Laparoscopic anatomical left hemihepatectomy guided by middle hepatic vein in the treatment of left hepatolithiasis with a history of upper abdominal surgery.

BACKGROUND: This study aimed to investigate the safety and efficacy of laparoscopic anatomical left hemihepatectomy guided by the middle hepatic vein (MHV) for the treatment of patients with hepatolithiasis who had a history of upper abdominal surgery. METHODS: Retrospective data analysis was performed on patients who underwent laparoscopic left hepatectomy for hepatolithiasis and with previous upper abdominal surgery at the Second Affiliated Hospital of Nanchang University from January 2018 to April 2022. According to the different surgical approaches, patients were divided into laparoscopic anatomical left hepatectomy guided by the MHV group (MHV-AH group) and laparoscopic traditional anatomical left hepatectomy not guided by the MHV group (non-MHV-AH group). RESULTS: This study included 81 patients, with 37 and 44 patients in the MHV-AH and non-MHV-AH groups, respectively. There was no significant difference in the basic information between the two groups. Five cases were converted to laparotomy, and the remaining were successfully completed under laparoscopy. Compared to the non-MHV-AH group, the MHV-AH group had a slightly longer operation time (319.30 min vs 273.93 min, P = 0.032), lower bile leakage rate (5.4% vs 20.5%, P = 0.047), stone residual rate (2.7% vs 20.5%, P = 0.015), stone recurrence rate (5.4% vs 22.7%, P = 0.028), and cholangitis recurrence rate (2.7% vs 22.7%, P = 0.008).There were no significant differences in the results of other observation indices between the groups. CONCLUSIONS: Laparoscopic anatomical left hepatectomy guided by the MHV is safe and effective in the treatment of left hepatolithiasis with a history of upper abdominal surgery. It does not increase intraoperative bleeding and reduces the risk of postoperative bile leakage, residual stones, stone recurrence, and cholangitis recurrence.

Exposure of the hepatic vein trunk via tracing of its branches: a useful surgical procedure for laparoscopic anatomical hepatectomy.

BACKGROUND: Although there are various advantages of laparoscopic liver resection (LLR) over open liver resection, some problems have been reported, such as disorientation and lack of control of bleeding during liver parenchymal dissection. In this study, we discuss a strategy to overcome the disorientation experienced during liver parenchymal dissection, especially in anatomical LLR. TECHNICAL PRESENTATION: This procedure involves hepatic parenchymal dissection from the hepatic vein branch along its trunk to reveal an important landmark in anatomical LLR. Knowing which region of the liver is perfused into each hepatic vein in preoperative 3D simulation allows the tracing of the hepatic vein branch that naturally leads to the hepatic vein trunk. After that, hepatic resection can be easily completed by dissecting the line connected to the other landmarks, the Glisson branch, the root of the hepatic vein, and the liver demarcation line. CONCLUSION: In conclusion, this surgical procedure that traces the branch of the hepatic vein exposes the trunk, which makes it a very useful tool for limited laparoscopic anatomical hepatectomy.

Right anatomical hepatectomy: pioneers, evolution, and the future.

To identify the pioneers of right anatomical hepatectomy (RAH), and clarify the development of associated operative procedures, concepts, and the future, we reviewed the "hidden" literature published in Eastern and Western countries since the 1940s. We searched the English and non-English literature on RAH through web search engines, text books and documents, and also referred to experts' comments. Non-English literature, other than in Japanese, was translated. Changes in the anatomical concept, anatomical identification, vascular control technique, approaches, pre-operative management, and other aspects of RAH were analyzed. Honjo and Lortat-Jacob, in 1949 and 1951, respectively, reported the first cases of successful RAH; since then, RAH has been used in the treatment of liver malignancies worldwide. Vascular in-flow control is divided into intrafascial, extrafascial or transfissual access. The anatomical border along the main hepatic veins was proposed for transection, and anterior approaches have been suggested as alternative options in the hazardous situation of right liver rotation. In the laparoscopic era, several procedures and positions have been devised for RAH. In summary, RAH and related anatomical hepatectomy have been established as treatment methods for 70 years, and the future of RAH includes new concepts, approaches, and techniques to optimize patient safety and disease curability.

Perioperative and oncological outcomes of laparoscopic anatomical hepatectomy for hepatocellular carcinoma introduced gradually in a single center.

