Robotic versus laparoscopic liver resection: a comparative study from a single center.

PURPOSE: The significant advantages of robotic surgery have expanded the scope of surgical procedures that can be performed through minimally invasive techniques. The aim of this study was to compare the perioperative outcomes between robotic and laparoscopic liver surgeries at a single center. METHODS: From July 2007 to October 2011, a total of 206 patients underwent laparoscopic or robotic liver surgery at the Asan Medical Center, Seoul, Korea. We compared the surgical outcomes between robotic liver surgery and laparoscopic liver surgery during the same period. Only patients who underwent left hemihepatectomy or left lateral sectionectomy were included in this study. RESULTS: The robotic group consisted of 13 patients who underwent robotic liver resection including 10 left lateral sectionectomies and three left hemihepatectomies. The laparoscopic group consisted of 17 patients who underwent laparoscopic liver resection during the same period including six left lateral sectionectomies and 11 left hemihepatectomies. The groups were similar with regard to age, gender, tumor type, and tumor size. There were no significant differences in perioperative outcome such as operative time, intraoperative blood loss, postoperative liver function tests, complication rate, and hospital stay between robotic liver resection and laparoscopic liver resection. However, the medical cost was higher in the robotic group. CONCLUSIONS: Robotic liver resection is a safe and feasible option for liver resection in experienced hands. The authors suggest that since the robotic surgical system provides sophisticated advantages, the retrenchment of medical cost for the robotic system in addition to refining its liver transection tool may substantially increase its application in clinical practice in the near future.

Section 6. Management of extensive nontumorous portal vein thrombosis in adult living donor liver transplantation.

BACKGROUND: Patent portal vein (PV) and adequate portal inflow is essential for successful living donor liver transplantation (LDLT). In extensive portal vein thrombosis (PVT) patients, however, complete PV thrombectomy is not feasible particularly at intrapancreatic portion, and subsequently portal flow steal through preexisting sizable collaterals or rethrombosis can occur. To overcome those problems, we introduced interruption of sizable collaterals and intraoperative cine-portogram (IOP), which is useful for diagnosis and treatment of residual PVT and sizable collaterals. METHODS: Fourteen percent of adult LDLT (188/1399) had PVT from February 2008 to December 2012 and were subdivided into Yerdel's grades 1, 2, 3, and 4 based on preoperative imaging and operative findings. Considering the severity of PVT and presence of sizable collaterals, the managements were as follows: thrombectomy alone, additional PV plasty, PV stenting, interposition graft, or additional interruption of collaterals. RESULTS: The Yerdel's grade of PVT patients were 1 (42%), 2 (54%), 3 (3%), and 4 (1%). One hundred one (77%) patients underwent interruption of sizable collaterals. The most common management for PVT was thrombectomy alone in grades 1 and 2, thrombectomy plus PV stenting and/or ballooning in grade 3, and interposition graft in grade 4. In LDLT for PVT patients, 1-year mortality was 9%, and PV-related complication occurred in 5%. The severity of PVT made no difference in the outcome. CONCLUSION: Multi-disciplinary approaches including surgical correction of PVT, IOP, and interruption of sizable collaterals resulted in excellent outcome, and it was not affected by the severity of PVT.

Restoration of portal flow using a pericholedochal varix in adult living donor liver transplantation for patients with total portosplenomesenteric thrombosis.

In total portosplenomesenteric thrombosis patients, cavoportal hemitransposition (CPHT) is indicated but rarely applicable for adult-to-adult (A-to-A) living donor liver transplantation (LDLT) because partial liver graft requires splanchno-portal inflow for liver graft regeneration. If intra- & peri-pancreatic collaterals draining into pericholedochal varix were present, pericholedochal varix may provide splanchnic blood flow to the transplanted liver and also relieve recipient's portal hypertension. To date, however, there is no successful report using pericholedochal varix in liver transplantation (LT). We successfully performed A-to-A LDLTs using pericholedochal varix for those 2 patients. The surgical strategies are followings: (a) dissection of hepatic hilum to isolate left hepatic artery using for arterial reconstruction of implanted right lobe graft, (b) en-mass clamping of the undissected remaining hilum if we can leave adequate length of stump from the clamping site, and then hilum is divided, (c) delay the donor hepatectomy until the feasibility of the recipient operation is confirmed. Portal flow was established between the sizable pericholedochal varix (caliber > 1cm) and graft portal vein, but the individually designed approaches were used for each patients. Currently, they have been enjoying normal life on posttransplant 92 and 44 months respectively. In conclusion, enlarged pericholedochal varix in patients with totally obliterated splanchnic veins might be an useful inflow to restore portal flow and secure good outcome in A-to-A LDLT. AASLD.

Laparoscopic liver resection for hepatocellular carcinoma: a three-year study of 57 Patients.

BACKGROUND/AIMS: Laparoscopic liver resection has become an increasingly popular operation but is still in relatively limited use. Here we evaluate the intermediate-term results of laparoscopic liver resection. METHODOLOGY: Fifty-seven patients with HCC underwent laparoscopic liver resection at the Asan Medical Center. Data for all resections were recorded and analyzed retrospectively. Patient gender, age, preoperative laboratory data, presence of cirrhosis, blood loss, hospital stay length, pathology report, tumor site and size, resection type, resection margin, morbidity and mortality were assessed. RESULTS: The mean patient age ranged from 35-74 years and the mean tumor size from 0.8-5.5 cm. Tumors were located in the left lateral lobe, left medial lobe and right lobe. Left lateral sectionectomy was performed in 32 cases, partial hepatectomy in 11, left hepatectomy in 6, right hepatectomy in 2, laparoscopy-assisted right hepatectomy in 2 and laparoscopy-assisted right posterior sectionectomy in 4. Median operation time ranged from 95-380 min while median blood loss ranged from 150-800 mL. The mean resection margin was 2.08±1.68 cm with no in-hospital mortalities. Return to normal diet was achieved on average at 1.83±0.8 days; mean hospital stay ranged from 3 to 17 days. The 3-year overall and disease-free survival rates were 81% and 71%, respectively. CONCLUSIONS: Laparoscopic liver resection for HCC is feasible, safe and promising for a select group of patients. Its benefits include short hospital stays, rapid return to normal diet, full mobility and minimal morbidity with acceptable oncological parameters.