In the past 20 years, with the development of laparoscopic surgical instruments and the accumulation of surgical operation techniques and experience of minimally invasive surgeons, laparoscopic liver surgery has made great progress. However, because the liver has a double blood supply of hepatic artery and portal vein, and the blood flow is abnormally rich, laparoscopic hepatectomy (LH) is very easy to bleed, and it is difficult to control bleeding by open hemostatic techniques such as hepatic portal block, finger pressure hemostasis and suture hemostasis, which is risky, so it is especially important to master the indications strictly. From March 2010 to November 2010, the Department of Hepatobiliary and Pancreatic Surgery of Henan Cancer Hospital performed 12 cases of laparoscopic hepatocellular carcinoma resection by strict case selection with satisfactory results, compared with 20 cases of Open Hepatectomy (OH) in the same period. Zhou Jinxue, Department of Hepatobiliary and Pancreatic Surgery, Henan Cancer Hospital
1 Data and methods
1.1 Clinical data Twelve patients underwent laparoscopic hepatectomy (LH group), 9 males and 3 females, aged 30-65 years, average 49.25±8.76 years, among which 2 cases had lesions located at the edge of the liver, 2 cases on the surface of the right liver and 8 cases on the left half of the liver. In the same period, 20 patients with hepatocellular carcinoma underwent conventional open surgical resection (OH group), 14 males and 6 females, aged 28-71 years, mean 51.50±10.62 years, with 3 lesions located on the liver margin, 5 on the right hepatic surface, and 12 on the left hemisphere. The differences in age, sex, body mass index (BMI), surgical history, lesion size and location between the two groups were not statistically significant (Table 1). The preoperative liver function status of the selected cases was A grade according to Child classification, without ascites and hypoproteinemia, and all of them were pathologically confirmed as hepatocellular carcinoma after surgery.
1.2 Surgical methods
1.2.1 Laparoscopic hepatectomy The operation was performed under general anesthesia with the patient in the supine position, and the angle of the operating table was adjusted to change the position as necessary. A small incision was made at the infraumbilical margin and a pneumoperitoneum needle was inserted to establish a CO2 pneumoperitoneum, maintaining intra-abdominal pressure at 12 mmHg; a 30° laparoscope was placed in the small incision at the infraumbilical margin; the subxiphoid (lesion in the right liver) or subcostal margin of the left midclavicular line (lesion in the left liver) puncture hole was used as the main operation hole at the level of the mid-axillary line under the left costal margin.
Table 1 Comparison of general clinical data between the LH and OH groups
LH group OH group P value
Gender 0.883
Male 9 (75.0%) 14 (70.0%)
Female 3 (25.0%) 6 (30.0%)
Age (years) 49.25±8.76 51.50±10.62 0.267
BMI (kg/ cm2) 21.69±2.12 0.98±2.57 0.514
Surgical history (yes) 2 (16.7%) 4 (20.0%) 0.726
Tumor size 3.28±1.26 4.13±1.51 0.350
Tumor location 0.479
Segment II and III 6 (50.0%) 9 (45.0%)
Segment IV 2 (16.7%) 3 (15.0%)
V, VI segments 3 (25.0%) 6 (30.0%)
VII, VIII segment 1 (8.30%) 2 (10.0%)
The puncture holes in the right subcostal margin at the mid-axillary line, the right subcostal margin at the mid-clavicular line, the left mid-axillary line at the level of the flat umbilicus, or the left anterior axillary line at the level of the flat umbilicus were used as auxiliary operation holes. The liver tumor site was observed, and the location of the tumor and its relationship with the surrounding blood vessels and bile ducts were clarified by intra-laparoscopic ultrasound. The laparoscopic Peng’s multifunctional operative dissector (LPMOD) was used to draw the proposed cutting line along the liver surface, and the LPMOD or ultrasonic knife was used to dissect the liver tissue along the proposed cutting line, and the smaller vessels and bile ducts encountered were treated with electrocoagulation or spray coagulation with ultrasonic knife, and the larger vessels and bile ducts in the liver were freed and closed with titanium clips or biological clips. After resection of the tumor, the liver was sprayed with bioprotein gel and the specimen was placed in a specimen bag and removed by enlarging the umbilical or subxiphoid incision according to the size of the tumor.
1.2.2 Open hepatectomy for hepatocellular carcinoma was performed by using an oblique incision under the rib margin, and after entering the abdominal cavity, the left or right half of the liver was fully freed from the perihepatic ligament to fully expose the lesion, and the hilar block was performed according to the situation, and the blocking time generally did not exceed 15 min. The hepatic vessels and bile ducts were ligated and the bleeding was stopped by sutures.
1.3 Statistical methods All statistical data were entered into SPSS 17.0 statistical software to perform t-test and chi-square test for group data (statistically significant at P<0.05< span="">).
2 Results
All 12 laparoscopic liver cancer resections were successful. Both groups were operated with general anesthesia and completed by the same surgical team. There was no significant difference in the operative time (179.23 s.55.68 min vs 165.06 s.59.56 min) and bleeding volume (287.60 s.126.47 ml vs 214.68 s.152.28 ml) between the two groups of patients. There was no difference in complications and no perioperative death between the two groups; one case of bleeding and one case of bile leak in the LH group; one case of bleeding, one case of incisional infection and one case of subdiaphragmatic effusion in the OH group; the length of incision, postoperative anal venting time, postoperative fasting time, indwelling drainage time and postoperative hospital stay were significantly lower in the LH group than in the open group, and the difference was statistically significant (P<0.05). There was no significant difference in the total hospitalization cost between the two groups (Table 2).