BACKGROUND: Anatomical hepatectomy is an ideal curative treatment for hepatocellular carcinoma (HCC). We have standardized our laparoscopic anatomical hepatectomy (LAH) procedure, gradually extending its indications. In the present study, we describe our experience and the perioperative and oncological outcomes of LAH for HCC compared to those of open anatomical hepatectomy (OAH) during the gradual introduction of LAH. METHODS: Seventy patients with primary HCC underwent anatomical hepatectomy in our institution from November 2008 to April 2014. As we gained experience with LAH, our indications for choosing LAH over OAH gradually expanded. Ultimately, 40 and 30 patients underwent LAH and OAH, respectively. Perioperative and oncological outcomes were compared between the two groups. RESULTS: There were no significant differences in age, sex, background of liver disease, liver function, tumor size, tumor number, or type of liver resection between the two groups. Major complications and mortality rates were similar between the LAH and OAH groups (12.5% vs. 20%; p = 0.582, and 0% vs. 3.3%; p = 0.429, respectively). The median follow-up time after surgery was 40.5 months in the LAH group and 32.9 months in the OAH group (p = 0.835). The 1-, 3-, and 5-year overall survival rates were 89.9, 84.7, and 70.9%, in the LAH group, and 89.8, 68.0, and 63.1% in the OAH group, respectively (p = 0.255). The 1-, 3-, and 5-year disease-free survival rates were 79.5, 58.0, and 42.5%, in the LAH group, and 72.4, 56.1, and 50.4% in the OAH group, respectively (p = 0.980). CONCLUSIONS: Through gradual introduction of LAH, we obtained comparable results to those achieved with OAH. LAH can be a feasible surgical treatment for primary HCC, with good oncological outcomes.

[Comparative analysis of anatomic and non-anatomic hepatectomy for single small hepatocellular carcinoma with microvascular invasion].

Objective: To compare the efficacy and safety of anatomic hepatectomy and non-anatomic hepatectomy in the treatment of single small Hepatocellular carcinoma with MVI. Methods: The clinical data of 84 patients with single small Hepatocellular carcinoma with MVI in Beijing Chaoyang Hospital between January 2008 and December 2013 were retrospectively analyzed. Patients undergoing anatomical hepatectomy were enrolled in the AR group, and the patients undergoing non-anatomic hepatectomy were enrolled in the NR group. The efficacy and survival rate of the two groups were compared. Results: (1) Operation time, numbers of patients with volume of intraoperative blood loss ≥300 ml and number of patients with blood transfusion were (170±41)minutes, 8, 7 in the AR group and (148±35)minutes, 19, 18 in the NR group, respectively, with statistically significant differences between the 2 groups (P<0.05). (2) The 1-year, 2-year and 3-year overall survival rate were 85.7%, 68.6%, 57.1% in the AR group and 79.6%, 53.1%, 42.9% in the NR group, respectively. The 1-year, 2-year and 3-year progression-free survival rate were 80.0%, 62.9%, 51.4% in the AR group and 71.4%, 49.0%, 38.8%, in the NR group, respectively. There were statistically significant differences between the 2 groups both in the overall survival rate and the progression-free survival rate (P<0.05). (3) Prognostic factors analysis of HCC patients with MVI: result of univariate analysis showed that maximum diameter of tumor and surgical procedures were relative factors affecting overall survival and progression-free survival of HCC patients with MVI, AFP level was relative factors affecting progression-free survival of HCC patients with MVI, with statistically significant differences (P<0.05). Result of multivariate analysis showed that maximum diameter of tumor between 3.0 and 5.0 cm and non-anatomic liver resection were independent factors affecting poor overall survival and progression-free survival of HCC patients with MVI, and AFP≥20 µg/L and total bilirubin ≥20 µmol/L were independent factors affecting poor progression-free survival of HCC patients with MVI, with a statistically significant differences (P< 0.05). Conclusion: Anatomic hepatectomy for patients with single small hepatocellular carcinoma with microvascular invasion has better clinical efficacy and safety.

[The role of anatomical hepatectomy in the treatment of intrahepatic cholangiocarcinoma].

