra-abdominal abscesses had both antibiotic therapy and percutaneous drainage. One patient had embolization of a left gastric artery pseudoaneurysm. Six patients (3⋅3 per
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Table 3
T. Nomi, D. Fuks, M. Govindasamy, F. Mal, Y. Nakajima and B. Gayet
Logistic regression analysis of risk factors for postoperative complications Univariable analysis Total (n = 183)*
Age ≥ 75 years Male sex Hypertension Bilobar resection Additional hepatic procedures Radiofrequency ablation Wedge resection Combined resection of adjacent organs Duration of surgery ≥ 250 min Blood loss ≥ 500 ml Intraoperative transfusion Use of Pringle manoeuvre Conversion
Multivariable analysis
No complication (n = 83)*
Complication (n = 100)*
P
29 (15⋅8) 107 (58⋅5) 45 (24⋅6) 41 (22⋅4)
12 (14) 43 (52) 13 (16) 17 (20)
17 (17⋅0) 64 (64⋅0) 32 (32⋅0) 24 (24⋅0)
0⋅688 0⋅101 0⋅015 0⋅597
19 (10⋅4) 40 (21⋅9) 20 (10⋅9) 88 (48⋅1) 47 (25⋅7) 19 (10⋅4) 19 (10⋅4) 21 (11⋅5)
3 (4) 21 (25) 4 (5) 35 (42) 20 (24) 7 (8) 6 (7) 7 (8)
16 (16⋅0) 19 (19⋅0) 16 (16⋅0) 53 (53⋅0) 27 (27⋅0) 12 (12⋅0) 13 (13⋅0) 14 (14⋅0)
0⋅006 0⋅369 0⋅017 0⋅181 0⋅734 0⋅474 0⋅231 0⋅256
Odds ratio†
P
2⋅17 (0⋅96, 4⋅90)
0⋅061
6⋅93 (1⋅49, 32⋅14)
0⋅013
2⋅89 (0⋅70, 11⋅81)
0⋅141
Values in parentheses are *percentages and †95 per cent c.i.
cent) underwent reoperation for bleeding (1 patient), postoperative small bowel obstruction (1), drainage of a diffuse abdominal effusion (2) and unexplained septic shock (2). No differences regarding postoperative outcomes were observed between the laparoscopic and open groups, but biliary leakage was diagnosed significantly later in the laparoscopic compared with the open group (10 versus 7 days respectively; P = 0⋅045). Length of stay was significantly shorter in the laparoscopic group (9 versus 11 days; P = 0⋅005). Hypertension (P = 0⋅015), concomitant RFA (P = 0⋅006) and combined resection of adjacent organs (P = 0⋅017) were associated with postoperative morbidity in univariable analysis (Table 3). Multivariable analysis revealed that only concomitant RFA (odds ratio (OR) 6⋅93, 95 per cent c.i. 1⋅49 to 32⋅14; P = 0⋅013) was an independent risk factor for increased postoperative morbidity. In univariable analysis, hypertension (P = 0⋅013), bilobar resection (P = 0⋅011), intraoperative blood loss greater than 500 ml (P = 0⋅027), intraoperative transfusion (P = 0⋅018) and R1 resection (P = 0⋅027) were associated with major complications. In the multivariable analysis, only intraoperative transfusion (OR 2⋅50, 95 per cent c.i. 1⋅01 to 6⋅23; P = 0⋅049) and bilobar resection (OR 2⋅47, 1⋅00 to 6⋅06; P = 0⋅049) were identified as being independently associated with an increased incidence of major complications. Discussion
This single-centre study reports the results of a large series of purely laparoscopic MH. The procedure appears to be feasible and safe, but caution is justified in bilobar resections. The diffusion of laparoscopic liver resection in the wider surgical community has been slow. The first © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
series of laparoscopic MH, which included 11 left hepatectomies performed with a purely laparoscopic approach, was reported in 199824 . It was nearly 10 years before larger series11,25 reporting more than 100 cases were published. These reports were all multicentre studies with a high proportion of hand-assisted and hybrid liver resections. It is highly likely that purely laparoscopic MH has not been applied worldwide because of the complexity of the procedure and fear of uncontrolled bleeding. Therefore, the 2008 consensus meeting on laparoscopic liver resection9 recommended that this procedure should be performed by surgeons experienced in both open and laparoscopic liver surgery. Indications for laparoscopic MH have slowly expanded since the first purely laparoscopic MH was performed at Institut Mutualiste Montsouris in 1998, and this may be due to the tendency of experienced surgeons to be more liberal in patient selection as time goes by6,10,15 – 18,26 . It has been suggested that laparoscopic MH minimizes the use of the Pringle manoeuvre, and is associated with less blood loss and lower transfusion requirements compared with open MH11,12,27,28 . In the present series, intraoperative characteristics were consistent with those reported previously11 – 13 . Differences in the above characteristics might be attributed to magnification of images, more meticulous dissection and the influence of pneumoperitoneum on blood loss in the laparoscopic approach29 . In the present study, central venous pressure was lowered to maximize the effect of the pneumoperitoneum in reducing bleeding from the hepatic veins26 . Intra-abdominal pressure was maintained at 12 mmHg. Bleeding from small holes in the hepatic veins was usually controlled by bipolar coagulation and compression. Laparoscopic ultrasonography was used to guide the resection plane, www.bjs.co.uk
