Colorectal cancer with liver metastases -- is there a chance for cure?

Combined treatment with chemotherapy and surgery is the currently accepted standard for patients with metastatic colorectal cancer which can be rendered to resectability and a very efficient way to increase survival of patients with hepatic metastases from colorectal cancer. Cooperation between surgeons and oncologists is mandatory to insure these patients' best chance for survival. Patients with resectable disease must follow adjuvant chemotherapy, while patients with initially unresectable marginally resectable disease after downsizing with the help of chemotherapy must be given the chance of surgical reevaluation for having the metastatic disease resected,and then follow adjuvant chemotherapy. An impressive amount of new surgical techniques warrants the success of hepatic resection in metastatic disease while a whole constellation of novel chemotherapeutical and even more effective targeted agents assure better response rates, surgical resection rates and overall survival in these patients.

Management of bile duct injuries secondary to laparoscopic and open cholecystectomy. The experience of a single surgical department.

UNLABELLED: Cholecystectomy is one of the most performed surgical interventions in general surgery. Laparoscopic cholecystectomy was associated with an increasing occurrence of biliary ducts lesions. The aim of this study is to draw the attention towards the permanent risk of these kind of complications, the curative difficulties and identifying the best therapeutic solution in order to obtain favorable results on long term. METHOD: There were retrospectively and prospectively analysed all the cases with diagnosis of iatrogenic biliary ducts lesion hospitalized and operated during 1987-2008 in the Surgical Clinic No 3 Cluj Napoca. RESULTS: The yearly distribution showed an increasing number of biliary lesions operated in the Surgical Clinic No 3 Cluj-Napoca. 81% of the iatrogenic lesions in our study occurred postlaparoscopic cholecystectomy, and 19% secondary to an open cholecystectomy. One hundred thirty-six patients had major biliary lesions (D, E classes according to Strasberg Soper) and 47 patients had minor lesions (A-C classes). The medium hospitalization range was 17 days. Eighty - three patients (45.3%) needed one, two or three surgical interventions before the complete cure of the lesions. The most frequent complication was plague suppuration (12.5%). The cardio-renal-pulmonary complications were present in 8.7% of the patients and the intra-abdominal abscess in 3.8% of the patients. The anastomotic fistula was present in 11% of the operated patients and 6% global mortality. CONCLUSIONS: The iatrogenic lesions of the biliary ducts are characterized by a complicated evolution, with series of interventions and progressive evolution to biliary stenosis. Delaying the final biliary treatment and the high number of interventions performed before patients were referred to hepato-biliary specialised centres lead to an increasing morbidity and hospitalization costs.

[Risk factors for anastomotic leakage following colorectal resection for cancer]. / Factorii de risc ai fistulelor anastomotice dupa chirurgia neoplaziilor colo-rectale.

PURPOSE: To identify the risk and prognosis factors and their predictive value for anastomotic leakage after colorectal resections following cancer. PATIENTS AND METHODS: 1743 consecutive patients who underwent colic resections or rectal resections for colo-rectal cancer between 1996-2005 in Surgical Clinic no. 3 (Cluj-Napoca, Romania) were retrospectively analysed. RESULTS: A total of 54 (3.09 percent) anastomotic leaks were confirmed. Univariate analisys showed that the preoperative variables significantly associated with anastomotic leakage included weight loss, smoking, cardiovascular disease, lung disease, hypoproteinemia, diabetes, anemia, leukocitosis, presence of two or more underlying diseases. Use of alcohol, cerebrovascular disease, bowel preparation, mode of antibiotic prophylaxis, type of handsewn anastomosis, tumor location, tumor stage and tumor histology were nonsignificant variables. Hipoproteniemia (S - proteins < 60g/dl) and anemia (S Hb < 11) remained significant in logistic regression model. CONCLUSIONS: Our study shows that a value of S-proteins lower than 60 g/l and s-Hb lower than 99 g/l can be consider as predictive marker for anastomotik leak deshiscence.

[Hepatoprotective effects of orally administered melatonin and tinospora cordifolia in experimental jaundice]. / Efectele hepatoprotectoare ale Melatoninei si Tinospora cordifolia administrate per os în icterul colestatic indus experimental.