Table 2 Comparison of the results between the LH and OH groups
LH group OH group P value
Operative time (min) 179.23sh55.68 165.06sh59.56 0.267
Bleeding volume (ml) 287.60s 126.47 214.68s 152.28 0.321
Incision length (cm) 3.28ś0.56 18.19ś4.32 0.001
Postoperative fasting time (d) 1.66s 0.72 2.59s 0.83 0.003
Anal venting time (h) 6.12±10.87 60.25±18.61 0.034
Duration of indwelling drainage (d) 2.64s2.26 4.31s1.52 0.036
Surgical complications 2 (16.7%) 3 (15%) 0.322
Postoperative hospital stay(d) 7.29s2.12 10.14s3.18 0.002
Total hospital stay(d) 11.21sh3.36 13.26sh3.25 0.028
Surgical cost(y) 4584.56 875.28 2713.68 428.72 0.003
Total hospitalization cost(y) 19882.52s 3171.51 21316.17s 2821.43 0.486
3 Discussion
After Wayand [1] reported the world’s first laparoscopic hepatectomy for hepatocellular carcinoma in 1993, the number of reports has increased in recent years, and the results of domestic and international studies have confirmed the obvious superiority of laparoscopic surgery compared with open surgery [2-5]. Laparoscopic hepatectomy has a small incision in the abdominal wall, which reduces local trauma; minimizes the compression of the liver and strictly adheres to the principle of “no-touch” in tumor surgery; significantly improves the quality of life of patients after surgery; early recovery of gastrointestinal function and short hospitalization time due to bed activity, anal discharge, and early feeding; less postoperative abdominal adhesions; and improved survival quality. The quality of life of patients after surgery is significantly improved; bed activity, anal discharge, and early feeding, quick recovery of gastrointestinal function, and short hospitalization time; postoperative abdominal adhesions are light, and the quality of survival is improved. Traditional open hepatectomy requires a large abdominal wall incision, significant postoperative pain, and long postoperative recovery time. Our results demonstrate the advantages of less pain, smaller incision, less abdominal wall trauma, faster postoperative recovery and shorter hospital stay after laparoscopic hepatectomy.
The key to laparoscopic hepatocellular carcinoma resection is how to effectively control intraoperative bleeding. The liver is very rich in blood flow, and it is difficult to apply open hemostatic techniques such as hepatic portal block and suture hemostasis under laparoscopy, especially in cirrhosis, which makes it more likely to bleed, and it is very difficult to stop bleeding under laparoscopy, therefore, it is especially important to strictly master the indications for surgery and choose the appropriate tool for hepatectomy. All 12 patients met the following conditions: (1) malignant tumor in the liver margin, right hepatic surface or left hemisphere; (2) tumor diameter less than 10 cm; (3) tumor far from the 1st and 2nd hepatic hilum; (4) malignant tumor without portal vein thrombus; (5) no serious sclerotic changes in the liver; (6) no serious coagulation (6) no serious coagulation disorders; (7) no serious cardiopulmonary diseases. The results suggest that this is a good indication for laparoscopic hepatectomy for hepatocellular carcinoma.
At present, there are many kinds of laparoscopic liver dissection tools, including the use of ordinary electric knife, microwave knife, ultrasonic knife, titanium clip, cutter, ligature speed, etc. Each method of liver dissection has certain advantages and disadvantages, and we believe that it should be determined according to the operator’s habit and the instrumentation. The LPMOD is a combination of scraping, blunt cutting, aspiration and electrocoagulation, which can dissect the intrahepatic canal structure, electrocoagulation or clamping, with fast dissection speed and accurate electrocoagulation. Synchronous suction can remove tissue debris, blood and fluid accumulation and smoke from electrocautery in time, with good hemostatic effect and light tissue damage, which is a more suitable tool for laparoscopic liver resection in China [6-7]. The ultrasonic knife method has a better coagulation effect and can safely coagulate arterioles or bile ducts less than 3 mm, and even vessels as thick as 5 mm, and the damage to the surrounding tissues is much less than that of the electric knife, and its precise cutting effect makes it safe to separate and cut next to important organs and large vessels, and can best protect the residual liver tissue: less smoke and less crust make the laparoscopic view clearer The procedure time is shortened, the absence of electric current through the body makes the procedure safer, and the difficulty of the procedure is reduced as well as the amount of intraoperative bleeding.
In addition to effective hemostasis, the successful performance of laparoscopic hepatectomy must also effectively prevent the occurrence of CO2 embolism. If the tumor is adjacent to the hepatic vein, if the hepatic vein is damaged during surgery, a large amount of high-pressure CO2 gas will enter the heart along with the hepatic vein, which is the biggest cause of death during laparoscopic hepatectomy. We routinely ligate the left hepatic vein with a deep stitch in the parenchyma about 2 cm to the left of the vena cava during left hepatectomy without dissecting and separating it, which can prevent CO2 embolism caused by damage to the left hepatic vein during the operation [8]. Choosing the correct surgical position, controlling intra-abdominal air pressure < 12 mmHg, avoiding damage to large hepatic veins, and continuously monitoring vital signs and end-expiratory CO2 pressure are all essential to prevent gas embolism [9].
Laparoscopic hepatectomy for hepatic malignancies embodies the concept of minimally invasive surgery, i.e., “eliminating tumors while maximizing preservation of the body”, and has great potential. It is believed that with the accumulation of surgical experience, improvement of laparoscopic instruments and refinement of relevant theories, laparoscopic hepatectomy for hepatocellular carcinoma will flourish.