Objective: To evaluate the role of anatomical hepatectomy in the treatment of intrahepatic cholangiocarcinoma. Methods: The cases of intrahepatic cholangiocarcinoma who received curative surgery in two hospitals from 2010 to 2015 were analyzed retrospectively. Among the 98 patients enrolled in this study, 55 were male and 43 were female. The median age was 61 years. According to receiving anatomical hepatectomy or not, the 98 cases were divided into two groups: non-anatomical hepatectomy(n=30) and anatomical hepatectomy(n=68). The surgical results were compared between the two groups.Survival curves were plotted by the Kaplan-Meier method and compared by the log-rank test. The influence of each prognostic factor identified by univariate analysis was multivariate analysis by Cox's proportional hazard regression. Results: The duration of surgery was significantly prolonged in the anatomical hepatectomy group((196.4±94.9)minutes vs. (166.2±65.7)minutes, P=0.027), while there was no significant difference in terms of other surgical results such as intraoperative blood transfusion, postoperative morbidity and mortality rate. Compared to non-anatomical hepatectomy, anatomical hepatectomy significantly improved long-term survival results(14 months vs. 11 months)(χ2=4.641, P=0.031). Single variable analysis indicated that tumor differentiation, tumor numbers, T stage, N stage, anatomical hepatectomy and adjuvant therapy significantly affected overall survival. Multivariate analysis demonstrated that tumor numbers(HR=0.522, 95% CI: 0.259-0.974, P=0.042) and anatomical hepatectomy(HR=1.858, 95%CI: 1.092-3.161, P=0.022) were two independent prognostic factors for overall survival. Conclusion: Compared to non-anatomical hepatectomy, anatomical hepatectomy performed for intrahepatic cholangiocarcinoma is not only safe but also beneficial for long-term survival.

Anatomical versus non-anatomical resection for solitary hepatocellular carcinoma without macroscopic vascular invasion: A propensity score matching analysis.

BACKGROUND AND AIM: The superiority of anatomical resection (AR) in patients with hepatocellular carcinoma compared with non-anatomical resection (NAR) remains controversial. We aimed to investigate the prognostic outcomes of AR and NAR for solitary hepatocellular carcinoma (HCC) patients without macroscopic vascular invasion, using a propensity score matching (PSM) analysis. METHODS: A total of 305 consecutive HCC patients without macroscopic vascular invasion who underwent curative hepatectomy were included in our study. PSM was performed in order to eliminate possible selection bias. RESULTS: By PSM, the patients were divided into propensity-matched anatomical resection (PS-AR) (n = 114) and propensity-matched non-anatomical resection (PS-NAR) (n = 114) groups. The 1-year, 3-year, and 5-year overall survival rates were 90.4%, 77.7%, and 65.7% in PS-AR and 88.6%, 70.7%, and 52.2% in PS-NAR (P = 0.053), respectively. The 1-year, 3-year, and 5-year recurrence-free survival (RFS) rates were 84.1%, 64.9%, and 45.1% in PS-AR and 75.4%, 48.1%, and 31.0% in PS-NAR (P = 0.005), respectively. Multivariate analysis showed that ICG-R15 (P = 0.022); the Barcelona clinic liver cancer staging (P = 0.044) and microvascular invasion (MVI; P = 0.005) were independent risk factors for the overall survival rate, while type of resection (P = 0.027), surgical margin (P = 0.039), and MVI (P = 0.024) were independent risk factors for the RFS rate. Patients who underwent NAR were prone to early recurrence and marginal recurrence. Subgroup analysis indicated that the RFS rate was significantly better in PS-AR than that in PS-NAR (surgical margin ≥ 1 cm) (P = 0.025). Better RFS rate was observed in PS-AR with MVI compared with PS-NAR (P = 0.016). CONCLUSIONS: Anatomical resection contributed to improve the RFS rate in solitary HCC patients without macroscopic vascular invasion using PSM analysis, especially in patients with MVI.

Laparoscopic anatomical segmentectomy of liver segments VII and VIII with the hepatic veins exposed from the head side (with videos).

BACKGROUND: The reported protocol was difficult to expose the hepatic veins for laparoscopic anatomical hepatectomy of segments VII and VIII. We introduce a new, convenient, applicable approach with the hepatic vein exposed from the head side. METHODS: This study included 10 patients who underwent laparoscopic liver resection for HCC in the segments VII and VIII between October, 2014 and November, 2015. Their perioperative course and operative techniques were retrospectively evaluated. RESULTS: All patients underwent laparoscopic anatomical segmentectomy of segments VII and/or VIII of the liver with the hepatic vein exposed from the head side. None of the cases was converted to open surgery. The average procedure duration was 326.20 ± 51.13 min, and the average blood loss volume was 375.0 ± 166.42 ml. No postoperative complications were observed. The average postoperative hospital stay was 6.7 ± 0.82 days. No recurrence or metastasis was observed. CONCLUSIONS: Laparoscopic anatomical segmentectomy of liver segments VII and VIII, with the hepatic vein exposed from the head side, may be safe, convenient, and applicable to perform. J. Surg. Oncol. 2016;114:752-756. © 2016 Wiley Periodicals, Inc.

