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.

Keywords: Ascites; Bridging therapy to transplantation; Chronic liver disease; Hepatocellular carcinoma; Laparoscopic hepatectomy; Liver Tumor; Liver cirrhosis; Liver resection; Postoperative liver failure; Repeat hepatectomy.

Figure 1

Repeat pure laparoscopic hepatectomy for patients with liver cirrhosis and hepatocellular carcinomas was feasible and safe: case 1. A: Computed tomorgraphy scan shows two hepatocellular carcinomas (HCC) in segment 3; B: The tumors (arrows) resected laparoscopycally.; C: A 69-year-old woman with type-C liver cirrhosis developed a new HCC on the caudal edge of segment 6 of the liver 2 years after the first hepatectomy; D: At the second laparoscopic hepatectomy, there was only mild adhesion around the resected area

Figure 2

Repeat pure laparoscopic hepatectomy for patients with liver cirrhosis and hepatocellular carcinomas was feasible and safe: case 1. The patient also had two early lesions in segment 4, which was treated with laparoscopic microwave coagulation therapy (A). After ablation therapy, the hepatocellular carcinomas (HCC) in segment 6 (B) was resected laparoscopically (C). The resected specimen (D) showed a single nodular HCC. The patient also underwent third hepatectomy for the lesion in segment 1 next to right adrenal gland two years after this operation.

Figure 3

Pure laparoscopic hepatectomy is efficient in the subphrenic space: case 2. An 80-year-old woman with liver cirrhosis developed a hepatocellular carcinomas in the dorsal area of subsegment 8c of the liver revealed in computed tomography examination (A and B). Since the tumor compressed the right hepatic vein and her liver function seemed not to tolerate right hepatectomy or extended anterior sectionectomy, she underwent partial resection of the liver with the dissection and exposure of right hepatic vein and tumor capsule in pure laparoscopic hepatectomy. The tumor was located deeply in the subphrenic space (C) just next to the attachment of retro-peritoneum (D).

Figure 4

Pure laparoscopic hepatectomy is efficient in the subphrenic space: case 2. A: Resection of the tumor with the exposure of the capsule; B: Encircling and dividing of the direct branch of the right hepatic vein; C: Exposure of right hepatic vein; D: Cutting surface after resection.

Figure 5

Pure laparoscopic hepatectomy is efficient between the adhesions and the peri-inferior vena cava area: case 3. Two years after a central bisectionectomy for hepatocellular carcinomas (HCC) at the roots of hepatic veins (A), a 66-year-old man developed a new prominent HCC on the left caudate lobe of the liver (B). Following the second pure laparoscopic hepatectomy, there was massive adhesion in the area of right upper abdomen (C). However, good view and access to the tumor were obtained with the dissection of omentum minus (D).

Figure 6

Pure laparoscopic hepatectomy is efficient between the adhesions and the peri-inferior vena cava area: case 3. A and B: Resection of the tumor; C and D: The view after the resection of the tumor.