Single-incision versus conventional multiport laparoscopic cholecystectomy in acute cholecystitis according to disease severity: single center retrospective study in Korea.

Purpose: The safety of single-incision laparoscopic cholecystectomy (SILC) for acute cholecystitis (AC) has not yet been confirmed. Methods: This single-center retrospective study included patients who underwent laparoscopic cholecystectomy (LC) for AC between April 2010 and December 2020. Propensity scores were used to match patients who underwent SILC with those who underwent conventional multiport LC (CMLC) in the entire cohort and in the two subgroups. Results: A total of 1,876 patients underwent LC for AC, and 427 (22.8%) underwent SILC. In the propensity score-matched analysis of the entire cohort (404 patients in each group), the length of hospital stay (2.9 days vs. 3.5 days, p = 0.029) was shorter in the SILC group than in the CMLC group. No significant differences were observed in other surgical outcomes. In grade I AC (336 patients in each group), the SILC group showed poorer surgical outcomes than the CMLC group, regarding operation time (57.6 minutes vs. 52.4 minutes, p = 0.001) and estimated blood loss (22.9 mL vs. 13.1 mL, p = 0.006). In grade II/III AC (58 patients in each group), there were no significant differences in surgical outcomes between the two groups. Postoperative pain outcomes were also not significantly different in the two groups, regardless of severity. Conclusion: This study demonstrated that SILC had similar surgical and pain outcomes to CMLC in patients with AC; however, subgroup analysis showed that SILC was associated with poor surgical outcomes than CMLC in grade I AC. Therefore, SILC should be carefully performed in patients with AC by experienced hepatobiliary surgeons.

Acute cholecystitis in old adults: the impact of advanced age on the clinical characteristics of the disease and on the surgical outcomes of laparoscopic cholecystectomy.

BACKGROUND: Impact of advanced age on disease characteristics of acute cholecystitis (AC), and surgical outcomes after laparoscopic cholecystectomy (LC) has not been established. METHODS: This single-center retrospective study included patients who underwent LC for AC between April 2010 and December 2020. We analyzed the disease characteristics and surgical outcomes according to age: Group 1 (age < 60 years), Group 2 (60 ≤ age < 80 years), and Group 3 (age ≥ 80 years). Risk factors for complications were assessed using logistic regression analysis. RESULTS: Of the 1,876 patients (809 [43.1%] women), 723 were in Group 1, 867 in Group 2, and 286 in Group 3. With increasing age, the severity of AC and combined common bile duct stones increased. Group 3 demonstrated significantly worse surgical outcomes when compared to Group 1 and 2 for overall (4.0 vs. 9.1 vs. 18.9%, p < 0.001) and serious complications (1.2 vs. 4.2 vs. 8.0%, p < 0.001), length of hospital stay (2.78 vs. 3.72 vs. 5.87 days, p < 0.001), and open conversion (0.1 vs. 1.0 vs. 2.1%, p = 0.007). Incidental gallbladder cancer was also the most common in Group 3 (0.3 vs. 1.5 vs. 3.1%, p = 0.001). In the multivariate analysis, body mass index < 18.5, moderate/severe AC, and albumin < 2.5 g/dL were significant risk factors for serious complications in Group 3. CONCLUSION: Advanced age was associated with severe AC, worse surgical outcomes, and a higher rate of incidental gallbladder cancer following LC. Therefore, in patients over 80 years of age with AC, especially those with poor nutritional status and high severity grading, urgent surgery should be avoided, and surgery should be performed after sufficient supportive care to restore nutritional status before LC.

Optimal indication of single-incision laparoscopic cholecystectomy using Konyang Standard Method in benign gallbladder diseases.

