evolution of the techniques - alliver aldrighetti - evolution of the techniques.pdf6 postoperative...

Luca Aldrighetti

Hepatobiliary Surgery Unit, San Raffaele Hospital, Milan

Advanced Laparoscopic LiveR (ALLiveR) Course

EVOLUTION OF THE TECHNIQUES: WHAT’S NEW

Ghent University Hospital & Institute of Anatomy GHENT – BELGIUM

June 13-14 2014

A. Increased safety: Technical issues

B. Toward further mini-invasiveness: SILS approach

C. Widening indications to LPS: Combined procedures and Two Stage Hepatectomy

San Raffaele Scientific Institute - Hepatobiliary Surgery – San Raffaele University

Lecture agenda

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1. Precise surgical planning: intraoperative ultrasound

2. Good hemostasis control:

a. Parenchymal transection

b. Vascular control

3. Being able to do it: Learning curve

4. Recognize to be close to the edge: Reasons for

conversion


A. Increased safety: technical issues

Liver anatomy

Number and size of lesions

Relationship with vascular structures

PRECISE SURGICAL PLANNING


Comparison of laparoscopic and open intraoperative ultrasonography for staging liver tumours.

Br J Surg 2013

Viganò L, Ferrero A, Amisano M, Russolillo N, Capussotti L.

A. Increased safety: technical issues Intraoperative ultrasound

Hepatic veins Portal vein Lesion

Liver vascular anatomy

• Site and size • Relationship

with vessels


A. Increased safety: technical issues Intraoperative ultrasound

6

Postoperative morbidity and mortality are closely related to the amount of intra-operative blood loss, the majority of which occurs during parenchymal transection.

Efficient and safe laparoscopic liver resection is dependent on the ability to simultaneously address two tasks: parenchymal division and hemostasis

Delis et al., W J Gastroenterol 2007


A. Increased safety: technical issues Parenchymal transection

Combined use of different tools:

• Ultrasonic dissector

• Water jet dissector

• Bipolar forceps

• Wet bipolar forceps

• Harmonic scalpel

• Bipolar vessel-sealing system (Ligasure)

• Vascular staplers

• Radiofrequency ablation (Habib-4x)

• Clips

• SuturesSaline-Linked Radiofrequency Coagulator (Tissue-Link)

Transection

Hemostasis






• Bipolar forceps






• Clips


Use of stapler devices to perform parenchymal transection is reported

High costs Potential risk of biliary

fistula Vascular injuries

Gumbs, HPB 2008 Saidi, HPB 2007






• Bipolar forceps






• Clips


As clear data for comparison of various

liver transection techniques are lacking

in laparoscopic surgery, currently the choice of

technique is often based on individual surgeon

preference.



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Five patients were operated for liver metastases fromcolorectal cancer, 4 for hepatocellular carcinoma, and in 5patients liver resection was performed for benign diseases.Resection margins were variable based on their diagnosis.The mean operative margin obtained during all benign andmalignant lesions was 1.1 cm (range .9–3.2 cm). In con-trast, resections performed for a malignant diagnosis re-sulted in a mean margin of 1.7 cm (range 1.1–3.2 cm). Nomortality and no morbidity [4] occurred in this series ofpatients; in particular, no bile leak or hemorrhage of anygrade was recorded.

CommentsThe optimal method of transecting liver parenchyma

during laparoscopic procedures has not been established.We suppose that the combined use of ultrasonic dissectorand ultrasonic coagulating cutter offers several advantagesin laparoscopic liver surgery. The ultrasonic dissector al-lows clear visualization of tissues, especially when expo-sure of the major vascular or biliary structures is requiredfor delineation of the transection plane, and it allows theidentification of key vascular and biliary structures, whichcan then be divided or preserved in a precise fashion. Thisprevents damage to important structures, and best ensuresrecognition of all intraparenchymal biliary branches, whichmay be the cause of bile leaks, abscesses, and sepsis in thepostoperative period. The occlusion of arteries and veinscrossing the line of transection by the ultrasonic coagulating

cutter is therefore made easier and safer by the use of theultrasonic dissector, which exposes the covered vessel.

