Laparoscopic liver resections for hepatocellular carcinoma:Current role and limitations

Liver resection for hepatocellular carcinoma(HCC)is currently known to be a safer procedure than it was before because of technical advances and improvement in postoperative patient management and remains the first-line treatment for HCC in compensated cirrhosis.The aim of this review is to assess current indications,advantages and limits of laparoscopic surgery for HCC resections.We also discussed the possible evolution of this surgical approach in parallel with new technologies.     

Role of minimally invasive surgery for rectal cancer

Rectal cancer is one of the most common malignancies worldwide.Surgical resection for rectal cancer usually requires a proctectomy with respective lymphadenectomy(total mesorectal excision).This has traditionally been performed transabdominally through an open incision.Over the last thirty years,minimally invasive surgery platforms have rapidly evolved with the goal to accomplish the same quality rectal resection through a less invasive approach.There are currently three resective modalities that complement the traditional open operation:(1) Laparoscopic surgery;(2) Robotic surgery;and(3) Transanal total mesorectal excision.In addition,there are several platforms to carry out transluminal local excisions(without lymphadenectomy).Evidence on the various modalities is of mixed to moderate quality.It is unreasonable to expect a randomized comparison of all options in a single trial.This review aims at reviewing in detail the various techniques in regard to intra-/perioperative benchmarks,recovery and complications,oncological and functional outcomes.     

Laparoscopic liver resection: Toward a truly minimally invasive approach

In the surgical treatment of hepatocellular carcinoma and colorectal liver metastasis, it is important to preserve sufficient liver volume after resection in order to avoid post-hepatectomy liver sufficiency and to increase the feasibility of repeated hepatectomyin case of intrahepatic recurrence. Parenchymasparing approach, which minimizes the extent of resection while obtaining sufficient surgical margins, has been developed in open hepatectomy. Although this approach can possibly have positive impacts on morbidity and mortality, it is not popular in laparoscopic approach because parenchyma-sparing resection is technically demanding especially by laparoscopy due to its intricate curved transection planes. "Small incision, big resection" is the words to caution laparoscopic surgeons against an easygoing trend to seek for a superficial minimal-invasiveness rather than substantial patient-benefits. Minimal parenchyma excision is often more important than minimal incision. Recently, several reports have shown that technical evolution and accumulation of experience allow surgeons to overcome the hurdle in laparoscopic parenchymasparing resection of difficult-to-access liver lesions in posterosuperior segments, paracaval portion, and central liver. Laparoscopic surgeons should now seek for the possibility of laparoscopic parenchyma-sparing hepatectomy as open approach can, which we believe is beneficial for patients rather than just a small incision and lead laparoscopic hepatectomy toward a truly minimally-invasive approach.     

Laparoscopic and robot-assisted gastrectomy for gastric cancer: Current considerations

R a d i c a l g a s t r e c t o m y w i t h a n a d e q u a t e l y m p h-adenectomy is the main procedure which makes it possible to cure patients with resectable gastric cancer(GC). A number of randomized controlled trials and meta-analysis provide phase Ⅲ evidence that laparoscopic gastrectomy is technically safe and that it yields better short-term outcomes than conventional open gastrectomy for early-stage GC. While laparoscopic gastrectomy has become standard therapy for early-stage GC, especially in Asian countries such as Japan and South Korea, the use of minimally invasive techniques is still controversial for the treatment of more advanced tumours, principally due to existing concerns about its oncological adequacy and capacity to carry out an adequately extended lymphadenectomy. Some intrinsic drawbacks of the conventional laparoscopic technique have prevented the worldwide spread of laparoscopic gastrectomyfor cancer and, despite technological advances in recent year, it remains a technically challenging procedure. The introduction of robotic surgery over the last ten years has implied a notable mutation of certain minimally invasive procedures, making it possible to overcome some limitations of the traditional laparoscopic technique. Robot-assisted gastric resection with D2 lymph node dissection has been shown to be safe and feasible in prospective and retrospective studies. However, to date there are no high quality comparative studies investigating the advantages of a robotic approach to GC over traditional laparoscopic and open gastrectomy. On the basis of the literature review here presented, robot-assisted surgery seems to fulfill oncologic criteria for D2 dissection and has a comparable oncologic outcome to traditional laparoscopic and open procedure. Robot-assisted gastrectomy was associated with the trend toward a shorter hospital stay with a comparable morbidity of conventional laparoscopic and open gastrectomy, but randomized clinical trials and longer follow-ups are needed to evaluate the possible influence of robot gastrectomy on GC patient survival.     

