Initial experience with robotic liver resection: Audit of 120 consecutive cases at a single center and comparison with open and laparoscopic approaches.

BACKGROUND/PURPOSE: Surgical outcomes and utility of robotic liver resection (RLR) are undefined. METHODS: We retrospectively studied perioperative and long-term outcomes of the single-center 120 RLRs including non-anatomic (NAR, n = 58) and anatomic (AR, n = 62) resections. To evaluate the feasibility and safety of RLR, perioperative outcomes of RLR (n = 103) were compared to those of open (OLR, n = 495) or laparoscopic (LLR, n = 451) resection in liver-only resections without reconstruction, using 1:1 propensity score matching (PSM). The changing trends from the earlier to the later RLR cases were assessed. Long-term outcomes were compared between RLR and LLR. RESULTS: Various types of RLR with different surgical difficulties were performed, with mostly comparable postoperative morbidity between AR and NAR, or among AR subtypes. In segmentectomy and sectionectomy cases, perioperative outcomes significantly improved in the later period. In comparison between PSM-selected OLR and RLR cases (87:87), RLR had significantly longer operative time, less blood loss, and shorter hospital stay. PSM-selected LLR and RLR cases (91:91) showed comparable perioperative outcomes. Overall and recurrence-free survivals after RLR for newly diagnosed hepatocellular carcinoma and colorectal metastasis were comparable to those after LLR. CONCLUSIONS: RLR is applicable to various types of liver resection with acceptable perioperative and long-term outcomes in select patients.

Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) using retroperitoneal-first laparoscopic approach (Retlap): A novel minimally invasive approach for determining resectability and achieving tumor-free resection margins of locally advanced pancreatic body cancer.

BACKGROUND: Conventional open distal pancreatectomy with en bloc celiac axis resection (DP-CAR) using the ventral approach is technically challenging, highly invasive, and not easy to ensure ample dorsal surgical margins. Hence, we describe a novel minimally invasive strategy for DP-CAR using the retroperitoneal-first laparoscopic approach (Retlap), i.e., Retlap DP-CAR, for locally advanced pancreatic body cancer (LAPC), and assess its utility. METHODS: Retlap DP-CAR was performed in 10 patients with LAPC that was categorized as either unresectable (UR-LA, n = 4) or borderline (BR-A, n = 6). Neoadjuvant chemotherapy was applied on 8 patients and upfront surgery on 2. Retlap was used to create a working space in the retroperitoneal cavity between the pancreatic body and the left kidney and confirm technical resectability, such as securing the celiac axis and preserving the superior mesenteric artery in an early operative stage. Retlap DP-CAR was laparoscopic in 8 patients and robotic in 2. Surgical procedures are directly manipulated from the dorsal side of the pancreas and tumor, facilitating confirmation of technical resectability and obtaining ample dorsal margins in a no-touch isolation approach. Once technical resectability was confirmed, the procedure was converted to the ventral approach for completing DP-CAR. RESULTS: Median operating time and blood loss during Retlap were 271 min and 10 mL, respectively, while median resection time and intraoperative blood loss were 582 min and 412 mL, respectively. Tumor-free resection margins were obtained in all cases. The major morbidity rate (C-D > IIIa) was 10%. No mortality was recorded within 90 days. Median overall survival was 53.8 months [95% confidence interval 32.7-75.0]. CONCLUSIONS: Retlap DP-CAR is a novel minimally invasive procedure for resecting LAPC located close to the celiac axis. It is both safe and feasible, enables determination of technical resectability, achieves dorsal surgical margins, and can improve outcomes and QOL in patients with LAPC.

Laparoscopic isolated liver segmentectomy 8 for malignant tumors: techniques and comparison of surgical results with the open approach using a propensity score-matched study.

