Laparoscopic liver resection for peripheral hepatocellular carcinoma in patients with chronic liver disease: midterm results and perspectives

Abstract

Objective: Report the midterm results of laparoscopic resection for hepatocellular in chronic liver disease (CLD).

Summary background data: Surgical resection for hepatocellular carcinoma (HCC) in chronic liver disease (CLD) remains controversial because of high morbidity and recurrence rates. Laparoscopic resection of liver tumors has recently been developed and could reduce morbidity.

Methods: From 1998 to 2003, patients with HCC and CLD were considered for laparoscopic liver resection. Inclusion criteria were chronic hepatitis or Child's A cirrhosis, solitary tumor < or =5 cm in size, and location in peripheral segments of the liver. Mortality, morbidity, recurrence rates, and survival were analyzed.

Results: A total of 27 patients were included. Liver resections included anatomic resection in 17 cases and non anatomic resection in 10. Seven conversions to laparotomy (26%) occurred for moderate hemorrhage in 5 cases and technical difficulties in 2 cases. Mortality and morbidity rates were 0% and 33%, respectively. Postoperative ascites and encephalopathy occurred in 2 patients (7%) who both had undergone conversion to laparotomy. Mean surgical margin was 11 mm (range, 1-47 mm). After a mean follow-up of 2 years (range, 1.1-4.7), 8 patients (30%) developed intrahepatic tumor recurrence of which one died. Treatment of recurrence was possible in 4 patients (50%), including orthotopic liver transplantation, right hepatectomy, radiofrequency ablation, and chemoembolization in 1 case each. There were no adhesions in the 2 reoperated patients. Overall and disease-free 3-year survival rates were 93% and 64%, respectively.

Conclusion: Our study shows that laparoscopic liver resection for HCC in selected patients is a safe procedure with very good midterm results. This approach could have an impact on the therapeutic strategy of HCC complicating CLD as a treatment with curative intent or as a bridge to liver transplantation.

FIGURE 1. Tumor locations. *Conversion to laparotomy.

FIGURE 2. Left lateral sectionectomy for a 3-cm HCC in segment 2. Preoperative magnetic resonance (above) and operative view of completed resection (below). Arrow 1 shows a locked clip on a left arterial branch, and arrow 2 shows the stapled stump of the left hepatic vein.

FIGURE 3. Resection of the anterior part of segment 4 (segment 4b) for a 4-cm HCC. Preoperative computed tomography showing the tumor in segment 4 enhanced by previous lipiodol injection (above) and operative view of completed resection (below). Arrow 1 shows the liver hilum, and arrow 2 shows the round ligament.

FIGURE 4. Resection of segment 6 for a 3-cm HCC (arrows show the tumor). Preoperative magnetic resonance (above) and operative view (below) showing the transection in progress using intermittent Pringle maneuver in a patient in left lateral decubitus position.

FIGURE 5. Specimen from non anatomic resection of segment 5 for a 2.5-cm encapsulated HCC. Surgical margin is 1 cm.

FIGURE 6. Specimen of resection of segment 3 for a 5-cm HCC. This tumor was previously ruptured as shown by residual hematoma (arrow). Surgical margin is 2 cm.

FIGURE 7. Postoperative change in prothrombin rate, total bilirubin level, and aspartate aminotransferase level.

FIGURE 8. Actuarial overall (continuous line) and disease-free survival (dotted line).