Comparison Between Minimally Invasive Right Anterior and Right Posterior Sectionectomy vs Right Hepatectomy: An International Multicenter Propensity Score-Matched and Coarsened-Exact-Matched Analysis of 1,100 Patients.

BACKGROUND: The role of minimally invasive right anterior and right posterior sectionectomy (MI-RAS/MI-RPS) for right-sided liver lesions remains debatable. Although technically more demanding, these procedures might result in faster recovery and lower postoperative morbidity compared with minimally invasive right hemihepatectomy. STUDY DESIGN: This is an international multicenter retrospective analysis of 1,114 patients undergoing minimally invasive right hemihepatectomy, MI-RAS, and MI-RPS at 21 centers between 2006 and 2019. Minimally invasive surgery included pure laparoscopic, robotic, hand-assisted, or a hybrid approach. A propensity-matched and coarsened-exact-matched analysis was performed. RESULTS: A total of 1,100 cases met study criteria, of whom 759 underwent laparoscopic, 283 robotic, 11 hand-assisted, and 47 laparoscopic-assisted (hybrid) surgery. There were 632 right hemihepatectomies, 373 right posterior sectionectomies, and 95 right anterior sectionectomies. There were no differences in baseline characteristics after matching. In the MI-RAS/MI-RPS group, median blood loss was higher (400 vs 300 mL, p = 0.001) as well as intraoperative blood transfusion rate (19.6% vs 10.7%, p = 0.004). However, the overall morbidity rate was lower including major morbidity (7.1% vs 14.3%, p = 0.007) and reoperation rate (1.4% vs 4.6%, p = 0.029). The rate of close/involved margins was higher in the MI-RAS/MI-RPS group (23.4% vs 8.9%, p < 0.001). These findings were consistent after both propensity and coarsened-exact matching. CONCLUSIONS: Although technically more demanding, MI-RAS/MI-RPS is a valuable alternative for minimally invasive right hemihepatectomy in right-sided liver lesions with lower postoperative morbidity, possibly due to the preservation of parenchyma. However, the rate of close/involved margins is higher in these procedures. These findings might guide surgeons in preoperative counselling and in selecting the appropriate procedure for their patients.

A Comparative Study of an Integrated Ultrasonic/Bipolar Sealing Device Versus an Articulating Bipolar Sealing Device for Laparoscopic Liver Surgery.

BACKGROUND: Sealing devices (SD) seal and cut tissue through different energy modalities, and are routinely used in laparoscopic liver surgery (LLS). The aim of this study is to compare the outcome of Thunderbeat (TB), an integrated ultrasonic/bipolar SD, versus Enseal (ES), an articulating bipolar SD, in LLS. METHODS: A retrospective analysis was conducted in a single center from December 2013 to September 2020. The primary endpoint was difference in blood loss (BL) between ES and TB. Secondary endpoints were complications, operative time, hospital stay, and 90-day mortality. RESULTS: 352 patients were identified: TB (n = 105) and ES (n = 247). Median BL was significantly lower with TB (50 mL [20-120]) compared to ES (100 mL [50-250]) (p < 0.0001). Significant differences were identified for median operative time (TB 115 min [45-300]) vs. ES 140 min [40-370]; p = 0.0008) and median hospital stay (TB 2 days [1-4] vs. ES 4 days [3-6]; p < 0.0001). No major differences were encountered for postoperative bleeding (TB 0% vs. ES 1%; p = 0.5574), biliary leak (TB 1% vs. ES 2%; p = 1.0000), and 90-day mortality (TB 0% vs. ES 1%; p = 1.0000). CONCLUSION: The integrated ultrasonic/bipolar SD is superior to the articulating bipolar SD in LLS for intraoperative BL without an increase in complications.

Foreign body granuloma reaction following SIRT mimicking peritoneal metastases: a word of caution.

Intrahepatic cholangiocarcinoma (iCCA) is the second most common primary liver malignancy with poor survival rates. Surgical resection is the only curative treatment option, yet only a small portion of cases are resectable. In unresectable situations, suggested therapy consists of a systemic chemotherapy regimen with cisplatinum and gemcitabine. Selective internal radiation therapy (SIRT) has been proposed as an alternative treatment option and may lead to downstaging of unresectable iCCA to surgery. We present a case of a female patient diagnosed with an unresectable iCCA treated with SIRT in order to obtain downstaging. Explorative laparoscopy three months later showed multiple peritoneal lesions in the left upper quadrant, mimicking peritoneal metastases. Anatomopathological investigation showed a foreign body granuloma surrounding the SIRT resin particles. These findings have important consequences, as the presence of peritoneal metastases implies a palliative situation. Anatomopathological confirmation of any intra-abdominal lesion mimicking peritoneal metastases should be carried out.