Posthepatic cholestasis is figured by the onset of an intense oxidative stress, followed by important cellular morphological and functional abnormalities. The aim of this experimental study is to assess the hepatoprotective effects of Melatonin and extract of Tinospora cordifolia in bile duct ligation induced jaundice in rats. We choosed to administrate both pharmacological products per os, in order to compare the results with those already published, in which melatonin was administrated injectable. The assessment of microscopy, lab tests and the measurement of oxidative stress products indicates a marked hepatoprotective effect of those two compounds. The results allowed us to recomand the use of melatonin and Tinospora cordifolia to reduce the cholestasis's oxidative stress in human.

[Therapeutic approach for patients with positive resection line (R1) after gastrectomy for gastric cancer]. / Atitudinea terapeutica la pacientii cu transa de rezectie pozitiva (R1) dupa gastrectomii pentru cancer gastric.

INTRODUCTION: The radical treatment of the gastric cancer consist in large gastric resections and lymphadenectomy. Resection line involvement at microscopic histopathological examination (R1) could change prognostic unfavorable. MATERIAL AND METHODS: They were 135 patients with gastric cancer operated between 2006-2007, with radical gastric resections and lymphadenectomy. In 3 patients with early gastric cancer and 23 patients with different stages of cancers, histopathological examination showed resection line involvement. From this study were eliminated the patients with stage IV cancers in whom resections were palliative. RESULTS: Incidence of positive resection line involvement was 19,25%. 88,46% of the tumors were staged pT2 and pT3 and the majority was poorly differentiated or undifferentiated (G3 and G4). Lymphatic involvement (pN1 or pN2) was demonstrated in 18 (69,23%0 patients with R1. Perioperative complications were encountered in 15,38% of this patients, with 7,69% mortality. CONCLUSIONS: Presence of tumoral tissue at resection line level could decrease survival in this patients. Therapeutic protocol in patients with resection line involvement (re-laparotomy with re-resection or surveillance) must be establish in accordance with several factors: T and N category, risks of another surgical interventions, patients acceptance.

[Non-ulcerous duodenal perforations: a clinical analysis of 23 cases]. / Perforatiile neulceroase ale duodenului: analiza a 23 de cazuri.

Non-ulcerous duodenal perforations are a rare and seldom studied pathology. The present retrospective study analyses a group of 23 patients, over a 10 year period (Jan 1st 2000 - Dec 31st 2009) with this pathology. The most frequent etiology was iatrogenic (52.17 % after ERCP and 17.39% after upper gastrointestinal endoscopy). Other rare etiologies included were tumoral perforations, penetrating wounds, and ingestion of foreign bodies. The lesions vary from millimetric perforations to total necrosis of the wall of a duodenal segment and are often associated with other complex lesions. The overall mortality was 52.17%, a little lower for the post ERCP injuries (40%). Usually the iatrogenic lesions are diagnosed earlier (ex. 54.54% of the post ERCP lesions undergo surgery during the first 24 h), probably increasing the chance of surviving. 43.47% of cases undergo surgery in the condition of severe sepsis, with multiple organ failure, thus aggravating the prognosis. Sometimes the patient required multiple interventions (with a maximum of 8 in our group). In 26% of the cases the primary intervention was just paraduodenal and/or retroperitoneal drainage, suture of the duodenum (6 cases - 26%), usually under the protection of a gastro-enteroanastomosis (4 cases - 17.39%), suture of the duodenum around a decompression tube (26%), sometimes suture of the duodenum with a jejunal serous patch or duodeno-jejunal anastomosis. The bile drainage and the jejunostomy were associated sometimes. The procedures in this pathology have a significant morbidity, with a high rate of reinterventions (30.4%).

PARASURG hybrid parallel robot for minimally invasive surgery.

This paper presents the parallel hybrid robot, PARASURG 9M, for robotically assisted surgery, a robot which was entirely designed and produced in Romania. It is a versatile robot, being composed of a positioning and orientation module, PARASURG 5M with five degrees of freedom, having the possibility of attaching at its end either a laparoscope or an active surgical instrument for cutting/grasping, PARASIM, with four degrees of freedom. Based on its mathematical modelling, the first low-cost experimental model of the surgical robot has been built. The robot is part of the surgical robotic system, PARAMIS, with three arms, one used as a laparoscope holder, and other two for manipulating active instruments. When it is used as a manipulator of the camera, the user has the possibility to give commands in a large area for the positioning of the laparoscope using different interfaces: joystick, microphone, keyboard & mouse and haptic device. If the active surgical instrument, PARASIM, is attached, the robot commands are given through a haptic device. The main features that make the PARASURG 9M surgical robot suited for minimally invasive surgery are: precision, the elimination of the natural tremor of the surgeon, direct control over a smooth, precise, stable view of the internal surgical field for the surgeon. It also eliminates the need of a second surgeon to be present for the entire procedure (in the case of using the robot as a camera holder). In addition, there is improvement of surgeon dexterity in the case of using the PARASIM active instrument and better ergonomics in using the robot (in the case of the classic laparoscopy, the surgeon must adopt a difficult position for a long period of time, while the robot never gets tired). Having a relatively easy to understand, intuitive commanding system, the surgeons can rapidly adapt to the use of the PARASURG 9M robot in surgical procedures.

