Abordaje laparoscópico por incisión única del hígado izquierdo: experiencia inicial / Single-port laparoscopic approach of the left liver: Initial experience

INTRODUCCIÓN: Los avances tecnológicos han permitido el desarrollo de la cirugía laparoscópica por incisión única, iniciada con la colecistectomía y usada, posteriormente, para abordar otras enfermedades abdominales. Sin embargo, la cirugía hepática laparoscópica por puerto único es excepcional. Se presenta la experiencia inicial en cirugía hepática por incisión única. MATERIAL Y MÉTODO: Entre mayo de 2012 y diciembre de 2013 se intervino a 5 pacientes mediante abordaje laparoscópico por incisión única. La indicación quirúrgica fue por enfermedad benigna en un caso y maligna en 4. Para la colocación del dispositivo de puerto único se practicó una incisión supraumbilical derecha de 3-5 cm. En todos los casos las lesiones estaban situadas en los segmentos II o III hepáticos. Se realizaron 4 seccionectomías laterales izquierdas y una hepatectomía izquierda. RESULTADOS: El tiempo operatorio fue de 135 min. No hubo casos de conversión a cirugía laparoscópica convencional ni a cirugía abierta. La dieta oral se inició a las 18 h. No hubo complicaciones postoperatorias ni necesidad de transfusión sanguínea. La estancia hospitalaria mediana fue de 3 días. El grado de satisfacción fue muy bueno en 4 casos y bueno en uno y los pacientes retornaron a las actividades de la vida diaria a los 8 días. DISCUSIÓN: La cirugía hepática laparoscópica por incisión única es segura y factible en casos seleccionados y podría aportar menor agresión quirúrgica y mejores resultados estéticos. Se requieren estudios comparativos para determinar las ventajas reales de este abordaje

INTRODUCTION: New technological advances have enabled the development of single-port laparoscopic surgery. This approach began with cholecystectomy and subsequently with other abdominal surgeries. However, few publications on laparoscopic liver surgery have described the use of complete single-port access. We present our initial experience of a single-port laparoscopic hepatectomy. MATERIAL AND METHODS: Between May 2012 and December 2013, 5 single-port laparoscopic hepatectomies were performed: one for benign disease and four for colorectal liver metastases. The lesions were approached through a 3-5 cm right supraumbilical incision using a single-port access device. All the lesions were located in hepatic segments II or III. Four left lateral sectorectomies and one left hepatectomy were performed. RESULTS: Median operative time was 135 min. No cases were converted to conventional laparoscopic or open surgery. The oral intake began at 18 h. There were no postoperative complications and no patients required blood transfusion. The median hospital stay was 3 days. The degree of satisfaction was very good in 4 cases and good in one. Patients resumed their normal daily activities at 8 days. DISCUSSION: Single-port laparoscopic hepatectomy is safe and feasible in selected cases and may reduce surgical aggression and offer better cosmetic results. Comparative studies are needed to determine the real advantages of this approach

Single-port laparoscopic approach of the left liver: initial experience.

INTRODUCTION: New technological advances have enabled the development of single-port laparoscopic surgery. This approach began with cholecystectomy and subsequently with other abdominal surgeries. However, few publications on laparoscopic liver surgery have described the use of complete single-port access. We present our initial experience of a single-port laparoscopic hepatectomy. MATERIAL AND METHODS: Between May 2012 and December 2013, 5 single-port laparoscopic hepatectomies were performed: one for benign disease and four for colorectal liver metastases. The lesions were approached through a 3-5 cm right supraumbilical incision using a single-port access device. All the lesions were located in hepatic segments II or III. Four left lateral sectorectomies and one left hepatectomy were performed. RESULTS: Median operative time was 135 min. No cases were converted to conventional laparoscopic or open surgery. The oral intake began at 18 h. There were no postoperative complications and no patients required blood transfusion. The median hospital stay was 3 days. The degree of satisfaction was very good in 4 cases and good in one. Patients resumed their normal daily activities at 8 days. DISCUSSION: Single-port laparoscopic hepatectomy is safe and feasible in selected cases and may reduce surgical aggression and offer better cosmetic results. Comparative studies are needed to determine the real advantages of this approach.

