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Otsuka et al. Indications and technique for LLR in HCC with liver cirrhosis

hepatoduodenal ligament, which develop as a result Robot-assisted technique in LLR has been attempted,
of portal hypertension, should be minimized in the although the population of patients with liver cirrhosis
cirrhotic liver. is quite limited. A recent report suggested that the
[38]
augmented dexterity and greater range of motion provided
Parenchymal transection in cirrhotic liver is more by endowristed instruments are helpful, especially in LLR
hemorrhagic than in non-cirrhotic liver, because of of posterosuperior segments of the liver. [39]
loss of elasticity due to fibrosis and regeneration of
liver tissue, the weakness of the altered intrahepatic Specimen retrieval
vasculature, difficulty in identifying intraparenchymal After liver resection is completed, the removed specimen
structures, coagulative disorders caused by liver should be placed in a plastic bag, to avoid seeding and
dysfunction, portal hypertension, and hypersplenism. implantation of tumor cells in the operative field. Small
Therefore, reduction of blood loss is a key to successful specimens can be retrieved from a trocar wound made
LLR. Although controversial in laparoscopic surgery, at the umbilical site. Larger specimens are retrieved from
temporary or intermittent application of Pringle’s an extended umbilical incision, suprapubic incision, or an
maneuver, use of a vessel tape tourniquet or vessel incision made at an incision site for a previous surgery.
clamp, can help reduce blood loss during liver
parenchymal transection. While performing Pringle’s OPERATIVE OUTCOMES OF LLR FOR HCC
maneuver, surgeons should be careful not to injure WITH LIVER CIRRHOSIS
collaterals around the hepatoduodenal ligament.
Short-term outcomes
Pre-coagulation technique, in which the resection line Liver resection for HCC can be performed in some
is diathermically coagulated using a microwave tissue patients with advanced liver disease. Post-hepatectomy
coagulator or monopolar electrocautery before liver morbidity is reported to be high, and long-term prognosis
parenchymal transection, can help reduce blood loss in is poor in patients with portal hypertension. [40-42] Such
cirrhotic liver. In anatomical hepatectomy, hepatic inflow patients might be better served by liver transplantation
vessels are isolated with tape traction and occluded or ablation. [43] However, some recent studies reported
before liver parenchymal transection, to identify optimal encouraging liver resection outcomes, even in patients
segmental territory before liver transection. In liver with portal hypertension. [21,44,45] Therefore, hepatic
parenchymal transection, laparoscopic coagulating resection may be regarded as the primary treatment
shears are used to divide the superficial layer of the liver. option for patients with mild portal hypertension, if liver
Deeper transection should be performed by meticulously transplantation is not possible.
exposing intraparenchymal structures with an ultrasonic
surgical aspirator or clamp-crushing technique. Vessels Systematic reviews and meta-analyses of
with a diameter of 3-7 mm are divided with vessel-sealing nonrandomized comparative or case-control studies of
devices or clips. Then, vessels with a diameter of 2 mm HCC suggest that LLR results in less blood loss and
or less are diathermically sealed using bipolar sealing shorter postoperative hospital stays [46-49] as compared
devices and then divided. Hemostasis of the resection with open hepatectomy. [50-54] With respect to technical
plane is achieved with monopolar or bipolar cautery. considerations, the reported conversion rate to open
A laparoscopic stapler is used to divide major hepatic surgery for LLR is 0-19.4%. [49,53,54] Hemorrhage during
vessels and for simple transection of liver parenchyma hepatic parenchymal transection is the most frequent
with a thickness of 1-1.5 cm. [36] reason for conversion. [49,53,54] To control hemorrhage
during liver parenchymal transection, it is essential
LLR is usually performed by pure laparoscopic procedure; to select the appropriate surgical devices, including
however, there are options for a minimally invasive diathermy precoagulation of the resection plane before
approach. Hand-assisted and laparoscopy-assisted liver transection. [55]
procedures are also occasionally used in technically
challenging cases. A hand-assisted procedure is suitable A clear benefit of minimally invasive surgery is that it
for resection of tumors located in the posterosuperior minimizes abdominal wall trauma. LLR preserves collateral
regions of the liver, to verify tumor margins in the limited formation in the abdominal wall and thus results in lower
operative field and control bleeding. The laparoscopy- incidences of ascites accumulation and postoperative
assisted procedure divides the liver attachment by liver failure, as compared with open surgery. [18,51,54] Less-
laparoscopy and transects the liver parenchyma through incisional procedures, such as single-port endoscopic
a small upper abdominal incision under direct vision. It surgery, are likely to be less destructive when performed
can be used for major hepatectomy or LLR when dense for carefully selected patients. [56]
adhesion is present in the abdomen. These approaches
[37]
may serve as a bridge to pure laparoscopic procedure. Additionally, repeat hepatectomy for recurrent HCC
244 Hepatoma Research ¦ Volume 2 ¦ September 19, 2016