[The advantages of implementing an e-learning platform for laparoscopic liver surgery]. / Avantajele implementarii unei platforme de e-learning pentru chirurgia laparoscopica hepatica.

The rapid expansion of laparoscopic surgery has led to the development of training methods for acquiring technical skills. The importance and complexity of laparoscopic liver surgery are arguments for developing a new integrated system of teaching, learning and evaluation, based on modern educational principles, on flexibility allowing wide accessibility among surgeons. This paper presents the development of e-learning platform designed for training in laparoscopic liver surgery and pre-planning of the operation in a virtual environment. E-learning platform makes it possible to simulate laparoscopic liver surgery remotely via internet connection. The addressability of this e-learning platform is large, being represented by young surgeons who are mainly preoccupied by laparoscopic liver surgery, as well as experienced surgeons interested in obtaining a competence in the hepatic minimally invasive surgery.

[Surgical management of malignant large bowel obstructions]. / Managementul chirurgical in urgenta al ocluziilor prin cancere colonice si rectale.

INTRODUCTION: Despite significant progress, the management of acute colonic obstruction still remains a challenging problem. The purpose of this study was represented by the evaluation of the clinical results of different techniques of resection for malignant colorectal (primary or staged) obstruction. METHODS: We performed a non-randomized clinical study. 590 patients with malignant colorectal occlusion who underwent surgery treatment an 3rd Surgical Clinic Cluj-Napoca between 1996-2005 were included. RESULTS: Patients with large bowel obstruction underwent one-stage primary resection with anastomosis in 267 cases or staged interventions in 323 cases. The groups were matched in: age, sex, comorbidities, tumor staging, serum preoperative levels of hemoglobin and proteins. The analysis of mortality and morbidity following surgical treatment for large bowel obstruction returned no significant difference among the two groups (p > 0.05). Moreover, the presented results showed a higher incidence of mortality (11.45% vs 9.33 %), morbidity (25.38% vs 14.6%) and increased hospitalization period (p = 0.029) among the patients that undergone seriate resections. CONCLUSIONS: One stage primary resections with anastomosis of the large bowel can be performed safely in case of emergency whenever patient comorbidities and local conditions do not stand as major restrictions.

[The evaluation of enzymatic and biochemical changes in radiofrequency liver resections]. / Evaluarea în dinamica a dezechilibrelor biochimice si enzimatice dupa rezectiile hepatice prin radiofrecventa.

INTRODUCTION: Liver resection represents the only curative treatment option in liver tumors. There are many bloodless techniques that can be used in liver surgery. The main advantage of these techniques is represented by low incidence of hemorrhagic accidents. Still, these techniques are controversial due to induction of important enzymatic changes in the postoperative period. This study analyses the dynamic of enzymatic and biochimic changes that occurs after liver resections by radiofrequency. MATERIALS AND METHODS: We designed a prospective study that includes all patients (57) with resected liver tumors by means of radiofrequency (Habib 4X) technique in Surgery Clinic no. 3 Cluj-Napoca, Romania. RESULTS: We report the increase levels of K, LDH, TGO, TGP, BT, BD, leukocites in 24-48 hours post-resection. Age more than 60 years was corelated with lower peaks of LDH and white blood cells. (p = 0.021) and high levels of serum urea (p = 0.023). DISSCUSIONS: We report lower transaminase values than other similar findings. Similar to other findings the enzymatic changes return to normal after 6 days from the surgery. CONCLUSION: We agree the idea of using RF liver resection in selected cases only and not hazarduos.Despite these benign enzymatic changes RF has a major advantage of bloodless liver transeection and should be used whenever it's feasibile.