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and helped to avoid accidental vascular and biliary injuries30 . The main reason for conversion was bleeding31 – 33 , and one patient in the present series died from massive haemorrhage. The rate of conversion to open hepatectomy was 11⋅5 per cent in the present study, similar to that reported previously11,28 . Conversion from laparoscopic to hand-assisted or open liver resection should not be considered a failure, and may help the surgeon to control bleeding. It has been reported34 that both the amount of blood lost and the need for transfusion are related to increased postoperative morbidity. From this perspective, laparoscopic liver resection could help to reduce postoperative morbidity. In addition, the laparoscopic approach results in decreased abdominal wall trauma, as only five or six port incisions are performed and the resected specimen is usually extracted through a Pfannenstiel incision. In this context, decreased postoperative pain and early postoperative rehabilitation may provide improved recovery35 , leading to a reduced length of hospital stay. In the present study, five patients died as a result of postoperative complications, an overall mortality rate of 2⋅7 per cent. In two of these patients, the cause of death could be considered to be related to the laparoscopic approach. The postoperative morbidity rate was 54⋅6 per cent, which was relatively high compared with that reported previously11 – 13 . This high rate may be explained by prospective registration of postoperative complications in the present study. These results might also be explained by patient and surgical characteristics, including patients who underwent more complex procedures (previous hepatectomy, adjacent organ resection, additional procedures on the contralateral liver). Among the 43 patients who developed major complications, the two patient-positioning complications could be related directly to the laparoscopic approach. Additionally, the unexpectedly high rate of postoperative biliary leakage (13⋅1 per cent) may be a consequence of the absence of intraoperative bile leak control and the no-drain policy. From this study, intraoperative bleeding and ablation or resection of tumours in the remnant liver appear to be associated with postoperative complications. Interestingly, intraoperative bleeding has already been identified as a risk factor for postoperative morbidity after laparoscopic MH. In a series of 300 laparoscopic liver resections including 133 laparoscopic MH procedures, Cannon and co-workers25 reported that the need for transfusion was the only independent significant predictor of complications. A study12 of 450 patients who underwent laparoscopic or open MH showed that open hepatectomy, intraoperative blood transfusion and blood loss were all independently
associated with an increased risk of any type of complication. In this setting, more frequent use of vascular clamping might reduce intraoperative blood loss. There are several limitations to the present study. A major limitation relates to the fact that data were collected prospectively and analysed retrospectively over a long study interval. The present study was also limited by the single surgeon’s experience in a specialized laparoscopic centre. The learning curve of a pioneer surgeon with advanced training in complex minimally invasive surgery techniques will be different from that of a novice surgeon36 . However, laparoscopy is becoming increasingly more common, and young surgeons are usually trained in this surgical approach. Therefore, the learning curve for younger surgeons might be reduced theoretically compared with that for surgeons trained in the era of open liver surgery.