Purpose: The optimal indications for single-incision laparoscopic cholecystectomy (SILC) have not yet been established. Methods: This single-center retrospective study included consecutive patients who underwent SILC between April 2010 and June 2020. Difficult surgery (DS) (conversion to multiport or open cholecystectomy, adjacent organ injury, operation time of ≥90 minutes, or estimated blood loss of ≥100 mL) and poor postoperative outcome (PPO) (postoperative hospital stay ≥ 7 days or Clavien-Dindo grade ≥ II postoperative complications) were defined to comprehensively evaluate surgical difficulty and postoperative outcomes, respectively. Results: Of 1,405 patients (mean age, 51.2 years; 802 female [57.1%]), 427 (grade I, n = 358; grade II/III, n = 69) underwent SILC for acute cholecystitis (AC), 34 (2.4%) needed conversion to multiport (n = 33) or open cholecystectomy (n = 1), 7 (0.5%) had adjacent organ injury during surgery, and 49 (3.5%) developed postoperative complications. Of the patients, 89 and 52 had DS and PPO, respectively. In the multivariate analysis, grade I AC, grade II/III AC, and body mass index of ≥30 kg/m2 were significant predictors of DS. Age of ≥70 years and DS were significant predictors of PPO. In a subgroup analysis of patients with AC, DS (9.5% vs. 27.5%, p < 0.001) and PPO (5.0% vs. 15.9%, p = 0.001) were more frequent in patients with grade II/III AC than in those with grade I AC. Conclusion: SILC is not recommended in patients with grade II/III AC and should be carefully performed by experienced and well-trained surgeons.

The role of postoperative neutrophil-to-lymphocyte ratio as a predictor of postoperative major complications following total gastrectomy for gastric cancer.

Purpose: This study was performed to investigate the role of the perioperative neutrophil-to-lymphocyte ratio (NLR) as an early predictor of major postoperative complications after total gastrectomy for gastric cancer. Methods: This single-center, retrospective study reviewed consecutive patients with gastric cancer who underwent total gastrectomy at a single institution from March 2009 to March 2021. The postoperative complications were graded according to the Clavien-Dindo classification. We analyzed the patient demographics and surgical outcomes according to the grade of postoperative complications in the major complications group (≥grade III) and the no major complications group (

Optimal drain management following complicated laparoscopic cholecystectomy for acute cholecystitis: a propensity-matched comparative study.

Purpose: This study was performed to investigate the effect of drain placement on complicated laparoscopic cholecystectomy (cLC) for acute cholecystitis (AC). Methods: This single-center retrospective study reviewed patients with AC who underwent cLC between January 2010 and December 2020. cLC was defined as open conversion, subtotal cholecystectomy, adjacent organ injury during surgery, operation time of ≥90 minutes, or estimated blood loss of ≥100 mL. One-to-one propensity score matching was performed to compare the surgical outcomes between patients with and without drain on cLC. Results: A total of 216 patients (mean age, 65.8 years; 75 female patients [34.7%]) underwent cLC, and 126 (58.3%) underwent intraoperative abdominal drainage. In the propensity score-matched cohort (61 patients in each group), early drain removal (≤postoperative day 3) was performed in 42 patients (68.9%). The overall rate of surgical site infection (SSI) was 10.7%. Late drain removal demonstrated significantly worse surgical outcomes than no drain placement and early drain removal for overall complications (13.1% vs. 21.4% vs. 47.4%, p = 0.006), postoperative hospital stay (3.8 days vs. 4.4 days vs. 12.7 days, p < 0.001), and SSI (4.9% vs. 11.9% vs. 31.6%, p = 0.006). In the multivariate analysis, late drain removal was the most significant risk factor for organ space SSI. Conclusion: This study demonstrated that drain placement is not routinely recommended, even after cLC for AC. When placing a drain, early drain removal is recommended because late drain removal is associated with a higher risk of organ space SSI.

Completion of single-incision laparoscopic cholecystectomy using the modified Konyang standard method.

