Key Points

History of laparoscopic hepatic resections

Gagner and colleagues is credited with reporting the first laparoscopic hepatic resection in 1992. In an abstract presented at the Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, he described 2 patients. The first was a young woman with a 6-cm lesion in segment VI, which was thought to be an adenoma, but after she underwent a laparoscopic wedge resection, it was found instead to be focal nodular hyperplasia. The second patient had metastatic colorectal cancer, and a wedge resection in segment V was undertaken. Both specimens were removed transvaginally and the patients were discharged within 4 days postoperatively.

The following year, the first report of a laparoscopic anatomic hepatic resection was published by Azagra and colleagues, who described a left lateral sectionectomy (resection of segments II and III) for a symptomatic hepatic adenoma. Not until 4 years later in 1997 was the first major anatomic hepatic resection reported. Huscher and colleagues reported a series of 20 patients in which 6 patients underwent left hemihepatectomy, 5 underwent right hemihepatectomies, and 3 had central hepatectomies.

Although the Italian group had reported the abovementioned series of complex resections 3 years prior, a seminal publication in 2000 by Cherqui and colleagues is often credited as being the first reported series of laparoscopic hepatic resections. The group from the Hopital Henri Mondor in Paris reported 30 patients who largely underwent laparoscopic segmentectomies. This publication in the Annals of Surgery seemed to ignite the spark in many hepatic surgeons, and the laparoscopic approach to hepatic resections began to be used more widely. These authors chose to use laparoscopic approaches on patients with hepatocellular carcinoma (HCC), and excluded any patients with colorectal metastases.

History of laparoscopic hepatic resections

Gagner and colleagues is credited with reporting the first laparoscopic hepatic resection in 1992. In an abstract presented at the Annual Meeting of the Society of American Gastrointestinal and Endoscopic Surgeons, he described 2 patients. The first was a young woman with a 6-cm lesion in segment VI, which was thought to be an adenoma, but after she underwent a laparoscopic wedge resection, it was found instead to be focal nodular hyperplasia. The second patient had metastatic colorectal cancer, and a wedge resection in segment V was undertaken. Both specimens were removed transvaginally and the patients were discharged within 4 days postoperatively.

The following year, the first report of a laparoscopic anatomic hepatic resection was published by Azagra and colleagues, who described a left lateral sectionectomy (resection of segments II and III) for a symptomatic hepatic adenoma. Not until 4 years later in 1997 was the first major anatomic hepatic resection reported. Huscher and colleagues reported a series of 20 patients in which 6 patients underwent left hemihepatectomy, 5 underwent right hemihepatectomies, and 3 had central hepatectomies.

Although the Italian group had reported the abovementioned series of complex resections 3 years prior, a seminal publication in 2000 by Cherqui and colleagues is often credited as being the first reported series of laparoscopic hepatic resections. The group from the Hopital Henri Mondor in Paris reported 30 patients who largely underwent laparoscopic segmentectomies. This publication in the Annals of Surgery seemed to ignite the spark in many hepatic surgeons, and the laparoscopic approach to hepatic resections began to be used more widely. These authors chose to use laparoscopic approaches on patients with hepatocellular carcinoma (HCC), and excluded any patients with colorectal metastases.

Evolution of laparoscopic hepatic resections

Between 1997 and 2007, many case series of laparoscopic liver resections were published, but most of these included fewer than 30 patients. Things changed rapidly, however, in 2007 when a series of 300 laparoscopic liver resections was presented by Koffron and colleagues from Northwestern University at the American Surgical Association’s Annual Meeting. This report was greeted with much skepticism, as reflected by the discussants questioning the applicability of the procedure to patients with cancer, its safety, and the method through which the technique could be disseminated safely. Despite the concern from senior surgeons, the following year at the same meeting, the group from Cincinnati presented a series of 500 minimally invasive hepatic procedures, which included 253 patients who underwent laparoscopic hepatic resection.

Although these 2 series are still the largest single-center experiences published, many other groups began to publish their experience with laparoscopic liver resection. By the end of 2008, reports of nearly 3000 patients had been published in the worldwide literature. In a review of this literature, nearly half of the cases were undertaken for hepatic malignancies. Of those with malignant indications for resection, 52% had HCC, 35% had metastatic colorectal cancer, and 13% had other malignancies. Further, the trend was that of an exponentially increasing number of patients undergoing laparoscopic resections each year, with the fraction of those with malignant indications rapidly increasing.