With the ultrasonic coagulating cutter, the cut surfaceappears even and brownish, making identification of biliaryleaks or persistent bleeding easy to detect. The absence ofcollateral damage to adjacent tissues represents an addi-tional important advantage of ultrasonic coagulating cutter[5]. Even though electrocoagulation has been proposed as asimple method to achieve hemostasis during laparoscopicliver resection; the heat generated is considerable and maycause damage far from the plane of dissection [5].

The SonoSurg system integrates 2 major surgical instru-ments. Using ultrasonic energy, through the integration ofsurgical devices, exchanges of appropriate instruments canbe quickly and easily made, and maneuverability is greatlyimproved. Moreover, this device contributes to the reduc-tion of the cost because it is reusable.

Adequate surgical margin still remains a significant con-cern of laparoscopic liver surgery [2]. However, the use ofan ultrasonic dissector allows adequate surgical margin withminimal sacrifice of normal liver parenchyma and the lapa-roscopic ultrasound evaluation guarantees precise determi-nation of the tumor location and the relationship of thetumor to adjacent vascular structures.

The combined use of the ultrasonic dissector and ultra-sonic coagulating cutter allows liver resection to be per-formed safely, with the advantage of minimal surgical com-plication and satisfactory surgical margin.

References[1] Fong Y, Jarnagin W, Conlon KC, et al. Hand-assisted laparoscopic

liver resection: lessons from an initial experience. Arch Surg 2000;135:854–9.

[2] Gigot JF, Glineur D, Azagra JS, et al. Laparoscopic liver resection formalignant liver tumors: preliminary results of a multicenter Europeanstudy. Ann Surg 2000;236:90–7.

[3] Aldrighetti L, Pulitanò C, Arru M, et al. “Technological” approachversus clamp crushing technique for hepatic parenchymal transection:a comparative study. J Gastrointest Surg 2006;10:974–9.

[4] Dindo D, Demartines N, Clavien PA. Classification of surgical com-plications: a new proposal with evaluation in a cohort of 6336 patientsand results of a survey. Ann Surg 2004;240:205–13.

[5] Amaral JF. Depth of thermal injury: ultracisionally activated scalpelvs. electrosurgery. Surg Endosc 1995;9:226.

Fig. 5. Larger vessels are ultrasonically dissected and divided using linear

stapler.

272 L. Aldrighetti et al. / The American Journal of Surgery 195 (2008) 270–272

vessels up to 4 mm in diameter are easily coagulated in 4 to5 seconds using the ultrasonic coagulating cutter and largervessels up to 15 mm and biliary branches are sealed withtitanium clip. The few larger vessels and portal triads thatare encountered are ultrasonically dissected and dividedusing a linear stapler (Fig. 5). For left lateral sectoriectomyand left hepatectomy, the triangular and coronary ligamentsare divided, using the ultrasonic coagulating cutter, leavingthe left lobe attached only by the hepatic vein. At this point,

the limited liver tissue surrounding the hepatic vein is di-vided using the ultrasonic dissector, and the hepatic vein canbe easily sectioned using a linear stapler. This approachhelps to avoid damage to the hepatic vein, reducing the riskof large blood losses and air embolism. An argon beamcoagulator is not used for hemostasis. A single, flat Jackson-Pratt drain is then placed in the posterior aspect of theresection bed through a port site. With a careful liver tran-section, the Pringle maneuver is not necessary.

