Laparoscopic liver resection: Experience based guidelines

Abstract

Laparoscopic liver resection (LLR) has been progressively developed along the past two decades. Despite initial skepticism, improved operative results made laparoscopic approach incorporated to surgical practice and operations increased in frequency and complexity. Evidence supporting LLR comes from case-series, comparative studies and meta-analysis. Despite lack of level 1 evidence, the body of literature is stronger and existing data confirms the safety, feasibility and benefits of laparoscopic approach when compared to open resection. Indications for LLR do not differ from those for open surgery. They include benign and malignant (both primary and metastatic) tumors and living donor liver harvesting. Currently, resection of lesions located on anterolateral segments and left lateral sectionectomy are performed systematically by laparoscopy in hepatobiliary specialized centers. Resection of lesions located on posterosuperior segments (1, 4a, 7, 8) and major liver resections were shown to be feasible but remain technically demanding procedures, which should be reserved to experienced surgeons. Hand-assisted and laparoscopy-assisted procedures appeared to increase the indications of minimally invasive liver surgery and are useful strategies applied to difficult and major resections. LLR proved to be safe for malignant lesions and offers some short-term advantages over open resection. Oncological results including resection margin status and long-term survival were not inferior to open resection. At present, surgical community expects high quality studies to base the already perceived better outcomes achieved by laparoscopy in major centers' practice. Continuous surgical training, as well as new technologies should augment the application of laparoscopic liver surgery. Future applicability of new technologies such as robot assistance and image-guided surgery is still under investigation.

Keywords: Hand-assisted laparoscopy; Hepatectomy; Laparoscopic surgery; Liver; Liver cirrhosis; Liver neoplasm; Liver transplantation; Living donor; Minimally invasive surgery.

Figure 1

Flowchart demonstrating a suggested approach to the liver nodules using the minimally invasive approach (Liver Surgery Unit, University of São Paulo Medical School). ¹HALS or hybrid in selected cases; ²When technical difficulties are anticipated/intraoperative difficulties; ³When abdominal approach is not possible. HALS: Hand-assisted liver surgery; LLR: Laparoscopic liver resection; OLR: Open liver resection; LLS: Left lateral sectionectomy; PLLR: Pure laparoscopic liver resection.