Laparoscopic liver resection: lessons learnt after 100 cases.

OBJECTIVE: To share our institutional experience in laparoscopic liver resection and our learning curve after the first 100 cases of laparoscopic liver resection. DESIGN: Case series with internal comparison. SETTING: A regional hospital in Hong Kong. PATIENTS: Our institution started performing laparoscopic liver resection since 2006. All patients who underwent laparoscopic liver resections from March 2006 to October 2012 were identified in a prospectively collected database. The demographic data and operative outcomes of these patients were extracted, and results of the early (from March 2006 to May 2010) and late (from June 2010 to October 2012) study periods were compared. RESULTS: Between March 2006 and October 2012, 100 laparoscopic liver resections were performed for 98 patients in the Department of Surgery, Kwong Wah Hospital, Hong Kong. They were 69 (70%) males and 29 (30%) females, and the median age was 65 years. The final histological diagnoses were as follows: hepatocellular carcinoma (n=72), colorectal liver metastases (n=14), intrahepatic cholangiocarcinoma (n=4), and benign disease (n=10). There were more anatomical resections, major hepatectomies as well as resections of more anatomically challenging right-sided and posterosuperior lesions in the late versus the early period; however, operative outcomes remained comparable in both periods. CONCLUSION: Laparoscopic hepatectomies are feasible with growing experience. Bearing in mind the diversity in the level of operative techniques with various types of laparoscopic liver resections, more experience is needed to overcome the learning curve.

Multimedia manuscript: laparoscopic resection of hepatocellular carcinoma at segment 7: the posterior approach to anatomic resection.

BACKGROUND: Open anatomical liver resections remain one of the most effective treatments of hepatocellular carcinoma (HCC) and results in better recurrence-free and overall survival compared to nonanatomical resections [1]. On the other hand, laparoscopic hepatectomies for HCC have recently emerged with the benefits of reduced blood loss, shorter hospital stay, and less severe wound pain [2, 3]. Classically, liver lesions considered suitable for laparoscopic resection were those small tumors (<4 cm) located over the anterior and left lateral segments [3]. However, we would like to expand the current indications and here we present our techniques of laparoscopic anatomical resection for a HCC that was located at right posteriosuperior segment 7. METHODS: Our patient was a 60-year-old gentleman who had Child's A hepatitis B cirrhosis and was on entecavir. During a follow-up CT scan, a 2.6-cm segment 7 lesion with early arterial enhancement and contrast washout was noted and was subsequently confirmed with arteriogram. α-Fetoprotein was 3 ng/ml (normal < 20 ng/ml). The video demonstrates a posterior approach to laparoscopic resection of segment 7. RESULTS: Operative time was 510 min. Blood loss was 800 ml and no perioperative transfusion was required. Postoperative recovery was uneventful and only simple oral analgesics were required for pain control. He was discharged on postoperative day 6. Histology showed a moderately differentiated hepatocellular carcinoma and all resection margins were clear. Subsequent follow-up CT scan 6 months after the operation showed no evidence of recurrence and α-fetoprotein level was normal. CONCLUSIONS: Laparoscopic hepatectomy for HCC over the right posterior segment of the liver is feasible in selected patients with favorable results in terms of wound size, postoperative recovery, and hospital stay. Maximal liver conservation was achieved in performing oncologic anatomical resection of segment 7 instead of a posterior sectionectomy. On the other hand, a posterior approach was recommended because it allowed early intrahepatic control of pedicles and identification of the right hepatic vein to guide parenchymal transection along the intersegmental plane.

Palliation of distal malignant biliary obstruction: a selective approach.

A retrospective study of 39 patients with inoperable distal malignant biliary obstruction (MBO) treated between March 2001 and March 2004 was conducted. There were 20 men and 19 women, and their mean age was 72 years. Eighteen patients were treated with hepatico-jejunostomy (bypass group) and 21 with metal stent (stent group). At the time of analysis, 32 patients died, and 7 were still alive. The median survival was 4.2 months. Thirty-day mortality, in-hospital morbidity, and recurrent jaundice were 10.3% (4/39), 10.3% (4/39), and 12.8% (5/39), respectively. Gastric outlet obstruction occurred in 3 (7.7%) patients before their death. The median survival in the bypass group was significantly longer than that in the stent group (7.2 versus 3.6 months; P = 0.01). The finding that bypass operation confers better survival compared with the metal stent in the treatment of inoperable distal MBO needs to be validated by a randomized controlled trial.

Surveillance and outcome of liver metastasis in patients with colorectal cancer who had undergone curative-intent operation.

OBJECTIVE: To assess the outcome of patients diagnosed to have liver metastasis by ultrasonography, following curative-intent resection of colorectal adenocarcinoma. DESIGN: Prospective study. SETTING: Regional hospital, Hong Kong. PATIENTS: A total of 650 patients who underwent curative-intent resection of colorectal adenocarcinoma between January 2000 and December 2006. MAIN OUTCOME MEASURES: Pattern of liver recurrence, treatment and outcome after recurrence, and overall patient survival. RESULTS: Of the 650 patients, 553 (85%) were followed up per protocol. Of 104 patients who developed systemic recurrence, 45 (43%) had liver-only metastases. The resection rate for liver metastases was 38% (17/45). The median survival of such patients was significantly longer than those who did not undergo liver metastasectomy (50 vs 26 months, P=0.017). CONCLUSION: Our ultrasonography-based surveillance protocol was low-cost, simple, and effective in detecting asymptomatic liver metastases, so that curative-intent metastasectomy could be performed. Further prospective studies are required to determine the optimal frequency and imaging mode for surveillance, so as to improve the resectability of liver-only colorectal metastases as well as overall patient survival.