ResultsFrom January to September 2006, this method of hepatic

transection has been used for 14 consecutive laparoscopic liverresections. Type of procedure included 6 left lateral sectoriec-tomies, 4 segmentectomies, 2 wedge resections, and 2 lefthepatectomies. Cirrhosis was present in 4 patients. No conver-sion to open surgery was necessary. Intraoperative medianblood loss was 150 mL (range 100–250 mL) and medianoperative time was 340 minutes (range 290–400 minutes).

Fig.1. Trocar location.

Fig. 2. The superficial liver tissue is divided using the ultrasonic coagu-

lating cutter.

Fig. 3. The ultrasonic dissector is used to divide liver parenchyma.

Fig. 4. Vessels are sealed and divided using the ultrasonic coagulating

cutter.

271L. Aldrighetti et al. / The American Journal of Surgery 195 (2008) 270–272

In Open, Laparoscopic and Robotic Hepatic Transection. Springer 2012 Surg Endosc, 2008


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A. Increased safety: technical issues Vascular control – Hepatic pedicle

13


Left hepatic vein Left hepatic artery

A. Increased safety: technical issues Vascular control – Hepatic vessels

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Left portal vein - clips Left portal vein - stapler


15


Left hepatic artery Hem-O-Lock

Left portal vein Hem-O-Lock


16


Right hepatic artery Hem-O-Lock

Right portal vein Hem-O-Lock


17


Left bile duct Stapler

Right bile duct Hem-O-Lock

A. Increased safety: technical issues Biliary tree

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“The shape of the learning curve is similar to left-sided colonic surgery, changing its direction after the 60th consecutive case. These results suggest that LLR is reproducible in centers regularly performing liver surgery, but requires specific training to advanced laparoscopy”.


A. Increased safety: technical issues Learning curve


Laparoscopic major hepatectomy can be safely performed, but have been limited by technical difficulty and lack of standardization.

A. Increased safety: technical issues Learning curve


20

Ann Surg, 2009

A trend toward increased conversion rates was also observed in cirrhotic and

in aged patients, and in case of multiple, large or posterosuperior lesions, but differences were not

significant.

A. Increased safety: technical issues Conversion

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The conversion rate among INSSG centers was 10.7% (180 patients out of 1677), with an incidence ranging between 0% and 34.4%.

Cause of conversion Number of pts Percentage

Intraoperative haemorrhage 62 34.4

Oncological radicality 47 26.1

Technical difficulties 43 23.8

Severe adhesions 14 7.7

Anaesthesiological problems 5 2.7

Injury to adjacent organs 1 0.5

Not documented 8 4.4 San Raffaele Scientific Institute - Hepatobiliary Surgery – San Raffaele University

A. T

ech

nic

al is

sue

s A. Increased safety: technical issues

Conversion

B. Toward further mini-invasiveness: SILS approach SILS: The newborn in abdominal surgery

Open

Conventional laparoscopy

SILS

(Single Incision Laparoscopic Surgery)

Towards further mini-

invasiveness…


SILS in liver surgery:

Feasible


B. Toward further mini-invasiveness: SILS approach Feasibility

QuadPort

TriPort

B. Toward further mini-invasiveness: SILS approach Feasibility

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B. Toward further mini-invasiveness: SILS approach Indications

CONVENTIONAL LPS SILS

CONVENTIONAL LPS SILS

13 LLS

• Lesion location and dimension

• Underlying cirrhosis

• Hystopathological features

• Other associated surgical procedures

Matched FOR:

13 LLS

Laparoscopic approach

Conventional LESS

n=13 n=13

Sex, n (%) Male 8 (61.5) 9 (69.2)

Female 5 (38.5) 4 (30.8)

Age Mean ± SD 52 ± 17 65 ± 13

ASA score, n (%) 1 3 (23.1) 1 (7.7)

2 8 (61.5) 9 (69.2)

3 2 (15.4) 3 (23.1)

BMI Mean ± SD 23,3 ± 4,1 25,7 ± 3,5

Underlying liver disease, n (%) None 9 (69.2) 4 (30.8)

