Laparoscopic central hepatectomy using a parenchymal-first approach: how we do it.

BACKGROUND: Laparoscopic central hepatectomy (LCH) is a difficult and challenging procedure. This study aimed to describe our experience with LCH using a parenchymal-first approach. METHODS: Between July 2017 and June 2021, 19 consecutive patients underwent LCH using a parenchymal-first approach at our institution. Herein, the details of this procedural strategy are described, and the demographic and clinical data of the included patients were retrospectively analyzed. RESULTS: There were 1 female and 18 male patients, all with hepatocellular carcinoma without major vascular invasion. The mean age was 57 ± 10 years. No patients underwent conversion to open surgery, and no blood transfusions were needed intraoperatively. The average operative duration and the average Pringle maneuver duration were 223 ± 65 min and 58 ± 11 min. respectively. The median blood loss was 200 ml (range: 100-800 ml). Postoperative morbidities occurred in 3 patients (15.8%), including 2 cases of bile leakage and 1 case of acquired pulmonary infection; there were no postoperative complications happened such as bleeding, hepatic failure, or mortality. The average postoperative hospital stay was 10 ± 3 days. CONCLUSION: The optimized procedure of LCH using a parenchymal-first approach is not only feasible but also expected to provide an advantage in laparoscopic anatomical hepatectomy.

Minimally invasive mesohepatectomy for centrally located liver lesions-a case series.

BACKGROUND: Resection of centrally located liver lesions remains a technically demanding procedure. To date, there are limited data on the effectiveness and safety of minimally invasive mesohepatectomy for benign and malignant lesions. It was therefore the objective of this study to evaluate the perioperative outcomes of minimally invasive mesohepatectomy for liver tumors at a tertiary care hospital. METHODS: Consecutive patients who underwent a minimally invasive anatomic mesohepatectomy using a Glissonean pedicle approach from April 2018 to November 2021 were identified from a prospective database. Demographics, operative details, and postoperative outcomes were analyzed using descriptive statistics for continuous and categorical variables. RESULTS: A total of ten patients were included, of whom five patients had hepatocellular carcinoma, one patient had cholangiocarcinoma, three patients had colorectal liver metastases, and one patient had a hydatid cyst. Two and eight patients underwent robotic-assisted and laparoscopic resections, respectively. The median operative time was 393 min (interquartile range (IQR) 298-573 min). Conversion to laparotomy was required in one case. The median lesion size was 60 mm and all cases had negative resection margins on final histopathological analysis. The median total blood loss was 550 ml (IQR 413-850 ml). One patient had a grade III complication. The median length of stay was 7 days (IQR 5-12 days). Time-to-functional recovery was achieved after a median of 2 days (IQR 1-4 days). There were no readmissions within 90 days after surgery. CONCLUSION: Minimally invasive mesohepatectomy is a feasible and safe approach in selected patients with benign and malignant liver lesions.

Parenchyma-Sparing Central Hepatectomy Versus Extended Resections for Liver Tumors: a Value-Based Comparative Analysis.

BACKGROUND: Parenchyma-sparing (PS) liver resection is recommended for liver tumors. The value of PS-approaches as compared to more extended resections is unknown. We sought to examine value-based differences (quality/cost) of central hepatectomy (CH) versus more extended resections. METHODS: A retrospective cohort study including consecutive patients having CH or right/extended hepatectomies (R/EH) at a high-volume cancer center was performed (2015-2019). The primary outcome was the value ratio, calculated as quality/cost. Quality was defined as the proportion of patients achieving a textbook outcome. Perioperative actual direct costs ($USD) for each patient were abstracted from institutional financial records spanning throughout the perioperative period. Value ratios were calculated and compared for each approach; sensitivity analysis was performed by modelling TO and cost thresholds. RESULTS: Among 651 hepatobiliary operations (426 liver resections), 90 patients met inclusion criteria: 19 CH and 71 R/EH. TO occurred in 68% and 69% of CH and R/EH, respectively (P = 0.96). Mean direct costs were $21,826 for CH and $28,599 for R/EH (P = 0.008). CH provided a greater value (value ratio CH = 0.33 vs. R/EH = 0.26; P = 0.004) with a shift favoring R/EH only when the TO threshold for CH was below 51% (CH = 0.23 vs. R/EH = 0.24) or that of R/EH was over 90% (CH = 0.31 vs. R/EH = 0.32). CONCLUSIONS: These findings support a PS approach for central liver tumors (central hepatectomy) as it offers higher value than more extended resections. In the context of high-volume centers with outcomes within established national benchmarks, patients with central tumors should be considered for CH over more extended non-PS approaches.