An Efficient Saline-Linked Cautery (SLiC) Method for Robotic Liver Parenchymal Transection Using Simultaneous Activation of Saline-Linked Cautery and Robotic Suctioning: Detailed Technical Aspects and Short-Term Outcomes.

Introduction While there are several advantages to utilizing robotics in liver surgery compared to traditional open and laparoscopic approaches, the most challenging part of robotic liver resection (RLR) remains the liver parenchymal transection. This is primarily due to the constraints of the existing robotic tools and the absence of a standard procedure. This study presents detailed technical aspects of our novel saline-linked cautery (SLiC) method for RLR and assesses the short-term outcomes for both non-anatomical and anatomical RLRs. Methods In this study, 82 cases that underwent RLR utilizing the SLiC method at our hospital from September 2021 to December 2023 were examined. A novel SLiC method is introduced in this study for robotically transecting the liver parenchyma utilizing bipolar cautery or monopolar scissors. The technique involves activating the SLiC and robotic suctioning simultaneously. The included patients were divided into two groups: patients undergoing robotic anatomical hepatectomy (n=39), and those receiving robotic non-anatomical hepatectomy (n=43). Short-term outcomes, including intraoperative and postoperative complications, were assessed in patients receiving both anatomical and non-anatomical hepatectomies. Results In the whole cohort, 74% of patients had performance status 1 or 2, and 24% were classified as Child-Pugh class B. RLR was performed without Pringle's maneuver in more than 80% of cases in patients receiving robotic non-anatomical hepatectomy, and more than 80% of patients undergoing robotic anatomical hepatectomy required only four or fewer 15-minute Pringle's maneuvers. There was no conversion to open hepatectomy, no cases of grade B or C post-hepatectomy liver failure, and no mortality in the entire cohort. Four postoperative complications with CDC IIIa or higher occurred (small bowel obstruction in two cases, intraabdominal hemorrhage in one, and bile leak in another), but no differences in the frequency of complications were found between those undergoing non-anatomical and anatomical hepatectomy (p=0.342). Conclusions The SLiC method, which involves simultaneously activating SLiC and robotic suctioning with either monopolar scissors or bipolar cautery, appears to be a secure and convenient technique for liver parenchymal transection in RLR. This innovative method permits precise access to the major Glissonean and venous structures within the liver, making RLR more standardized and easily applicable in routine patient care.

Efficiency of Anatomical Hepatectomy in the Treatment of Hepatic Cystic Echinococcosis.

Introduction: Total cystectomy and hepatectomy are the main radical surgical procedures for hepatic cystic echinococcosis (CE). When CE lesions severely invade intrahepatic biliary ducts and vessels or single or multiple lesions occupy one hepatic lobe, performing total cystectomy is not indicated. This study aimed to analyze the clinical efficiency of anatomical hepatectomy in the treatment of patients with hepatic CE. Methods: Clinical data of 74 patients with hepatic CE who received anatomical hepatectomy were retrospectively analyzed from January 2005 to January 2022. The patients were classified into the intrahepatic biliary duct invasion group (group A), the intrahepatic vessel invasion group (group B), and the hepatic lobe occupation group (group C). Results: Among these 74 patients who received anatomical hepatectomy, right hepatectomy was performed in 20 cases (27.03%), left hepatectomy in 26 cases (35.13%), right posterior lobectomy in nine cases (12.16%), and left lateral sectionectomy in 19 cases (25.68%). Short-term post-operative complications occurred in seven cases (9.50%), including abdominal abscess in one case, pleural effusion in three cases, intestinal obstruction in one case, incision infection in one case, and ascites in one case. Long-term post-operative complications occurred in four cases (5.4%), including recurrences of CE in two cases and incisional hernias in another two cases. There were no statistical differences in the concentrations of total bilirubin, alanine aminotransferase, and aspartic transaminase before and after surgery between groups (p > 0.05). However, differences in operative time, short-term post-operative complications, average hospital stay, and number of open hepatectomy cases were statistically significant between groups (p < 0.05). The differences in cases receiving hepatic portal occlusion, intra-operative blood loss, and intra-operative blood transfusion were not statistically significant between groups (p > 0.05). Conclusions: Anatomical hepatectomy is an effective and feasible surgical procedure for patients with hepatic CE with severe invasion of intrahepatic biliary ducts and vessels or patients with huge lesions occupying one hepatic lobe, which effectively avoids residual cavity-related complications.

Parenchymal-sparing anatomical hepatectomy based on portal ramification of the right anterior section: A prospective multicenter experience with short-term outcomes.

