Since Reich et al. performed the world’s first laparoscopic hepatectomy in 1991, the application of laparoscopic techniques in liver diseases has been gradually recognized and promoted with the continuous maturation of laparoscopic techniques. The scope of laparoscopic hepatectomy has been expanded from local resection of liver margins and superficial lesions to regular resection of half of the liver and even larger areas. At present, the difficulty and scope of laparoscopic liver resection in China and abroad are basically at the same level of development, but compared with foreign developed countries, the number of centers performing laparoscopic liver resection in China is still relatively small, and the overall number of surgical cases is low, and there is a big difference in the level of development between regions.
The available clinical studies have shown that with the increasing proficiency of laparoscopic techniques and the shortening of the learning curve, the incidence of complications during and after laparoscopic liver resection is no longer significantly different from that of open surgery and is characterized by less trauma, faster postoperative recovery, and less impact on the patient’s immune function. Its feasibility and safety in operation technology have been gradually confirmed. Today, with the concept of minimally invasive surgery gaining popularity, the development and promotion of laparoscopic liver resection has become an urgent task for us.
Therefore, after synthesizing the opinions, suggestions and experiences of various laparoscopic liver surgery centers in China, we have written the “Operating Guidelines for Laparoscopic Liver Resection Surgery” in the hope that it can serve as a guide and reference for colleagues who are currently conducting or aspire to conduct clinical research on laparoscopic liver surgery.
1.Surgical methods
(1) Total laparoscopic liver resection: complete laparoscopic liver resection with a small incision for specimen removal only. ②Hand-assisted laparoscopic liver resection: During the laparoscopic operation, the hand is inserted into the abdominal cavity through a small incision in the abdominal wall to assist in the operation to complete the liver resection.
③Laparoscopic-assisted hepatectomy: partial operation is completed through laparoscopy or hand-assisted laparoscopy, and finally liver resection is completed through a small incision.
2.The anatomical scope of laparoscopic hepatectomy
①Local resection is applicable to lesions located in segments II, III, IVb, V and VI.
②Anatomical resection is applicable to left hepatic outer lobe, left hemihepatic and right hemihepatic resection. Laparoscopic left and right hemihepatectomy has been proven to be feasible, but the procedure is difficult and should be performed by an experienced surgeon and surgical team.
(iii) Laparoscopic resection and laparoscopic left and right trilobar resection for lesions located in segments I, IVa, VII and VIII have not been widely accepted. It belongs to the applicable scope of clinical exploratory study.
3. Indications for laparoscopic hepatectomy
(i) benign hepatic lesions: intrahepatic bile duct stones, symptomatic hemangiomas, symptomatic focal nodular hyperplasia, adenomas, multiple hepatic cysts with lesions confined to the hemi-hepatic.
② malignant neoplasms of the liver: including primary liver cancer, metastatic liver tumors and other malignant lesions. To ensure adequate cut margins, it is recommended for lesions where the major ducts are not invaded and are <3 cm in diameter. (ii) If the tumor protrudes extrahepatically and the lumpectomy ensures a cut margin, the range of indications for tumor diameter can be extended to 5 cm.
(iii) For live donor liver resection for liver transplantation, including left outer lobe, left hemiportal, and right hemiportal donor livers. (iv) It has not been reported in China and is the applicable scope of clinical exploratory study.
④ Uncertain lesions of malignancy cannot be excluded.
4.Contraindications to laparoscopic hepatectomy
Any contraindication to open liver resection; patients with difficulty in tolerating pneumoperitoneum; dense intra-abdominal adhesions; lesions too close to large vessels; lesions too large to safely perform laparoscopic operation because they affect the exposure and separation of the first and second hilum; portal invasion of the liver and portal vein cancer embolism.
5.Pre-surgery preparation
① Conduct a comprehensive assessment of the patient’s general condition, understand the function of the heart, lungs, liver, kidneys and other important organs, and clarify whether there are any contraindications to surgery.