Parenchymal preserving liver resection for centrally located liver tumors: how I do it?

Central liver tumors often require extended hepatectomy or a central hepatectomy with complex biliary reconstructions. Extended resections are prone to higher chances of post-operative liver failure, while the resections mandating reconstructions run a risk of biliary leaks. Non-anatomical liver resections for these centrally located tumors provide a benefit of functional parenchymal preservation but a higher perceived risk of oncological inadequacy. This manuscript is an attempt to showcase author's technique of parenchymal sparing liver resection for central located liver tumor without the need for any biliary reconstruction while ensuring oncological adequacy during the conduct of the procedure.

Outcomes of Central Hepatectomy for Pediatric Liver Tumors.

BACKGROUND: Central hepatectomy (CH) is an uncommon surgical technique that is an option for resection of centrally located tumors, with the advantage of sparing normal hepatic parenchyma. Few studies have described outcomes in children undergoing CH. MATERIALS AND METHODS: An IRB-approved, retrospective chart review of patients who underwent CH at Children's Hospital Los Angeles between 2005 and 2016 was performed. Data included patient demographics, peri-operative factors, and post-operative outcomes. The IRB approved waiver of consent. RESULTS: Eight patients (4F:4M) with median age of 1.9 Y underwent CH: 7 patients for HB and 1 patient for focal nodular hyperplasia. Two of the seven HB patients had metastatic disease at diagnosis. Six of the seven HB patients received a median of 4 rounds (3-7 rounds) of pre-operative chemotherapy. The median operative time was 197.5 Min (143-394 Min) with median blood loss of 175 mL (100-1200 mL). Complications included a bile fluid collection requiring aspiration. Seven patients had negative margins on pathology. One patient with a positive margin successfully completed therapy, without recurrent disease. All patients survived to follow-up, with a median follow-up duration of 1.1 Y (0.1-12.1 Y). Two patients developed recurrent disease requiring formal hepatic lobectomy and orthotopic liver transplantation. These patients had negative pathologic margins, with tumor within 1 mm of resection margins. CONCLUSION: CH is an effective alternative to extended hepatectomy for patients with centrally located liver tumors and is associated with good clinical and pathologic outcomes.

Parenchymal-sparing approaches for resection of tumors located in the paracaval portion of the caudate lobe of the liver-utility of limited resection and central hepatectomy.

PURPOSE: Resection of liver cancer involving the paracaval portion (PC) of the caudate lobe is challenging because the PC is located deepest in the liver. This study aimed to elucidate the utility of two parenchymal-sparing approaches of limited resection and central hepatectomy for resecting tumors located in the PC. METHODS: In 2018 and 2020, 12 out of 143 patients underwent hepatectomy for tumors located in the PC of the liver. In six patients, limited resection (LR) of the PC after full mobilization of the liver off the inferior vena cava (IVC) was performed for tumors excluding the hilar plate or large hepatic veins (large HVs), including major hepatic veins or thick short hepatic veins. In six patients, central hepatectomy (CH) using liver tunnel was performed for tumors involving or close to the hilar plate and/or large HVs. RESULTS: During CH, the surgical view of the cranial side of the hilar plate was wide enough to perform combined resection of the large HVs in front of the IVC. Five of the six CHs were performed with resection of the LHVs. No LRs were accompanied with resection of the LHVs. The CH was associated with longer Pringle's time (76 min vs. 29.5 min, p = 0.015) and blood loss (1104 ml vs. 370 ml, p = 0.041). The preserved liver parenchyma volumes were 82% and 95% of the total liver volume after CH and LR, respectively. CONCLUSION: Our parenchymal-sparing approach for resection of liver cancer located in the PC is feasible for curative resection.