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Acknowledgements
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23 Koch M, Garden OJ, Padbury R, Rahbari NN, Adam R, Capussotti L et al. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery 2011; 149: 680–688. 24 Huscher CG, Lirici MM, Chiodini S. Laparoscopic liver resections. Semin Laparosc Surg 1998; 5: 204–210. 25 Cannon RM, Brock GN, Marvin MR, Buell JF. Laparoscopic liver resection: an examination of our first 300 patients. J Am Coll Surg 2011; 213: 501–507. 26 Ishizawa T, Gumbs AA, Kokudo N, Gayet B. Laparoscopic segmentectomy of the liver: from segment I to VIII. Ann Surg 2012; 256: 959–964. 27 Cai XJ, Yang J, Yu H, Liang X, Wang YF, Zhu ZY et al. Clinical study of laparoscopic versus open hepatectomy for malignant liver tumors. Surg Endosc 2008; 22: 2350–2356. 28 Cai XJ, Wang YF, Liang YL, Yu H, Liang X. Laparoscopic left hemihepatectomy: a safety and feasibility study of 19 cases. Surg Endosc 2009; 23: 2556–2562. 29 Kazaryan AM, Marangos IP, Rosok BI, Rosseland AR, Villanger O, Fosse E et al. Laparoscopic resection of colorectal liver metastases: surgical and long-term oncologic outcome. Ann Surg 2010; 252: 1005–1012. 30 Araki K, Conrad C, Ogiso S, Kuwano H, Gayet B. Intraoperative ultrasonography of laparoscopic hepatectomy: key technique for safe liver transection. J Am Coll Surg 2014; 218: e37–e41. 31 Kazaryan AM, Pavlik Marangos I, Rosseland AR, Rosok BI, Mala T, Villanger O et al. Laparoscopic liver resection for malignant and benign lesions: ten-year Norwegian single-center experience. Arch Surg 2010; 145: 34–40. 32 Dagher I, Proske JM, Carloni A, Richa H, Tranchart H, Franco D. Laparoscopic liver resection: results for 70 patients. Surg Endosc 2007; 21: 619–624. 33 Cho JY, Han HS, Yoon YS, Shin SH. Feasibility of laparoscopic liver resection for tumors located in the posterosuperior segments of the liver, with a special reference to overcoming current limitations on tumor location. Surgery 2008; 144: 32–38. 34 Chiappa A, Makuuchi M, Lygidakis NJ, Zbar AP, Chong G, Bertani E et al. The management of colorectal liver metastases: expanding the role of hepatic resection in the age of multimodal therapy. Crit Rev Oncol Hematol 2009; 72: 65–75. 35 Soubrane O, Schwarz L, Cauchy F, Perotto LO, Brustia R, Bernard D et al. A conceptual technique for laparoscopic right hepatectomy based on facts and oncologic principles: the caudal approach. Ann Surg 2014; [Epub ahead of print]. 36 Sudan R, Bennett KM, Jacobs DO, Sudan DL. Multifactorial analysis of the learning curve for robot-assisted laparoscopic biliopancreatic diversion with duodenal switch. Ann Surg 2012; 255: 940–945.
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Copyright of British Journal of Surgery is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Risk factors for complications after laparoscopic major hepatectomy T. Nomi1,2 , D. Fuks1 , M. Govindasamy1 , F. Mal1 , Y. Nakajima2 and B. Gayet1 1 Department
of Digestive Disease, Institut Mutualiste Montsouris, Université Paris Descartes, Paris, France, and 2 Department of Surgery, Nara Medical University, Nara, Japan Correspondence to: Dr B. Gayet, Department of Digestive Disease, Institut Mutualiste Montsouris, Université Paris Descartes, 42 Boulevard Jourdan, 75014 Paris, France (e-mail: [email protected])
Background: Although laparoscopic major hepatectomy (MH) is becoming increasingly common in
several specialized centres, data regarding outcomes are limited. The aim of this study was to identify the risk factors for postoperative complications of purely laparoscopic MH at a single centre. Methods: All patients who underwent purely laparoscopic MH between January 1998 and March 2014 at the authors’ institution were enrolled. Demographic, clinicopathological and perioperative factors were collected prospectively, and data were analysed retrospectively. The dependent variables studied were the occurrence of overall and major complications (Dindo–Clavien grade III or above). Results: A total of 183 patients were enrolled. The types of MH included left-sided hepatectomy in 40 patients (21⋅9 per cent), right-sided hepatectomy in 135 (73⋅8 per cent) and central hepatectomy in eight (4⋅4 per cent). Median duration of surgery was 255 (range 100–540) min, and median blood loss was 280 (10–4500) ml. Complications occurred in 100 patients (54⋅6 per cent), and the 90-day all-cause mortality rate was 2⋅7 per cent. Liver-specific and general complications occurred in 62 (33⋅9 per cent) and 38 (20⋅8 per cent) patients respectively. Multivariable analysis identified one independent risk factor for global postoperative complications: intraoperative simultaneous radiofrequency ablation (RFA) (odds ratio (OR) 6⋅93, 95 per cent c.i. 1⋅49 to 32⋅14; P = 0⋅013). There were two independent risk factors for major complications: intraoperative blood transfusion (OR 2⋅50, 1⋅01 to 6⋅23; P = 0⋅049) and bilobar resection (OR 2⋅47, 1⋅00 to 6⋅06; P = 0⋅049). Conclusion: Purely laparoscopic MH is feasible and safe. Simultaneous RFA and bilobar resection should probably be avoided. Paper accepted 29 October 2014 Published online 17 December 2014 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9726
Introduction