② Understand the size, scope and location of the lesion through imaging (ultrasound, CT, MRI), and clarify whether laparoscopic hepatectomy can be performed and the scope of the liver to be resected. If malignant tumor is suspected, the presence of distant metastasis, hepatic portal invasion and portal vein cancer embolism should be clarified.
③ Correct anemia, hypoproteinemia and imbalance of water-electrolyte acid-base metabolism, and improve the nutritional status of the patient.
④ All laparoscopic liver resections need to be prepared for conversion to open abdomen before surgery, and the possibility of conversion to open abdomen should be explained to patients and their families before surgery.
6.Surgical staffing
The surgeon must have skillful laparoscopic techniques and rich experience in open liver and biliary tract surgery. The main laparoscopic liver surgery surgeon and assistant (2) are required to work well together, and it is recommended that the surgical team be fixed and a consistent learning curve be established. The anesthesiologist is recommended to be relatively fixed.
7.Anesthesia mode
General anesthesia with endotracheal intubation is often used. It is recommended that general anesthesia compounded with epidural anesthesia is more appropriate because epidural anesthesia can block the intraoperative afferent of injurious stimuli, reduce the degree of stress reaction, the patient’s intraoperative respiratory and circulatory fluctuations are smooth, and the postoperative awakening time and quality of awakening are better than general anesthesia with tracheal intubation alone.
8.Surgical equipment and surgical instruments
①Conventional equipment: high-definition camera and display system, automatic high-flow pneumoperitoneum machine, flushing and suction device, video and image storage equipment, ultrasound equipment and laparoscopic adjustable ultrasound probe. Pneumoperitoneum-free hooks are not recommended for laparoscopic hepatectomy because they affect the operating space. (②Conventional laparoscopic surgical instruments: pneumoperitoneum needle, 5-12 mm trocar puncture needle (trocar), separation forceps, injury-free grasping forceps, monopolar electrocoagulation, bipolar electrocoagulation, scissors, needle holder, laparoscopic pull hook, disposable sizing forceps and titanium clips, bioprotein glue, hemostatic gauze and disposable extraction bags. (③Separation and liver dissection instruments: available include Harmonicscalpel, LPMOD, CUSA, Ligasure, Microwavetissuecoagulators, Waterjetdissector, TissueLinkfloatingball. Argonbeamcoagulator, etc. and endoscopic cutting closures, each unit can choose liver dissection instruments according to their own conditions and existing surgical experience. ④ Routine preparation of open surgical instruments.
9. Intraoperative patient position
Generally take the supine position, head high and foot low position, about whether the patient needs to separate both lower limbs, the operator’s standing position can be decided according to their own experience and habits.
10.CO2 pneumoperitoneum pressure
CO2 pneumoperitoneum pressure is recommended to be maintained below 12mmHg (1mmHg=0.133kPa), and large changes in pneumoperitoneum pressure should be avoided.
11.Number and position of operation holes
It is recommended to adopt the four-hole method or five-hole method for hepatic resection, and the three-hole method can be selectively adopted for some peripheral smaller lesions.
The location of the operation hole is determined according to the location of the liver lesion to be treated, in order to facilitate the operation and not to affect each other. The observation hole is located above or below the umbilicus, the main operation hole is as close as possible to the lesion site, under the saber process for lesions in the right liver, and under the rib margin of the left midclavicular line for lesions in the left liver, and the secondary operation hole must be kept at a certain distance from the main operation hole and the lens. See Figure 1.
12. Intraoperative laparoscopic ultrasound exploration
Intraoperative laparoscopic ultrasound exploration is recommended: (1) to locate the location and boundary of the tumor to avoid incomplete resection of the tumor; (2) to clarify the course and relationship of the tumor adjacent to the intrahepatic vessels and bile ducts to reduce the risk of uncontrollable hemorrhage under the microscope; (3) to investigate whether there is residual tumor and blood supply to the remaining liver (whether the hepatic vein is patent) after resection of the lesion.
13.Hepatic portal blood flow blocking
At present, there is no mature and simple laparoscopic portal hepatic blocking device, so routine laparoscopic total access hepatic flow blocking is not recommended. Hand-assisted and laparoscopic-assisted liver resection can be applied with optional hilar block.