Cirrhosis 1 (7.7) 3 (23.1)

Liver impairment 3 (23.1) 6 (46.1)

Previous surgery, n (%) None 11 (84.6) 9 (69.2)

Colecistectomy 1 (7.7) 2 (15.4)

Colic resection 0 (0) 2 (15.4)

Rectal resection 1 (7.7) 0 (0)

Diagnosis, n (%) Colorectal metastases 2 (15.4) 2 (15.4)

HCC 5 (38.5) 6 (46.1)

Cholangiocarcinoma 1 (7.7) 0 (0)

Hemangioma 2 (15.4) 2 (15.4)

FNH 1 (7.7) 1 (7.7)

Liver adenoma 2 (15.4) 2 (15.4)

Nodule diametre, n (%) Mean ± SD 5,1 ± 2,8 5,1 ± 2,9

Patients and disease characteristics

Conventional LESS p

n=13 n=13

Pringle Manuevre, n (%) Not performed 13 (100) 13 (100)

Performed 0 (0) 0 (0) NS

Lenght of surgery (min) Median (range) 165 (145 - 200) 195 (125 - 330) NS

Blood Loss (mL) Median (range) 150 (75 - 350) 175 (100 - 220) NS

Associated surgical procedures, n (%) None 12 (92.3) 13 (100)

Colecistectomy 1 (7.7) 0 (0) NS

Surgical margin, n (%) R0 13 (100) 13 (100)

R1 0 (0) 0 (0) NS

Surgical margin (mm) Mean ± SD 16 ± 34 18 ± 17 NS

I.o. blood transfusions, n (%) No 12 (92.3) 13 (100)

Yes 1 (7.7) 0 (0) NS

P.o. blood transfusions, n (%) No 12 (92.3) 11 (84.6) NS

Yes 1 (7.7) 2 (15.4)

Lenght of p.o. analgesia (hours) Median (range) 70 (56 - 94) 65 (50 - 110)

Lenght of p.o. stay (days) Mean ± SD 4,2 ± 1,4 6,3 ± 4 NS

Median (range) 4 (3 - 6) 5 (3 - 21) NS

B. Toward further mini-invasiveness: SILS approach Left lateral sectionctomy

Conventional LESS p

n=13 n=13

P.o. complications, n (%) None 10 (76.9) 10 (76.9)

Hemorrhage 1 (7.7) 2 (15.4)

Transient liver failure 1 (7.7) 1 (7.7)

Pleural effusion 0 (0) 2 (15.4)

Heart failure 0 (0) 1 (7.7)

Fever 1 (7.7) 0 (0) NS

Morbidity n (%) 3 (23.1) 3 (23.1) NS

Grade of complications, n (%) None 10 (76.9) 10 (76.9)

Minor I grade 0 (0) 0 (0)

II grade 3 (23.1) 2 (15.4)

Major IIIa grade 0 (0) 0 (0)

IIIb grade 0 (0) 0 (0)

V grade 0 (0) 1 (7.7) NS

Mortality n (%) 0 (0) 1 (7.7) NS

B. Toward further mini-invasiveness: SILS approach Left lateral sectionctomy

PROS CONS

• Pain control

Seems better

• Incisional hernias

Seems reduced

• Cosmesis

Better

• Impact on P-S shunts

To be investigated

• Learning curve

Similar to traditional LPS

• Complex triangulation

In-line surgical field

• Instruments conflict

Technical development



C. Widening indications to LPS: Combined procedures

Liver metastases approach

Colorectal cancer approach

Patients with synchronous left colonic or rectal cancer and liver metastases who

underwent combined surgery

93 patients

Group LPS (57 pz)

LPT (51 pz) LPS (6 pz)

Group LPT (36 pz)

LPT (36 pz)

VS

Case matched analysis

LPS (6 pts) LPT (18 pts)


VS

Case matched analysis

LPS (6 pts) LPT (18 pts)

