Our data are in line with previous publications showing that laparoscopic liver resections (LLR) results in shorter operation times, reduced intraoperative blood loss, less wound infections, faster recovery, and hence shorter hospital stay (18). Moreover, it demonstrates that the implementation and adaption of laparoscopic liver surgery does not adversely impact morbidity and mortality in a surgical high-volume liver center.
Biliary leakage remains a serious complication after liver resection with an incidence of up to 12% in previous studies (29). Intraperitoneal septic complications resulting from biliary leakages may lead to secondary organ failure and even death (30) (31). Leakages can derive from previously ligated bile ducts at the resection surface of the liver, either based on a separated biliary system or based on an elevated intrabiliary pressure due to downstream stenosis of the biliary system or papillary dysfunction. Risk factors include prolonged operation time, age, preoperative chemotherapy and special types of liver resections such as left hemi-hepatectomy (33). Moreover, leakage from a bilioenteric anastomosis if performed, is another source of BL (32). In our study bile leaks were detected after three major and three minor open liver resections (P = 0.399). An increased incidence for biliary leakages after left hemi-hepatectomies has been recently highlighted in a meta-analysis on laparoscopic liver resections (9). Fortunately, we did not detect any biliary leakages in our series of LLR which included four laparoscopic left hemi-hepatectomies.
The introduction of a minimally invasive liver resection program at our department did not increase the BL-rate, despite modifications in the technique of parenchymal transection. With 4.3%, the rate of type B or C bile leakages is low in our center and comparable with other studies (35). Prevention of bile leaks may include several measures as: (1) omitting of abdominal drains, (2) meticulous anatomy orientated liver surgery, (3) pre- or intraoperative recognition of variants of the biliary system, (4) application of bile leak tests and (5) eventually biliary decompression e.g., by means of T-tubes in case of complex liver surgery. However, the latter is not supported by enough evidence, so far. All these measures were considered in the present series. The lower rate of bile leaks in patients without abdominal drains has been confirmed in other analysis with an OR of 2.04 (36) to 5.6 (37). During the study period the use of abdominal drains was successively reduced, leading to about 55% of patients without abdominal drains. The ‘white test’ was also adopted liberally in OLR, since it could be shown in a meta-analysis, that its use leads to a significant reduction of postoperative BL (OR 0.3; P = 0.002) (15), however it was not used in LLR. Other measures, which did not prove effective in the prevention of BL like routine application of fibrin sealant was not used at all in the present series. However, surveys e.g. from the Netherlands have shown that more than around 25% of surgeons use fibrin sealants on a frequent/routine basis (38), among others to reduce resection surface-related complications like BL. However, the use of fibrin sealants disproved to reduce the incidence of BL in a meta-analysis (39). However, insertion of a T-tube was afflicted with a (slightly) higher incidence of BL in the present series. Since a T-tube was used mainly in complex cases or in case of long central exposure of the bile duct, this phenomenon is supposed to be based on a consecutive selection of a high risk population for BL based on our previous experience (7) rather than an increased rate of bile leaks caused by T-tube insertion itself. However, this hypothesis cannot be finally proven, but no patient developed BL caused by the T-tube itself, e.g., at the site of insertion into the common bile duct.
However, the incidence of BL in our series is comparable with other analyses, e.g., of the National Clinical Database (NCD) of Japan including 14,970 patients with a revealed a BL-rate of 8.0% (40). In this analysis gallbladder cancer and extrahepatic bile duct carcinoma were also unraveled as risk factors for BL, moreover peripheral vascular disease and open wounds were pointed out as further risk factors.
Postoperative biliary leakages were predominantly detected in patients with Cholangiocarcinoma or gallbladder carcinoma. In our cohort, only two patients with intrahepatic CCA were treated by laparoscopic liver resection. All other CCA patients, and especially those with perihilar cholangiocarcinoma received an open liver resection, as described by our group earlier (13). Reports on laparoscopic liver resection for patients with cholangiocarcinoma (CCA) are still scarce. To date, due to oncological superiority, portal vein embolization for preoperative future liver remnant augmentation and “hilar on block resection” remains our treatment strategy for central bile duct carcinomas (14). However, this type of resection which also requires vascular reconstruction of the portal vein, to date was not performed laparoscopically by our group. Furthermore, postoperative hepatic insufficiency and bile leakage after demanding biliary reconstruction, often with several small orifices, contribute to the postoperative complication rate of this complex surgical disease pattern (46).
Increased experience is commonly paralleled by increased confidence to perform more complex resections. Our overall morbidity and mortality rates are satisfying, especially when compared to the overall German average (50). The rate of other complications was low in the present analysis for LLR as well as OLR, including blood loss and blood transfusions, e.g., compared to NSQIP data (41), where transfusions were required in 33% of patients. Also, the overall morbidity was very low after LLR and significantly reduced compared to OLR. Even the morbidity of the OLR group compares well with other reports from other European centers (35) and clinics from North America (42). However, since patient characteristics differed between both groups, a direct comparison of both groups is debatable. Especially the mortality seems to be rather dependent on patient characteristics than on surgical technique. Likewise, in an analysis using data on 7621 hepatectomies form the US- NSQIP-database (42) it has been shown that mortality after liver resection is predominantly seen in elderly patients in combination with major liver resection. The incidence of post hepatectomy liver failure however was comparatively low in our study, probably due to extensive perioperative liver function testing including the LiMAx test for this selected group of patients.