Minimally invasive versus open right anterior sectionectomy and central hepatectomy for central liver malignancies: a propensity-score-matched analysis.

BACKGROUND: The utility of minimally-invasive liver resection (MILR) for deep centrally located tumours (CLT) remains controversial. We aimed to review our institution's experience and outcomes with minimally invasive central hepatectomy (CH) and right anterior sectionectomy (RAS) for CLT in a propensity score-matched (PSM) analysis. METHODS: Retrospective review of a prospectively maintained surgical database revealed 23 patients who underwent MILR (6 CH, 17 RAS) and 53 patients who underwent open liver resection (OLR; 24 CH, 29 RAS) for CLT. PSM in a 1:1 ratio identified two groups of patients with similar baseline clinicopathological characteristics. Peri-operative outcomes were then compared. RESULTS: There was one laparoscopic-assisted, one robot-assisted and two laparoscopic-converted-open procedures in the MILR cohort. Across the unmatched cohort, there was only one mortality (MILR) and five patients with major morbidity (all OLR). MILR was associated with a longer operating time (P < 0.001), but shorter post-operative hospital stay (P = 0.002) and decreased morbidity (P = 0.018) in the unmatched cohort. Examination of peri-operative outcomes after PSM revealed that MILR was similarly associated with a longer operating time (P = 0.001) and shortened post-operative hospital stay (P = 0.043). OLR was associated with a significantly reduced application of Pringle manoeuvre (P = 0.004). There were no significant differences between MILR and OLR with regards to blood loss, blood transfusions, morbidity and margin status in the PSM analysis. CONCLUSION: MILR for CLT is safe and feasible when performed by experienced surgeons. It is associated with shorter hospital stays but at the expense of longer operation times and more frequent application of Pringle manoeuver.

Necrosectomy of hepatic left lateral section after blunt abdominal trauma in a patient who underwent central hepatectomy and bile duct resection for perihilar cholangiocarcinoma.

When the liver is divided into the right and left halves after central hepatectomy, a serious injury to the one half of the liver can destroy the ipsilateral half. We report a case showing total necrosis of the hepatic left lateral section (LLS) caused by blunt abdominal trauma in a patient who had undergone central hepatectomy and bile duct resection for perihilar cholangiocarcinoma. A 47-year-old female patient was transferred because of postoperative status following blunt abdominal trauma. Five years before, she had been diagnosed with perihilar cholangiocarcinoma. Since the tumor extent was compatible with Bismuth-Corlette type IV, she underwent central hepatectomy and bile duct resection. After five years, she experienced an industrial safety accident, in which a heavy refrigerator fell over her body. She underwent emergency duodenal diversion surgery with distal gastrectomy and Roux-en-Y gastrojejunostomy. During this surgery, serious ischemic injury of the LLS with occlusion of the left portal vein and hepatic artery was identified, but not treated. After three weeks, LLS necrosectomy with repair of the jejunal limb was done. Postoperative bile leak developed and required supportive care for two months for its healing. She is currently doing well without any physical discomfort four months after the necrosectomy. Our experience with this case suggests that an injury to the afferent jejunal limb requires an individualized treatment strategy including long-standing waiting with effective drainage for spontaneous healing. The experience of this case appears to be theoretically matched with late-stage resection of LLS following central hepatectomy and bile duct resection.

Central hepatectomy for hepatocellular carcinoma in a patient with anti-Gerbich antibody.

