Background: The use of a successful Enhanced Recovery After Surgery (ERAS) in colorectal surgery favored its application in other organs, and hepatic resections were not excluded from this tendency. Some authors suggest that the laparoscopic approach is a central element to obtain better results. Aim: To compare the laparoscopic vs. open hepatic resections within an ERAS to evaluate if there are any differences between them. Methods: In a descriptive study 80 hepatic resections that were divided into two groups, regarding to whether they were submitted to laparoscopy or open surgery. Demographic data, those referring to the hepatectomy and the ERAS was analyzed. Results: Forty-seven resections were carried out in open surgery and the rest laparoscopically; in the first group there was only one conversion to open surgery. Of the total, 17 resections were major hepatectomies and in 18 simultaneous resections. There were no differences between procedures regarding hospital stay and number of complications. There was a greater adherence to the ERAS (p=0.046) and a faster ambulation (p=0.001) in the open surgery. Conclusion: The procedure, whether open or laparoscopically done in hepatic resections, does not seem to show differences in an ERAS evaluation.

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Although laparoscopic surgery has been widely adopted for also Hepato-biliary-pancreatic surgery, laparoscopic resection of hilar cholangiocarcinoma remains uncommon because of its difficult procedures consisted of major hepatectomy, lymph node dissection and biliary reconstruction. Methods: The patient was placed in left hemilateral position and five laparoscopic trocars were positioned. The right lobe and the caudate lobe were completely mobilized. After the Kocher maneuver, lymphadenectomy was performed using LCS. Then the common bile duct, the right hepatic artery and the right portal vein were divided. A hepatic parenchymal transection was performed by BiClamp using a modified hanging maneuver and the right hepatic vein was divided using a linear stapler. The left hepatic duct was divided adjacent to the umbilical portion and the specimen was retrieved through the minilaparotomy. End-to-side endoscopic hepaticojejunostomy was performed with running sutures. Results: From October 2012 through November 2014, three patients with hilar cholangiocarcinoma underwent laparoscopic extended right hepatectomy with biliary reconstruction. The median operative time was 867 min (range, 853e1010 min), and median estimated blood loss was 100 ml (range, 43e400 ml). The median length of hospital stay was 19 days (range, 16e23 days), and there was no postoperative mortality. Conclusions: Laparoscopic resections for hilar cholangiocarcinomas are safe and feasible in selected patients and when performed by surgeons with expertise in hepatic surgery and minimally invasive techniques. Further studies are still needed to confirm the benefit of this approach over conventional surgery for hilar cholangiocarcinoma.

Aims: Preoperative prediction of postoperative future liver remnant volume (FLRV) is considered as state of the art in risk evaluation in patients undergoing extended partial liver resection. However, in case of liver disease, e.g. cirrhosis, NASH or preoperative chemotherapy, a simple volume calculation is insufficient since actual liver function is deteriorated in those patients. In the presented results, we did evaluate the feasibility of predicting postoperative future liver remnant function (FLRF) in patients undergoing major hepatectomy. Methods: Data was acquired in a prospective clinical study. Preoperative liver function was assessed by the enzymatic based 13C-breath test LiMAx. FRLV was estimated using a 3-dimensional volumetric analysis of a preoperative 4-phase CT-scan in close cooperation with the attending liver surgeon. FRLF was calculated on the basis of preoperative liver function and FRLV. Directly after the operation (1e4 hours) all patients received an additional CT-scan as well as LiMAx test. The actual postoperative liver function was compared to the preoperative predicted function (FRLF). Results: A number of 28 patients have been enrolled in this study. Predicted FRLV correlates with the measured postoperative liver volume (r = 0.95, p < .001). The actual postoperative measured liver function by LiMAx also showed a good correlation with the predicted FRLF (r = 0.89, p < .001). Mean LiMAx difference between estimated and measured function was À33 g/h/kg. Conclusions: Volume/function analysis for FRLF using the LiMAx test and virtual liver resection with 3D-CT can accurately predict residual liver function and therefore could improve the preoperative planning. Since postoperative liver function assessed by LiMAx has proven to be an excellent predictor of postoperative morbidity and mortality, preoperative prediction of FRLF has the potential to decrease the rate of postoperative liver failure and major complications.

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