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Kilburn et al. Laparoscopic resection of HCC

INTRODUCTION in the abdominal wall, hilum and retroperitoneum, and
a stiffened liver that resists laparoscopic handling.
Hepatocellular carcinoma (HCC) is the fifth most However, laparoscopic resection of HCC in both non-
common cause of cancer and the third most common cirrhotic and cirrhotic patients can provide good clinical
cause of cancer-related death worldwide. Furthermore, outcomes, act as bridge-to-transplant and deliver
it is the leading cause of death for patients with acceptable survival rates. [19]
cirrhosis. [1,2] In North America and Europe, the incidence
of HCC has been rising, likely due to changing risk The worldwide experience in laparoscopic liver resection
factors for cirrhosis, including hepatitis C infection in for HCC is increasing, although major resections are
baby-boomers, alcohol use, obesity, and non-alcoholic still limited to few centers. The current study describes
fatty liver disease. [3,4] At presentation, only 10-15% of our experience in Brisbane, Australia, with focus on
patients are candidates for surgical resection. Other perioperative outcomes.
treatment options include liver transplantation, ablation,
transcatheter artrial chemoembolisation, and systemic METHODS
chemotherapy. Liver resection, more commonly
reported as an open procedure, is a well-established, Data acquired from a prospectively collected
potentially curative treatment for patients with HCC, laparoscopic liver surgery database from multiple
and is the procedure of choice in many patients with centers in Brisbane, Australia, were examined and
preserved liver function. [5,6] retrospectively reviewed. Ethics approval was obtained
prior to the commencement of the study. Consecutive
Minimally invasive management of HCC is increasing patients who underwent laparoscopic resection
in frequency, including patients with underlying of HCC between January, 1999 and September,
cirrhosis. [2,7-11] There may be a number of benefits of 2015 were selected. All patients underwent high
laparoscopy over laparotomy for HCC, which have been quality preoperative imaging with contrast-enhanced
widely reported. Potential benefits include decreased computer tomography and magnetic resonance
blood loss and need for blood transfusion, decreased imaging. Selection for laparoscopic resection took into
complications (i.e. less postoperative ascites, wound consideration tumor size and location, the degree of
infection), decreased length of stay, and reduced underlying liver disease and portal hypertension, and
technical difficulty with subsequent surgery, including the patient’s fitness and ability to tolerate a prolonged
transplantation. [2,9,10,12,13] Oncological principles can pneumoperitoneum. Patients with Child-Pugh B and
be maintained with laparoscopy and outcomes are C cirrhosis were generally excluded. All patients were
comparable, if not better, with laparoscopy compared discussed and management was agreed upon at a
to open HCC resection. [13-17] The benefits may derive multi-disciplinary team meeting.
from the pathophysiological changes that occur with
laparoscopy compared to laparotomy, which may Collected intraoperative data included details of the
be accentuated in the presence of cirrhosis. These surgical procedure (minor vs. major; anatomic vs. non-
include less disruption of the abdominal wall, reduced anatomic), operation duration, blood loss and conversion
immune response, and the tamponade effect of to laparotomy. A wide range of clinicopathological
pneumoperitoneum. factors were collected regarding underlying liver disease
(METAVIR score), etiology, number and size of tumors,
Laparoscopic resection of HCC is technically lymphatic or vascular invasion, tumor differentiation,
challenging. It requires both laparoscopic skills and presence of satellite nodules, and pathological margins.
advanced liver surgical skills. The limited viewing A microscopic margin of ≥ 1 mm was defined as R0.
angles, fulcrum effect of laparoscopic ports, instrument
clash, reduced tactile feedback, and reduced operating Surgical technique had been described previously. [20,21]
dexterity pose significant challenges in complex surgery. In brief, pneumoperitoneum was established via an open
Liver exploration and mobilization, hemorrhage control access technique and maintained at 12-15 mmHg. Four
during parenchymal transection, the use of laparoscopic to 6 working ports were used. The Pringle maneuver
ultrasound, ensuring adequate oncological margins, was used selectively. In selected patients with dome
and suturing can be more difficult with laparoscopy, lesions, additional intercostal and transthoracic trocars
especially in the presence of cirrhosis. The operative were used. For major hepatectomies, inflow vascular
[18]
time is generally longer than open surgery. Skilled structures were controlled with clips or vascular staplers
assistance is essential, and for long cases surgeon and the hepatic veins were controlled extrahepatically.
and assistant fatigue is common. The cirrhotic poses Parenchymal transection was performed using
additional complexity with potentially altered vasculature LigaSure (Covidien, Mansfield, MA, USA), harmonic
Hepatoma Research ¦ Volume 2 ¦ September 30, 2016 265