Resultados tras resección hepática laparoscópica: una opción adecuada en patología maligna / Results after laparoscopic liver resection: An appropriate option in malignant disease

Introducción El abordaje laparoscópico no ha tenido una gran difusión en la cirugía hepática, aunque ha demostrado ser seguro y factible en pacientes seleccionados incluso en enfermedad maligna. Se presenta la experiencia y resultados en el tratamiento de la enfermedad hepática maligna por laparoscopia. Material y método Entre febrero de 2002 y mayo de 2011 se realizaron 71 resecciones hepáticas laparoscópicas, 43 por enfermedad maligna (solo se incluyó a pacientes con más de un año de seguimiento). La edad media fue de 63 años y el 58% fueron varones. El 49% de las lesiones estaban situadas en los segmentos ii - iii . Se realizaron 30 segmentectomías, 7 resecciones limitadas y 6 hepatectomías mayores. Resultados El tiempo operatorio fue de 163 min. Hubo 3 conversiones. Cinco casos (11%) fueron transfundidos. La ingesta se inició a las 32 h y la estancia hospitalaria fue de 6,7 días. No hubo reintervenciones y sí un caso de mortalidad. Nueve pacientes (21%) presentaron complicaciones. El número medio de lesiones resecadas fue 1,2, con un tamaño de 3,5 cm. Todas las resecciones fueron R0. La supervivencia fue del 69 y del 43,5% a los 36 y 60 meses en metástasis hepáticas de cáncer colorrectal (MHCCR), y del 89 y 68% a los 36 y 60 meses en hepatocarcinoma (HCC).Conclusiones La resección hepática por laparoscopia en enfermedad maligna es factible y segura. Debe cumplir los mismos preceptos oncológicos que la cirugía abierta. En pacientes seleccionados ofrece resultados oncológicos a largo plazo similares a los obtenidos en cirugía abierta (AU)

Introduction Treatment of oesophageal cancer with curative intent requires a multidisciplinary approach. Neoadjuvant therapy, the radicality of resection and extension of lymphadenectomy have been associated with increased operative morbidity and mortality. The aim of this study was to assess the results of surgical treatment of oesophageal cancer since the presence of an interdisciplinary esophagogastric tumour board. Methods Patients with cancer of the oesophagus and oesophagogastric junction who underwent oesophagectomy between January 2005 and March 2012 were included in this retrospective study. Data concerning type of resection, postoperative complications, mortality and survival were analysed. Results Of the 392 patients with a diagnosis of oesophageal cancer over the study period, 100 underwent oesophagectomy. Seventy-four patients received neoadjuvant treatment. Eighty-two patients underwent transthoracic resection while a transhiatal was used in 10 patients. Colon interposition was required in 8 cases. An R0 resection was achieved in 98 patients. Anastomotic leaks developed in 15 patients, 9 were intrathoracic and 6 were cervical. Postoperative morbidity occurred in 42% of patients, and intra-hospital and 90-day mortality was 2%. Median length of hospital stay was 16 days. The respective actuarial survival at 1 and 5 years were 82% and 56%.ConclusionsSurgical treatment with curative intention for oesophageal cancer is only possible in a quarter of patients diagnosed. The high morbidity rate was mainly due to intrathoracic complications (AU)

[Results after laparoscopic liver resection: an appropriate option in malignant disease]. / Resultados tras resección hepática laparoscópica: una opción adecuada en patología maligna.

INTRODUCTION: The laparoscopic approach is not yet widely used in liver surgery, but has proven to be safe and feasible in selected patients even in malignant disease. The experience and results of a hepato-pancreato-biliary (HPB) surgery unit in the treatment of malignant liver disease by laparoscopic approach is presented. MATERIAL AND METHODS: Between February 2002 and May 2011, 71 laparoscopic liver resections were performed, 43 for malignant disease (only patients with more than one year of follow-up were included). Mean age was 63 years old and 58% of the patients were male. Forty-nine per cent of the lesions were located in segments ii-iii. Thirty segmentectomies were performed, 7 limited resections and 6 major hepatectomies. RESULTS: The median operative time was 163 min. There were 3 conversions. Five cases (11%) required blood transfusion. The oral intake began at 32 h and the median hospital stay was 6.7 days. There were no reoperations and there was one case of mortality. Nine patients (21%) had postoperative complications. The mean number of resected lesions was 1.2, with an average size of 3.5 cm. All resections were R0. The median survival after resection of colorectal liver metastases (CLM) was 69% and 43.5% at 36 and 60 months, respectively, and 89% and 68% at 36 and 60 months, respectively, in hepatocellular carcinoma (HCC). CONCLUSION: The laparoscopic liver resection in malignant disease is feasible and safe in selected patients. The same oncological rules as for open surgery should be followed. In selected patients it offers similar long-term oncological results as open surgery.