BACKGROUND: To date, a surgical method for single-incision laparoscopic cholecystectomy (SILC) has not been standardized. Therefore, this study aimed to introduce a standardized surgical method for SILC, in addition to reporting our experience over 10 years. METHODS: Patients who underwent SILC at a single institution between April 2010 and December 2019 were included in this study. We analyzed the patient demographics and surgical outcomes according to the surgical method used: phase 1 (Konyang standard method, KSM) comprising initial 3-channel SILC, phase 2 (modified KSM, mKSM) comprising 4-channel SILC with a snake retractor, and phase 3 (commercial mKSM, C-mKSM) using a commercial 4-channel port. RESULTS: Of 1372 patients (mean age, 51.3 years; 781 [56.9%] women), 418 (30.5%) surgeries were performed for acute cholecystitis (AC), 33 (2.4%) were converted to multiport or open cholecystectomy, and 49 (3.6%) developed postoperative complications. The mean operation time (OT) and length of postoperative hospital stay (LOS) were 51.9 min and 2.6 days, respectively. Overall, 325 patients underwent SILC with the KSM, 660 with the mKSM, and 387 with the C-mKSM. In the C-mKSM group, the number of patients with AC was the lowest (26.8% vs. 38.2% vs. 20.4%, p < 0.001) and the OT (51.7 min vs. 55.4 min vs. 46.1 min, p < 0.001), estimated blood loss (24.5 mL vs. 15.5 mL vs. 6.1 mL, p < 0.001), and LOS (2.8 days vs. 2.5 days vs. 2.3 days, p = 0.001) were significantly improved. The surgical outcomes were better in the non-AC group than in the AC group. CONCLUSION: Based on our 10 year experience, C-mKSM is a safe and feasible method of SILC in selected patients, although there were lower percentage of patients with AC compared to other groups.

Efficacy of sentinel lymph node biopsy with radioisotope alone and the prediction of sentinel node status using PET-CT in breast cancer.

Purpose: Sentinel lymph node biopsy (SLNB) using both a radioactive isotope (RI) and blue dye is considered highly effective; however, there were limitations with the use of both agents in some hospitals, and blue dye has been shown to have some adverse effects. Additionally, preoperative prediction of sentinel lymph node (SLN) status using the maximum standardized uptake value (SUVmax) on positron emission tomography-computed tomography (PET-CT) can help avoid unnecessary axillary dissection or SLNB. Thus, we evaluated the efficacy and oncologic safety of SLNB using an RI alone in terms of long-term outcomes and determined the association between SLN metastasis and SUVmax of the primary tumor. Methods: This retrospective study was conducted at Konyang University Hospital between March 2011 and May 2018. Overall, 142 patients with breast cancer who underwent SLNB using an RI alone were enrolled. Data on identification and false-negative rates were collected. The SUVmax of primary tumors on PET-CT were analyzed for their association with SLN metastasis. Results: The identification and false-negative rates were 98.6% and 0%, respectively. There was no axillary local recurrence in patients with negative SLN findings. The correlation between the SUVmax of the primary tumor and SLN status was significant (r=0.249, P=0.005); the cutoff value for negative SLN metastasis was <2.15. Conclusion: The single agent method using an RI is not inferior to other methods and serves as a feasible option for SLNB. And the number of excised SLNs could be minimized when the SUVmax of primary tumor is extremely low.

Which Patients Are a Better Candidate of Laparoscopic Repair in Obturator Hernia Patients?

Purpose: Obturator hernia is a difficult disease to diagnose. If a surgical treatment is delayed in obturator hernia, a bowel resection may be required due to strangulation. The surgical treatment of this disease is to use a classical laparotomy. Recently, the laparoscopic approach has been reported and reviewed for efficiency. We checked the indicators that determine the most appropriate surgical method according to the patient's condition. Methods: In the study, a single-institution, retrospective analysis of surgical patients undergoing an obturator hernia surgery between 2003 and 2018 was performed. The patients were divided into a laparoscopic group (5 patients underwent laparoscopic repair; no intestinal resection) and an open group (13 patients who underwent open repair; 10 with and 3 without intestinal resection). The outcomes were compared between the groups. We analyzed the relevant factors that could predict the proper method of surgery. Results: A total 18 patients were included in the study. All patients were female, with body mass index (BMI) of under 21 kg/m2. Of the various factors, only the WBC and CRP counts were the factors that had shown significant differences between the two groups. It is noted that patients with open surgery had a higher WBC counts (10406 versus 6520/µl; p=0.011) and CRP counts (7.84 vs. 0.32 mg/dl; p=0.027). Conclusion: Obturator hernia can be treated with a laparoscopic surgery. The choice of surgical treatment can be considered in advance through the review of the patient's WBC count or CRP count.

