Single-port laparoscopic hepatectomy: Slovenian single center experience

doi:10.21203/rs.3.rs-1958613/v1

Download PDF

Research Article

Single-port laparoscopic hepatectomy: Slovenian single center experience

https://doi.org/10.21203/rs.3.rs-1958613/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background: Single-port laparoscopic hepatectomy is a minimally invasive modality for the treatment of the benign and malignant liver lesions. Due to the methods technical challenges it is suitable for experienced hepatobilliary surgeons in selected group of patients. The aim of this study was to evaluate the results of a single Slovenian centre performing single-port laparoscopic hepatectomy with literature overview.

Methods: A single centre retrospective consecutive case series of the thirteen patients with liver disease operated with the single-port technique form January 2018 to April 2022 at the Department of the Abdominal Surgery in the University Medical Centre Ljubljana was performed. Lesions were located in the easy to treat segments. The operative time, conversion rate, length of the hospital stay and surgical complications were recorded and evaluated.

Results: We performed thirteen single-port liver hepatectomies (median age 60, range 31 to 79 years). Mean operative time was 98 ± 37 min. None of the cases was converted to multi-port laparoscopic or open surgery. Safe resection margins were obtained in case of malignant disease. The mean hospital stay was 4 days. Post-operative complication involving intervention was 7% (1/13). No life-threatening surgical complication or morbidity were noted.

Conclusions: The single-port laparoscopic hepatectomy is a safe and feasible technique for the operation of benign and malignant liver lesions in hands of skilled and well trained surgeons.

Hepatectomy

minimally invasive hepatobiliary surgery

single-port laparoscopy

Laparoscopic surgical procedures have become routine procedures in almost all fields of abdominal surgery and have, in many cases, replaced traditional open surgical procedures [1]. Due to the complexity of the liver anatomy and technical difficulties during open hepatobiliary surgery, minimally invasive surgery approaches have been adopted slowly and with caution [2, 3]. With the progress of technology, surgical technique and skills, laparoscopic and robotic liver surgery have, in the recent years, become safe and effective modality for the treatment of both benign and malignant liver disease [4]. With the further progression of the minimally invasive surgery, the aim is to minimize the number and size of the abdominal incisions, therefore single-port laparoscopic hepatectomy (SPLH) has been arising as a new surgical method for the treatment of liver disease with the promising results from the published reports [5-22].

The aim of the present study was to evaluate the results of a single centre SPLH experience in Slovenia with the priority to assess the safety, efficiency and benefit of the procedure for the patients with malignant and benign liver disease. An overview of the literature was performed to evaluate our results in comparison to the other published studies.

A single centre retrospective consecutive case series was performed. Approval for the study was obtained from The Medical Ethics Committee of the Republic of Slovenia, the Protocol Review Board (MZ 0120-557/2020/11). Chart review of thirteen patients undergoing SPLH who were operated at the Department of the Abdominal Surgery in the University Medical Centre Ljubljana from January 2018 to April 2022 was conducted. Written informed consent was obtained from all of the included patients. SPLH was performed by one experienced hepatobiliary surgeon. Operation technique was used to treat both benign and malignant disease. Liver lesions were chiefly located in the left lateral section or sixth liver segment (detailed information in Table 1). No major hepatectomy was performed.

The operative time, transfusion rate, conversion rate, ASA physical status score, body mass index (BMI), length of the hospital stay and surgical complications according to the Dindo-Clavien classification were recorded. The clinicopathologic features of the study population and surgical procedures performed are described in Table 1.

Operative technique

Patients were operated under general anaesthesia and placed in the supine position. In all patients Gel POINT advanced access platform (Applied Medical, Rancho Santa Margarita, USA) was used. Platform was applied into the abdomen through four centimetre long midline transumbilical laparotomy (Figure 1). Pneumoperitoneum was established with the insufflation of the carbon dioxide. Intra-abdominal pressure of 12 mmHg was maintained during the procedure. Three troacars were inserted through the platform. In selected cases, placement of the additional working port was required to ensure proper triangulation, safe liver preparation and resection and was later used for drainage placement (Table 1, Figure 2). Laparoscopic intraoperative ultrasound was used in two cases with malignant disease to provide adequate resection margins. Adhesiolysis, mobilisation of the liver and transparenchymal phase of the operation were done with a LigaSure^TMdevice(Medtronic, Minneapolis, MN, USA). Vascular stapler was used for dissection of the larger vessels and bile ducts. TachoSil fibrin sealant patch (Takeda, Linz, Austria) was placed on the liver resection plane. Specimen was retrieved through the midline incision. All specimens were sent to definitive histopathological examination.