Backgrounds/Aims: Parenchymal-sparing anatomical hepatectomy (Ps-AH) based on portal ramification of the right anterior section (RAS) is a new technique to avoid unnecessarily transecting too much liver parenchyma, especially in cases of major anatomical hepatectomy. Methods: We prospectively assessed 26 patients with primary hepatic malignancies having undergone major Ps-AH based on portal ramification of the RAS from August 2018 to August 2022 (48 months). The perioperative indications, clinical data, intra-operative index, pathological postoperative specimens, postoperative complications, and follow-up results were retrospectively evaluated. Results: Among the 26 patients analyzed, there was just one case that had intrahepatic cholangiocarcinoma The preoperative level of α-Fetoprotein was 25.2 ng/mL. All cases (100%) had Child-Pugh A liver function preoperatively. The ventral/dorsal RAS was preserved in 19 and 7 patients, respectively. The mean surgical margin was 6.2 mm. The mean surgical time was 228.5 minutes, while the mean blood loss was 255 mL. In pathology, 5 cases (19.2%) had microvascular invasion, and in the group of HCC patients, 92% of all cases had moderate or poor tumor differentiation. Six cases (23.1%) of postoperative complications were graded over III according to the Clavien-Dindo system, including in three patients resistant ascites or intra-abdominal abscess that required intervention. Conclusions: Parenchymal-sparing anatomical hepatectomy based on portal ramification of the RAS to achieve R0-resection was safe and effective, with favorable short-term outcomes. This technique can be used widely in clinical practice.

Right anatomical hepatectomy using extrahepatic glissonean pedicle approach combined liver hanging for hepatocellular carcinoma: surgical approach in a developing country.

Backgrounds/aims: To evaluate the outcomes of hepatocellular carcinoma (HCC) patients who underwent right anatomical hepatectomy using the combination of the extrahepatic Glissonean pedicle approach (Takasaki's technique) and liver hanging maneuver (LHM) (Belghiti's technique). Patients and methods: A retrospective analysis of 30 cases of HCC treated with right hepatectomy using extrahepatic Glissonean pedicle approach and LHM by only one surgeon at our department from March 2020 to August 2023. Clinical characteristics, pathological results, postoperative outcomes, and survival rate were analyzed. Results: Among the 30 HCC patients analyzed, males accounted for 96.7% of patients. The mean age was 54.9±11 years. 96.7% had normal preoperative liver function (Child-Pugh A). LHM with an extrahepatic Glissonean approach was feasible in 100% of cases with minor blood loss, no blood transfusion, intraoperative complications, or perioperative mortality. The mean operative time was 123.8±29.0 min. The mean hospital stay was 9.37±4.02 days. Postoperative liver failure accounted for 6.7%. Pathological results: 63.3% moderately differentiated HCC; 36.7% poorly differentiated HCC. 1-year, 2-year, and 3-year survival rates were 86.1, 73.8, and 59.0%, respectively. Recurrence was witnessed in 13 (43.3%) cases, with 6 (20%) cases in remnant liver. 1-year, 2-year, and 3-year disease-free survival were 69.3, 42.0, and 28.0%, respectively. Conclusion: Right anatomical hepatectomy using extrahepatic Glissonean pedicle approach combined LHM for HCC was feasible and safe at our high-volume oncology center in a developing country.

3D laparoscopic anatomical hepatectomy guided by 2D real-time indocyanine green fluorescence imaging for hepatocellular carcinoma.

Laparoscopic anatomical hepatectomy (LAH) for patients with hepatocellular carcinoma (HCC) has been advocated by many surgeons in the hope of producing better oncological outcomes. Two recent techniques, 3D laparoscopic system and 2D real-time indocyanine green fluorescence imaging (r-ICG) guidance, are benefit for improving the operative precision of LAH in different aspects. However, these two techniques cannot be applied concomitantly because of the technical limitation. Although a new modern laparoscopic system with both 3D and indocyanine green (ICG) imaging mode has been designed, it has not been listed in many countries including China. Thus, we design a new procedure to perform the 3D LAH with 2D r-ICG guidance for HCCs with conventional laparoscopic systems. In this procedure, both 3D and 2D laparoscopic systems were used. A total of 11 patients with HCC received 3D laparoscopic right posterior sectionectomy (LRPS) with 2D r-ICG guidance. The right posterior Glissonian pedicle was clamped under the 3D vision. Then ICG solution was then intravenously administrated. The liver parenchyma was transected under the 3D vision and guided by 2D ICG vision simultaneously. There was no severe complications (Clavien-Dindo ≥III) and operation related death. The 90-day mortality was also nil. By using this procedure, the advantages of two techniques, 3D laparoscopic system and 2D r-ICG guidance, were combined so that LAH could be performed with more precision. However, it should be validated in more studies.