The Usefulness of Preoperative Colonoscopic Tattooing with Autologous Blood for Localization in Laparoscopic Colorectal Surgery.

Purpose: In colorectal cancer surgery, it is important to have accurate resection margins. However, it is challenging to localize lesions during laparoscopy. Therefore, to reduce surgical errors, many preoperative localizing methods have been introduced. In this study, we aimed to assess the preoperative feasibility and safety of autologous blood tattooing. Methods: A total of 11 patients underwent preoperative colonoscopic autologous blood tattooing from August 2017 to February 2020. At the start of the surgery, the surgeon assessed the patients for the precision of visibility and other complications such as abscess or spillage. The patients' characteristics, outcomes, and complications were collected retrospectively. Results: The study comprised 8 men and 3 women, with an average age of 63 years. Ten patients showed precise visibility, and no localization errors were observed during surgery. No complication was observed in all patients. Conclusion: Preoperative autologous blood tattooing is a very useful and safe technique because it has high visibility with no complications. This method does not require additional agents or facilities. A large-scale study will be required to develop standard guidelines.

Evolution of the Konyang Standard Method for single incision laparoscopic cholecystectomy: the result from a thousand case of a single center experience.

PURPOSE: Single incision laparoscopic cholecystectomy (SILC) is increasingly performed worldwide. Accordingly, the Konyang Standard Method (KSM) for SILC has been developed over the past 6 years. We report the outcomes of our procedures. METHODS: Between April 2010 and December 2016, 1,005 patients underwent SILC at Konyang University Hospital. Initially 3-channel SILC with KSM was changed to 4-channel SILC using a modified technique with a snake retractor for exposure of Calot triangle; we called this a modified KSM (mKSM). Recently, we have used a commercial 4-channel (Glove) port for simplicity. RESULTS: SILC was performed in 323 patients with the KSM, in 645 with the mKSM, and in 37 with the commercial 4-channel port. Age was not significantly different between the 3 groups (P = 0.942). The postoperative hospital days (P = 0.051), operative time (P < 0.001) and intraoperative bleeding volume (P < 0.001) were significantly improved in the 3 groups. Drain insertion (P = 0.214), additional port insertion (P = 0.639), and postoperative complications (P = 0.608) were not significantly different in all groups. Postoperative complications were evaluated with the Clavien-Dindo classification. There were 3 cases (0.9%) over grade IIIb (bile duct injury, incisional hernia, duodenal perforation, or small bowel injury) with KSM and 3 (0.5%) with mKSM. CONCLUSION: We evaluated the evolution of the KSM for SILC. The use of the mKSM with a commercial 4-channel port may be the safest and most effective method for SILC.

Comparative Performance of the Complexity Classification and the Conventional Major/Minor Classification for Predicting the Difficulty of Liver Resection for Hepatocellular Carcinoma.

