Evolution and trends in the adoption of laparoscopic liver resection in Singapore: Analysis of 300 cases

Abstract

Introduction: The introduction of laparoscopic surgery has changed abdominal surgery. We evaluated the evolution and changing trends associated with adoption of laparoscopic liver resection (LLR) and the experience of a surgeon without prior LLR experience. Methods: A retrospective review of 310 patients who underwent LLR performed by a single surgeon from 2011 to 2020 was conducted. Exclusion criteria were patients who underwent laparoscopic liver surgeries such as excision biopsy, local ablation, drainage of abscesses and deroofing of liver cysts. There were 300 cases and the cohort was divided into 5 groups of 60 patients. Results: There were 288 patients who underwent a totally minimally invasive approach, including 28 robotic-assisted procedures. Open conversion occurred for 13 (4.3%) patients; the conversion rate decreased significantly from 10% in the initial period to 3.3% subsequently. There were 83 (27.7%) major resections and 131 (43.7%) resections were performed for tumours in the difficult posterosuperior location. There were 152 (50.7%) patients with previous abdominal surgery, including 52 (17.3%) repeat liver resections for recurrent tumours, and 60 patients had other concomitant operations. According to the Iwate criteria, 135 (44.7%) were graded as high/expert difficulty. Major morbidity (>grade 3a) occurred in 12 (4.0%) patients and there was no 30-day mortality. Comparison across the 5 patient groups demonstrated a significant trend towards older patients, higher American Society of Anesthesiologists (ASA) score, increasing frequency of LLR with previous abdominal surgery, increasing frequency of portal hypertension and huge tumours, decreasing blood loss and decreasing transfusion rate across the study period. Surgeon experience (≤60 cases) and Institut Mutualiste Montsouris (IMM) high grade resections were independent predictors of open conversion. Open conversion was associated with worse perioperative outcomes such as increased blood loss, transfusion rate, morbidity and length of stay. Conclusion: LLR can be safely adopted for resections of all difficulty grades, including major resections and for tumours located in the difficult posterosuperior segments, with a low open conversion rate. Keywords: Laparoscopic hepatectomy, laparoscopic liver resection, robotic hepatectomy, robotic liver resection, Singapore

Systematic review and meta‐analysis of difficulty scoring systems for laparoscopic and robotic liver resections

“…The aim would be for the DSS to accurately discriminate LLR based on its technical difficulty to allow surgeons at different stages of the learning curve to attempt cases suitable for their skill and experience level. 47,48 This also allows a standardized approach to auditing outcomes and comparing results between centres and countries, 49,50 as well as comparing outcomes between approaches, such as LLR compared to RLR. 51 Our systematic review found 11 unique DSS.…”

Comparison between the difficulty of laparoscopic limited liver resections of tumors located in segment 7 versus segment 8: An international multicenter propensity‐score matched study

“…[6][7][8]14 These challenges may be partially overcome by using the lateral position, additional intercostal trocars, and the flexible tip laparoscope. [6][7][8][15][16][17] Nonetheless, despite the greater complexity, LLR of segments 7 and 8 have shown the known advantages of minimally invasive surgery over the open approach such as significantly lower blood loss and length of hospital stay. 15,18 To date, there are no head-to-head comparative studies between LLR of Segments 7 and 8.…”

“…When adopting the laparoscopic approach, the difficulty of these resections is further augmented due to the caudal‐cranial view impairing adequate visualization of the operative field and difficulty of the rigid laparoscopic instruments accessing these areas 6–8,14 . These challenges may be partially overcome by using the lateral position, additional intercostal trocars, and the flexible tip laparoscope 6–8,15–17 . Nonetheless, despite the greater complexity, LLR of segments 7 and 8 have shown the known advantages of minimally invasive surgery over the open approach such as significantly lower blood loss and length of hospital stay 15,18 …”

Laparoscopic versus open caudate lobe liver resections: a 1:2 propensity score‐matched controlled study based on a single institution experience

“…26,27 However, resection for tumours located in the difficult segments continue to be less widely performed due to the technical challenges of the procedures resulting in increased risk of nononcological resections or uncontrollable bleeding. [28][29][30][31] The caudate lobe with its peculiar anatomy has a history of changing definitions and classifications. [7][8][32][33] It is widely considered to be the one of the most difficult liver segments to approach surgically.…”

“…In many specialized liver centres, less complicated liver resections such as left lateral sectionectomies are now routinely performed via the minimally invasive approach 26,27 . However, resection for tumours located in the difficult segments continue to be less widely performed due to the technical challenges of the procedures resulting in increased risk of non‐oncological resections or uncontrollable bleeding 28–31 …”