Since the first successful report1 of laparoscopic liver wedge resection in 1991, laparoscopic liver resection has progressively gained popularity. For minor liver resections, comparative studies2 – 5 between open and laparoscopic procedures have shown that laparoscopic liver resection resulted in decreased intraoperative bleeding, fewer complications and shorter postoperative hospital stays. Moreover, the oncological outcomes are comparable for patients undergoing laparoscopic minor liver resection compared with those having open hepatectomy for hepatocellular carcinoma and colorectal cancer liver metastases2,6 – 8 . In contrast, the progress of laparoscopic major hepatectomy (MH) has been very slow worldwide because of its inherent technical difficulties. Buell and colleagues9 reported © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
at the Louisville Consensus Conference that laparoscopic MH should be performed only by experienced hepatobiliary surgeons with advanced laparoscopic skills. Over the past few years, technological and instrumental improvements have resulted in several centres10 – 13 reporting good results after laparoscopic MH. The present study aimed to identify the risk factors for postoperative complications of purely laparoscopic MH at a single centre. Methods
Data for consecutive patients who had purely laparoscopic MH between January 1998 and March 2014 at the Institut Mutualiste Montsouris, Paris, France, were retrieved retrospectively from a prospectively collected computer database of all patients who had undergone laparoscopic BJS 2015; 102: 254–260
Risk factors for complications after laparoscopic major hepatectomy
hepatectomy. MH was defined as the resection of three or more contiguous Couinaud segments. The decision to perform laparoscopic MH was made by the hepatobiliary multidisciplinary team, which included surgeons, pathologists, oncologists, gastroenterologists and radiologists at the authors’ institution.
Preoperative evaluation Preoperative investigations included blood and liver function tests as well as routine cardiorespiratory evaluations. CT and MRI were performed during the later years of the study to assess both underlying liver and tumour characteristics. Initially, a preoperative percutaneous biopsy of the non-tumorous parenchyma was performed on a case-by-case basis. If severe fibrosis or cirrhosis was suspected, patients under consideration for major resection underwent portal vein embolization (PVE)14 when the volume of the future remnant liver was 25 per cent or less in non-cirrhotic livers and 40 per cent or less in cirrhotic livers.
Surgical procedures All resections were performed with curative intent, and were performed by a single surgeon. The operative procedure, including the position of trocars, has been described previously10,15 – 18 . Briefly, for all right-sided hepatectomies, including right hemihepatectomy, right hemihepatectomy with resection of segment I and right trisectionectomy (right hemiliver plus left medial section)19 , the patient was placed in the supine position, in a slightly reverse-Trendelenburg orientation. Intra-abdominal pressure was maintained at 12 mmHg. Resectability was always confirmed by intraoperative ultrasonography. The cystic duct and artery were divided but the gallbladder was not removed, to allow for its use as a handle for retraction. Starting from the junction of the cystic and common hepatic duct, the portal vein was dissected in a cephalic direction with routine lymphadenectomy of the hepatoduodenal ligament. Following the common bile duct to the confluence of the right and left hepatic ducts, Glisson’s capsule was incised. The biliary convergence was then gently retracted medially to expose the right hepatic artery, which was clipped and divided. The portal vein was mobilized up to the bifurcation of the right and left portal veins. The right trunk was dissected for 1–2 cm; the portal vein to the other side was clearly identified and then the right portal vein was either clipped or stapled. The hilar plate was lowered to allow safe dissection and division of the right hepatic duct above the biliary © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
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convergence. The right hepatic duct was either clipped or suture-ligated before transection, if visualized clearly. Parenchymal division was initiated along the demarcated line. For all procedures, tissue dissection and haemostasis were performed using an ultrasonic dissector, primarily SonoSurg® or Thunderbeat® (Olympus, Tokyo, Japan) or HARMONIC™ (Ethicon Endo-Surgery, Cincinnati, Ohio, USA); the Gayet bipolar forceps (MicroFrance CEV134; Medtronic, Minneapolis, Minnesota, USA) provided retraction and rescue haemostasis. Bleeding from small holes in the hepatic veins was usually controlled by instantaneous bipolar coagulation and/or compression. The branches of the middle hepatic vein from segment V to segment VIII were ligated when exposed. In the anterior approach, the inferior vena cava was dissected in a caudal to cephalic direction. The right hepatic vein was dissected free and then sectioned with an endoscopic vascular stapler. Finally, the resection specimen was extracted in a plastic retrieval bag through a suprapubic incision. Drains were used only if there was concern about intraoperative control of biliary tree radicals or adequacy of haemostasis. In principle, a left-sided hepatectomy was done using the same procedure as the right-sided hepatectomy described above, except for the mobilization. Methylene blue injection through the cystic drain was not performed routinely. All intraoperative parameters, including type and duration of vascular clamping, blood loss with subsequent intraoperative blood transfusion and duration of surgery, were recorded.