PURPOSE: Anatomic isolated liver segmentectomy 8 (ILSeg8) for malignancies remains technically challenging. The feasibility, safety, and oncologic validity of laparoscopic ILSeg8 are undefined, and thus were evaluated in comparison with the open approach. METHODS: This study enrolled 35 open and 29 laparoscopic ILSeg8 cases of hepatocellular carcinoma (n = 47), metastatic liver tumors (n = 16), and intrahepatic cholangiocarcinoma (n = 1) at our institution. The surgical techniques were based on the pre-hepatectomy extrahepatic Glissonian pedicle control, followed by cranial-to-caudal parenchymal dissection from the hepatic vein root side. The short- and long-term outcomes after ILSeg8 were retrospectively evaluated and compared between the open and laparoscopic approaches using 1:1 propensity score matching (PSM). RESULTS: Both before and after PSM, the laparoscopic ILSeg8 group had significantly less blood loss, lower postoperative serum bilirubin level, and a shorter postoperative hospital stay than the open group. The overall survival rates were comparable between the laparoscopic and open groups before (P = 0.017) and after (P = 0.043) PSM, with the similar recurrence-free survival rates between the groups. In a multivariable analysis of the cohort before PSM (n = 64), the laparoscopic approach was identified to be an independent factor for favorable overall survival (hazard ratio = 0.20, P = 0.039). CONCLUSION: Laparoscopic ILSeg8 using the extrahepatic Glissonian approach and hepatic vein root at first parenchymal dissection was feasible, safe, and oncologically acceptable. In ILSeg8 for malignancy, the laparoscopic approach potentially confers short-term advantages over the open approach with comparable long-term outcomes in select patients.

Retroperitoneal-first laparoscopic approach (Retlap)-assisted distal pancreatectomy with celiac axis resection (DP-CAR): A novel minimally invasive approach for achieving adequate dorsal surgical margin.

BACKGROUND: Distal pancreatectomy with celiac axis resection (DP-CAR) is a procedure to secure a surgical margin for a locally advanced pancreatic body cancer that invades the celiac axis. However, in patients with cancer close to the root of the celiac axis, obtaining adequate surgical margins can be difficult because the tumor obstructs the field of vision to the root of the celiac axis. Previously, we described the retroperitoneal-first laparoscopic approach (Retlap) to achieve both accurate evaluation of resectability for locally advanced pancreatic cancer requiring DP-CAR [1] and adequate surgical margin for laparoscopic distal pancreatectomy [2]. In this video, we introduce Retlap-assisted DP-CAR as a minimally invasive approach for performing an artery-first pancreatectomy [3, 4] and achieving sufficient dorsal surgical margin (Fig. 1). METHODS: Our patient is a 67-year-old man with a 55 × 29-mm pancreatic body tumor after chemotherapy. Preoperative computed tomography revealed a tumor close to the root of the celiac axis. Because the area of tumor invasion on preoperative images was near the root of the celiac artery, Retlap-assisted DP-CAR was performed to determine whether the celiac axis can be secured and obtain an adequate dorsal surgical margin (Fig. 2). RESULTS: The operative time and estimated blood loss was 715 min and 449 mL, respectively. In spite of the advanced tumor's location and size, R0 resection was achieved in a minimally invasive way. CONCLUSION: Retlap-assisted DP-CAR is not only technically feasible and useful for achieving accurate evaluation of resectability but also facilitates obtaining an adequate surgical margin.

Wrapping double-mattress anastomosis for pancreaticojejunostomy in minimally invasive pancreaticoduodenectomy can significantly reduce postoperative pancreatic fistula rate compared with conventional pancreaticojejunostomy in open surgery: An analysis of a propensity score-matched sample.