Estudio prospectivo aleatorizado comparativo entre colecistectomía laparoscópica versus colecistectomía por puerto único en régimen ambulatorio / A randomised prospective comparative study between laparoscopic cholecystectomy and single port cholecystectomy in a major outpatient surgery unit

Introducción: El objetivo de este estudio es comparar la colecistectomía laparoscópica (CL) con la realizada a través de una incisión única umbilical (SILC) en régimen de cirugía mayor ambulatoria (CMA).Material y métodos De octubre 2009 a junio 2011 se aleatorizaron prospectivamente 50 pacientes con colelitiasis sintomática; a 26 se les realizó SILC y a 24 CL en CMA. Se analizó el dolor postoperatorio, requerimientos de analgesia, presencia de náuseas y/o vómitos, tiempo operatorio, complicaciones, tasa de éxito de ambulatorización y resultados estéticos. Resultados No hubo diferencias en cuanto al dolor postoperatorio, la analgesia de rescate, náuseas y/o vómitos y tiempo operatorio (SILC 54 ± 21 min, CL 48,5 ± 17 min, p = 0,29). Hubo un caso de morbilidad en el grupo SILC que requirió reintervención. Se completó el procedimiento ambulatoriamente en el 77% de pacientes del grupo SILC y en el 83% del grupo CL. Seis pacientes del grupo SILC (23%) y 4 del grupo CL (17%) permanecieron ingresados más de 24 h (p = 0,58). Los resultados estéticos fueron valorados subjetivamente como muy bueno en el grupo SILC y bueno en el grupo CL. Conclusión La colecistectomía SILC es factible y segura comparándola con colecistectomía laparoscópica en pacientes seleccionados y obtiene resultados similares al aplicarla en CMA. Se requieren estudios más amplios para determinar los beneficios reales de este abordaje antes de recomendarlo como técnica rutinaria. Con mayor experiencia de los equipos quirúrgicos y mayor concienciación de los pacientes posiblemente aumente el número de candidatos a colecistectomía ambulatoria (AU)

Introduction: The aim of this study is to compare laparoscopic cholecystectomy (LC) with that performed using single umbilical incision laparoscopic surgery (SILS) in a major outpatient surgery (MOS) unit. Material and methods: A total of 50 patients with symptomatic cholelithiasis were prospectively randomised between October 2009 and June 2011, with 26 of them subjected to SILS, and 24 to CL. The variables analysed were, postoperative pain, analgesia requirements, presence of nausea/vomiting, operation time, complications, outpatient success rate, and aesthetic results. Results: There were no differences as regards postoperative pain, analgesia rescue, nausea/vomiting, or operation time (SILS 54 21 min, CL 48.5 17 min, P = .29). There was one case of morbidity in the SILS group which required further surgery. The outpatient surgical procedure was completed in 77% of patients of the SILS group, and in 83% of the CL group. Six patients (23%) from the SILS group, and 4 (17%) from the CL group remained in the unit for more than 24 h (P = .58). The aesthetic results were subjectively assessed as ‘‘very good’’ in the SILS group, and ‘‘good’’ in the CL group. Conclusion: SILS cholecystectomy is feasible and safe when comparing it with laparoscopiccholecystectomy in selected patients, and obtains similar results when performed in a MOS unit. Larger studies are needed to determine the real benefits of this approach beforere commending it as a routine technique. With more experienced surgical teams and greater awareness of the patients could possibly increase the number of candidates for outpatient cholecystectomy (AU)

[A randomised prospective comparative study between laparoscopic cholecystectomy and single port cholecystectomy in a major outpatient surgery unit]. / Estudio prospectivo aleatorizado comparativo entre colecistectomía laparoscópica versus colecistectomía por puerto único en régimen ambulatorio.