Postoperative outcomes Postoperative complications after laparoscopic MH were compared with those observed after MH performed by upfront laparotomy during the study period. These complications were stratified according to the Dindo–Clavien classification20 ; major complications were defined as those with grade III or above. If a patient had two or more complications, the most severe was taken into account. Liver-specific complications commonly encountered after major liver procedures were detailed as follows: liver failure was defined according to the ‘50–50 criteria’ on postoperative day 521 ; ascites was defined as abdominal drainage output of more than 10 ml per kg per day after the third postoperative day22 ; and biliary leakage was defined by a bilirubin concentration in the drainage fluid more than threefold that in serum23 . Complications and operative mortality considered were those that occurred within 90 days of surgery, or at any time during the postoperative hospital stay. The pathological surgical margin was defined as either microscopically positive (R1) or negative (R0). www.bjs.co.uk
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Statistical analysis Baseline patient characteristics were expressed as median (range) for continuous data and as numbers with percentages for categorical data. Preoperative, operative and postoperative characteristics were compared according to the presence of a complication or major complication. Fisher’s exact test was used to compare differences in categorical variables, and the Wilcoxon rank sum test for continuous variables. Variables with statistical significance at the 0⋅100 level in univariable analysis were considered for multivariable analysis. A backward variable procedure was used to identify the independent predictive factors. Because of the small number of events, a multivariable analysis of risk factors for mortality was not conducted. All statistical analyses were performed using SPSS® for Windows® version 18.0 (IBM, Armonk, New York, USA), and statistical significance was accepted at the 0⋅050 level. Results
Among the 183 patients enrolled in the study, there were 107 men (58⋅5 per cent) and 76 women (41⋅5 per cent) with a median age of 64 (range 24–86) years (Table 1). Thirty-six patients (19⋅7 per cent) wese classified as having American Society of Anesthesiologists fitness grade III. The indication for hepatectomy was malignancy in 166 patients (90⋅7 per cent) and benign disease in 17. Some 114 patients (62⋅3 per cent) had undergone previous abdominal surgery, including 31 (16⋅9 per cent) with a previous hepatectomy. Preoperative portal vein embolization was performed in 32 patients (17⋅5 per cent) because of anticipated insufficient volume of the future remnant liver. Of 123 patients treated for colorectal liver metastases, 80 (65⋅0 per cent) had received preoperative chemotherapy.
Surgical procedures and pathological specimen The intraoperative characteristics of the patients are summarized in Table 1. The types of MH included left-sided hepatectomy in 40 patients (21⋅9 per cent), right-sided hepatectomy in 135 (73⋅8 per cent) and central hepatectomy in eight (4⋅4 per cent). Intermittent vascular inflow clamping was required in 19 patients (10⋅4 per cent). Additional wedge resection in the contralateral liver was performed in 40 patients (21⋅9 per cent), and 19 (10⋅4 per cent) had intraoperative radiofrequency ablation. Median duration of surgery was 255 (range 100–540) min. Concomitant extrahepatic resection was performed in 20 patients (10⋅9 per cent). Transfusion was required during surgery in 19 patients (10⋅4 per cent). There were 21 (11⋅5 per cent) © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
T. Nomi, D. Fuks, M. Govindasamy, F. Mal, Y. Nakajima and B. Gayet
Preoperative and intraoperative characteristics of 183 patients undergoing major laparoscopic liver resection
Table 1
No. of patients (n = 183) Age (years)* Sex ratio (M : F) Body mass index (kg/m2 )* ASA fitness grade I II III Co-morbidities Diabetes mellitus Cardiopulmonary Hypertension Hyperlipidaemia Hepatitis B or C Alcohol abuse Smoking Diagnosis HCC Cholangiocarcinoma Colorectal carcinoma metastases Non-colorectal carcinoma metastases Benign Extent of liver resection Left hepatectomy Right hepatectomy Left trisectionectomy Right trisectionectomy Central hepatectomy Bilobar resection Combined resection of adjacent organs Diaphragm Common bile duct Inferior vena cava Adrenal gland Kidney Colon Pancreas Duodenum Blood loss (ml)* Drain
64 (24–86) 107 : 76 24⋅3 (15⋅9–35⋅5) 42 105 36 13 (7⋅1) 33 (18⋅0) 45 (24⋅6) 32 (17⋅5) 8 (4⋅4) 33 (18⋅0) 51 (27⋅9) 20 (10⋅9) 18 (9⋅8) 123 (67⋅2) 5 (2⋅7) 17 (9⋅3) 29 (15⋅8) 122 (66⋅7) 11 (6⋅0) 13 (7⋅1) 8 (4⋅4) 41 (22⋅4) 20 (10⋅9) 7 (3⋅8) 6 (3⋅3) 2 (1⋅1) 1 (0⋅5) 1 (0⋅5) 1 (0⋅5) 1 (0⋅5) 1 (0⋅5) 280 (10–4500) 42 (23⋅0)
Values in parentheses are percentages unless indicated otherwise; *values are median (range). ASA, American Society of Anesthesiologists; HCC, hepatocellular carcinoma.