OBJECTIVE: To compare performances for predicting surgical difficulty and postoperative complications. BACKGROUND: An expert panel recently proposed a complexity classification for liver resection with 3 categories of complexity (low, medium, or high). We compared this new classification with the conventional major/minor classification. METHODS: We retrospectively reviewed 469 hepatocellular carcinoma patients who underwent liver resection between 1 January 1, 2004 and June 30, 2015. We used receiver-operating characteristic curve analysis to compare the performances of both classifications for predicting perioperative outcomes. RESULTS: Both classifications effectively differentiated subgroups of patients in terms of their intraoperative findings and short-term outcomes, including blood loss, transfusion rate, operation time, and postoperative hospital stay (all P < 0.05). The ability to predict complications was not significantly different between the major/minor classification and the complexity classification [area under the curve (AUC) 0.625 vs 0.617, respectively; P= 0.754). However, the complexity classification showed stronger correlations with blood loss (AUC 0.690 vs 0.617, respectively; P = 0.001) and operation time (AUC 0.727 vs 0.619, respectively; P < 0.001) compared with the major/minor classification. To check heterogeneity, the minor resection group was further divided into low (n = 184), medium (n = 149), and high complexity (n = 13) groups. Operation time and blood loss were significantly different among these 3 subgroups of patients. CONCLUSIONS: The complexity classification outperformed the major/minor classification for predicting the surgical difficulty of liver resection.

Laparoscopic liver resection of hepatocellular carcinoma located in segments 7 or 8.

BACKGROUND: Many centers consider hepatocellular carcinoma (HCC) located in segments 7 or 8 to be unsuitable for laparoscopic liver resection (LLR). We evaluated the safety of LLR of HCC in segments 7 or 8 following the introduction of new laparoscopic techniques. METHODS: This retrospective study included 104 patients who underwent LLR (n = 46) or open liver resection (OLR) (n = 58) for HCC located in segments 7 or 8 between October 2004 and June 2015. The LLR group was subdivided into two subgroups according to whether LLR was performed before (Lap1; n = 29) or after (Lap2; n = 17) the introduction of the Pringle maneuver, intercostal trocars, and semi-lateral patient positioning. RESULTS: Non-anatomical resection was more frequent (63.0 vs. 29.3%; P < 0.001) and tumor size was smaller (2.8 vs. 4.7 cm; P < 0.001) in the LLR group than in the OLR group. Blood transfusion (P = 0.526), operation time (P = 0.267), postoperative complications (P = 0.051), and resection margin (P = 0.705) were similar in both groups. LLR was associated with less blood loss (550 vs. 700 ml, P = 0.030) and shorter hospital stay (8 vs. 10 days; P = 0.001). The 3-year overall (90.2 vs. 81.2%, P = 0.096) and disease-free survival (15.1 vs. 12.1%; P = 0.857) rates were similar in both groups. The Lap2 group has less blood loss (230 vs. 500 ml; P = 0.005) and shorter hospital stay (7 vs. 9 days; P = 0.038) compared with the Lap1 group. CONCLUSION: LLR can be safely performed for HCC located in segments 7 or 8 with recent improvements in surgical techniques and accumulated experience.

Prediction of surgical outcomes of laparoscopic liver resections for hepatocellular carcinoma by defining surgical difficulty.

BACKGROUND: Several classification systems for assessing the surgical difficulty of laparoscopic liver resection (LLR) have been proposed. We evaluated three current classification systems, including traditional Major/Minor Classification, Complexity Classification, and the Difficulty Scoring System for predicting the surgical outcomes after LLR. METHODS: We reviewed the clinical data of 301 patients who underwent LLR for hepatocellular carcinoma between March 1, 2004 and June 30, 2015. We compared the intraoperative, pathologic, and postoperative outcomes according to the three classifications. We also compared the prognostic value of the three classifications using receiver operating characteristic (ROC) curves. RESULTS: The Major/Minor Classification, Complexity Classification, and the Difficulty Scoring System efficiently differentiated surgical difficulty in terms of blood loss (P = 0.001, P = 0.009, and P < 0.001, respectively) and operation time (all P < 0.001). Regarding intraoperative outcomes, the Difficulty Scoring System and Complexity Classification successfully differentiated the transfusion rate (P = 0.001 and P < 0.001, respectively). However, only the Complexity Classification adequately predicted severe postoperative complications (P = 0.032), the severity of complications (P < 0.001), and the length of hospital stay (P = 0.005). In ROC curve analysis, the Complexity Classification (area under the curve [AUC] = 0.611) outperformed the Major/Minor Classification (AUC = 0.544) and the Difficulty Scoring System (AUC = 0.530) for predicting severe postoperative complications. None of the classification systems predicted recurrence or patient survival. CONCLUSION: The Complexity Classification was superior to the other methods for assessing surgical difficulty and predicting complications after LLR for hepatocellular carcinoma.