INTRODUCTION: The aim of this study is to compare laparoscopic cholecystectomy (LC) with that performed using single umbilical incision laparoscopic surgery (SILS) in a major outpatient surgery (MOS) unit. MATERIAL AND METHODS: A total of 50 patients with symptomatic cholelithiasis were prospectively randomised between October 2009 and June 2011, with 26 of them subjected to SILS, and 24 to CL. The variables analysed were, postoperative pain, analgesia requirements, presence of nausea/vomiting, operation time, complications, outpatient success rate, and aesthetic results. RESULTS: There were no differences as regards postoperative pain, analgesia rescue, nausea/vomiting, or operation time (SILS 54 ± 21 min, CL 48.5 ± 17 min, P=.29). There was one case of morbidity in the SILS group which required further surgery. The outpatient surgical procedure was completed in 77% of patients of the SILS group, and in 83% of the CL group. Six patients (23%) from the SILS group, and 4 (17%) from the CL group remained in the unit for more than 24h (P=.58). The aesthetic results were subjectively assessed as "very good" in the SILS group, and "good" in the CL group. CONCLUSION: SILS cholecystectomy is feasible and safe when comparing it with laparoscopic cholecystectomy in selected patients, and obtains similar results when performed in a MOS unit. Larger studies are needed to determine the real benefits of this approach before recommending it as a routine technique. With more experienced surgical teams and greater awareness of the patients could possibly increase the number of candidates for outpatient cholecystectomy.

Seccionectomía lateral izquierda por laparoscopia. Presentación de nuestra técnica / Laparoscopic Left Lateral Sectionectomy. Presentation of Our Technique

Introducción En cirugía hepática, la laparoscopia no ha conseguido la difusión obtenida en otras áreas debido a la complejidad de este tipo de cirugía y a la falta de equipos quirúrgicos con experiencia en ambos campos. Material y métodos El objetivo de este trabajo es presentar la técnica utilizada en nuestro centro para realizar la seccionectomía lateral izquierda por laparoscopia (SLI). Entre febrero de 2000 y julio de 2010, 70 pacientes han sido intervenidos por laparoscopia por patología hepática, tanto benigna como maligna. En veintiún casos se realizó una SLI según la técnica descrita. Se describe la técnica quirúrgica, destacando aspectos como la disposición de los trocares, la movilización del hígado o la transección hepática. Se analiza la morbimortalidad relacionada con el procedimiento. Resultados Se ha realizado la SLI en 12 mujeres y 9 hombres con edades comprendidas entre los 35 y los 89 años. El número de lesiones fue de 1,4 (entre 1 y 4), con un tamaño de 3,5cm. El tiempo operatorio fue de 142min (entre 90 y 210). Hubo una conversión a laparotomía. Se registraron complicaciones en 3 pacientes (14%). No hubo reintervenciones y un paciente requirió una transfusión. La estancia media hospitalaria fue de 4,3 días. Conclusiones Las mejoras técnicas y la mayor experiencia en laparoscopia han permitido plantear la realización de este procedimiento con una morbilidad inferior al 15% y una mortalidad nula. La SLI es una técnica segura y efectiva en pacientes seleccionados. La descripción detallada de este procedimiento puede estimular a otros grupos de cirugía hepática a realizar este abordaje (AU)

Introduction Laparoscopy has not been as widely used in hepatic surgery as in other areas due to the complexity of this type of surgery and the lack of surgical teams with experience in both fields. Material and methods The aim of this work is to present the technique used in our centre to perform left lateral sectionectomy (LLS) using laparoscopy. A total of 70 patients have been operated on using laparoscopy due to both benign and malignant liver between February 2000 and July 2010. An LLS was performed on twenty-one cases using the technique described. The surgical technique is described, highlighting aspects such as, the arrangement of the trocars, the mobilisation of the liver or hepatic transection. The morbidity and mortality associated with the procedure are analysed. Results LLS was performed on 12 women and nine men, with ages between 35 and 89 years. The mean number of lesions was 1.4 (between 1 and 4), with a mean size of 3.5cm. The mean surgical time was 142min (between 90 and 210). There was one conversion to laparotomy. Complications were recorded in 3 (14%) patients. There were no repeat surgery, and one patient required a transfusion. The mean hospital stay was 4.3 days. Conclusions The best techniques and the wide experience in laparoscopy have enabled this technique to become established, with a morbidity of less than 15% and zero mortality. LLS is a safe and effective technique in selected patients. The detailed description of this procedure may stimulate other surgery groups to perform this approach (AU)