Anatomical justification of Belghiti's 'liver hanging manoeuvre' in right hepatectomy with anterior approach.

BACKGROUND: In cases of right hepatectomy for huge tumour encroaching onto the diaphragm, the 'anterior approach' is the most common surgical procedure undertaken. The 'liver hanging manoeuvre' has been described previously as an adjunct to this procedure. It involves the dissection of a retrohepatic avascular plane anterior to the surface of the inferior vena cava. A tape is then passed through and the liver is resected under suspension. METHODS: Cadaveric specimens were used to identify the structural relationship of the avascular plane and also to determine whether it is truly avascular. RESULTS: Thirteen cases were analysed. The mean length of the avascular tunnel was 6.4 +/- 1.0 cm. The median number of accessory hepatic veins within the tunnel was two (zero to three). At the caudal half of the tunnel, the median number of veins was two (zero to three). As for the cranial half of the tunnel, there were two cases with one vein in each. CONCLUSIONS: The key to the liver hanging manoeuvre is to develop the retrohepatic tunnel. However, our study showed that it is not absolutely avascular. During the blind dissection, there is a chance of damaging a retrohepatic vein. This may result in troublesome haemorrhage within the confines of the tunnel. Video-assisted dissection of this region may help in visualisation, and hence control, in order to avoid bleeding.

Day-case inguinal herniotomy in Chinese children: retrospective study.

OBJECTIVE: To review the results of day-case procedures performed for inguinal hernia or hernia-hydrocele complex in Chinese children. DESIGN: Retrospective study. SETTING: Day Surgery Centre of a district hospital, Hong Kong. PATIENTS: Medical records of 255 consecutive paediatric patients admitted to the Day Surgery Centre for inguinal herniotomy between July 1993 and December 1997 were reviewed. A telephone survey was conducted to assess any long-term morbidity relating to the operation. MAIN OUTCOME MEASURES: Patient demographics, success of day-case herniotomy, short-term and long-term morbidity. RESULTS: There were 230 boys and 25 girls with a mean age of 8.8 years (range, 3 months to 18 years). Seven patients had bilateral herniotomy for bilateral hernia and 14 had circumcision for co-existing phimosis. Eight boys developed recurrence and three had a contralateral inguinal hernia. Postoperative ascent of the testis occurred in three patients, one of whom required orchidopexy. The unplanned admission rate was 1.6%, all for poor pain control. There were four herniotomy wound complications (two haematomas and two infections) and two circumcision wound haemorrhages. CONCLUSIONS: Day-case inguinal herniotomy is safe and acceptable to Chinese children. Given these satisfactory results, paediatric patients with inguinal hernia can be safely managed with ambulatory surgery performed by suitably experienced surgeons.

Surgical treatment of recalcitrant radiation-induced gastric erosions.

BACKGROUND: Uncontrolled bleeding as a result of radiation gastritis in patients who have pharyngo-laryngo-esophagectomy and gastric pull-up is seldom reported. Surgical resection in the management of this condition has rarely been described. METHOD: A 66-year-old man with hypopharyngeal cancer was treated by pharyngo-laryngo-esophagectomy and gastric transposition. He received postoperative radiotherapy and had recurrent hemorrhagic gastritis, necessitating surgical resection. The manubrium was resected to access the mediastinal part of the gastric conduit. The diseased part of the gastric conduit was removed and a free jejunal graft was interposed to replace the resected stomach. RESULTS: Manubrial resection offered adequate access to the stomach transposed in the mediastinum, and the life-threatening bleeding gastritis was successfully controlled by surgical resection. CONCLUSION: Surgical resection of the radiation-damaged transposed stomach through a manubrial resection approach can safely be performed. Free jejunal graft is the choice of reconstruction of the circumferential defect.

A study of pre-antibiotic bacteriology in 125 patients with necrotizing enterocolitis.

Over a five-year period, 125 newborns with necrotizing enterocolitis (NEC) were managed by us. Their mean birthweight was 1700 g and mean maturity was 32 weeks. Before commencement of antibiotics, routine septic work-up was done in order to define the bacterial spectrum and antibiotic sensitivity. The study includes aerobic and anaerobic cultures of gastric and pharyngeal aspirates, blood cultures, umbilical swabs and culture of umbilical catheter tips in relevant cases. Peritoneal swab results were also analyzed if laparatomy was performed. Positive cultures were present in 45 patients (36%) with 55 positive specimens. Fifteen types of organism were isolated: the commonest was Enterobacter (29%), followed by E. coli (14.5%) and Klebsiella (13%). They were resistant to ampicillin and first-generation cephalosporin. These organisms were usually opportunistic pathogens. Overgrowth of them may be the cause of NEC. Regular review of the antibiotic sensitivity of these organisms allows prompt and appropriate choice of antibiotics. At the same time, antibiotic sensitivity for these organisms was analyzed to guide us in the choice of antibiotic therapy.