Patients characteristics

• Age, sex, BMI, ASA score, associated comorbidities

Disease characteristics

• Number and location of liver lesions, primary tumor staging, number of CT cycles

Surgery

• Colorectal resection

• Liver resection extension (only minor resections were included)



Variable LPS Group (n = 6) LPT Group (n=18) p Age, median (range) years 59 ( 34 - 65) 64 ( 32 - 71) NS Gender, n (%) NS

Male 3 (50) 10 (55,6) Female 3 (50) 8 (44,4)

ASA Score, n(%) NS I 1 (16,6) 3 (16,6) II 4 (66,6) 12 (66,6) III 1 (16,6) 3 (16,6) IV 0 (0) 0 (0)

Neoadjuvant CT, n (%) 5 (83,3) 16 (88,8) NS CT regimen, n (%) NS

Oxaliplatin based 3 (50) 8 (44,4) Irinotecan based 2 (33,3) 8 (44,4) Associated biological therapy 4 (66,6) 11 (61,1)

Associated comorbidites, n (%) 3 (50) 9 (50) NS Underlying liver disease, n (%) NS

None 6 (100) 18 (100) Cirrhosis 0 (0) 0 (0)

Previous abdominal surgery, n (%) NS None 4 (66,6) 14 (77,7) Cholecistectomy 1 (16,6) 4 (22,2) Other 1 (16,6) 3 (16,6)



Variable LPS Group (n = 6) LPT Group (n=18) p

Primary tumor location, n(%)

Colon 4 (66,6) 13 (72,2) NS

Rectum 2 (33,3) 5 (27,7)

Staging, n(%) NS

T1 0 (0) 1 (5,5)

T2 3 (50) 5 (27,7)

T3 3 (50) 9 (50)

T4 0 (0) 3 (16,7)

Grading, n (%) NS

G1 1 (16,6) 1 (5,5)

G2 4 (66,6) 11 (61,1)

G3 1 (16,6) 7 (38,9)

Primary node status, n(%) NS

N0 2 (33,3) 6 (33,)

N1 3 (50) 8 (44,4)

N2 1 (16,6) 4 (22,2)

Number of liver lesions, median (range) 2 (1-4) 2 (1-5) NS

Nodularity, n (%) NS

Monofocal 4 (66,6) 13 (72,2)

Multifocal 2 (33,3) 5 (27,7)

Lobe distibution of mets, n (%) NS

Unilobar 4 (66,6) 14 (77,8)

Bilobar 2 (33,3) 4 (22,2)

Liver met diametre, median (range) 3 (2-5) 3.5 (1-7) NS

CEA level, median (range) 130 (40-370) 144 (45-490) NS



Variable LPS Group (n = 6) LPT Group (n=18) p Colorectal resection, n (%) NS

Left hemicolectomy 3 (50) 11 (61,1) Anterior rectal resection 2 (33,3) 5 (27,7) Sigmoid resection 1 (16,6) 2 (11,1)

Stoma, n (%) NS Extent of liver resection, n (%) NS

Major 0 (0) 0 (0) Extended 0 (0) 0 (0) Minor 6 (100) 18 (100)

Liver resection, n (%) NS Left lateral sectionectomy 2 (33,3) 3 (16,7) Segmentectomy 1 (16,6) 4 (22,2) Single nodulectomy 1 (16,6) 3 (16,7) Multiple nodulectomies 2 (33,3) 7 (38,9) Right lateral sectionectomy 0 (0) 1 (5,5)

Intraoperative RF, n(%) 0 (0) 1 (5,5) NS Two stage hepatectomy program, n(%) 2 (33,3) 4 (22,2) NS