BACKGROUND: Anti-Gerbich (Ge) alloantibody against high-frequency erythrocyte antigen is extremely rare. Owing to incomplete evidence regarding the degree and severity of adverse events induced by hemolytic transfusion reactions, the transfusion management often remains cumbersome in these patients. We report an anti-Ge alloantibody positive patient with hepatocellular carcinoma (HCC) who underwent central hepatectomy (CH) without the need for an allogeneic blood transfusion. CASE PRESENTATION: A 76-year-old Japanese woman was diagnosed with HCC measuring 9.5 × 8.0 cm in segments 4, 5, and 8 of the liver. This patient with anti-Ge alloantibody had a history of two pregnancies without transfusion. CH was planned, and based on the suggestion from the multidisciplinary team meeting, preoperative autologous donation (PAD) and acute normovolemic hemodilution (ANH) were performed. CH was successfully performed by using CUSA and Thunderbeat® with Pringle maneuver and infra-hepatic inferior vena cava clamping without perioperative need for an allogeneic blood transfusion. She has been alive without recurrence after a follow-up period of 45 months. CONCLUSION: To our knowledge, this is the first case report of hepatectomy in a patient with anti-Ge alloantibody. A multidisciplinary team approach, PAD and ANH, and bloodless liver surgical techniques appear to be useful for major hepatectomy in patients with extremely rare blood type.

Standardized laparoscopic central hepatectomy based on hilar caudal view and root approach of the right hepatic vein.

Central hepatectomy is one of the most difficult procedures to perform laparoscopically. Rotellar and colleagues described a standardized technique, tailored specifically to laparoscopy, which facilitates its safe performance based on three principles: no liver mobilization, initial Glissonean control (based on Laennec's capsule approach) and root approach of the major veins.

The technique and outcomes of central hepatectomy by the Glissonian suprahilar approach.

INTRODUCTION: Central hepatectomy (CH) is technically challenging and seldom-used to treat centrally located tumors. However, CH is a parenchyma-sparing resection that may decrease the risk of postoperative liver failure. This retrospective study presents our technique of CH and assesses the outcomes. METHODS: All CH performed in our department over two decades (1997-2017) were identified. Indications and short-term outcomes were compared between the two decades. Long-term outcomes were assessed. RESULTS: Sixty-four patients underwent CH using a suprahilar approach for hepatocellular carcinoma (HCC: n = 30), metastasis (n = 23), intrahepatic cholangiocarcinoma (IHCCA: n = 9) or other diseases (n = 2). CH represented 6% of 1004 major hepatectomies, (7.4% (n = 35) before 2007 vs 5.4% (n = 29) after 2007). The mean operating time was 219 ±â€¯56 min. A perioperative blood transfusion was required in 14 patients (22%). Intraoperative bile duct injuries occurred in 5 patients (8%), and they were repaired. One patient died postoperatively (1,5%). Ten patients (16%) experienced a major complication. Nine patients (14%) suffered from bile leakage, of which 6 healed spontaneously. Only one patient had low grade liver failure. The R0-resection rate was 69%. After 2007, there were no bile duct injuries (0/29 vs 5/35, p < 0.05), and the average hospital stay was shorter but not significantly (11 vs 14 days). Actuarial 5-year survival was 56% for HCC patients and 34% for those with colorectal metastasis CONCLUSIONS: CH is associated with significant biliary morbidity and may increase positive surgical margins. Nevertheless, it should be recommended in selected patients to avoid the risk of postoperative liver failure.

Outcomes of central hepatectomy versus extended hepatectomy.

BACKGROUND: Central hepatectomy (CH) is more difficult than extended hepatectomy (EH) and is associated with greater morbidity. In this modern era of liver management with aims to prevent post-hepatectomy liver failure (PHLF), there is a need to assess outcomes of CH as a parenchyma-sparing procedure for centrally located liver tumors. METHODS: A total of 178 major liver resections performed by specialist surgeons from two Australian tertiary institutions between June 2009 and March 2017 were reviewed. Eleven patients had CH and 24 had EH over this study period. Indications and perioperative outcomes were compared between the groups. RESULTS: The main indication for performing CH was colorectal liver metastases. There was no perioperative mortality in the CH group and four (16.7%) in the EH group (P = 0.285). No group differences were found in median operative time [CH vs. EH: 450 min (290-840) vs. 523 min (310-860), P = 0.328], intraoperative blood loss [850 mL (400-1500) vs. 650 mL (100-2000), P = 0.746] or patients requiring intraoperative blood transfusion [1 (9.1%) vs. 7 (30.4%), P = 0.227]. There was a trend towards fewer hepatectomy-specific complications in the CH group [3 (27.3%) vs. 13 (54.2%), P = 0.167], including PHLF (CH vs. EH: 0 vs. 29.2%, P = 0.072). Median length of stay was similar between groups [CH vs. EH: 9 days (5-23) vs. 12 days (4-85), P = 0.244]. CONCLUSIONS: CH has equivalent postoperative outcomes to EH. There is a trend towards fewer hepatectomy-specific complications, including PHLF. In appropriate patients, CH may be considered as a safe parenchyma-sparing alternative to EH.