[Laparoscopic left lateral sectionectomy. Presentation of our technique]. / Seccionectomía lateral izquierda por laparoscopia. Presentación de nuestra técnica.

INTRODUCTION: Laparoscopy has not been as widely used in hepatic surgery as in other areas due to the complexity of this type of surgery and the lack of surgical teams with experience in both fields. MATERIAL AND METHODS: The aim of this work is to present the technique used in our centre to perform left lateral sectionectomy (LLS) using laparoscopy. A total of 70 patients have been operated on using laparoscopy due to both benign and malignant liver between February 2000 and July 2010. An LLS was performed on twenty-one cases using the technique described. The surgical technique is described, highlighting aspects such as, the arrangement of the trocars, the mobilisation of the liver or hepatic transection. The morbidity and mortality associated with the procedure is analysed. RESULTS: LLS was performed on 12 women and nine men, with ages between 35 and 89 years. The mean number of lesions was 1.4 (between 1 and 4), with a mean size of 3.5 cm. The mean surgical time was 142 minutes (between 90 and 210). There was one conversion to laparotomy. Complications were recorded in 3 (14%) patients. There were no repeat surgery, and one patient required a transfusion. The mean hospital stay was 4.3 days. CONCLUSIONS: The best techniques and the wide experience in laparoscopy has enabled this technique to become established, with a morbidity of less than 15% and zero mortality. LLS is a safe and effective technique in selected patients. The detailed description of this procedure may stimulate other surgery groups to perform this approach.

Laparoscopia y cirugía hepática: técnica e indicaciones / Laparoscopic liver surgery: technique and indications

Introducción. La cirugía laparoscópica de los órganos sólidos ha ido ganando aceptación durante los últimos años. Sin embargo, la utilización del abordaje laparoscópico en las resecciones hepáticas ha sido muy limitado. En este artículo presentamos nuestra experiencia en la cirugía hepática laparoscópica, y establecemos sus indicaciones y las limitaciones técnicas que ésta conlleva. Pacientes y método. Estudio prospectivo y descriptivo de 14 pacientes con lesiones hepáticas quísticas y sólidas tratadas por vía laparoscópica desde febrero de 2000 a marzo de 2003. La mayoría de las lesiones se localizaban en los segmentos hepáticos izquierdos o periféricos derechos (segmentos II-VI). La técnica quirúrgica incluyó neumoperitoneo con CO2, resección hepática con bisturí armónico con o sin control vascular de la tríada portal. Las piezas de resección se extrajeron de la cavidad abdominal mediante una bolsa a través de una incisión accesoria. Resultados. Ocho pacientes presentaban lesiones quísticas y 6 lesiones sólidas (un hepatocarcinoma, una metástasis hepática de neoplasia de pulmón, una metástasis hepática de melanoma maligno, un adenoma y 2 lesiones de etiología desconocida tras el estudio diagnóstico). El tiempo quirúrgico medio fue de 149 min, el índice de conversión del 14,3 por ciento (2 pacientes), la estancia hospitalaria de 4 días; sólo se observaron complicaciones postoperatorias en un paciente con cefalea y fiebre, y en otro que presentó náuseas en el postoperatorio inmediato. La mortalidad de la serie fue del 0 por ciento. Conclusiones. La resección hepática laparoscópica es factible y segura en casos seleccionados; sin embargo, las indicaciones quirúrgicas no deben modificarse por la introducción de esta técnica. Las lesiones más favorables son las benignas o nódulos de pequeño tamaño localizados en los segmentos II, III, IVb,V y VI (AU)