We performed thirteen SPLH (median age 60, range 31 to 79 years). Adhesiolysis was performed in four cases. In three cases adhesions were due to the previous intraabdominal procedures (cholecystectomy, gastric sleeve resection and laparoscopic colon resection, respectively) and in one case due to a large echinoccocus cyst. Mean operative time was 98 ± 37 minutes. None of the cases was converted to multiport laparoscopic or open surgery. All the specimens were extracted through the midline laparotomy. No extension of the laparotomy or additional abdominal incision were needed. In malignant disease, R0 resection was performed in all cases (3/3).

According to the ASA physical status classification system all patients were perioperatively classified as ASA 2. No transfusion of red blood cells, fresh frozen plasma or thrombocites were necessary. In this cohort no life-threatening intra-operative, postoperative complications or mortality were recorded. Regarding post-operative complications, a case of a biliary leak from clipped cystic duct was noted, necessitating ERCP with choledochal stenting on postoperative day 2 (Case 12, Table 1).

After the surgery, all included patients were transferred to the surgical ward and early enteral feeding was started. Mean hospital stay was 4 ± 1 days. All patients are still alive and under surveillance.

Over the last few decades, especially with the introduction of laparoscopy, surgery has become progressively less invasive. With the tendency to further minimize the invasiveness of surgical procedures, single port laparoscopic surgery was introduced to the field of abdominal surgery [23]. Although the technique has been safely used for different, less complex abdominal procedures, such as cholecystectomy, appendectomy, inguinal hernia repair and colectomy, the results of single-port laparoscopic surgery in liver disease are still limited [24-28]. The aim of underlying study was to evaluate the results of single Slovenian centre performing SPLH, the method that can, in our opinion, be safely used for the treatment of benign and malignant liver lesions in selected patients.

Some retrospective studies, comparing single-port versus multiport laparoscopic hepatectomy (MPLH), have already been performed [18-20, 22]. The number of the included patients undergoing SPLH was generally small, ranging from just a few patients to 155 patients [18-22]. As the procedure is technically difficult, mainly due to the loss of triangulation and narrow surgical view, it is not suited for every patient with liver disease [18-22]. According to the studies, SPLH can be safely used to perform left lateral sectionectomy and partial hepatectomy in benign and malignant liver disease [17-22]. In the largest published study of Han and associated, SPLH was also performed for major hepatectomies with the resection of more than two segments [18].

In this study SPLH was performed for treating benign and malignant lesions in the left lateral liver segment and sixth liver segment which is in concordance to other studies [17-22]. Compared to other studies, all the operations was performed by one experienced hepatobiliary surgeon. Similar to other authors we also experienced that SPLH is technically more challenging than MPLH, mainly due to the loss of triangulation. Therefore, corresponding to the literature, placement of the additional port was needed in selected cases to provide adequate triangulation for safe surgical procedure [19]. Additional port was needed to effectively performed adhesyolisis in patients with extended adhesions after previous surgeries and moreover for safe preparation in cases of large cystic formations. The site was then used for the drainage placement.

Studies comparing SPLH to MPLH reported significantly shorter operation time in the SPLH group [18-20]. Reported mean operative times were comparable to our results (ranging from 113 minutes to 137 minutes compared to 98 min, respectively) [18-20]. Moreover, comparing SPLH to MPLH, authors also found significantly smaller blood loss, faster enteral feeding and shorter length of stay in the SPLH group [18, 20, 22]. The mean length of hospitalization in our study was comparable to the results of other studies (ranging from 4 to 7 days compared to 4, respectively) [18-21]. Related to the studies where lesions from the left lateral segment and sixth and/or fifth liver segment were removed, no conversion to multiport laparoscopic surgery or open surgery was needed [19, 21, 22]. In comparison, conversion rate in the Han's group was higher (22.6% for SPLH and 19.8% for MPLH, respectively). As laparoscopic approach was favoured for all hepatic resections, including major ones, this is an expected result [18]. The main reasons for conversion in SPLH group were bleeding and technical failure (60% and 14.3%, respectively) [18]. In this study no life-threatening surgical complication were noted, but recorded post-operative complication rate involving intervention was 7% (1/13). In other published studies the complication rate in SPLH was low and was similar to the MPLH group [18, 20].

