Laparoscopic liver resection for malignant liver tumors: preliminary results of a multicenter European study

Abstract

Objective: To assess the feasibility, safety, and outcome of laparoscopic liver resection for malignant liver tumors.

Summary background data: The precise role of laparoscopy in resection of liver malignancies (hepatocellular carcinoma [HCC] and liver metastases) remains controversial despite an increasing number of publications reporting laparoscopic resection of benign liver tumors.

Methods: A retrospective study was performed in 11 surgical centers in Europe regarding their experience with laparoscopic resection of liver malignancies. Detailed questionnaires were sent to each surgeon focusing on patient characteristics, clinical data, type and characteristics of the tumor, technical details of the operation, and early and late clinical outcome. All patients had radiologic investigations at follow-up to exclude disease recurrence.

Results: From February 1994 to December 2000, 37 patients with malignant liver tumors were included in this study. Ten patients had HCC, including 9 with cirrhotic liver, and 27 patients had liver metastases. The mean tumor size was 3.3 cm, and 89% of the tumors were located in the left lobe or in the anterior segments of the right liver. Liver procedures included 12 wedge resections, 9 segmentectomies, 14 bisegmentectomies (including 13 left lateral segmentectomies), and 2 major hepatectomies. The transfusion rate, the use of pedicular clamping, the conversion rate (13.5% in the whole series), and the complication rate were significantly greater in patients with HCC. There were no deaths. Postoperative complications occurred in eight patients (22%). The surgical margin was less than 1 cm in 30% of the patients. During a mean follow-up of 14 months, the 2-year disease-free survival was 44% for patients with HCC and 53% for patients having hepatic metastases from colorectal cancer. No port-site metastases were observed during follow-up.

Conclusions: In patients with small malignant tumors, located in the left lateral segments or in the anterior segments of the right liver, laparoscopic resection is feasible and safe. The complication rate is low, except in patients with HCC on cirrhotic liver. By using laparoscopic ultrasound, a 1-cm free surgical margin should be routinely obtained. The late outcome needs to be evaluated in expert centers.

Figure 1. Patient with Child-Pugh B liver cirrhosis suffering from a 4 cm deep-sited hepatocellular carcinoma (arrow), located in the left lateral segment of the liver and treated by laparoscopic left lateral segmentectomy.

Figure 2. Detection on routine carcinologic screening of 1 cm liver metastase located in segment VI of the right lobe of the liver in a patient previously operated for colorectal cancer. Despite the presence of dense peritoneal adhesions, the patient was considered as an excellent candidate for laparoscopic wedge resection with a 1-cm free surgical margin. (A) Transverse view of magnetic resonance imaging. (B) Frontal view of magnetic resonance imaging.

Figure 3. Detection during laparoscopic right colectomy for cancer of a synchronous 3 cm liver metastases, located in the left lateral segment of the liver, detected by intraoperative ultrasound and treated by associated laparoscopic left lateral segmentectomy during the same operation: operative view of the resected specimens.

Figure 4. Postoperative endoscopic retrograde cholangiography in a patient undergoing a right hepatic lobectomy for a 6-cm neuroendocrine liver metastase located deeply in segment VI-VII of the right lobe of the liver: presence of an iatrogenic stricture of the left hepatic duct, requiring reoperation for construction of an hepatico-jejunostomy.