conversions to an open procedure, for intraoperative bleeding in 12 patients. None of the 183 patients had evidence of gas embolism. Based on pathology evaluation of the specimens, the median number of tumours was 2⋅0 (range 1–25), and the median size of resected tumours was 40⋅1 (5–170) mm. The median surgical margin was 5 (0–5) mm. R0 resection was achieved in 177 patients (96⋅7 per cent), and six (3⋅3 per cent) had microscopically incomplete resection. No patient had macroscopically incomplete resection. www.bjs.co.uk
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Table 2
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Postoperative results for patients undergoing purely open versus laparoscopic major hepatectomy Open major hepatectomy (n = 28)
Laparoscopic major hepatectomy (n = 183)
P*
1 (4) 16 (57) 8 (29) 2 (7) 1 (4) 3 (11) 1 (4) 1 (4) 8 (29) 1 (4) 0 (0) 4 (14) 1 (4) 0 (0) 2 (7) 7 (25) 1 (4) 1 (4) 2 (7) 0 (0) 1 (1) 2 (7) 0 (0) 0 (0) 0 (0) 7 4 0 2 1
5 (2⋅7) 100 (54⋅6) 62 (33⋅9) 20 (10⋅9) 6 (3⋅3) 24 (13⋅1) 10 (5⋅5) 2 (1⋅1) 38 (20⋅8) 6 (3⋅3) 3 (1⋅6) 13 (7⋅1) 1 (0⋅5) 3 (1⋅6) 12 (6⋅6) 43 (23⋅5) 4 (2⋅2) 3 (1⋅6) 23 (12⋅6) 4 (2⋅2) 2 (1⋅1) 3 (1⋅6) 1 (0⋅5) 1 (0⋅5) 2 (1⋅1) 43 23 4 6 10
0⋅579 0⋅841 0⋅699 0⋅745 1⋅000 1⋅000 1⋅000 0⋅349 0⋅336 1⋅000 1⋅000 0⋅252 0⋅248 1⋅000 1⋅000 0⋅815 0⋅512 0⋅436 0⋅102 1⋅000 0⋅349 0⋅131 1⋅000 1⋅000 1⋅000 1⋅000 1⋅000 1⋅000 0⋅309 1⋅000
Mortality Morbidity Liver-specific morbidity Liver failure Ascites Biliary leakage Intra-abdominal abscess Intra-abdominal bleeding General morbidity Fever Leucocytosis Pulmonary Cardiac Neurological Other Major morbidity (Dindo–Clavien grade ≥ III) Liver failure Ascites Biliary leakage Intra-abdominal abscess Intra-abdominal bleeding Pleural effusion Small bowel obstruction Septic shock Patient positioning complications Treatment of major complications Percutaneous drainage Interventional endoscopy Reoperation (open) Other
Values in parentheses are percentages. *Fisher’s exact test.
Postoperative mortality
Postoperative morbidity
Five patients (2⋅7 per cent) died in the postoperative period (Table 2). The indication for hepatic resection had been HCC in two patients who died, hilar cholangiocarcinoma in one, colorectal cancer metastases in one, and gallbladder cancer in one. Three patients had underlying liver disease (1 cirrhosis, 1 steatosis, 1 cholestasis). One patient with cirrhosis and inferior vena cava injury underwent conversion to an open procedure, and died 8 days after surgery from a massive cerebral infarction secondary to hypotension. One patient died from massive intra-abdominal bleeding due to a slipped clip on the right branch of the portal vein on postoperative day 6, despite reoperation. One patient died 16 days after operation from liver failure following right trisectionectomy with en bloc resection of segment I and the common bile duct for hilar cholangiocarcinoma. Two patients died from septic complications following endoscopic retrograde cholangiopancreatography (ERCP) for persistent bile leakage. Although all patients (except 1) who died had undergone right-sided hepatectomy and extended resection, no risk factor for mortality could be identified in the univariable analysis.