Hepatolithiasis Classification Based on Anatomical Hepatectomy.

BACKGROUND: This study aims to propose a novel classification system to standardize the treatment of hepatolithiasis. METHODS: A hepatolithiasis classification named LHO was proposed to represent the distribution of stones in the segmental bile ducts and the hepatic atrophy associated with the stones (L), the existence of stones or strictures in the hilar bile duct (H), and dysfunction of the Oddi sphincter (O), which can be used to formulate ideal surgical protocols. One hundred and forty-seven primary hepatolithiasis patients treated between 2013 and 2018 were classified into different types and divided into two groups. If the patient's actual surgical procedure matched the ideal surgical protocol, the patients were included in the matching group; otherwise, patients were included in the nonmatching group. The rates of residual stones, recurrence, and a good quality of life (QOL) were analyzed among the patients in the matching and nonmatching groups and previous reports. RESULTS: According to the classification of each patient, 77.6% of the patients were included in the matching group, and 22.4% were included in the nonmatching group. The rates of residual stones, recurrence, and a good QOL were significantly better in the matching group than in the nonmatching group (9.6% vs. 27.3%; 8.0% vs. 35.0%; 89.5% vs. 65.4%); the rates of residual stones and a good QOL were also better than those in previous reports (9.6% vs. 19.1%; 89.5% vs. 61.6%). CONCLUSIONS: The LHO classification can comprehensively reflect the key points of treatment, which is beneficial for formulating effective and standardized surgical plans of hepatolithiasis.

A multicenter validation study for determining the condition of nonanatomical or minor anatomical hepatectomies satisfying technical difficulty of current high-level hepatectomy certificated by the Japanese Society of Hepato-Biliary-Pancreatic Surgery.

BACKGROUND: The current high-level hepatectomy (HLH) is certified by the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS), comprising only anatomical hepatectomies above Couinaud's segmentectomy. This multicenter study aimed to identify the conditions of non-HLH that satisfy equivalent technical difficulties to HLH. METHODS: Between 2018 and 2021, 595 first open hepatectomies without biliary reconstruction (374 HLHs and 221 non-HLHs) were performed in the five institutions. Non-HLHs belonging to at least one of the three conditions; depth of hepatectomy ≥5 cm, number of resections ≥3 locations and at least one location with a depth of hepatectomy ≥3 cm, and hepatectomy involving the paracaval portion of the caudate lobe was proposed as the candidate for difficult non-HLH. The technical difficulty was estimated by the operative time and blood loss. RESULTS: Difficult non-HLHs were neither associated with shorter operative time (373 min vs. 354 min, p = .184) nor lesser blood loss than those with HLHs (503 mL vs. 436 mL, p = .126). Postoperative complications such as Clavien-Dindo classification grade III or more were not significant between the two groups (18.6% vs. 13.4%, p = 0212). CONCLUSIONS: Difficult non-HLHs were associated with no lesser technical difficulty than those with HLH.

Prevalence and clinical significance of the Sg6/Sg7 intersegmental veins based on re-evaluation of the Couinaud classification for the right posterior portal vein.

Although Segment 6(Sg6) and Segment 7(Sg7) are two independent units, there are currently no clear anatomical boundary markers between Sg6 and Sg7. This study aimed to identify intersegmental veins (ISV) in the intersegmental plane of Sg6 and Sg7, and evaluate the prevalence of ISV, and its clinical significance in anatomical hepatectomy. We analyzed data from 180 patients undergoing abdominal computed tomography (CT) examination, and simultaneously performed 3D reconstruction models of the liver for each patient. The right posterior portal vein was analyzed and re-typed. Furthermore, the existence of ISV was defined, and prevalence and confluence patterns of ISV were analyzed. The author attempted to apply ISV to laparoscopic S6/S7 segmentectomy. We sorted data from the right posterior portal vein and divided it into six types. The ISV could be identified in 82.2% (148/180) of the patients, which were derived from the right hepatic vein (RHV) (91.9%) and right posterior inferior vein (IRHV) (8.1%). Ten ISV-guided laparoscopic Sg6/Sg7 segmentectomy were successfully carried out, seven patients underwent Sg6 segmentectomy, and three patients underwent Sg7 segmentectomy. There was no perioperative mortality. The median operative time was 223 min (range 181-260 min). The median blood loss was 200 ml (range 150-310 ml). The R0 resection rate was 100%. The ISV may be a candidate vessel to distinguish the boundary of the right posterior sector; it is expected to be a landmark in the liver parenchyma of anatomical hepatectomy.