Cryoablation of colorectal liver metastases: minimally invasive tumour control

Background: Freezing is used for in situ destruction (ablation) of liver tumours not eligible for resection. The procedure is typically done during laparotomy. The objective of this report was to study tumour control at the site of freezing and a minimally invasive approach to cryoablation of colorectal liver metastases. Methods: A prospective study of 19 patients was conducted between 1999 and 2003. Twenty‐five tumours were ablated during 24 procedures (i.e. 5 reablations). Sixteen procedures were performed percutaneously, 5 during laparotomy and 3 laparoscopically. Magnetic resonance imaging (MRI) was used for intraprocedural monitoring during most procedures. Nine patients had concomitant liver resections performed (5 during laparoscopy, 4 during laparotomy). Results: Out of 25 ablations, 18 (72%) were assumed adequate. Total ice‐ball volume during percutaneous procedures was median 62?cm ³ (range 32–114). Excellent imaging of the extent of freezing was achieved using MRI. Hospital stay for patients treated percutaneously was median 4 days (range 3–30). No perioperative mortality occurred. Tumour recurrence at the site of ablation occurred in 8 of 18 (44%) tumours adequately ablated. Actuarial 2‐year tumour‐free survival at site of ablation was 48%. At the time of analyses 12 out of 13 (92%) patients assumed to be adequately ablated were alive. Of all patients, 14 out of 19 (74%) survived. Conclusions: Short‐term tumour control can be achieved following cryoablation of colorectal liver metastases. A minimally invasive approach is feasible but the diameter of metastases considered for percutaneous cryoablation should not exceed 3?cm.     

Single port laparoscopic liver surgery:A minireview

Nowadays,the trend is to perform surgeries with"scarless"incisions.In light of this,the single-port laparoscopic surgery(SPLS)technique is rapidly becoming widespread due to its lack of invasiveness and its cosmetic advantages,as the only entry point is usually hidden in the umbilicus.The interest in"scarless"liver resections did not grow as rapidly as the interest in other scarless surgeries.Hepatopancreatobiliary surgeons are reluctant to operate a malignant lesion through a narrowincision with limited exposure.There are concerns over adverse oncological outcomes for single-port laparoscopic liver resections(SPL-LR)for hepatocellular carcinoma or metastatic colorectal cancer.In addition,getting familiar with using the operating instruments through a narrow incision with limited exposure is very challenging.In this article,we reviewed the published literature to describe history,indications,contraindications,ideal patients for new beginners,technical difficulty,advantages,disadvantages,oncological concern and the future of SPL-LR.     

Considerations on the learning curve for laparoscopic colorectal surgery: a view from the bottom

Introduction

Those who have surmounted the learning curve for laparoscopic colorectal resection state that considerable numbers of highly selected cases should comprise a department’s early experience to ensure reliability of technique before routine implementation. The objective of this study was to determine how this advice may interrupt case flow.

Methods

Details on all colorectal operations performed in a single institution over a 4-year period were gleaned from a prospectively maintained database. Patient profiles were scrutinised to identify how the application of various published exclusion criteria would impact upon the theoretical completion rates of our proposed learning curve.

Results

In total, 317 colorectal resections were performed; 259 operations were for adenocarcinoma (including 100 rectal tumours) while 58 were for benign disease. Of those with malignancy, 25(10%) were obese, 61(24%) had previous intra-abdominal surgery, while 52(20%) were aged over 80 years and 60(23%) were ASA ¾. Strictest exclusion criteria would halve the number of cases to be commenced laparoscopically. A specialist registrar rotating through the department would have case exposure cut from a mean of 33 to 11 in 6 months under this regimen. Prioritising benign cases in the initial experience as has been recommended by certain groups would mean that, at most, 1.2 cases would be performed every 4 weeks during the learning period.

Conclusion

Although our caseload seems sufficient to allow the acquisition of expertise in a timely fashion, procedural flow would be markedly interrupted by stringent pre-selection. A low threshold for initiating the procedure laparoscopically seems a pragmatic way of ensuring departmental confidence through familiarity.

     

结直肠手术中微创技术和理念的进展

近年来随着微创技术的发展,结直肠外科手术取得了重大进步。内镜技术最初作为一项诊查手段,现已越来越多地用于胃肠道疾病的治疗。其中内镜下粘膜切除术和内镜下粘膜剥离术可用于治疗早期结直肠癌,避免了开腹或腹腔镜手术,且体表不遗留手术疤痕。随着器械的完善和技术的进步,腹腔镜技术也已广泛用于结直肠癌的根治性切除,且大量的临床实践证明其具有良好的可行性和安全性。三维腹腔镜的应用改善了术中的视野,提升了腹腔镜操作的精细程度。机器人手术系统的出现则将外科手术引入一个新时代,远程手术得以成功实施,且更加精细灵活的操作可在腹腔镜下狭小的空间里完成。此外,功能学的微创理念日益受到重视。外科医生不仅仅追求更小的切口和创伤,更开始追求更小的应激反应和更快的术后恢复。本文回顾了近年来微创技术和理念的进展,并对微创外科在结直肠手术中的应用做出了展望。     