One hundred patients (54⋅6 per cent) experienced postoperative complications after laparoscopic MH, compared with 16 (57 per cent) in the open group (Table 2). Major complications occurred in 43 patients (23⋅5 per cent) after laparoscopic MH, including biliary leakage in 23 (12⋅6 per cent), liver failure in four (2⋅2 per cent), intra-abdominal abscess in four (2⋅2 per cent), ascites in three (1⋅6 per cent) and intra-abdominal bleeding in two (1⋅1 per cent). Two patients (1⋅1 per cent) had complications related to patient positioning (dropping foot, cervicobrachial neuralgia). Among patients undergoing laparoscopic MH who experienced postoperative major complications, four (2⋅2 per cent) with liver failure were transferred to the intensive care unit (ICU) and three with ascites had percutaneous abdominal paracentesis. Four patients (2⋅2 per cent) underwent ERCP for persistent biliary leakage, and 19 others (10⋅4 per cent) were treated with percutaneous drainage of a postoperative biloma. Two patients (1⋅1 per cent) with intra-abdominal abscesses had both antibiotic therapy and percutaneous drainage. One patient had embolization of a left gastric artery pseudoaneurysm. Six patients (3⋅3 per
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Table 3
T. Nomi, D. Fuks, M. Govindasamy, F. Mal, Y. Nakajima and B. Gayet
Logistic regression analysis of risk factors for postoperative complications Univariable analysis Total (n = 183)*
Age ≥ 75 years Male sex Hypertension Bilobar resection Additional hepatic procedures Radiofrequency ablation Wedge resection Combined resection of adjacent organs Duration of surgery ≥ 250 min Blood loss ≥ 500 ml Intraoperative transfusion Use of Pringle manoeuvre Conversion
Multivariable analysis
No complication (n = 83)*
Complication (n = 100)*
P
29 (15⋅8) 107 (58⋅5) 45 (24⋅6) 41 (22⋅4)
12 (14) 43 (52) 13 (16) 17 (20)
17 (17⋅0) 64 (64⋅0) 32 (32⋅0) 24 (24⋅0)
0⋅688 0⋅101 0⋅015 0⋅597
19 (10⋅4) 40 (21⋅9) 20 (10⋅9) 88 (48⋅1) 47 (25⋅7) 19 (10⋅4) 19 (10⋅4) 21 (11⋅5)
3 (4) 21 (25) 4 (5) 35 (42) 20 (24) 7 (8) 6 (7) 7 (8)
16 (16⋅0) 19 (19⋅0) 16 (16⋅0) 53 (53⋅0) 27 (27⋅0) 12 (12⋅0) 13 (13⋅0) 14 (14⋅0)
0⋅006 0⋅369 0⋅017 0⋅181 0⋅734 0⋅474 0⋅231 0⋅256
Odds ratio†
P
2⋅17 (0⋅96, 4⋅90)
0⋅061
6⋅93 (1⋅49, 32⋅14)
0⋅013
2⋅89 (0⋅70, 11⋅81)
0⋅141
Values in parentheses are *percentages and †95 per cent c.i.
cent) underwent reoperation for bleeding (1 patient), postoperative small bowel obstruction (1), drainage of a diffuse abdominal effusion (2) and unexplained septic shock (2). No differences regarding postoperative outcomes were observed between the laparoscopic and open groups, but biliary leakage was diagnosed significantly later in the laparoscopic compared with the open group (10 versus 7 days respectively; P = 0⋅045). Length of stay was significantly shorter in the laparoscopic group (9 versus 11 days; P = 0⋅005). Hypertension (P = 0⋅015), concomitant RFA (P = 0⋅006) and combined resection of adjacent organs (P = 0⋅017) were associated with postoperative morbidity in univariable analysis (Table 3). Multivariable analysis revealed that only concomitant RFA (odds ratio (OR) 6⋅93, 95 per cent c.i. 1⋅49 to 32⋅14; P = 0⋅013) was an independent risk factor for increased postoperative morbidity. In univariable analysis, hypertension (P = 0⋅013), bilobar resection (P = 0⋅011), intraoperative blood loss greater than 500 ml (P = 0⋅027), intraoperative transfusion (P = 0⋅018) and R1 resection (P = 0⋅027) were associated with major complications. In the multivariable analysis, only intraoperative transfusion (OR 2⋅50, 95 per cent c.i. 1⋅01 to 6⋅23; P = 0⋅049) and bilobar resection (OR 2⋅47, 1⋅00 to 6⋅06; P = 0⋅049) were identified as being independently associated with an increased incidence of major complications. Discussion
This single-centre study reports the results of a large series of purely laparoscopic MH. The procedure appears to be feasible and safe, but caution is justified in bilobar resections. The diffusion of laparoscopic liver resection in the wider surgical community has been slow. The first © 2014 BJS Society Ltd Published by John Wiley & Sons Ltd
series of laparoscopic MH, which included 11 left hepatectomies performed with a purely laparoscopic approach, was reported in 199824 . It was nearly 10 years before larger series11,25 reporting more than 100 cases were published. These reports were all multicentre studies with a high proportion of hand-assisted and hybrid liver resections. It is highly likely that purely laparoscopic MH has not been applied worldwide because of the complexity of the procedure and fear of uncontrolled bleeding. Therefore, the 2008 consensus meeting on laparoscopic liver resection9 recommended that this procedure should be performed by surgeons experienced in both open and laparoscopic liver surgery. Indications for laparoscopic MH have slowly expanded since the first purely laparoscopic MH was performed at Institut