Central hepatectomy versus major hepatectomy for patients with centrally located hepatocellular carcinoma: A meta-analysis.

BACKGROUND: Both central hepatectomy (CH) and major hepatectomy (MH) are suggested surgical treatments for patients with centrally located hepatocellular carcinoma (CL-HCC). However, no consensus has been reached regarding which method is superior for managing these patients. This meta-analysis was conducted to compare the short- and long-term outcomes of CH and MH in patients with CL-HCC. METHODS: An electronic search for studies published in all years up to July 2017 in PubMed (Medline), EMBASE, Cochrane Library and Web of Science was performed. The short-term outcome was the incidence of postoperative complications, and the long-term outcomes included 1-, 3- and 5-year overall survival (OS) and corresponding disease-free survival (DFS), mortality and morbidity. The results were presented as Risk Ratios (RRs) or weighted mean differences with 95% confidence intervals. RESULTS: Four retrospective studies containing 465 patients with CL-HCC were included (248 in the CH group and 217 in the MH group). The results suggested no significant differences in the 1-, 3- and 5-year DFS, 1, 3 and 5-year OS, total morbidity or mortality between these groups. Nevertheless, the patients in the CH group presented a lower prevalence of vascular invasion (RR 0.70, 95% CI 0.52-0.93, P = 0.020) than did the MH group. In addition, CH led to a higher incidence of biliary fistula, while MH showed a higher incidence of postoperative liver failure. CONCLUSION: This study demonstrated that the long-term outcomes of the patients with CL-HCC in these two groups were not significantly different. For short-term outcomes, CH resulted in a lower rate of postoperative liver failure, while MH resulted in a lower incidence of biliary fistula. Nonetheless, compared with MH, CH provided CL-HCC patients with greater future remnant liver volume without an increased risk of early intra-hepatic recurrence. More multi-centre, randomized controlled trials comparing the therapeutic efficacy of CH and MH are urgently warranted.

Bilateral anatomic resection of the ventral parts of the paramedian sectors of the liver with total caudate lobectomy for deeply/centrally located liver tumors: a new technique maximizing both oncological and surgical safety.

Systematic resection of the tumor-bearing portal territory is reportedly correlated with an improved survival of patients with liver tumors, especially in hepatocellular carcinoma. Despite advances in surgical management, however, anatomic resection of deeply/centrally located tumors remains a challenging procedure not only with technical difficulty but also because of decreased hepatic functional reserve frequently observed due to underlying liver disease. In this report, we have reported a novel technique that allows a promising approach for deeply/centrally located tumors with maximizing both the surgical and oncological safety. Bilateral anatomic resection of the ventral parts of the paramedian sectors (BVPM) offers a sufficient surgical window for safe access to the perihilar region. This technique is based on Hjortsjo's theory for liver anatomy and enables systematic removal of the 3rd-order portal territories. In addition, the current technique is advantageous in minimizing the loss of the normal liver parenchyma without leaving ischemia or congestion in the future liver remnant. Of the seven consecutive patients who were treated with this procedure, all the patients achieved R0 resection with acceptable rate of major morbidity (1/7, 14%). The BVPM may offer a safe and maximized chance of curative resection for deeply/centrally located liver tumors.

Left hepatectomy after right paramedian sectoriectomy.