[New generation chemotherapy in the treatment of operated gastric cancer--an alternative to traditional chemotherapy]. / Chimioterapia de generatie noua in cancerul gastric operat--o alternativa la chimioterapia clasica.

Gastric cancer remains one of the most difficult tumour type despite his relative reduction of his global incidence, it remains on of the most deadly cancer. The latest advances in therapy of the gastric cancer ameliorate the results in terms of survival. In our prospective, non-randomized study, we enrolled 40 patients with gastric adenocarcinoma stage IB to IV (M0) who were surgically treated, treated with chemoradioterapy, but with chemotherapy modified by ECX (epirubicine, cisplatine, xeloda) which is now considered standard in metastatic setting. We report the toxicities and possible predictive factors to toxicity. The ECX regimen seems to be a reliable alternative to the traditional regimen with convenient toxicity and therapeutic index.

[Correlation between C677T and A1298C mutations of the MTHFR gene and therapeutic prognostic elements in colorectal cancer]. / Relatia mutatiilor C677T si A1298C ale genei MTHFR cu elemente de prognostic terapeutic in cancerul colorectal.

The MTHFR gene polymorphism may influence the risk of developing sporadic CRC. The aim of this study is to assess the relationship between the mutations of this gene and certain aspects of the surgical practice: the tumoral resectability, the tumoral recurrence and the disease-free interval. 69 patients with sporadic colorectal cancer that underwent surgery at the 3rd Surgery Department of Cluj-Napoca between October 2003-May 2005 were randomly selected. The correlations between the C677T, A1298C mutations and the prognostic factors mentioned above were analyzed. The results show that the C677T mutation increases the risk of non-resectability (OR = 3.5, p = 0.099), while the A1298C mutation does not (OR = 1.1). For the A1298C mutation there is a major risk of recurrence (OR = 3,063), but in the group with C677T mutation there is only a small increase of the risk, non-significant statistically (OR = 1,196). Both the groups with the C677T mutation and the "wild" genotype 1298AA have more precocious recurrences then the other groups, so a shorter disease-free interval (HR = 0.9458 respectively 3.1070). The patients with the A1298C mutations have more often non-resectable recurrences. In conclusion, the mutations of the MTHFR gene are a prognostic factor for the treatment and evolution of patients with CRC.

PARAMIS parallel robot for laparoscopic surgery.

The paper presents the parallel robot, which has been developed in Romania and it is used for laparoscope camera positioning. Based on its mathematical modeling, the first low-cost experimental model of the PARAMIS surgical robot has been built. The system has been built in such a way that it has the possibility to transform it in a multiarm robot controlled from the console. The control input allows the user to give commands in a large area for the positioning of the laparoscope using different interfaces: joystick, microphone, keyboard & mouse and haptic device. The first results have been obtained through the performing of an experimental laparoscopic cholecystectomy using PARAMIS surgical robot. The model which was used was a porcine liver, removed with the gall-bladder and the bile ducts. Due to its very easy use control system, surgeons have adapted rapidly to the use of PARAMIS in surgical procedures. Some of its advantages could be emphasized: precision of the movements; absence of the laparoscope operator's natural tremor, direct control over a smooth, precise, stable view of the internal surgical field for the surgeon; no fatigue; allows the use of both hands for the actual procedure; reduces eye fatigue; eliminates the need for a second surgeon to be present for the entire procedure.

[Laparoscopic treatment of a large trichobezoar in the stomach with gastric perforation and abdominal wall abscess]. / Tratamentul laparoscopic al unui tricobezoar gastric de mari dimensiuni complicat cu perforatie gastrica blocata in peretele abdominal anterior.

Trichobezoar represents a mass of swallowed hair inside the stomach. Here we report a 17-year-old girl who presented in our department with symptoms of gastric ulcer. Ultrasound examination followed by upper endoscopy revealed a large trichobezoar in the stomach with simultaneous gastric perforation. Laparoscopy also revealed a penetration into the anterior abdominal wall accompanied by abscess at this level. We performed a laparoscopic gastrotomy with trichobezoar extraction and laparoscopic treatment of perforation and abdominal wall abscess. The postoperative evolution was normal and the patient was discharged on the fifth postoperative day. We show that laparoscopic approach may be safely used in the treatment of the large gastric complicated trichobezoar. Several laparoscopic approaches were described for the treatment of tricobezoar and its complications but as far as we know this is the first report of laparoscopic treatment of large tricobezoar and associate gastric perforation.

