Laparoscopic versus open right hepatectomy for colorectal liver metastases after portal vein embolization: international multicentre study.

BACKGROUND: Laparoscopic liver surgery is increasingly used for more challenging procedures. The aim of this study was to assess the feasibility and oncological safety of laparoscopic right hepatectomy for colorectal liver metastases after portal vein embolization. METHODS: This was an international retrospective multicentre study of patients with colorectal liver metastases who underwent open or laparoscopic right and extended right hepatectomy after portal vein embolization between 2004 and 2020. The perioperative and oncological outcomes for patients who underwent laparoscopic and open approaches were compared using propensity score matching. RESULTS: Of 338 patients, 84 patients underwent a laparoscopic procedure and 254 patients underwent an open procedure. Patients in the laparoscopic group less often underwent extended right hepatectomy (18% versus 34.6% (P = 0.004)), procedures in the setting of a two-stage hepatectomy (42% versus 65% (P < 0.001)), and major concurrent procedures (4% versus 16.1% (P = 0.003)). After propensity score matching, 78 patients remained in each group. The laparoscopic approach was associated with longer operating and Pringle times (330 versus 258.5 min (P < 0.001) and 65 versus 30 min (P = 0.001) respectively) and a shorter length of stay (7 versus 8 days (P = 0.011)). The R0 resection rate was not different (71% for the laparoscopic approach versus 60% for the open approach (P = 0.230)). The median disease-free survival was 12 (95% c.i. 10 to 20) months for the laparoscopic approach versus 20 (95% c.i. 13 to 31) months for the open approach (P = 0.145). The median overall survival was 28 (95% c.i. 22 to 48) months for the laparoscopic approach versus 42 (95% c.i. 35 to 52) months for the open approach (P = 0.614). CONCLUSION: The advantages of a laparoscopic over an open approach for (extended) right hepatectomy for colorectal liver metastases after portal vein embolization are limited.

Pure Laparoscopic Anatomic Resection of the Segment 8 Dorsal Area Using the Dorsal Approach of the Right Hepatic Vein.

BACKGROUND: Anatomical resection of segment 8 (s8) is a challenging procedure. S8 can be subdivided into two areas: ventral (s8v) and dorsal (s8d). In the last years, different approaches for performing laparoscopic resection of s8 or any of its subsegments have been described, i.e. the hilar extrafascial approach, transfissural approach for s8v, transparenchymal approach for s8d, and the intrahepatic Glissonean approach. We recently described the dorsal approach of the right hepatic vein (RHV) for anatomical segment 7 resection. This video report describes the approach to a dorsal s8 pedicle using the RHV dorsal approach. METHODS: A 50-year-old woman with a history of morbid obesity and sleep apnea was diagnosed after episodes of hematochezia sigmoid cancer and a 2-cm liver metastases in the s8d, according to vascular reconstruction (Cella Medical Solutions, Murcia, Spain). The surgical technique started with mobilization of the right liver until the root of the RHV was identified and exposed in a craniocaudal fashion and until the s8d Glissonean pedicle was identified and clamped. Indocyanine green counterstaining depicted an intersegmental plane between the s8d and segment 5 and s8v. Transection continued until the anterior fissural vein was exposed at its root, as a landmark of the medial plane. RESULTS: Operative time lasted 265 min. Transection was carried out using the intermittent Pringle maneuver over a period of 81 min. Estimated blood loss was 252 cc. There were no postoperative complications and the patient was discharged on postoperative day 2. CONCLUSIONS: In some cases, the RHV dorsal approach can be used as the landmark for the s8d Glissonean pedicle, allowing anatomical resection of this particular area.

Correlation between intraoperative surgical diagnosis of complicated acute appendicitis and the pathology report: clinical implications.

BACKGROUND: The post-operative management of appendectomy for acute appendicitis is based primarily on the operative findings. The surgeon describes the severity of the disease, and antibiotic therapy is administered accordingly. The histologic findings are not always considered in the decision about the management and may not be correlated with the clinical outcome. The aim of this study was to investigate the agreement between the surgeon's intra-operative visual description of the appendix and the pathologist's report in a consecutive series of patients with acute appendicitis. Complications were analyzed in relation to the classification. METHODS: A comparative observational study was performed in 69 patients who underwent surgery for acute appendicitis at the same hospital during a one-year period (the entire year of 2011). The surgeon's classification of the severity of appendicitis was compared with the pathologist's report using the kappa coefficient. Patient demographics, surgical techniques, and post-operative complications also were analyzed. RESULTS: Complicated appendicitis (gangrenous or perforated) was considered to be present in 36.2% of patients in the surgeon's classification and 43% of the patients in the histopathologic reports (p=0.033). The kappa coefficient showed only a weak correlation between the surgeons' and pathologists' descriptions (κ=0.25). Significant differences in post-operative complications were found only in the surgeon's classification. CONCLUSION: We found a weak correlation between the surgeon's macroscopic diagnosis and the pathologic findings. However, the differences did not have meaningful clinical implications. Further studies are required to evaluate the clinical meaning of these results.