Page 28 - Read Online

Kumar et al. Mini-invasive Surg 2018;2:41 I http://dx.doi.org/10.20517/2574-1225.2018.49 Page 5 of 12

suggested continuing thromboprophylaxis for 4 weeks post-operatively, especially in patients bearing liver
[40]
malignancies . The combination of pharmacologic and mechanical prophylaxis, such as compressive
stocking and intermittent pneumatic compression, may further reduce the risk in the high-risk group of
[41]
patients . In summary, routine prophylaxis with LMWH or unfragmented heparin should be initiated
2-12 h before surgery in major hepatectomies, restarted 8-12 h after surgery if there are no signs of bleed-
[5]
ing, and discontinued once the patient is discharged . Given the absence of high-level evidence, extended
thromboprophylaxis (28 days) should be considered only in selected patients with high-risk scores.

Minimally invasive approach
Even though none of the four incisions used for open liver surgery (median, Chevron, Mercedes-benz and
Makuuchi) has shown to offer any advantages over the others and perioperative complications remain
comparable, mini-invasive approaches have consistently demonstrated a substantial benefit with regards
to patient recovery over the open approach. The central concept of surgical stress response attenuation
orbits around the minimally invasive approach. Laparoscopic liver resection (LLR) was introduced in the
early 1990’s [42-44] . Over the years, the many advantages of LLR have became widely accepted, with reduced
intraoperative bleeding, shorter LOS, less pain, lower infection rates, earlier recovery and better quality of
life (QOL) [45-51] . In addition, emerging data has now confirmed the safety and oncologic equivalence of the
[55]
laparoscopic approach for both malignant liver lesions [48,52-54] . A recent meta-analysis by Liu et al. found
that laparoscopic left lateral sectionectomy had significantly better results regarding blood transfusion,
blood loss, total morbidity and LOS compared to the open approach. In fact, while major LLRs are still
under development, minor LLRs including left lateral sectionectomy have become standard practice nowa-
[56]
days [47,48,55] . With regards to ERAS protocols in LLR, Stoot et al. reported from retrospective data a reduc-
tion in LOS from 7 days to 5 days when laparoscopy and ERAS program were combined. More recently,
[57]
a propensity score-based analysis between the open and laparoscopic approaches from Ratti et al. has
found that the combination of a minimally invasive approach with a fast-track protocol allows a reduced
rate of postoperative morbidity and satisfactory functional recovery, even in the setting of complex liver
resections. Although laparoscopic surgery offers an additional advantage to ERAS protocols during post-
operative recovery, adequate patient selection and surgeon expertise are key determinants of success [47,48] .
Patients with lesions located in peripheral liver segments (Segments 2 to 6) that require minor resections
(≤ segments) are considered the best candidates for this approach [47,48] . So far there are no studies assessing
robotic liver surgery within ERAS frameworks.

Prophylactic nasogastric intubation
[58]
Pathogenesis of postoperative ileus as demonstrated by Wangensteen arose from excess of swallowed
air, which can be relieved by NGT insertion. However, a NGT has been consistently associated with higher
[59]
pulmonary complications and this may be due to several reasons . First, it may be due to the incomplete
closure of the glottis during cough hence leading to the accumulation of secretions, with increased risk of
atelectasis and infection. Secondly, it acts as a conduit for transfer of bacteria from the oropharynx to the
lungs. Thirdly, NGT also may cause diaphragmatic dysfunction through reflex mechanisms [60,61] . Time to
passage of flatus and return to oral intake are delayed due to NGT, and around 70% of patients experience
marked discomfort limiting mobility with increased nursing care [62-64] . Furthermore, NGT is also associ-
ated with laryngeal injury, esophagitis, pharyngitis, otitis, electrolyte losses, aerophagia and rhinosinus-
itis [65-67] . A Cochrane review concluded that routine prophylactic use of NGT in general abdominal surgery
can increase pulmonary complications and delay bowel function, therefore recommending its selective
[68]
use . With regards specifically to NGT use after liver resections, two recent RCTs have confirmed the
increased risk of complications and the absence of any advantages after elective liver surgery [59,69] . In sum-
mary, even though NGT decompression may be necessary during surgery, immediate on-table removal
after surgery is strongly recommended as it has been proven to be safe and associated with better outcomes
[5]
and an improved peri-operative experience for the patient .