The Role of Laparoscopy in Advanced Liver Disease

Fig. 19.1

Intraoperative view of laparoscopic ultrasound evaluation in a case of multiple bilateral metastases

Tumor Ablation

The LUS can be used as a guidance method to perform radiofrequency ablation (RFA) or microwave ablation of liver metastases. The main advantage of this approach over the percutaneous approach is the possibility of treating tumors in challenging locations, such as those in close proximity to adjacent organs (contact with the colon, duodenum, stomach, and kidneys) or located in the dome of the right hemiliver. A more accurate ablation needle placement explains the lower recurrence rate when compared with the percutaneous approach. However, this approach has very selected indications, mainly in cases where liver resections are contraindicated. Tumor size is the main limitation for this local treatment modality, with proved lower efficacy for lesions larger than 3 cm [7].

Laparoscopic Liver Resections (LLRs)

A steady and sustainable global diffusion of LLRs has occurred since the first international consensus conference in 2008 [1]. Despite the number of publications having increased in the last years, the level of evidence is still low and based on retrospective comparative series. Prospective randomized trials have not been published yet. Patients with CLM represent the main indication for LLRs in Western countries, in contrast with hepatocellular carcinoma in Eastern countries [8]. In our own series of 109 LLRs, 44% of the cases were CLM [9].

At the First International Consensus Conference on laparoscopic liver surgery held in Louisville (USA) in 2008, indications for LLRs were well defined [1]. During the Second Consensus Conference in Morioka (Japan) in October 2014, indications were extended regardless of the type, number, and localization of the metastases [8]. At the beginning, the ideal cases were those with small metastatic lesions in the anterior segments of the liver (II, III, IVB, V, VI) (Fig. 19.2). In recent years, indications progressed to the “deep, posterior, or complex” segments (I, IVA, VII y VIII). The LLRs in this last group are considered major liver resections not due to the amount of parenchyma resected nor the risk of postoperative liver failure, but due to their anatomical relationship with main vascular structures and the risk of intraoperative severe hemorrhagic complications [10]. The laparoscopic approach of liver resections has some technical advantages over open surgery: excellent visibility of vascular pedicles, the magnification provides an optimal view of the parenchymal transection, and the pneumoperitoneum pressure reduces bleedings from the hepatic veins [2, 8, 11] (Fig. 19.3). The applicability of the laparoscopic approach for liver resections is variable and related mainly to the type of patients managed at each center, the expertise of the team, and the confidence with the approach. As an example, the rate of LLRs was 19% in the Henri Mondor Hospital series of 2009, 46.5% at the Institut Mutualiste Montsouris in 2006, and passed from 10 to 80% of all liver resections at the Northwestern University of Chicago between 2001 and 2006 [12–14]. In our own series, the applicability was initially 5.2% and it increased to 20% during 2014 [9].

Fig. 19.2

(a) Colorectal cancer metastases in segment 5 of the liver. (b) Transection line after laparoscopic resection

Fig. 19.3

Left hepatic pedicle. Arterial branches were clipped and transected. Left portal branch is mobilized with right angle forceps

For LLRs, four different techniques can be used: totally laparoscopic, hand-assisted, hybrid, and robotic-assisted techniques.

In the totally laparoscopic technique, all the procedure is done by laparoscopy and an abdominal incision (for example a Pfannestield incision) is performed at the end of the procedure only to remove the specimen [1, 8].
In the hand-assisted technique, a hand is introduced in the abdomen through a special device that prevents losing pneumoperitoneum. This approach is useful at the beginning of the experience and in cases with tumors located in posterior segments of the liver [1, 8].
In the hybrid technique, part of the procedure (i.e., pedicle dissection) is carried out by laparoscopy, and after that a limited abdominal incision is performed to complete the surgery (i.e., parenchymal transection and specimen removal). This approach is helpful at the beginning of the experience with major LLRs [1, 8].
In robotic-assisted LLR, the robot technology is used in some technical steps of the procedure. The advantages of the robot are safe dissection of the pedicle, and ergonomic benefits for the surgeon. However, it has not shown any clinical advantages when compared to classical LLRs. High costs related to the robotic technology are still an issue to be discussed [2, 8].

Surgical Technique

The technique depends on each surgical group. The laparoscopic devices should be placed following the principles of laparoscopic surgery, thus the surgeon standing in front of the site of the lesion to be resected. Some surgeons prefer to stay between the legs of the patients (“French position”). For right LLRs, intermediate left later decubitus is recommended. For all the other LLRs, the patient should be positioned in supine decubitus. The trocar placement sites rely on the location of the tumors (Fig. 19.4). Reverse Trendelenburg’s position, near-zero central venous pressure (CVP), and increased pneumoperitoneum pressure (16 mmHg) are recommended for LLRs [2, 11–13, 15, 16].

Fig. 19.4

Trocar placement for right liver resection. The forceps is clamping the tourniquet for percutaneous Pringle maneuver

Nowadays, it is possible to perform almost all types of minor and major LLRs (according to the expertise of the surgical team), for example: staged liver resections, simultaneous colorrectal and liver resections, and ALPPS [2, 11–13, 15–17]. In Fig. 19.5, a step-by-step evolution in the complexity of LLRs is represented.

Fig. 19.5

A step-by-step evolution in the complexity of LLRs

The transection of the liver parenchyma is still a topic of discussion and is the most challenging step in LLRs, mainly in the case of major resections. There are basically two ways to transect liver: sharp dissection with an ultrasonic dissector (CUSA^®) combined with bipolar energy devices, or energy sealant devices (Ligasure^®, Ultracision^®) combined with vascular staplers. The main purpose of the devices designed for this procedure is to avoid bleeding. In our institution, the preferred strategy is the use of energy devices (Ultracision^®) combined with vascular staplers (Figs. 19.6, 19.7, 19.8, and 19.9). The principal disadvantages to this technique are higher costs and a less refined anatomical dissection. The use of ultrasonic dissector (CUSA^®) combined with bipolar energy is the other possible technique, and it is employed mainly in France and Asia. The principal disadvantage of this approach is a longer operative time [16]. In order to reduce blood loss, the vascular pedicle of the liver can be clamped as it is done in open surgery. Intermittent clamping (Pringle maneuver) is employed more frequently at the beginning of the experience [2, 8, 12] (Fig. 19.10). When performing anatomic major liver resections, the right or left vasculo-biliary elements are dissected and individually controlled using either vascular staplers (white cartridge) or locking ligation systems such as Hem-o-lok clips (Figs. 19.11 and 19.12). The control and transection of the hepatic veins is one of the most challenging steps of the procedure, due to the possibility of gas embolism and massive bleeding. Vascular staplers (white cartridge) are usually employed by most surgeons [2, 8, 12, 16] (Fig. 19.13).