Mutualiste Montsouris in 1998, and this may be due to the tendency of experienced surgeons to be more liberal in patient selection as time goes by6,10,15 – 18,26 . It has been suggested that laparoscopic MH minimizes the use of the Pringle manoeuvre, and is associated with less blood loss and lower transfusion requirements compared with open MH11,12,27,28 . In the present series, intraoperative characteristics were consistent with those reported previously11 – 13 . Differences in the above characteristics might be attributed to magnification of images, more meticulous dissection and the influence of pneumoperitoneum on blood loss in the laparoscopic approach29 . In the present study, central venous pressure was lowered to maximize the effect of the pneumoperitoneum in reducing bleeding from the hepatic veins26 . Intra-abdominal pressure was maintained at 12 mmHg. Bleeding from small holes in the hepatic veins was usually controlled by bipolar coagulation and compression. Laparoscopic ultrasonography was used to guide the resection plane, www.bjs.co.uk
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and helped to avoid accidental vascular and biliary injuries30 . The main reason for conversion was bleeding31 – 33 , and one patient in the present series died from massive haemorrhage. The rate of conversion to open hepatectomy was 11⋅5 per cent in the present study, similar to that reported previously11,28 . Conversion from laparoscopic to hand-assisted or open liver resection should not be considered a failure, and may help the surgeon to control bleeding. It has been reported34 that both the amount of blood lost and the need for transfusion are related to increased postoperative morbidity. From this perspective, laparoscopic liver resection could help to reduce postoperative morbidity. In addition, the laparoscopic approach results in decreased abdominal wall trauma, as only five or six port incisions are performed and the resected specimen is usually extracted through a Pfannenstiel incision. In this context, decreased postoperative pain and early postoperative rehabilitation may provide improved recovery35 , leading to a reduced length of hospital stay. In the present study, five patients died as a result of postoperative complications, an overall mortality rate of 2⋅7 per cent. In two of these patients, the cause of death could be considered to be related to the laparoscopic approach. The postoperative morbidity rate was 54⋅6 per cent, which was relatively high compared with that reported previously11 – 13 . This high rate may be explained by prospective registration of postoperative complications in the present study. These results might also be explained by patient and surgical characteristics, including patients who underwent more complex procedures (previous hepatectomy, adjacent organ resection, additional procedures on the contralateral liver). Among the 43 patients who developed major complications, the two patient-positioning complications could be related directly to the laparoscopic approach. Additionally, the unexpectedly high rate of postoperative biliary leakage (13⋅1 per cent) may be a consequence of the absence of intraoperative bile leak control and the no-drain policy. From this study, intraoperative bleeding and ablation or resection of tumours in the remnant liver appear to be associated with postoperative complications. Interestingly, intraoperative bleeding has already been identified as a risk factor for postoperative morbidity after laparoscopic MH. In a series of 300 laparoscopic liver resections including 133 laparoscopic MH procedures, Cannon and co-workers25 reported that the need for transfusion was the only independent significant predictor of complications. A study12 of 450 patients who underwent laparoscopic or open MH showed that open hepatectomy, intraoperative blood transfusion and blood loss were all independently
associated with an increased risk of any type of complication. In this setting, more frequent use of vascular clamping might reduce intraoperative blood loss. There are several limitations to the present study. A major limitation relates to the fact that data were collected prospectively and analysed retrospectively over a long study interval. The present study was also limited by the single surgeon’s experience in a specialized laparoscopic centre. The learning curve of a pioneer surgeon with advanced training in complex minimally invasive surgery techniques will be different from that of a novice surgeon36 . However, laparoscopy is becoming increasingly more common, and young surgeons are usually trained in this surgical approach. Therefore, the learning curve for younger surgeons might be reduced theoretically compared with that for surgeons trained in the era of open liver surgery.
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Acknowledgements
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