Majority of the studies concurred that SPLH can be safely applied to treat not only benign but also malignant liver disease [17-22]. Resection margins can be adequately achieved, as were also the result in the underlying study [18, 20]. In the recently published studies, authors analyzed the long-term outcomes in HCC patients undergoing minimally invasive liver surgery. No significant difference in long-term survival and recurrent-free survival between the SPLH and MPLH was noted [20]. In our centre, no HCC patient was yet to be operated with the single-port method, but as the results of SPLH method are promising and outcomes are comparable to MPLH, SPLH may be implemented to treat selected HCC patients in our centre.

The biggest limitation of this study is its retrospective form and small sample size. As the SPLH is a complex and technically difficult procedure and therefore some learning curve is expected, selection of the patients is crucial in the early phase of the learning curve. As a result of that, only small number of patients were suitable for SPLH. With the gain of experience and comparable results to the larger studies, we are confident that in the future SPLH will be offered to more patients will both benign and malignant liver disease. As the literature and our experience suggest, the method can be safely applied for left lateral sectionectomy and partial hepatectomy for fifth and sixth liver segments [18, 20].

The SPLH is a safe and feasible technique for the operation of benign and malignant liver lesions when performed by skilled and well trained surgeons. Although our cohort group is small with specific patient selection, we believe that, compared to conventional open liver surgery and even MPLH, operation times and length of hospitalisation are shorter. Moreover aesthetic outcomes are better, especially compared to open surgery. With the practice and further development of the surgical instruments, this minimally invasive surgical technique has a potential to become even more established.

SPLH: single-port laparoscopic hepatectomy

MPLH: multi-port laparoscopic hepatectomy

ERCP: endoscopic retrograde cholangiopancreatography

BMI: body mass index

ASA: American society of anaesthesiologists

GIST: gastrointestinal stromal tumor

Ethics approval and consent to participate

Approval for the study was obtained from The Medical Ethics Committee of the Republic of Slovenia, the Protocol Review Board (MZ 0120-557/2020/11). All procedures were in accordance with the ethical standards of The Medical Ethics Committee of the Republic of Slovenia and 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consents were obtained from all individual participants included in this study.

Consent for publication

Informed written consent was obtained from the patients for the publication of the clinical details and clinical images.

Availability of data and material

All available data are presented in the case.

Competing interests

The authors declare that they have no competing interests.

Funding

None.

Authors' contributions

JN collected and analysed the data and wrote the manuscript. MD was the lead surgeon and has been involved in the management of the patient. MD and BT critically reviewed the manuscript. All authors read and approved the final manuscript.