Laparoscopic Anatomical Segment 2 Segmentectomy by the Glissonian Approach.

BACKGROUND: When hepatocellular carcinoma (HCC) was located in segment 2 (S2), segment-oriented hepatectomy was more beneficial than left lateral sectionectomy as this type of anatomical resection preserved the volume of the nontumor-bearing segment. Herein, we presented 2 cases (1 with video) of laparoscopic anatomical S2 segmentectomy by the Glissonian approach. METHODS: The first patient was a 69-year-old woman, who had an incidentally detected liver nodule on abdominal ultrasound for systemic surveillance for her breast cancer. The preoperative liver function was Child-Pugh class A. Abdominal computed tomography showed a 2 cm low attenuating lesion in S2. Contrast magnetic resonance imaging (MRI) showed the same lesion with features more suggestive of HCC. In view of the inconclusive imaging findings, a needle biopsy was performed and it confirmed the diagnosis of HCC. The second patient was a 57-year-old man with hepatitis B and Child-Pugh class B liver cirrhosis. He had an enlarging nonenhancing liver nodule in S2 noted on MRI. Laparoscopic anatomical S2 segmentectomy was performed for these 2 patients. RESULTS: The operative time for the first and second patients was 240 and 185 minutes, respectively. The respective estimated intraoperative blood loss was 50 and 250 mL and no transfusion was necessary. The patients were discharged on the fourth and fifth postoperative day without any complications, respectively. CONCLUSION: This study showed the feasibility of performing a laparoscopic S2 segmentectomy by the Glissonian approach.

Association of Remnant Liver Ischemia With Early Recurrence and Poor Survival After Liver Resection in Patients With Hepatocellular Carcinoma.

Importance: The remnant liver after hepatectomy may have inadequate blood supply, especially following nonanatomical resection or vascular damage. Objective: To evaluate whether remnant liver ischemia (RLI) may have an adverse effect on long-term survival and morbidity after liver resection in patients with hepatocellular carcinoma. Design, Setting, and Participants: This study was a retrospective analysis at Seoul National University Bundang Hospital. Remnant liver ischemia was graded on postoperative computed tomographic scans in 328 patients who underwent hepatectomy for hepatocellular carcinoma between January 1, 2004, and December 31, 2013. Main Outcomes and Measures: Remnant liver ischemia was defined as reduced or absent contrast enhancement during the venous phase. Remnant liver ischemia was classified as minimal (none or marginal) or severe (partial, segmental, or necrotic). Results: Among 328 patients (252 male and 76 female; age range, 26-83 years [mean age, 58.2 years]), radiologic signs of severe RLI were found in 98 patients (29.9%), of whom 63, 16, and 19 had partial, segmental, or necrotic RLI, respectively. These patients experienced more complications and longer hospital stay than patients with minimal RLI. Preoperative history of transarterial embolization (odds ratio [OR], 1.77; 95% CI, 1.02-3.03; P = .04), use of the Pringle maneuver (OR, 1.96; 95% CI, 1.08-3.58; P = .03), and longer operative time (OR, 1.003; 95% CI, 1.002-1.005; P < .001) were independent risk factors for severe RLI. Early recurrence rates within 6 (60.2% vs 9.6%) or 12 (79.6% vs 18.7%) months after hepatectomy were higher in patients with severe RLI than in patients without RLI (P < .001). Severe remnant liver ischemia was an independent risk factor for overall survival (OR, 6.98; 95% CI, 4.27-11.43; P < .001) and disease-free survival (OR, 5.15; 95% CI, 3.62-7.35; P < .001). Conclusions and Relevance: Preventive management and technical refinements in hepatectomy are important to decrease the risk of RLI and to improve survival of patients with hepatocellular carcinoma.

