Laparoscopic liver surgery is a safe and effective approach to the management of surgical liver disease in the hands of trained surgeons with experience in hepatobiliary and laparoscopic surgery. National and international societies, as well as governing boards, should become involved in the goal of establishing training standards and credentialing, to ensure consistent standards and clinical outcomes.

No abstract

Background: The laparoscopic approach in distal pancreatectomy is associated with higher rates of splenic preservation compared to open surgery. Although favorable postoperative short-term outcomes have been reported in open spleen-preserving distal pancreatectomy compared with distal pancreatectomy with splenectomy, it is unclear whether this observation applies to the laparoscopic approach. The aim of this study is to compare laparoscopic spleen preserving distal pancreatectomy (LSPDP) with laparoscopic distal pancreatectomy with splenectomy (LDPS), using propensity score matching. Methods: This is a UK wide, propensity score matched study, including all patients who underwent LSPDP or LDPS between 2006 and 2016. Patients were categorized according to intention to treat. Subsequently, propensity score matching was applied and short-term outcomes were compared between LSPDP and LDPS. Additionally, risk factors for unplanned splenectomy were explored. Results: 456 patients were included from eleven centers (229 LSPDP and 227 LDPS). The mean age of the cohort was 56AE16 years and 293 (64%) were female. The most common histopathologic diagnoses were neuroendocrine tumor (NET), Mucinous Cystic Neoplasm (MCN) and Intraductal Papillary Mucinous Neoplasm (IPMN). Splenic preservation was achieved in 184 (80%) of the attempted LSPDP. We were able to match 173 LSPDP cases to 173 LDPS cases. After matching, the groups were well balanced in terms of tumor size, age and sex. No differences were seen in postoperative morbidity between the groups. The only identified risk factor for unplanned splenectomy was tumor size !30mm. Conclusions: A high splenic preservation rate was achieved with tumor size as a risk factor for unplanned splenectomy. Preserving the spleen during laparoscopic distal pancreatectomy is not associated with reduced postoperative morbidity compared with sacrifising the spleen. However, taking in consideration the long-term risks of post-splenectomy patients, we believe splenic preservation should be attempted in laparoscopic distal pancreatectomy for benign or low-grade malignant lesions.

The liver is an extremely vascular organ and it is unique in that it has a dual vascular supply, receiving 1500 mL of blood per minute. It is therefore not surprising that bleeding is considered to be a natural accompaniment to liver surgery. Liver transplantation in particular is a very demanding procedure and can in some circumstances result in heavy blood loss. These patients often have two or three system organ failure, not just end-stage liver disease (ESLD) but also associated hepato-renal and hepato-pulmonary syndromes on a background of significant coagulation abnormalities. Severe haemorrhage during the perioperative period is deleterious not only for recovery from surgery but also having an impact on the outcome from primary illness, most notably for early hepatocellular carcinoma (HCC) and colorectal liver metastases. With advances in anaesthetic and surgical techniques it should be possible to perform major liver resections with minimal transfusion requirements.Good access is a key component to safe bloodless liver surgery. There are important anaesthetic considerations and other surgical manoeuvres that facilitate major liver resections to be performed with minimal transfusion requirements. The major contributors to this are low central venous pressure (CVP) anaesthesia, inflow occlusion of the hepatoduodenal ligament (Pringle's manoeuvre) or total vascular occlusion (IVC control) and intraoperative ultrasound to identify major vessels.Haemorrhage during liver resection is mainly derived from the hepatic venous system. Hepatic sinusoidal pressure is directly related to CVP. By lowering blood pressure in the IVC, the hepatic venous pressure and hepatic sinusoidal pressure is reduced. Anaesthetic management should aim to keep CVP low without subjecting patients' to the risk of air embolism and systemic tissue hypoperfusion.Hepatic pedicle clamping is the oldest and commonest method of decreasing bleeding from the liver. It is very effective at reducing bleeding but also causes hepatic ischaemia and portal hypertension when carried out continuously for prolonged periods of time (a maximum of 60 -90 minutes is most frequently cited). Intermittent periods of total inflow occlusion (15 -20 minutes) followed by a short period (5 minutes) of reperfusion seem to be best. With this technique the total period of warm ischaemia can be nearly doubled to around 120 minutes in both normal and cirrhotic livers. Indeed a prospective study revealed a lower transaminase rise with intermittent occlusion especially in patients with fatty change, as compared to continuous occlusion, with no difference in blood loss. 1 Total hepatic vascular exclusion (TVE) is a technique where the liver is completely isolated from both the systemic and portal circulations. Following complete mobilization, inflow occlusion is achieved with a Pringle's manoeuvre, the infra-hepatic cava is controlled and occluded above the right renal vein. The supra-hepatic cava is clamped proximal to the confluence of the major hepatic veins. This techniqu...