Variable LPS Group (n = 6) LPT Group (n=18) p

Operating time, median (range) Minutes 500 (190 - 650) 400 (180 - 560) NS

Number of removed nodes, median (range) 17 (10 - 25) 20 (6 - 41) NS

Blood loss, median (range) mL 250 (100 - 450) 400 (200 - 750) <0,01

Pringle manouevre, n (%) 2 (33,3) 5 (27,7) NS

Lenght of Pringle manouevre, median (range) Minutes 20 (10 - 30) 35 (15 - 45) NS

Intraoperative blood transfusion, n(%) 1 (16,6) 5 (27,7) 0,04

R1 colorectal resection, n (%) 0 1 (5,5) NS

R1 liver resection, n (%) 0 1 (5,5) NS

Depth of liver margin, median (range) mm 3 (1 - 9) 3 (0 - 7) NS



Variable LPS Group (n = 6) LPT Group (n=18) p Time to first flatus, median (range) days 4 (2 - 6) 5 (2 - 7) NS Return to diet, median (range) days 3 (2 - 7) 3 (2 - 9) NS Morbidity, n (%)

Total 1 (16,6) 5 (27,7) <0,05 Hemorrage 0 1

Biliary fistula 0 1 Fever 0 2

Pneumonia 1 0 Pleural effusion 0 1

Low urinary tract infection 0 1

Colonic fistula 1 2 Morbidity according to severity, n (%)

Minor (Clavien I-II) 0 (0) 4 (22,2) <0,05 Major (Clavien III-V) 1 (16,6) 1 (5,5) NS

Mortality, n (%) 0 (0) 0 (0) NS Postoperative transfusions, n(%) 1 (16,6) 4 (22,2) NS Total transfusions, n(%) 1 (16,6) 5 (27,7) NS Re-laparotomy, n (%) 0 (0) 0 (0) NS Lenght of postoperative stay, median (range) days 7 (6-13) 10 (8-18) <0,05 Need for ICU, n (%) 0 (0) 0 (0) NS



Open second stage (Right hepatectomy)

Laparoscopic first stage (Left liver clearance and portal vein ligation)


C. Widening indications to LPS: Two stage hepatectomy


C. Widening indications to LPS: Two stage hepatectomy

“The advantage of the first-stage laparoscopic hepatectomy in inducing fewer adhesions

and rapid postoperative recovery may play a positive role in the management of patients with

bilobar CRLMs. Feasibility of laparoscopic second-stage hepatectomy may be challenged

by technically demanding hilar dissection as a consequence of PV embolization or ligation

and should be limited to selected cases”.

49

Ann Surg, 2012

• Laparoscopy? • Use of bioactive sealants to reduce adhesions?


C. Widening indications to LPS: ALPPS

50

Conclusions

Evolution in laparoscopic devices allow to perform parenchymal transection safely and effectively

Approach to portobiliary and hepatic pedicles is feasible in laparoscopy as well as in open technique

LESS technique is an evolution of laparoscopy, toward further mini-invasiveness: its benefits are still under investigation

Benefits of laparoscopy are evident even in combined colorectal and hepatic procedures

51

Study group

Prospective National registry

IGOMILS ASSOCIATION

[email protected]

the Italian Group Of Minimally Invasive Liver Surgery

• Available for every partecipating centre for scientific projects (after approval from scientific board)

• Approval from Ethical Committee on March 6°

• Approval from other Ethical Committees in progress

• Increase of results quality, reduction of time and costs

• Adesion is possible for every italian centre performing minimally invasive liver resections

Observative multi-

institutional prospective

registry

Innovative web-based platform

(CR-Technology)

Support for mono- or

multi- institutional

projects

Start-up: current

here

the Italian Group Of Minimally Invasive Liver Surgery

Scientific Board

• Aldrighetti Luca

• Belli Giulio

• Boni Luigi

• Calise Fulvio

• Casciola Luciano

• Cillo Umberto

• De Carlis Luciano

• Ettorre Giuseppe

• Pinna Antonio

evolution of the techniques - alliver aldrighetti - evolution of the techniques.pdf6 postoperative...

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