Laparoscopic liver resection for liver tumours in proximity to major vasculature: A single-center comparative study.

BACKGROUND: With growing popularity and experience in laparoscopic liver surgery, the options for more difficult procedures increase. Only small case series have been published regarding laparoscopic liver resection (LLR) for tumours in proximity to major vessels (MVs). The aim was to compare outcomes of LLR for tumours located less or more than 15 mm from MVs. METHODS: This was a retrospective analysis of a prospectively collected database of consecutive LLR (October 2011-August 2017). Proximity to MVs (PMV) was defined as lesions located within 15 mm to the caval vein, hepatic veins and portal vein (main trunk and first branches). The control group were all lesions located more than 15 mm from MVs. RESULTS: Some 60/235 LLR were performed for lesions in proximity to major vasculature (24%). In the PMV group, median IWATE Difficulty Score was higher (8.5 (IQR: 6.0-9.0) VS 5.0 (IQR: 3.0-6.0), p < 0.001) as was the use of CUSA® (45.0% VS 8.6%, p < 0.001) and Pringle manoeuvre (8.3% VS 1.7%; p = 0.028). Operative time was longer (180min (IQR: 140-210) VS 120min (IQR: 75-150), p < 0.001) and blood loss was higher (190 ml (IQR: 100-325) VS 75 ml (IQR: 50-220), p < 0.001) in the PMV group. There was no difference in perioperative blood transfusion (3.3% VS 1.7%, p = 0.60) or postoperative morbidity (15.0% VS 14.3%, p = 0.89). There was no mortality in both groups. On mean follow-up of 21 months, no significant differences could be found in disease free (p = 0.77) and overall survival (p = 0.12). CONCLUSION: In experienced hands, LLR of lesions in proximity to MVs is safe and feasible with acceptable short and long-term results.

Stepwise implementation of laparoscopic pancreatic surgery. Case series of a single centre's experience.

BACKGROUND: Laparoscopic pancreatic surgery still represents a challenge for surgeons. However, in recent decades the experience is expanding. Recent systematic reviews and meta-analyses confirm that laparoscopic pancreatic resection (LPR) is safe, feasible and worthwhile. This study analyses the first 100 consecutive LPRs in our centre. METHODS: A retrospective analysis was conducted of the first 100 LPRs in a single supra-regional Belgian centre, performed between January 2012 and January 2019. Pre-, peri- and postoperative data were retrieved from a prospectively maintained database. All procedures were performed laparoscopically by two attending surgeons, specialized in minimally invasive and hepatopancreatobiliary surgery. RESULTS: Of 100 procedures, 62 laparoscopic pancreatoduodenectomies (LPD) and 36 laparoscopic distal pancreatectomies (LDP) were performed, along with 1 enucleation and 1 central pancreatectomy. Indication was malignancy in 70%. Conversion rate was 24,2% in LPD and 11% in LDP. Median operative time was 330 min (IQR 300-360) in LPD and 150 min (IQR 142.5-210) in LDP. Median blood loss was 200 mL (IQR 100-487.5) in LPD and 150 mL (IQR 50-500) in LDP, transfusion rate was 22.6% and 8.3% respectively. Median length of stay (LOS) was 13 days (IQR 10-19.25) in LPD and 9 days (IQR 9-14) in LDP. R0 resection rate was 88.6% (62/70). Major complication rate (Clavien-Dindo grade III-IV) was 12%. Thirty-day mortality was 0%, 90-day mortality was 2%. CONCLUSION: Our results confirm that LPR is a feasible and safe alternative to open pancreatic surgery. Safe implementation with a clear strategy is fundamental to gain experience and overcome the learning curve of this technically demanding procedures.

Transmesenteric hernia: a rare case of acute abdominal pain in children: a case report and review of the literature.

In this report, we discuss the case of an 11-year old girl presenting with acute abdominal pain caused by gangrene of a large part of the small bowel. During urgent surgical exploration, the cause of gangrene appeared to be herniation of the small bowel through a congenital defect in the mesentery with subsequent strangulation. A resection was performed leaving the patient with only 130 cm of small bowel remaining. Transmesenteric hernia is a rare type of internal herniation consisting of a small congenital defect in the small bowel mesentery through which the intestine can herniate and subsequently become strangulated. We present a case of transmesenteric hernia with disastrous effects and review the literature regarding this rare type of hernia.

Robotically enhanced mediastinal teratoma resection: a case report and review of the literature.

Mediastinal teratomata are rare, extragonadal germ cell tumors, which can occur at any age and are often asymptomatic. We present the case of a 57-year-old female with chronic cough diagnosed with a mass in the anterior mediastinum. The mass was successfully resected using the Intuitive Da Vinci® robotic system. The patient had an uneventful recovery. Review of the literature demonstrates that robotic surgery of the mediastinum is a safe and feasible alternative in selected cases.