[The role of diagnostic laparoscopy in periampullary and pancreatic cancers. A study based on 27 cases]. / Rolul laparoscopiei diagnostice în cancerele periampulare si pancreatice. studiu bazat pe un numar de 27 cazuri.

BACKGROUND: Starting from the premise that abdominal tumours require very accurate assessment and staging, the study "DIASTAL" (laparoscopic diagnosis and staging of abdominal tumours) proposed to establish the effectiveness of laparoscopy in the diagnosis and resectability of these neoplasms. The aim of this study was to evaluate diagnostic laparoscopy for periampullary and pancreatic neoplasms. METHODS: The clinical study was based on the analysis two different groups including 27 patients in total, in whom we used also diagnostic laparoscopy as a staging method. RESULTS: The percentage of understaged patients after preoperative examinations was high in both groups range 59.09%-63.63%. Diagnostic laparoscopy reduced the number of unnecessary laparotomies. CONCLUSIONS: Diagnostic laparoscopy could lead to more accurate assessment of periampullary and pancreatic cancers, not only as a staging method but also as a minimally invasive surgical technique for palliation.

[Coumarin-induced necrosis--a rare complication of oral anticoagulant therapy]. / Necroza cumarinica--complicatie rara a terapiei anticoagulante orale.

Coumarin-induced skin necrosis represents a clinical entity that occurs very rarely, with an approximate incidence of 0.01-0.1% at patients following oral anticoagulant therapy. Most of the cases become clinical manifest between the 3rd and 6th of anticoagulant treatment (there were reports of late onset of skin necrosis after 15 years of anticoagulant therapy) and the most involved areas include breast, buttocks and thighs microcirculation-rich areas. Early symptoms include paresthesia and sensation of tension associated with an erythematous flush in the affected area. Lesions are well demarcated, painful, initially erythematous or hemorrhagic, with the onset of skin necrosis in the end stage. Early lesions can be reversible with the discontinuation of anticoagulant therapy, but skin necrosis can reoccur even without any other coumarin based treatment. We report the case of a 55-year-old female who presented with coumarin-induced skin necrosis affecting the right breast and the right deltoid area.

[Liver transplantation--indications, surgical technique, results--the analysis of a clinical series of 200 cases]. / Transplantul hepatic--indicati, tehnica, rezultate-analiza unei serii clinice de 200 de cazuri.

INTRODUCTION: Initially considered experimental, liver transplantation (LT) has become the treatment of choice for the patients with end-stage liver diseases. MATERIAL AND METHODS: Between April 2000 and October 2009, 200 LTs (10 reLTs) were performed in 190 patients, this study being retrospective. There were transplanted 110 men and 80 women, 159 adults and 31 children with the age between 1 and 64 years old (mean age--39.9). The main indication in the adult group was represented by viral cirrhosis, while the pediatric series the etiology was mainly glycogenosis and biliary atresia. There were performed 143 whole graft LTs, 46 living donor LTs, 6 split LTs, 4 reduced LTs and one domino LT RESULTS: The postoperative survival was 90% (170 patients). The patient and graft one-year and five-year survivals were 76.9%, 73.6% and 71%, 68.2%, respectively. The early complications occurred in 127 patients (67%). The late complications were recorded in 71 patients (37.3%). The intraoperative and early postoperative mortality rate was 9.5% (18 patients). CONCLUSIONS: The Romanian liver transplantation program from Fundeni includes all types of current surgical techniques and the results are comparable with those from other international centers.

[Liver resection for benign hepatic lesion: mortality, morbidity and risk factors for postoperative complications]. / Hepatectomiile pentru leziuni focale hepatice benigne: mortalitate, morbiditate si factorii de risc corelati cu complicatiile postoperatorii.