In left and right hemicolectomy, it is recommended to dissect the left and right hepatic hilum for selective block, i.e., the left and right hepatic tissues are freed and then unilateral entry hepatic flow is blocked. This can achieve the goal of less bleeding and less impact on liver function. See Figure 2.
The laparoscopic dissection of the second hepatic hilum is extremely difficult, and each unit can selectively perform laparoscopic dissection of the second hepatic hilum, hepatic vein freeing and blocking according to its own conditions. If the hepatic vein and inferior vena cava are damaged intraoperatively it can lead to death of the patient within a short time.
14.About laparoscopic hepatectomy for malignant tumor
In principle of treatment, laparoscopic liver tumor surgery must also follow the principles of tumor radicalization in traditional open surgery, including adequate incision margin (2 cm from the tumor margin), and the principle of non-contact of tumor manipulation. The specimen should be cut open immediately after removal to check whether the tumor is completely resected and whether the resected area meets the standard of radical treatment, and if necessary, send intraoperative freezing examination for further confirmation.
15.Separation of liver parenchyma
①All liver dissection tools can be used to separate the liver parenchyma, and for cirrhotic liver, it is recommended to combine multiple instruments for liver dissection. ②It can be handled accordingly according to the thickness of intrahepatic ducts. The use of endoscopic cutting closures for liver dissection must ensure the complete separation of large vessels within the cut tissue.
16.Treatment of liver trauma
The main purpose is to stop bleeding and prevent bile leakage. Small vessels and bile ducts can be closed with electrocoagulation; if bleeding does not stop after repeated electrocoagulation, the trauma should be carefully observed to find the bleeding point and clamped with titanium clamps to stop bleeding; if the diameter of the duct is >2mm, titanium clamps should be used. After the trauma treatment, the trauma must be rinsed again to confirm that there is no bleeding and bile leakage.
17.Interventional open abdomen
①When performing total laparoscopic or hand-assisted laparoscopic liver resection, if the bleeding is difficult to control, the bleeding volume is >800ml or the patient has difficulty in tolerating pneumoperitoneum, the operation should be immediately transferred to open abdomen or enlarged incision.
②When performing total laparoscopic liver resection, if resection is difficult due to poor exposure, large lesions, etc., it can be converted to hand-assisted laparoscopic resection or direct intermediate open resection.
③Intermediate open abdomen should be regarded as intraoperative conversion of surgical modality and not considered as a complication.
18.Postoperative observation and treatment
① Closely observe the patient’s vital signs, the nature and amount of drainage.
②Maintain water-electrolyte acid-base metabolic balance and give prophylactic antibiotics before surgery to reduce postoperative infection.
③ Remove the gastrointestinal decompression tube 24-48 hours after surgery, and give a liquid diet and gradually transition to a normal diet.
19.Complications
①Air embolism: rare but fatal, avoid damaging the hepatic vein as much as possible during the operation.
② Bleeding: postoperative bleeding from the abdominal cavity or liver trauma should be explored laparoscopically and stopped as soon as possible.
③Biliary leakage: if the leakage is small and limited, the drainage tube should be kept open; if the leakage is large or the bile diffuses into the whole abdominal cavity; laparoscopy or open exploration is required.
④Liver failure: preoperative liver function assessment should be done, and routine indocyanine green excretion test is recommended for units with conditions. ⑤ Tumor implantation in the abdominal cavity and abdominal wall: attention to tumor-free operation techniques, reduction of pneumoperitoneum pressure, and application of specimen bags can effectively reduce the incidence of tumor implantation and metastasis.
(6) Intestinal tube injury and intestinal fistula: they are mostly caused by improper intraoperative operation, and should be surgically repaired immediately after discovery. (7) Fluid or pus accumulation in the abdominal cavity.
20. Outlook
Carrying out and developing laparoscopic hepatectomy is a subject with both challenges and opportunities. We firmly believe that with the continuous development and increasing popularity of laparoscopic liver resection surgery in China, its incomparable superiority will be increasingly reflected, followed by great social benefits and a broad prospect of showing laparoscopic liver surgery.
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