Validation of difficulty scoring system for laparoscopic liver resection in patients who underwent laparoscopic left lateral sectionectomy.

BACKGROUND: A difficulty scoring system (DSS) based on the extent of liver resection, tumor location, liver function, tumor size, and tumor proximity to major vessels was recently developed to assess the difficulty of various laparoscopic liver resection procedures. We validated DSS in patients who underwent laparoscopic left lateral sectionectomy (LLS). METHODS: We reviewed the clinical data of 124 patients who underwent laparoscopic LLS between July 2003 and November 2015 and validated the DSS in 90 patients who underwent laparoscopic LLS for tumor according to their surgical outcomes. We also developed and evaluated the modified DSS in 34 patients who underwent LLS for intrahepatic duct (IHD) stones. RESULTS: The DSS score ranged from 3 to 6 in laparoscopic LLS for tumors. The median blood loss (P = 0.002) was significantly different among patients divided into subgroups by DSS score. We made modified DSS for IHD stones using factors influencing longer operation time, including stone location (P = 0.002), atrophy of liver parenchyma (P = 0.012), ductal stricture <1 cm from the bifurcation (P = 0.047), and combined choledochoscopic examination for remnant IHD (P < 0.001). The modified DSS score for IHD stones ranged from 3 to 7. Blood loss (P = 0.02) and operation time (P < 0.001) were significantly different among subgroups of patients divided by their difficulty scores. The median hospital stay (P = 0.004) and operation time (P = 0.039) were significantly longer and the complication rate (P = 0.025) and complication grade (P = 0.021) were significantly greater in patients with IHD stones than in patients with tumors. CONCLUSIONS: The surgical difficulty varies among patients undergoing the same laparoscopic LLS procedure. The modified DSS developed here can also be applied to patients with IHD stones.

Laparoscopic Total Caudate Lobectomy for Hepatocellular Carcinoma.

BACKGROUND: Caudate lobe is located in the deep dorsal area of the liver between the portal triad and the inferior vena cava (IVC). Torrential bleeding can occur from the IVC and short hepatic veins during dissection. Isolated total caudate lobe resection is still rare and technically demanding. We herein present a video on the technical aspect of laparoscopic total caudate lobectomy. METHOD: A 61-year-old woman was admitted for recurrent hepatocellular carcinoma detected on imaging. She had history of multifocal hepatocellular carcinoma in July 2015 and underwent open cholecystectomy, segment 6 and segment 8 tumorectomy. Ten months later, the computed tomography scan and magnetic resonance imaging showed a 1 cm arterial enhancing lesion in segment I (S1) with no other foci of recurrence. Laparoscopic total caudate lobectomy was contemplated. RESULTS: The operative time was 270 minutes. The intraoperative blood loss was 200 mL and blood transfusion was not necessary. The patient was discharged on the fourth postoperative day without any complications. CONCLUSION: This report showed the safety and feasibility of laparoscopic total caudate lobectomy. Nonetheless, it is a technically demanding procedure. It should be performed in carefully selected patients and by experienced hepatobiliary surgeons proficient in laparoscopic liver resection.

Laparoscopic left lateral sectionectomy in patients with histologically confirmed cirrhosis.

BACKGROUND: Laparoscopic left lateral sectionectomy (LLS) is now considered as a standard practice. However, the safety of laparoscopic LLS in cirrhotic patients is unclear. This is the retrospective study of comparing the outcomes of laparoscopic LLS between cirrhotic and non-cirrhotic patients. METHODS: We reviewed the clinical data for 107 patients who underwent laparoscopic LLS between July 2003 and July 2013. The patients were divided into cirrhotic group (n = 31) and non-cirrhotic group (n = 76) with histologically confirmed F4 or F3 fibrosis. RESULTS: There were no differences between the two groups in terms of the operation time (P = 0.807), blood loss (P = 0.115), transfusion rate (P = 0.716), postoperative complication rate (P = 0.601) and duration of hospital stay (P = 0.261). Open conversion occurred in one non-cirrhotic patient (P = 1.000). The postoperative peak total bilirubin level was higher in cirrhotic patients than in non-cirrhotic patients (P < 0.001). Among patients with hepatocellular carcinoma, the disease-free survival (P = 0.249) and overall survival (P = 0.768) rates were not significantly different between cirrhotic patients (n = 28) and non-cirrhotic patients (n = 12). There were no significant differences in the complication rate (P = 0.085), operation time (P = 0.159), blood loss (P = 0.306), transfusion rate (P = 1.00), and hospital day (P = 0.408) between laparoscopic LLS and cases of open LLS performed in the same study period (n = 10). CONCLUSIONS: Laparoscopic LLS is safe and reproducible, even in cirrhotic patients.