A Multicenter, Open-Label, Single-Arm Phase I Trial of Dual-Wield Parenchymal Transection: A New Technique of Liver Resection Using the Cavitron Ultrasonic Surgical Aspirator and Water-Jet Scalpel Simultaneously (HiSCO-14 Trial).

PURPOSE: This study evaluated the safety and feasibility of a technique of liver resection named dual-wield parenchymal transection technique (DWT), using cavitron ultrasonic surgical aspirator (CUSA) and water-jet scalpel simultaneously. METHODS: This multicenter, prospective, open-label, and single-arm phase I trial included patients aged 20 years or older with hepatic tumors indicated for surgical resection and scheduled for open radical resection. This study was conducted at two institutions affiliated with the Hiroshima Surgical Study Group of Clinical Oncology (HiSCO). The primary endpoint was the proportion of massive intraoperative blood loss (≥ 1000 mL). The secondary endpoints were the amount of blood loss, operative time, parenchymal transection speed, postoperative complications, and mortality. The safety endpoints were device failure and adverse events associated with devices. RESULTS: From June 2022 to May 2023, 20 patients were enrolled; one was excluded and 19 were included in the full analysis set (FAS). In the FAS, segmentectomy was performed in nine cases, sectionectomy in four cases, and hemihepatectomy in six cases. Radical resection was achieved in all patients. Intraoperative blood loss greater than 1000 mL was observed in five patients (26.3%). The median amount of blood loss was 545 mL (range, 180-4413), and blood transfusions were performed on two patients (10.5%). The median operative time was 346 minutes (range, 238-543) and the median parenchymal transection speed was 1.2 cm2/minute (range, 0.5-5.1). Postoperative complications of Clavien-Dindo classification ≥ Grade 3 occurred in four patients (21.1%). No mortalities occurred in this study. In the safety analysis, there were no device failures or adverse events associated with devices. CONCLUSIONS: This study demonstrated the safety and feasibility of DWT for liver resection. The efficacy of the DWT will be evaluated in future clinical trials.

Laparoscopic vs. open anatomical hepatectomy for intrahepatic cholangiocarcinoma: A retrospective cohort study.

Background: Intrahepatic cholangiocarcinoma is a highly malignant and invasive cancer originating from biliary epithelial cells. The current study was designed to evaluate the feasibility, safety, and clinical outcomes of laparoscopic anatomical hepatectomy in patients with intrahepatic cholangiocarcinoma. Methods: After screening, 95 patients who underwent anatomical hepatectomy for intrahepatic cholangiocarcinoma at our center were enrolled and divided into two groups according to the surgical approach; the baseline characteristics, pathological findings, surgical outcomes, and long-term outcomes were compared. Moreover, univariate and multivariate analyses were performed to identify independent prognostic factors for overall survival (OS) and disease-free survival (DFS). Results: There were no significant differences in baseline characteristics or pathological findings between the two groups. Regarding short-term outcomes, the intraoperative blood loss, incision length, and length of postoperative hospital stay were more favorable in the laparoscopic anatomical hepatectomy group than the open anatomical hepatectomy group (P < 0.05). The two groups differed significantly in the extent of liver resection, with a lower lymph node dissection rate and lymph node yield in the laparoscopic anatomical hepatectomy group (P < 0.05). Furthermore, the postoperative complication rate was similar in the two groups (P > 0.05). The median postoperative follow-up times were 10.7 and 13.8 months in the laparoscopic anatomical hepatectomy and open anatomical hepatectomy groups, respectively. Regarding the long-term follow-up results, OS and DFS were similar in the two groups (P > 0.05). On multivariate analysis, the independent prognostic factors for OS were CA-199, CEA, HGB, tumor diameter, and T stage, and those for DFS were CA-199 (P < 0.05), and T stage (P < 0.05). Conclusion: laparoscopic anatomical hepatectomy for intrahepatic cholangiocarcinoma is safe and feasible when performed by experienced surgeons. Compared with open anatomical hepatectomy, laparoscopic anatomical hepatectomy provides better short-term outcomes and a comparable long-term prognosis.

Counterclockwise modular laparoscopic anatomical mesohepatectomy using combined glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches.