BACKGROUND: Minimally invasive pancreaticoduodenectomy (MIPD), including laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD), is technically demanding because of pancreaticojejunostomy (PJ). Postoperative pancreatic fistula (POPF) is the most serious complication of MIPD and open pancreaticoduodenectomy (OPD). Contrary to expectations, conventional PJ in MIPD did not improve POPF rate and length of hospital stay. High POPF rates are attributed to technical issues encountered during MIPD, which include motion restriction and insufficient water tightness. Therefore, we developed wrapping double-mattress anastomosis, the Kiguchi method, which is a novel PJ technique that can improve MIPD. Herein, we describe the Kiguchi method for PJ in MIPD and compare the outcomes between this technique and conventional PJ in OPD. METHODS: The current retrospective study included 83 patients in whom the complete obstruction of the main pancreatic duct by pancreatic tumors was absent on preoperative imaging. This research was performed from September 2016 to August 2020 at Fujita Health University Hospital. All patients were evaluated as having a soft pancreatic texture, which is the most important factor associated with POPF development. Briefly, 50 patients underwent OPD with conventional PJ (OPD group). Meanwhile, 33 patients, including 15 and 18 who had LPD and RPD, respectively, underwent MIPD using the Kiguchi method (MIPD group). After a 1:1 propensity score matching, 30 patients in the OPD group were matched to 30 patients in the MIPD group. RESULTS: The patients' preoperative data did not differ. The grade B/C POPF rate was significantly lower in the MIPD group than in the OPD group (6.7% vs 40.0%, p = 0.002). The MIPD group had a significantly shorter median length of hospital stay than the OPD group (24 vs 30 days, p = 0.004). CONCLUSION: The novel Kiguchi method in MIPD significantly reduced the POPF rate in patients without complete obstruction of the main pancreatic duct.

Urgent intraoperative endovascular stent placement to resolve acute hepatic or portal venous obstruction during liver surgery: a case series.

BACKGROUND: Acute obstruction of the hepatic vein (HV) or the portal vein (PV), particularly when it occurs during liver surgery, is potentially fatal unless repaired swiftly. As surgical interventions for this problem are technically demanding and potentially unsuccessful, other treatment options are needed. CASE PRESENTATION: We report two cases of acute, surgically uncorrectable HV or PV obstruction during liver resection or living donor liver transplantation (LDLT), which was successfully treated with urgent intraoperative placement of endovascular stents using interventional radiology (IVR). In Case 1, a patient with colonic liver metastases underwent a non-anatomic partial hepatectomy of the segments 4 and 8 with middle hepatic vein (MHV) resection. Additionally, the patient underwent an extended right posterior sectionectomy with right hepatic vein (RHV) resection for tumors involving RHV. Reconstruction of the MHV was needed to avoid HV congestion of the anterior section of the liver. The MHV was firstly reconstructed by an end-to-end anastomosis between the MHV and RHV resected stumps. However, the reconstruction failed to retain the HV outflow and the anterior section became congested. Serial trials of surgical revisions including re-anastomosis, vein graft interposition and vein graft patch-plasty on the anastomotic wall failed to recover the HV outflow. In Case 2, a pediatric patient with biliary atresia underwent an LDLT and developed an intractable PV obstruction during surgery. Re-anastomosis with vein graft interposition failed to restore the PV flow and elongated warm ischemic time became critical. In both cases, the misalignment in HV or PV reconstruction was likely to have caused flow obstruction, and various types of surgical interventions failed to recover the venous flow. In both cases, an urgent IVR-directed placement of self-expandable metallic stents (SEMS) restored the HV or PV perfusion quickly and effectively, and saved the patients from developing critical conditions. Furthermore, in Cases 1 and 2, the SEMS placed were patent for a sufficient period of time (32 and 44 months, respectively). CONCLUSIONS: The IVR-directed, urgent, intraoperative endovascular stenting is a safe and efficient treatment tool that serves to resolve the potentially fatal acute HV or PV obstruction that occurs in the middle of liver surgery.

Donor-dominant one-way matching of human leukocyte antigen-A/B/DR alleles predicts graft-versus-host disease following living donor liver transplantation.