The Louisville statement

In 2008, Buell’s group for the University of Louisville coordinated an international consensus conference to discuss the major issues in laparoscopic liver surgery. Approximately 300 attendees were present and a variety of important topics were addressed, some of which are summarized in the following list.

• 1.
  

  The terms for a variety of resection types that had emerged were more clearly defined. These included pure laparoscopy, hand-assisted laparoscopy, and the hybrid technique. The latter refers to laparoscopic mobilization and dissection, but standard open parenchymal transection via a small open incision.

  
  
• 2.
  

  The concern for patient safety was emphasized by the conclusion stating that safety could be compromised by too rapid a dissemination of the procedure, inadequate training, and lack of established standards. However, the group concluded that the evidence available at the time could not be assessed rigorously to address the issues of patient safety.

  
  
• 3.
  

  The best indications for a laparoscopic approach were thought to be solitary tumors smaller than 5 cm located in hepatic segments II through VI. The group concluded that laparoscopic resection of the left lateral section (segments II and III) should be the standard of care.

  
  
• 4.
  

  The group emphasized that the indications for the resection of benign tumors of the liver should not be adapted despite the easier method of abdominal access.

  
  
• 5.
  

  The group advocated the development of a cooperative patient registry for all laparoscopic hepatic resections, which could be used to monitor for safety concerns and outcomes. This resource was thought to be more useful and more practical than a clinical trial, which would likely be underfunded and underpowered and have difficulty with accrual. However, this registry has also proven to be difficult because of its voluntary nature, tendency for underreporting, and the possibility of reflecting patient selection.

  
  
• 6.
  

  Finally, the most controversial area of the consensus conference was the application of laparoscopic techniques to hepatic resection in those with HCC and metastatic colorectal cancer.

  
  
  
  
  • a.
    

    For metastatic colorectal cancer, the primary concerns discussed were those of margin status and inadequate evaluation of the remainder of the liver. The group concluded that patient selection and proper preoperative staging were critical to the use of laparoscopic liver resection in patients with metastatic colorectal cancer to avoid an increase in margin-positive resections and of unrecognized occult lesions.

    
    
  • b.
    

    For HCC, the role of resection relative to ablation and transplantation was debated, but the group concluded that laparoscopic approaches could be useful in its treatment.

  
  

The response of the surgical community

Although many surgeons facile with laparoscopic techniques were enthusiastic about the promise of laparoscopic hepatic resections, others were concerned about the potential for harm. In a letter to the editor entitled “A Serious Note of Caution,” Donadon and colleagues argue against several specific issues in Dr Buell’s manuscript, but conclude as follows: “We are afraid that the infectious enthusiasm on laparoscopy in liver surgery may lead to the adoption of a technique indiscriminately to the detriment of an increase in morbidity and mortality, which should be reduced, making this aim the absolute priority rather than the reduction of the length of the incisions.”

In a separate letter to the editor, Abdalla disputes the suggestion made by Buell and colleagues that laparoscopic major hepatic resection represents an “evolution in the standard of care.” He emphasizes the lack of data supporting this assertion, and asserts that no consensus exists about the general application of laparoscopic hepatic resections, particularly for patients with cancer. He contends that because high-quality data do not exist, one must be careful not to make assumptions about the procedure’s safety and efficacy based on the less reliable data in the literature to that point. He cautions, “Care must be exercised drawing far-reaching conclusions from insufficient, evolving data.”

Both sides of the coin

Clearly, laparoscopic hepatic resection has its clear proponents and those who are much less enthusiastic about its promise. Box 1 outlines the potential advantages and disadvantages of the approach.

Direct comparison of laparoscopic and open hepatic resections

To address the potential advantages and disadvantages of laparoscopic hepatectomy, many authors have reported series of laparoscopic liver resections and others have reported case-matched comparison studies to open hepatic resections. Currently, no randomized data comparing these 2 approaches exist, and therefore systematic review and meta-analysis should be used to best compare these 2 techniques with the available data.