Comparison of laparoscopic liver resection for hepatocellular carcinoma located in the posterosuperior segments or anterolateral segments: A case-matched analysis.

BACKGROUND: Laparoscopic liver resection is an attractive option for treating liver tumors. Laparoscopic liver resection is more difficult for hepatocellular carcinomas located in the posterosuperior segments than for hepatocellular carcinomas in the anterolateral segments. We compared perioperative and long-term outcomes between laparoscopic liver resection for hepatocellular carcinomas located in the posterosuperior and anterolateral segments. METHODS: We retrospectively reviewed the clinical data for 230 patients who underwent laparoscopic liver resection for hepatocellular carcinomas between September 2003 and July 2014. Of these, 116 patients were selected by case-matched analysis using age, sex, tumor number and size, Child-Pugh class, and extent of liver resection. Patients were classified into 2 groups according to tumor location: the anterolateral group (n = 58) and the posterosuperior group (n = 58). RESULTS: Operation time (355 minutes vs 212 minutes, P < .005), intraoperative blood loss (600 mL vs 410 mL, P < .001), and hospital stay (8.5 days vs 7 days, P = .040) were significantly greater in the posterosuperior group than in the anterolateral group. The open conversion (13.8% vs 10.3%, P = .777), postoperative complication (17.2% vs 10.3%, P = .420), 5-year overall survival (88.5% vs 85.7%, P = .370), and 5-year, recurrence-free survival (47.6% vs 40.9%, P = .678) rates were not significantly different between the posterosuperior and anterolateral groups. CONCLUSION: Although laparoscopic liver resection is more difficult for hepatocellular carcinomas located in the posterosuperior segment, there were no differences in the short- and long-term outcomes between the posterosuperior and anterolateral groups. The perceived impact of tumor location on patient outcomes could be overcome by experience and technical improvements.

Defining Surgical Difficulty According to the Perceived Complexity of Liver Resection: Validation of a Complexity Classification in Patients with Hepatocellular Carcinoma.

BACKGROUND: A classification system for defining the complexity of hepatectomy according to its technical difficulty was recently proposed as a consensus of a panel of experts. We validated this classification system for a prospective liver resection cohort in patients with hepatocellular carcinoma (HCC). METHOD: The complexity classification separated liver resections into three categories of complexity (low, medium, or high). We retrospectively reviewed 150 open hepatectomies between 1 March 2004 and 30 November 2013 in patients with HCC, and compared the perioperative outcomes according to the complexity classification. RESULTS: No differences in patient demographics or pathologic findings were observed among the three groups according to the complexity classification, which effectively differentiated the three groups in terms of intraoperative findings and short-term outcomes. The mean estimated blood loss (p = 0.001), rate of blood transfusion (p < 0.001), and mean operation time (p < 0.001) were significantly different among the three groups. The rates of overall and major complications (p = 0.026 and 0.005, respectively) were significantly greater in the high-complexity group. Multivariate analysis showed that the complexity classification was independently associated with major complications (odds ratio 4.73; p = 0.040); however, overall patient survival (p = 0.139) and disease-free survival (p = 0.076) were not significantly different among the three groups. CONCLUSION: The complexity classification effectively differentiated intraoperative and short-term outcomes, and was independently associated with major complications after hepatectomy in patients with HCC.