Laparoscopic Liver Resection: An Ongoing Revolution

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Laparoscopic liver resection (LLR) represents a major change in surgical practice requiring a whole new training process for the established liver surgeon.1 In the absence of available randomized controlled trials (RCT), it is felt by many that there is insufficient evidence to justify such a change with additional perceived hazards and undemonstrated benefits. This is in contrast with colon cancer surgery where the laparoscopic approach has proven to be noninferior in at least 1 large RCT2 and has since become standard of care. Differences between colon and liver resection include that liver resection is less frequently performed (approximately 10 times less) and it addresses various diseases, including primary and secondary liver cancer, and a wide variety of procedures including minor and major, simple and complex, anatomical and nonanatomical hepatectomies in various areas of the liver. Lack of standardization of LLR is another limiting factor.3,4 All these reasons make it difficult to accrue sufficient numbers of homogeneous patients for an adequately powered RCT in a reasonable time frame. Despite those difficulties, 2 RCTs are currently underway, a single-center one on limited resection for colorectal liver metastases (Oslo-CoMet Study NCT01516710) and a multicenter one for major resections (ie, right and left hepatectomy) for various indications (Orange II+ Study NCT01441856). The former has finished recruiting but has not yet been published or fully presented, whereas the latter is still recruiting. In the meantime, available evidence lies on retrospective comparative and noncomparative studies. A jury-based consensus conference was held in Japan in 2014.5 The jury acknowledged that minor LLRs have a sufficient safety and benefit record to achieve “standard practice” level, whereas major resections were still at an investigational stage.
In the current issue of Annals of Surgery, Yoon et al6 report the largest series to date of pure laparoscopic right hepatectomy (LRH) that is compared with a control group of open right hepatectomy (ORH) operated on during the same period, all being performed for hepatocellular carcinoma (HCC). The reason for allocation to LRH or ORH was patient preference. Propensity 1:1 score matching was applied allowing for the comparison of 2 groups of 33 patients. On a technical point of view, Yoon et al have used a technique similar to the recently published one by Soubrane et al4 aiming at standardizing right hepatectomy. This included extrahepatic inflow division by individual right portal vein and artery dissection or Glisonnean en bloc dissection, followed by transection without previous mobilization, hepatic vein division, and completion specimen mobilization. Of note, the Pringle maneuver was used in >90% of the patients in each group.
The merit of this study lies in the fact that it addresses 1 procedure, right hepatectomy, performed for 1 disease, HCC in patients with cirrhosis. On a methodological point of view, the study sample is reasonably sized and its design with 1 primary endpoint, being morbidity, and 2 secondary end-points, operative details and oncologic outcomes, is appropriate. In addition, the authors have used the recently proposed Comprehensive Complication Index (CCI) that considers all complications and has been shown to be a more sensitive end-point than graded morbidity.7,8 The authors found that LRH was associated with a complication rate comparable to that of ORH, but a lower CCI, accounting for less severe overall morbidity. LRH was also associated with identical blood loss, longer operative times, reduced pain, and shorter hospital stay. Long-term outcomes were similar in both groups with identical 2-year overall and disease-free survival rates.

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