AIM: Graft-versus-host disease (GVHD) following liver transplantation is rare but fatal. Therefore, it is important to identify possible risk factors before transplantation. Although it has been suggested that donor-dominant one-way human leukocyte antigen (HLA) matching of three loci (HLA-A/B/DR) is associated with the occurrence of GVHD, the precise significance of HLA matching including HLA-C/DQ/DP remains unclear. METHODS: We retrospectively analyzed the impact of donor-dominant one-way HLA matching at six HLA loci at the allele level on GVHD using clinical registry data from 1759 cases who underwent living donor liver transplantation between June 1990 and June 2019. We extracted cases with donor-dominant one-way HLA matching at the antigen level and reconfirmed them at the allele level using preserved DNA samples. RESULTS: Three of four cases (75%) who developed GVHD showed donor-dominant one-way HLA matching at three HLA-A/B/DR loci. These cases also showed donor-dominant one-way HLA matching at HLA-C/DQ/DP. Three of six cases (50%) with donor-dominant one-way HLA matching at three loci of HLA-A/B/DR developed GVHD. Notably, none of the cases with donor-dominant one-way HLA matching at one or two HLA-A/B/DR loci developed GVHD, irrespective of matching status at HLA-C/DQ/DP. The HLA matching status at the antigen level was revised in 22 of 56 cases, following reconfirmation at the allele level. CONCLUSIONS: Pairing of donors and recipients with donor-dominant one-way HLA matching at three HLA-A/B/DR loci should be avoided to prevent GVHD. No impact of HLA-C/DQ/DP on GVHD was identified. For liver transplantation, HLA genotypes should be determined at the allele level.

Left-posterior approach for artery-first en bloc resection in laparoscopic distal pancreatectomy for left-sided pancreatic cancer.

PURPOSE: We describe a "left-posterior approach" in which the important steps in laparoscopic distal pancreatectomy (LDP) for left-sided pancreatic cancer are accomplished in the direction caudal and dorsal to the pancreas. METHODS: The patients who underwent LDP with a left-posterior approach at our hospital from January 2016 to April 2020 were reviewed to evaluate the short-term postoperative outcomes. In LDP, we first dissected retroperitoneal tissues above the left renal vein and superior mesenteric artery, yielding the mobilization of the pancreatic body widely. Then, the splenic artery was divided behind the ventrally lifted pancreas as an artery-first approach. The regional lymphadenectomy was performed in an en bloc manner consecutively in the same operative field. The neck of the pancreas was transected with a linear stapler after mobilization of the spleen. RESULTS: In nine patients (five men and four women) aged 76 years (range: 64-82 years), the operative time was 398 min (276-482 min) with the estimated blood loss of 40 ml (0-80 ml). No patients developed grade B/C pancreatic fistula or delayed gastric emptying. Postoperative complications classified as grade III in the Clavien-Dindo classification occurred in one patient (abdominal abscess). The pathology confirmed R0 resection in all patients who had pancreatic cancer (n = 5), IPMNs (n = 3), and high-grade pancreatic intraepithelial neoplasia (PanIN) (n = 1). The number of retrieved lymph nodes was 35 (11-49). CONCLUSION: The procedure with a left-posterior approach is a rational surgical technique in LDP for left-sided pancreatic cancer.

Laparoscopic distal pancreatectomy with regional lymphadenectomy through retroperitoneal-first laparoscopic approach (Retlap) for locally advanced pancreatic body cancer.

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) is widely performed [1,2]. However, LDP with regional lymphadenectomy for locally advanced pancreatic cancer (LAPC) is technically demanding [3]. We previously reported a new strategy named "retroperitoneal-first laparoscopic approach (Retlap)" for distal pancreatectomy with en bloc celiac axis resection [4]. In this study, Retlap is applied during LDP with regional lymphadenectomy (see Fig. 1). METHODS: This video demonstrates the case of a 70-year-old woman with a 100 × 40-mm LAPC. Preoperative computed tomography revealed a large tumor near the root of the celiac axis and acute pancreatitis in the pancreatic head. An ample dorsal margin should be secured and regional lymphadenectomy performed because of the large tumor. In Retlap, the celiac axis was exposed using the retroperitoneal approach from the dorsal side of the pancreatic body, and then the left adrenal grand and left celiac ganglion were removed. Without interfering with the tumor, the root of the splenic artery was identified, facilitating easy performance of lymphadenectomy around the celiac axis and superior mesenteric artery in Retlap. After dividing the splenic artery, the procedure was converted to laparoscopic approach and resection was completed. RESULTS: The operative time and estimated blood loss were 487 min and 45 mL, respectively. Pathological examination confirmed a negative surgical margin, and R0 resection was achieved with uneventful postoperative course. CONCLUSION: Retlap was technically feasible and useful for achieving adequate and secure surgical margin and regional lymphadenectomy. Retlap can help secure the operative field of view in difficult cases of LAPC.