Background: Although laparoscopic anatomical hepatectomy (LAH) is widely adopted today, laparoscopic anatomic mesohepatectomy (LAMH) for patients with hepatocellular carcinoma (HCC) remains technically challenging. Methods: In this study, 6 patients suffering from solitary liver tumors located in the middle lobe of the liver underwent counterclockwise modular LAMH using combined Glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches. In this process, the Glissonean pedicle approach (Takasaki approach) was first used to transect the liver pedicles of segment right anterior (G58) and segment 4 (G4). Second, the hepatic vein-guided approach was performed along the umbilical fissure vein (UFV) to sever the liver parenchyma from the caudal to cranial direction, and the middle hepatic vein (MHV) and anterior fissure vein (AFV) were then disconnected at the root. Last, the hepatic vein-guided approach was once more performed along the ventral side of the right hepatic vein (RHV) to transect the liver parenchyma from the cranial to anterior direction, and the middle lobe of the liver, including the tumor, was removed completely. The entire process was applied in a counterclockwise fashion, and the exposure or transection sequence was G58, and G4, followed by UFV, MHV, AFV, and finally, the liver parenchyma along the ventral side of RHV. Results: The counterclockwise modular LAMH using combined Glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches was feasible in all 6 cases. The median duration of the operation was 275 ± 35.07 min, and the mean estimated blood loss was 283.33 ml. All of the 6 patients recovered smoothly. The Clavien-Dindo Grade I-II complications rate was up to 33.33%, mainly characterized by postoperative pain and a small amount of ascites. No Clavien-Dindo Grade III-V complications occurred, and the mean postoperative hospital stay was 6.83 ± 1.47 days. Follow-up results showed that the average disease-free survival (DFS) was 12.17 months, and the 21-months OS rate, DFS rate and tumor recurrent rate were 100%, 83.33% and 16.67% respectively. Conclusions: Counterclockwise modular LAMH using combined Glissonean pedicle (Takasaki approach) and hepatic vein-guided approaches takes the advantages of the two approaches, is a novel protocol for LAMH. It is thought to be technically feasible for patients with a centrally located solitary HCC. The oncologic feasibility of this technique needs to be investigated based on long-term follow-up. A multicenter, large-scale, more careful study is necessary.

Hepatobiliary Phase Features of Preoperative Gadobenate-Enhanced MR can Predict Early Recurrence of Hepatocellular Carcinoma in Patients Who Underwent Anatomical Hepatectomy.

Purpose: The purpose of this study was to establish a model for predicting early recurrence (≤2 years) of hepatocellular carcinoma (HCC) after anatomical hepatectomy based on the hepatobiliary phase (HBP) imaging characteristics of gadobenate-enhanced MRI. Methods: A total of 155 patients who underwent anatomical hepatectomy HCC therapy and gadobenate-enhanced MRI were included retrospectively. The patients were divided into the early recurrence-free group (n = 103) and the early recurrence group (n = 52). Univariate and multivariate Cox regression analysis was used to determine the independent risk factors related to early recurrence, and four models were established. The preoperative model with/without HBP imaging features (HBP-pre/No HBP-pre model) and the postoperative model with/without HBP imaging features (HBP-post/No HBP-post model). Bootstrap resampling 1,000 times was used to verify the model and displayed by nomograms. The performance of nomograms was evaluated by discrimination, calibration, and clinical utility. Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were used to evaluate the differences between models and to select the optimal model. Results: Shape, arterial peritumoral enhancement, AFP-L3, and peritumoral hypointensity on HBP were identified as independent risk factors. Prothrombin time (PT) and r-glutamyltransferase (GGT) were selected by multivariate Cox regression. These six factors construct the HBP-pre model. Removing peritumoral hypointensity on HBP was the No HBP-pre model. Adding microvascular invasion (MVI) and microscopic capsule factors were the HBP-post and No HBP-post model. The C-index was 0.766, 0.738, 0.770, and 0.742, respectively. The NRI and IDI of the HBP-pre vs. the No HBP-pre model and the HBP-post vs. the No HBP-post model significantly increased 0.258, 0.092, 0.280, and 0.086, respectively. The calibration curve and decision curve analysis (DCA) had good consistency and clinical utility. However, the NRI and IDI of the No HBP-post vs. the No HBP-pre model and the HBP-post vs. the HBP-pre model did not increase significantly. Conclusions: Preoperative gadobenate-enhanced MR HBP imaging features significantly improve the model performance while the postoperative pathological factors do not. Therefore, the HBP-pre model is selected as the optimal model. The strong performance of this model may help hepatologists to assess the risk of recurrence in order to guide the selection of treatment options.