Laparoscopic Liver Resection : What to do and not do - Pr Daniel CH...

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Pr. Daniel Cherqui
Centre Hépatobiliaire
Hôpital Paul Brousse - Université Paris Sud
Villejuif, France
Laparoscopic Liver ...

Limitations of Laparoscopic Liver Resection
!  Tumor
-  Size: Mobilization, Vascular connexions, Margin, Extraction
-  Loc...

Requirements
!  LLR is liver surgery done by a different approach
" It must be based on a strong open hepatic surgery back...

Ann Surg 2016

Procedure N %
Minor (≤ 2 segments) 6707 70
Major (≥ 3 segments) 2305 24
Complex (Anatomical
Segment, Biseg)
1762 18
Ciria ...

Pathology N %
Malignant 6190 65
HCC 3072 50
CRLM 1582 25
Others 1531 25

Pathology N %
Benign 3337 35
Unspecified 806 24
IH Lithiasis 761 22
Cysts 388 11
FNH 326 9
Hemangioma 275 8
Adenoma 205 6
...

●  Single Center Open vs laparoscopic parenchymal sparing non anatomical (major
excluded) resection for CRLM
–  280 patien...

1. SHORT TERM OUTCOMES
" MINOR LLR: standard practice
•  IDEAL 3: adopted by an increasing proportion of surgeons
•  Recog...

Recommendations

Cherqui et al. Ann Surg 2000

IWATE Criteria
Difficulty index 0 1 2 3 4 5 6 7 8 9 10 11 12
Difficulty level Low Intermediate Advanced ...

ee
Wedge
Ante
Wedge
Post
Left
lateral
Seg
Ant
Left
Hep
SegPost
Right
Hep
Ex-
Right
Hep
Right
post
Central
Hep
Ex-Left
Hep
...

Conversion is not a failure…
but it has a cost

Risk factors and consequences of conversion in laparoscopic
major liver resection
F. Cauchy1,3, D. Fuks2, T. Nomi2, L. Sch...

Conversion for Unfavorable Intraoperative Events Results in
Significantly Worst Outcomes During Laparoscopic
Liver Resecti...

Conversion for Unfavorable Intraoperative Events Results in
Significantly Worst Outcomes During Laparoscopic
Liver Resecti...

Not for all patients
Proportion varies among centers and surgeons
-  Range: 25 – 95%
-  Personal: 42%
58% HCC
35% CRLM

!  By pathology
# HCC The best indication
# Colorectal mets The second best indication
# Benign No extension of indication...

Laparoscopic Liver Resection: Evolution of Indications
Courtesy of Han HS presented at the Morioka Consensus
October 2014

Lap Liver: HCC vs CRLM
HCC CR Mets
Solitary early tumors (surveillance) Often Multiple and Bilobar
No primary tumor Manage...

Laparoscopic liver resection for HCC

Forest plots of the in-
s of postoperative as-
d liver failure. Forest
ﬂecting (a) the inci-
of postoperative asci-
n from...

Ann Surg 2018
Reduced morbidity (CCI) and hospital stay

Laparoscopic liver resection for CRLM

Laparoscopic Versus Open Resection for Colorectal
Liver Metastases
The OSLO-COMET Randomized Controlled Trial
d Avdem Fret...

Laparoscopic hepatectomy signiﬁcantly shortens the time to
postoperative chemotherapy in patients undergoing major
hepatec...

Bilobar disease: intraoperative decisions

Benign disease
$  Do not change the indications because of laparoscopy
$  No indication in harmless asymptomatic FNH and
h...

Benign symptomatic lesions in young women
No Lap

Harmless asymptomatic well characterized lesions
NO SURGERY

Adenoma 5 cm
Lap Resection

Symptomatic FNH
Lap Resection

Intrahepatic Cholangiocarcinoma
!  Large infiltrating tumor, large resection
!  Prognosis depends on margins and lymph nod...

Perihilar Cholangiocarcinoma
!  Small tumor, small margin, large resection
!  Prognosis depends on margins and lymph node ...

Large Tumors
Lap OK
Caution
Open

Complex vascular connections
No Lap

!  By pathology
# HCC
# Colorectal mets
# Benign
# Cholangiocarcinoma
!  By procedure
# Minor
# Major
# Complex
What to do

!  State of the art facilities and equipment
Technical Requirement

!  Complete set of instruments and devices
Technical Requirement
86% of 5202 donor hepatectomies use CUSA
Rössler et al An...

Precise transection technique

Pringle Maneuver

Left Lateral Section
A well standardized procedure

Patient position
Port placement

Major Hepatectomy

Right Hepatectomy
Left Hepatectomy

A Conceptual Technique for Laparoscopic Right Hepatectomy
Based on Facts and Oncologic Principles
The Caudal Approach
Oliv...

The difficult locations

Partial Lateral Decubitus

Glissonian approach for anatomic resections

Full Lateral Decubitus

Full Lateral Decubitus

Diagnosis Count %
Colorectal liver metastasis 109 27.3%
Hepatocellular carcinoma
97 24.3%
Benign lesions 64 16,...

Lap vs Open
Open Laparoscopic or Hybrid Approach
Open Laparoscopic Hybrid
Count % Count % Count %
218 54,5% 17...

Evolution over time

Proportion of lap per procedure

Proportion of lap per procedure

Proportion of lap per diagnosis

Conversion to open
Global rate 14/170= 8%

Laparoscopic surgery: Bleeding and Transfusion

Operative bleeding (cc) Transfusion (RBC)
Mean (range) Mean (range)

...

Morbidity and severe morbidity (Clavien-Dindo ≥III)

Open or Laparoscopic Approach
Open Laparoscopic
Count % Count ...

Severe complications / conversion

What to (and not to do)
Keep in mind
- Patient safety
- Personal experience
- Oncologic principles and indications
- Avoid...

Preoperative assessment
$  First question
–  Indication for resection
$  Second question
–  Type of resection
»  Anatomic ...

Lap vs Open
$ Surgeon’s experience
-  Step by step progression with increasing complexity
- Preoperative planning

Lap vs Open
$ Surgeon’s experience
- Step by step progression with increasing complexity
- Preoperative planning
$ Diagnos...

Evoluting field
What to do will be different tomorrow
Primary goal:
Meaningful improvement in patient care

Laparoscopic Liver Resection : What to do and not do - Pr Daniel CHERQUI

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