Use of the inter-Laennec approach for laparoscopic anatomical right posterior sectionectomy in semi-prone position.

BACKGROUND: Among the laparoscopic anatomical liver resections, the right posterior sectionectomy is highly demanding [1, 2], particularly when exposing the right hepatic vein (RHV). To standardize the procedure, the inter-Laennec approach was developed based on the Laennec's capsule structure, composed of two layers surrounding the RHV. One is derived from the proper membrane (hepatic Laennec's capsule) and the other from the pericardium (cardiac Laennec's capsule) [3]. The inter-Laennec approach is a new strategy to expose the RHV by entering the space between the two layers. Herein, we present the concept and procedure of the inter-Laennec approach. METHODS: The patient with 15-mm metastatic tumor close to the right posterior Glissonean pedicle and RHV was placed in left semi-prone position to obtain a good visual field [4]. After the isolation of the extrahepatic right posterior Glissonean pedicle and mobilization of the right liver, we transected the inferior vena cava ligament that facilitated entry into the inter-Laennec space between the hepatic and cardiac Laennec's capsules. We started the liver parenchyma transection between the right posterior section and caudate lobe, followed by cranio-caudal parenchymal dissection along the inter-Laennec space that safely facilitated the exposure of the RHV and confluences of the V7s. RESULTS: The operative time and estimated blood loss were 538 min and 250 mL, respectively. The surface of the RHV was completely exposed with a whitish and shiny appearance, suggesting it was covered by the cardiac Laennec's capsule. CONCLUSION: The inter-Laennec approach is a feasible procedure to standardize laparoscopic right posterior sectionectomy.

Distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) through retroperitoneal-first laparoscopic approach (Retlap): A novel strategy for achieving accurate evaluation of resectability and minimal invasiveness.

BACKGROUND: Distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) for borderline resectable pancreatic body cancer is increasingly being performed [1,2]. For survival benefits, obtaining margin-free resection (R0 resection) is crucial [3]. However, in patients with cancer abutting the root of the celiac axis and/or SMA, accurate resectability using preoperative imaging is difficult to judge [4]. Recently, we developed a novel strategy named "Retlap: Retroperitoneal-first laparoscopic approach" to achieve accurate evaluation of resectability and minimal invasiveness for difficult hepatopancreatobiliary malignancies and retroperitoneal tumors. Retlap enables direct evaluation of invasion of the roots of the celiac axis and SMA through the retroperitoneal approach. METHODS: This video demonstrates the case of a 50-year-old man with a 47 × 36-mm pancreatic body tumor after chemoradiotherapy. Preoperative computed tomography revealed tumor abutting on the roots of the celiac axis and SMA. Changes in the surrounding tissues due to chemoradiotherapy prevented accurate determination of the tumor invasion extent via preoperative imaging; thus, Retlap was applied. Retlap enabled us to identify and secure the roots of the celiac axis and SMA easily despite the advanced tumor. After confirming resectability, DP-CAR was performed. RESULTS: The operative time and estimated blood loss were 841 min and 572 mL. A negative surgical margin using Retlap was confirmed in frozen sections and R0 resection was achieved with uneventful postoperative course. CONCLUSION: Retlap was technically feasible and useful for achieving accurate evaluation of resectability and minimal invasiveness for DP-CAR. Retlap can help provide optimal outcomes in locally advanced pancreatic cancer cases.