微创心脏外科手术的研究现状及进展

随着外科技术的发展，麻醉、体外循环（CPB）技术的提高及心肌保护技术的日益成熟，医疗市场的需求和人们对生活质量提高的要求，微创心脏外科（minimallv invasivecardiacsurgery，MICS）技术以切口小、出血少、疼痛轻、创伤小、恢复快、瘢痕隐蔽（尤其符合年轻女性患者的审美要求）、住院时间短、费用低等优点，且操作简便、易行、安全、效果好，     

Status and perspective of laparoscopic repeat liver resection

Liver resection(LR) is now actively applied to intrahepatic recurrence of liver metastases and hepatocellular carcinoma. Although indications of laparoscopic LR(LLR) have been expanded, there are increased risks of intraoperative complications and conversion in repeat LLR. Controversy still exists for the indication. There are 16 reports of small series to date. These studies generally reported that repeat LLR has better short-term outcomes than open(reduced bleedings, less or similar morbidity and shorter hospital stay) without compromising the long-term outcomes. The fact that complete adhesiolysis can be avoided in repeat LLR is also reported. In the comparison of previous procedures, it is reported that the operation time for repeat LLR was shorter for the patients previously treated with LLR than open. Furthermore, it is speculated that LLR for minor repeat LR of cirrhotic liver can be minimized the deterioration of liver function by LR. However, further experience and evaluation of anatomical resection or resections exposing major vessels as repeat LLR, especially after previous anatomical resection, are needed. There should be a chance to prolong the overall survival of the patients by using LLR as a powerful local therapy which can be applied repeatedly with minimal deterioration of liver function.     

肝癌微创介入治疗进展

原发性肝癌的治疗方法一直是许多学者研究的重点,近年来尽管新兴治疗方法层出不穷,但由于病变多发生于进展期肝病或肝硬化的基础上,因此目前原发性肝癌仍然是一种难治性恶性肿瘤。在治疗方面,外科手术切除及肝移植虽是根治性治疗方法,但由于移植相关问题的复杂性及原发性肝癌本身的隐匿性,使得上述两种治疗方法并不能适用于大多数患者。近些年,随着设备和技术水平的提高,原发性肝癌的微创介入治疗得到了越来越多的重视,其中应用最为广泛的就是肝动脉化疗栓塞术(TACE)和组织消融术(TA)。该文主要讨论上述两种介入疗法联合应用治疗原发性肝癌的有效性、可行性,以及近年来介入治疗在原发性肝癌治疗领域的研究进展。     

Minimally invasive surgery in gastric cancer

Minimally invasive surgery for gastric cancer has rapidly gained popularity due to the early detection of early gastric cancer. As advances in instruments and the accumulation of laparoscopic experience increase, laparoscopic techniques are being used for less invasive but highly technical procedures. Recent evidence suggests that the short- and long-term outcomes of minimally invasive surgery for early gastric cancer and advanced gastric cancer are comparable to those of conventional open surgery. However, these results should be confirmed by large-scale multicenter prospective randomized controlled clinical trials.     

Cost‐effectiveness of minimally invasive pancreatic resection

While clinical outcomes of minimally invasive pancreatic resection (MIPR) compared to open surgery are well examined, only few studies focus on its associated cost. The aim of this study is to evaluate cost analyses comparing MIPR to open pancreatic resection (OPR). A systematic review of the literature using PubMed of all published studies between 2000 and 2017 was performed. Studies reporting on cost of laparoscopic distal pancreatectomy (LDP) and laparoscopic pancreatoduodenectomy (LPD) compared to open surgery were identified. Fourteen studies were included, eight that reported a cost comparison between LDP and open surgery and six that compared costs between LPD and open surgery. For both, LDP and LPD, operative costs were higher due to higher costs for surgical equipment. Reports suggest that lower postoperative costs for LDP and LPD could balance out the operative costs resulting in overall decreased costs for the laparoscopic compared to the open approach. Recent results show a positive trend towards cost savings for MIPR. To assess the overall benefit of MIPR compared to OPR comprehensive cost analyses and long‐term quality outcomes need to be investigated.     