UNLABELLED: The aim of this study was to evaluate the result of liver resection for benign hepatic lesion and to determine the risk factors for postoperative complication. Between January 2001 and December 2006 (6 years), a total of 50 patients with benign hepatic lesion underwent hepatic resection and were retrospectively reviewed. The sex ratio was M/F=31/19 with a mean age of 44 years (range 2-74). The diagnosis was: hydatid cyst in 24 patients (48%); hemangioma in 14 patients (28%), focal nodular hyperplasia (FNH) in 6 (12%), hepatic adenoma in 3 cases (6%), and hepatoblastoma in 3 patients (6%). Fourty patients (80%) had symptoms prior to surgery (mainly abdominal pain). The abnormalities were located in 34 cases on the left liver (II-IV Couinaud segments) and in 16 cases on the right liver (V-VIII Couinaud segments). Twenty-nine patients (58%) underwent atypical resections, 4 underwent left hemihepatectomy (8%), 16 underwent left lobectomy (32%) and 1 patient was treated by segmentectomy (2%). Median operating time was 108 minutes (range 60-220) and the median blood lost was 310 ml range (30- 1500). The morbidity rate was 18% (9 patients). Independent risk factors associated with the development of postoperative complication were intraoperative blood lost more than 1200 ml (p=0,015; OR=1,7) and the operating time more than 150 minutes (p=0,048; OR=1,09). There was no mortality. The mean postoperative hospitalization was 7,86 days with the range 3-23 days. CONCLUSION: 1. Liver resections for benign hepatic lesion performed in specialized centers are safe and efficient, with low morbidity and mortality. 2. Postoperative morbidity was related to the intraoperative blood lost more than 1200 ml and to the operating time more than 150 minutes.

[TIVA-TCI (Total IntraVenous Anesthesia-Target Controlled Infusion) versus isoflurane anesthesia for laparoscopic cholecystectomy. Postoperative nausea and vomiting, and patient satisfaction]. / TIVA-tCI vs. anestezia inhalatorie pentru colecistectomia laparoscopica. Incidenta sindromului emetic postoperator si satisfactia pacientilor.

UNLABELLED: Numerous studies have shown that TIVA is followed by a significant reduction in the incidence of PONV in day-case surgery, including laparoscopic cholecystectomy, where the incidence of PONV can reach 70% according to some studies. TCI is the TIVA technique that maintain a constant plasma concentration due to pharmacokynetic models incorporated in TCI device that inject the anesthetic agent. Besides implementing TIVA-TCI in clinical practice in Romania, our study was designed to evaluate the impact of TIVA-TCI on postoperative outcome and our patient satisfaction after laparoscopic cholecystectomy. PATIENTS AND METHODS: After informed consent, 70 patients ASAI/II undergoing laparoscopic cholecystectomy were randomized in 2 equal study groups: group 1 (n = 35) included patients with TIVA-TCI with propofol (Cpi = 4 microg/ml) and remifentanil, and group 2 (n = 35) were patients undergoing Isoflurane anesthesia. In both groups propofol was administered during induction and remifentanil followed the same protocol: 0.5 microg/kg/min in the first minute during induction, followed by 0.25 microg/kg/min. This infusion was modified by 0.05 microg/kg/min steps according to analgesic needs. PONV (evaluated as both incidence and number of episodes), severity of pain and patient satisfaction score IOWA were compared between study groups. RESULTS: Both the incidence of PONV (p = 0.03) and the number of episodes/24 h/patients (p = 0.01) were significantly lower in TIVA-TCI group, while there was no significant difference in opioid requirements in study groups (p = 0.21). Patients IOWA satisfaction score at 24 hours postoperatively was significantly higher in TIVA-TCI groups (p = 0.0001). CONCLUSIONS: Compared with Isoflurane, TIVA-TCI was followed by significantly lower incidence of PONV and significantly greater patients satisfaction.

[Left laparoscopic lobectomy]. / Lobectomie stânga pe cale laparoscopica pentru hepatocarcinom dezvoltat pe ficat non-cirotic--prezentare de caz.

The authors present a case of a 61-year-old patient diagnosed with a hepatic tumor located in the second segment with expression on the anterior (diaphragmatic) side. The diagnosis and treatment applied in this case are presented. The specific feature was the surgical intervention because it was performed a left laparoscopic lobectomy using the LigaSure Atlas sealer. The short hospitalization period and quick recovery make this method an efficient one, with a wide application. Laparoscopic surgery started with a cholecystectomy which was performed by Mouret in 1987. Since then it knew a continuous development with progressive extension of this type of approach to almost all of the digestive tract organs, cavitary as well as parenchymal organs like liver or spleen. Second and third bisegmentectomy was made for the first time in 1996 by Azagra. The segments II, III, IVb, V and VI are the most frequently resected in hepatic laparoscopic surgery. Surgeons are more interested in left hepatic lobe diseases because of the anatomy which makes the approach of the biliary and blood vessels easier. Lately we assist to an increase of hepatic cancer incidence, primary or secondary; therefore we consider necessary the development of hepatic laparoscopic surgical techniques.