Pure laparoscopic hepatectomy for hepatocellular carcinoma with chronic liver disease

Abstract

Pure laparoscopic hepatectomy is a less invasive procedure than conventional open hepatectomy for the resection of hepatic lesions. Increases in experiences with the technique, in combination with advances in technology, have promoted the popularity of pure laparoscopic hepatectomy. However, indications for usage and potential contraindications of the procedure remain unresolved. The characteristics and specific advantages of the procedure, especially for hepatocellular carcinoma (HCC) patients with chronic liver diseases, are reviewed and discussed in this paper. For cirrhotic patients with liver tumors, pure laparoscopic hepatectomy minimizes destruction of the collateral blood and lymphatic flow from laparotomy and mobilization, and mesenchymal injury from compression. Therefore, pure laparoscopic hepatectomy has the specific advantage of minimal postoperative ascites production that leads to lowering the risk of disturbance in water or electrolyte balance and hypoproteinemia. It minimizes complications that routinely trigger postoperative serious liver failure. Under adequate patient positioning and port arrangement, the partial resection of the liver in the area of subphrenic space, peri-inferior vena cava area or next to the attachment of retro-peritoneum is facilitated in pure laparoscopic surgery by providing good vision and manipulation in the small operative field. Furthermore, the features of reduced post-operative adhesion, good vision, and manipulation within the small area between the adhesions make this procedure safer in the context of repeat hepatectomy procedures. These improved features are especially advantageous for patients with liver cirrhosis and multicentric and/or metachronous HCCs. Key words: Laparoscopic hepatectomy; Hepatocellular carcinoma; Liver cirrhosis; Chronic liver disease; Liver Tumor; Liver resection; Repeat hepatectomy; Bridging therapy to transplantation; Ascites; Postoperative liver failure Core tip: For cirrhotic patients with liver tumor, pure laparoscopic hepatectomy minimizes destruction of the collateral blood/lymphatic flow from laparotomy and mobilization, and has advantage of minimal postoperative ascites. It restrains the complications, which trigger the postoperative liver failure. The partial resection in the area of subphrenic space, peri-inferior vena cava area or next to the attachment of retro-peritoneum is facilitated with good vision and manipulation in the small operative field. Furthermore, repeat pure laparoscopic hepatectomy for patients with multicentric/ metachronous hepatocellular carcinomas was feasible and safe with the advantages of less post-operative adhesion and good vision and manipulation between the adhesions.

Treatment of Hepatocellular Carcinoma with Child-Pugh C Cirrhosis

“…At present, no concrete evidence exists for the recommendable treatment of CP-C HCC patients except for liver transplantation. However, we often experience cases in which treatment definitely prolongs survival, and there are several reports demonstrating the efficacy of treatments for CP-C HCC [12,13,14,15,16,17,18,19]. …”

Current advances made in the surgical treatment of hepatocellular carcinoma

“…41,42 Minor resections can be performed for ICG clearance rates of up to 22%, 43 limited hepatectomies (without sacrifice of non-tumorous liver) for values up to 40%, 23 and limited wedge laparoscopic resections can possibly be tolerated for even higher values. 44,45 Preoperative Portal Vein Embolization (PVE), first introduced by Makuuchi et al, 46 has been widely recognized as an effective method for the preoperative volume modulation of small FLR. However, the degree of hypertrophy of the FLR after PVE is variable in patients with CLD.…”

“…62 The safety and feasibility of the laparoscopic approach and its short-term benefits for HCC patients with CLD have been demonstrated by many studies. 45 Tranchart et al 63 reported better postoperative outcomes, without long-or short-term oncologic consequences, following laparoscopic LR of HCC for select patients. Laparoscopic LR has the advantage of minimal ascites, 64 due to preservation of venous and lymphatic collateral circulation, which leads to lower risk of disturbance in water and/or electrolyte balance and hypoproteinemia that could trigger fatal liver failure.…”

Laparoscopic and robotic approach for hepatocellular carcinoma—state of the art

“…Pure laparoscopic hepatectomy results in minimal postoperative ascites production, which leads to a lower risk of disturbance in water and/or electrolyte balance and hypoproteinemia. It leads to lower complications that could potentially lead to postoperative serious liver failure (44). In very little cases some authors suggest to perform the Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for HCC.…”