改良上下腔静脉阻断法在微创心脏手术中的应用

目的 总结改良上下腔静脉阻断法在胸腔镜辅助右胸小切口微创心脏手术中应用的可行性.方法 2011年7月至2013年11月,应用胸腔镜辅助右胸小切口微创心脏手术技术,结合使用“哈巴狗”钳及肠钳阻断上下腔静脉完成微创心脏手术24例,其中房间隔缺损修补术6例,室间隔缺损修补术5例,右房黏液瘤摘除术1例,二尖瓣置换术同期三尖瓣成型术12例.结果 全组手术顺利,术中上下腔静脉阻断充分,无漏血,无上下腔静脉损伤,无围术期死亡,所有患者均顺利出院.结论 改良上下腔静脉阻断法在胸腔镜辅助右胸小切口微创心脏手术中应用,安全、简单容易、阻断效果满意.     

术中超声——微创观念在肝脏肿瘤手术中的应用

目的:探讨术中超声在肝脏肿瘤手术中的作用.方法:对78例肝脏肿瘤患者行术中超声扫描,与术前超声和CT/增强CT进行对比分析.结果:本组肝脏恶性肿瘤共65例,术前超声和术前CT/增强CT分别有10例和6例不符合,而术中超声全部诊断准确.术中超声对于肝血管瘤的诊断准确率(92.31%)也要高于术前超声(69.23%)和CT/增强CT(76.92%).术中超声对直径≤1cm的小肿瘤检出率达90.48%.明显优于术前超声(59.52%)和CT/增强CT(69.05%)(P<0.05).术中超声对直径>1 cm者检出率为100%.术中超声总体病灶检出率为96.36%,也明显优于术前超声(74.55%) (P<0.05).对22例患者改变了原定的手术方案.所有切除病灶均由术中超声预先确定切除线和切除径路,使切缘无癌细胞残留.结论:与术前超声和CT/增强CT相比,术中超声对肝脏肿瘤定性定位诊断准确,提高了手术的安全性和彻底性,是微创观念在肝脏肿瘤手术中的体现.     

重症心力衰竭的微创外科治疗新进展

心力衰竭是一个主要的公共卫生问题,也是患者住院治疗的最常见原因。随着手术器械及心脏外科技术的发展,通过微创外科治疗心衰将成为未来心衰治疗的发展方向。本文论述了目前心衰微创外科干预的方式如微创心肌血运重建、经皮左室重建、经导管二尖瓣成形的现状、进展和局限性。     

Current status of surgery and transplantation in the management of hepatocellular carcinoma: an overview

Despite many therapeutic advances in the field of hepatocellular carcinoma over the past two decades, this disease continues to be a major cause of cancer‐related mortality worldwide. This review focuses on the recent advances in surgical technique, perioperative management, and transplantation of cirrhotic and noncirrhotic patients with hepatocellular carcinoma. Liver resection continues to be the mainstay of curative treatment in noncirrhotic patients and selected cirrhotic patients with small tumors and preserved liver function. Transplantation should be advocated for patients with poor liver function and localized lesions or for patients with large fibrolamellar carcinomas that are otherwise unresectable. Surgery has a definite role in the management of hepatic recurrences in the absence of systemic dissemination. Newer advances in the therapeutic armamentarium, such as cryotherapy, radiofrequency ablation, microwave coagulation, and ethanol injections are discussed, and their overall efficacy assessed.     

A 15-year experience of two hundred and twenty five consecutive right hepatectomies

BackgroundIn case of liver tumor, surgical resection is the therapeutic gold standard to increase patient survival. Among liver resections, right hepatectomy (RH) is defined as a major hepatectomy. The first aim of this study was to analyze the overall morbidity and mortality of patients undergoing RH, the second aim was to assess changes in both patients characteristic and surgical parameters and mortality rates in a single center institution.MaterialsFrom 2001 to December 2015, 225 RH were performed in our center. We analyzed two time period: 2001–2007 and 2008–2015.ResultsNinety days post operative mortality was observed in 9 cases (4%) for the overall cohort. We observed a difference between the two groups in the use of Pringle Maneuver (p < 0,001). This result is consistent in each major surgical indication: HCC (p = 0,001), CLM (p = 0,015) and BT (p = 0,015). The estimated blood losses improved (p = 0,028), particularly for the HCC cases (p = 0,024). No difference was observed in terms of number of transfusions received between the two groups. Reduced length of stay was observed in the second group (p < 0,001), more markedly for CLM cases (p = 0,001).ConclusionTo further improve the outcomes of RH, it is important to performed this major hepatectomy in hepatobiliary centers with an overall liver resection experience of at least few hundred cases.     

结直肠肿瘤治疗的微创和功能外科理念在实践与探索中前行

随着腹腔镜微创手术在结直肠癌等消化系统肿瘤的手术治疗中逐步推广和应用,微创理念得以在肿瘤外科中建立并发展。微创理念与功能外科的要求是相辅相成的,功能外科要求在手术治疗的基础上,最大限度地保留器官和机体的功能。在保证患者利益的前提下,临床医生要在规范中勇于创新,微创外科的发展是永无止境的,这也是功能外科的必然趋势。