Repeat hepatectomy is beneficial for selected patients with recurrence of liver malignancies. However, the operative procedure becomes technically demanding when the previous hepatectomy was complex, with hepatic veins and stump of portal pedicles exposed on the liver transection surface. We performed left hepatectomy after right paramedian sectoriectomy (RPMS) for three patients. Here, we describe our surgical technique and the postoperative outcomes achieved. This procedure allowed for safe adhesiolysis between the middle and right hepatic veins by following a fibrous plane. The mean operative time was 8.7 h, including 4.9 h of adhesiolysis. The mean remnant liver volume (right lateral sector and the caudate lobe) was calculated as 704 ml, being 62% of total liver volume. There was no postoperative liver failure or mortality. In conclusion, left hepatectomy after RPMS is a feasible procedure for patients with sufficient remnant liver volume, even though the middle and right hepatic veins run side by side after liver regeneration.

Impact of Glissonean pedicle approach for centrally located hepatocellular carcinoma in mongolia.

Approaches to surgical resection of centrally located HCC remain controversial. Traditionally, hemi- or extended hepatectomy is suggested. However, it carries a high risk of postoperative complications in patients with cirrhosis. An alternative approach is Glissonean pedicle transection method. This study was conducted to assess the surgical and survival outcomes associated with central liver resection using the Glissonean pedicle transection. Sixty-nine patients with centrally located HCC were studied retrospectively. They were divided into conventional approach group with hemi- or extended hepatectomy, and Glissonean approach group with multisegmental central liver resection using the Glissonean pedicle transection. Glissonean pedicle transection method has comparable or superior surgical and survival outcomes to conventional hemi- or extended hepatectomy with regard to intraoperative bleeding, complications, hospital stay, and postoperative mortality and survival outcomes in patients with centrally located HCC. The 1-, 3-, and 5-year overall survival rates of the conventional approach group were 74%, 64%, and 55% respectively. For the Glissonean approach group, the 1 and 3-year overall survival rates were 86% and 61%, respectively. Glissonean pedicle transection method is a safe and effective surgical procedure in patients with centrally located HCC.

Central hepatectomy for centrally located malignant liver tumors: A systematic review.

AIM: To study whether central hepatectomy (CH) can achieve similar overall patient survival and disease-free survival rates as conventional major hepatectomies or not. METHODS: A systematic literature search was performed in MEDLINE for articles published from January 1983 to June 2013 to evaluate the evidence for and against CH in the management of central hepatic malignancies and to compare the perioperative variables and outcomes of CH to lobar/extended hemihepatectomy. RESULTS: A total of 895 patients were included from 21 relevant studies. Most of these patients who underwent CH were a sub-cohort of larger liver resection studies. Only 4 studies directly compared Central vs hemi-/extended hepatectomies. The range of operative time for CH was reported to be 115 to 627 min and Pringle's maneuver was used for vascular control in the majority of studies. The mean intraoperative blood loss during CH ranged from 380 to 2450 mL. The reported morbidity rates ranged from 5.1% to 61.1%, the most common surgical complication was bile leakage and the most common cause of mortality was liver failure. Mortality ranged from 0.0% to 7.1% with an overall mortality of 2.3% following CH. The 1-year overall survival (OS) for patients underwent CH for hepatocellular carcinoma ranged from 67% to 94%; with the 3-year and 5-year OS having a reported range of 44% to 66.8%, and 31.7% to 66.8% respectively. CONCLUSION: Based on current literature, CH is a promising option for anatomical parenchymal-preserving procedure in patients with centrally located liver malignancies; it appears to be safe and comparable in both perioperative, early and long term outcomes when compared to patients undergoing hemi-/extended hepatectomy. More prospective studies are awaited to further define its role.

Double liver hanging manoeuvre for central hepatectomy.

We describe a modification of Belghiti's liver hanging manoeuvre (LHM) using two small tubes placed in the cut planes, the first between the left lateral and medial sections, and the second along the right hepatic vein, to achieve complete anatomic central hepatectomy for a large tumour compressing surrounding vessels. Using this technique, a large central hepatocellular carcinoma compressing hilar vessels and the right hepatic vein was easily and safely resected in a 57-year-old man.