Acknowledgements

Not applicable

Antoniou SA, Antoniou GA, Antoniou AI, Granderath FA. Past, present, and future of minimally invasive abdominal surgery. JSLS 205; 19: pii: e201500052
Tzanis D, Shivathirthan N, Laurent A, Abu Hilal M, Soubrane O et al. European experience of laparoscopic major hepatectomy. J Hepatobiliary Pancreat Sci 2013; 20: 120-4
Pearce NW, Di Fabio F, Teng MJ, Syed S, Primrose NJ et al. Laparoscopic right hepatectomy: a challenging but feasible, safe and efficient procedure. Ann J Surg 2011; 202: e52-8
Buell JF, Cherqui D, Geller DA, ORourke N, Iannitti D et al. World consensus conference on laparoscopic surgery. The international position on laparoscopic liver surgery: The Louisville statement, 2008. Ann Surg 2009; 250: 825-30
Romanelli JR, Earle DB. Single-port laparoscopic surgery: an overview. Surgical Endoscopy. 2009;23(7):1419–27.
Aldrighetti L, Guzzetti E, Ferla G. Laparoscopic hepatic left lateral sectionectomy using the LaparoEndoscopic Single Site approach: evolution of minimally invasive liver surgery. J Hepatobiliary Pancreat Sci 2011; 19: 103-5
Patel AG, Belgaumkar AP, James J, Singh UP, Carswell KA et al. Video. Single-incision laparoscopic left lateral segmentectomy of colorectal metastasis. Surg Endosc 2011: 25: 649-50
Gaujoux S, Kingham TP, Jarnagin WR, D’Angelica MI, Allen PJ et al. Single-incision laparoscopic liver resection. Surgical Endoscopy. 2011;25(5):1489–94.
Aikawa M, Miyazawa M, Okamoto K, Toshimitsu Y, Okada k et al. Single-port laparoscopic hepatectomy: technique, safety, and feasibility in a clinial case series. Surg Endosc 2012; 26: 1696-1701
Aldrighetti L, Ratti F, Catena M, Pulitano C, Ferla F et al. Laparoscopic single site (LESS) surgery for left-lateral hepatic sectionectomy as an alternative to laparoscopy: cas-matched analysis from single center. Surg Endosc 2012; 26: 2016-22
Shetty GS, You YK, Choi HJ, Na GH, Hong TH et al. Extending the limitations of liver surgery: outcomes of initial human experience in a high-volume center performing single-port laparoscopic liver resection for hepatocelullar carcinoma. Surg Endossc 2012; 26: 1602-8
Pan M, Jiang Z, Cheng Y, Xu X, Zhang Z et al. Single-Incision Laparoscopic Hepatectomy for Benign and Malignant Hepatopathy: Initial Experience in 8 Chinese Patients. Surgical Innovation. 2012;19(4):446–51
Toyama Y, Yoshida S, Okui N, Kitamura H, Yanagisawa S et al. Transumbilical single-incision laparoscopic hepatectomy using precoagulation and clipless technique in a patient with combined hepatocellular-cholangiocarcinoma: a case report. Surg Laparosc Endosc Percutan Tech 2013; 23: e194-9
Hu M, Zhao G, Wang F, Xu D, Liu R. Single-port and multi-port laparoscopic left lateral liver sectionectomy for treating benign liver disease: a prospective, randomized, controlled study. World J Surg 2014; 38: 2668-73
Wu S, Yu XP, Tian Y, Siwo EA, Li Y et al. Transumbilical single-incision laparoscopic resection of focal hepatic lesions. JSLS 2014; 18: pii:e2014.00397
Daniel A, Claude T, Daren S, Chady S, Alexandre M, Alexis L. Single incision laparoscopic hepatectomy: Advances in laparoscopic liver surgery. Journal of Minimal Access Surgery. 2014;10(1):14.
Karabicak I, Karabulut K, Yuruker S, Kesicioglu T, Ozen N. Single-port laparoscopic liver resection: largest Turkish experience. Indian J Surg 2016: 1-5
Han JH, You YK, Choi HJ, Hong TH, Kim DG. Clinical advantages of single port laparoscopic hepatectomy. World J Gastroenterol 2018; 24(3): 379-86
Struecker B, Haber P, Ollinger R, Bahra M, Pascher A et al. Comparison od single-port versus standard multiport left lateral liver sectionectomy. Surg Innov 2018; 25(2):136-141
Tsai KY, Chen HA, Wang WY, Huang MT. Long-term and short-term surgical outcomes of single-incision laparoscopic hepatectomy on anterolateral liver segments. Surg Endosc 2019: 29: e98-101
Pan Y, Chen J, Chen J, Xu L, Zhou Z et al. Single-port laparoscopic hepatectomy for liver tumor: operative steps (with video). Surg Laparosc Endosc Percutan Tech 2019
Wang JC, Pan Y, Chen J, Hu D, Touheti Y et al. Single versus multi port laparoscopic left lateral sectionectomy for hepatocellular carcinoma: a retrospective comparative study. Int J Surg 2020;77:15-21
Karabicak I, Karabulut K. Single port laparoscopic liver surgery: A minireview. World Journal of Gastrointestinal Endoscopy 2016;8(12):444
Chuang SH, Chen PH, Chang CM, Lin CS. Single-incision vs three-incision laparoscopic cholecystectomy for complicated and uncomplicated acute cholecystitis. World J Gastroenterol 2013; 19: 7743
Omar MA, Redwan AA, Mahmoud AG. Single-incision versus 3-port laparoscopic cholecystectomy in symptomatic gallstones: A prospective randomized study. Surgery. 2017;162(1):96–103
Tan X, Wang G, Tang Y, Bai J, Tao K et al. Minilaparoscopic versus single incision cholecystectomy for the treatment of cholecystolithiasis: a meta-analysis an systematic review. BMC Surg 2017; 17: 91
Antoniou SA, Koch OO, Antoniou GA, Lasithiotakis K, Chalkiadakis GE et al. Meta-analysis of randomized trials on single-incision laparoscopic versus convetional laparoscopic appendectomy. Am J Surg 2014; 207: 613-22
Katsuno G, Fakunaga M, Nagakari K, Yoshikawa S, Azuma D et al. Short-term and long-term outcomes of single-incision versus multi-incision laparoscopic resection for colorectal cancer: a propensity-score-matched analysis of 214 cases. Surg Endosc 2016; 30: 1317-25

Table 1 is available in the Supplementary Files section

No competing interests reported.

Table1.docx

Download PDF

Version 1

posted

You are reading this latest preprint version

Single-port laparoscopic hepatectomy: Slovenian single center experience

Status:

Version 1

Abstract

Figures

Background

Methods

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Table

Additional Declarations

Supplementary Files

Status:

Version 1