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Liu Z, Xia F, Guo B, Leng C, Zhang E, Xu L, Chen X, Zhu P. Comprehensive evaluation of the ramification patterns of hepatic vascular anatomy based on three-dimensional visualization technology. Updates Surg 2025:10.1007/s13304-025-02064-w. [PMID: 39853656 DOI: 10.1007/s13304-025-02064-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/07/2025] [Indexed: 01/26/2025]
Abstract
The liver segmentation method proposed by Couinaud is widely accepted by surgeons because of its convenience and practicality. However, this conventional eight-segment classification does not reflect realistic details of the liver and thus requires further adjustments to promote improvements in surgical strategies. This study aimed to explore the ramification patterns of the hepatic vasculature comprehensively. A total of 197 eligible patients meeting the study criteria were enrolled for three-dimensional reconstruction analysis. In the left hemiliver, the portal vein bifurcated into P2 and umbilical portion (UP) in 172 (98.3%) patients. The P4b of 103 patients (103/172, 59.9%) whose P4b branched from the right horn of the left portal vein (LPV) diverged from the main trunk of the UP. In the right paramedian sector (RPMS), the entire portal trunk directly bifurcates into P8vent and P8dor. Simple branching of P5 off the trunk of the RPMS was observed in 78 patients (78/130, 60%). The anterior fissure vein (AFV) was identified in 86 (86/148, 58.1%) patients. V8d entered the right hepatic vein (RHV) in all the patients. In 75.3% (113/150) of all the patients, V5d joined the RHV. In the right lateral sector (RLS), more than half (71/133, 53.4%) of the patients had an arch-like type. We summarize different patterns of liver vascular branches, providing a valuable reference for clinical surgery and liver transplantation. Cranio-caudal segmentation is more common than ventral-dorsal segmentation. The AFV can be regarded as a reliable anatomical landmark for subsegmentation in segment 8. In addition, the absence of AFV was associated with the P8 pattern.
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Affiliation(s)
- Zhicheng Liu
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 1095, China
| | - Feng Xia
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 1095, China
| | - Bin Guo
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 1095, China
| | - Chao Leng
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 1095, China
| | - Erlei Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 1095, China
| | - Lei Xu
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 1095, China
| | - Xiaoping Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 1095, China
| | - Peng Zhu
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Avenue, Wuhan, 1095, China.
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Liu R, Abu Hilal M, Wakabayashi G, Han HS, Palanivelu C, Boggi U, Hackert T, Kim HJ, Wang XY, Hu MG, Choi GH, Panaro F, He J, Efanov M, Yin XY, Croner RS, Fong YM, Zhu JY, Wu Z, Sun CD, Lee JH, Marino MV, Ganpati IS, Zhu P, Wang ZZ, Yang KH, Fan J, Chen XP, Lau WY. International experts consensus guidelines on robotic liver resection in 2023. World J Gastroenterol 2023; 29:4815-4830. [PMID: 37701136 PMCID: PMC10494765 DOI: 10.3748/wjg.v29.i32.4815] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/22/2023] [Accepted: 08/09/2023] [Indexed: 08/25/2023] Open
Abstract
The robotic liver resection (RLR) has been increasingly applied in recent years and its benefits shown in some aspects owing to the technical advancement of robotic surgical system, however, controversies still exist. Based on the foundation of the previous consensus statement, this new consensus document aimed to update clinical recommendations and provide guidance to improve the outcomes of RLR clinical practice. The guideline steering group and guideline expert group were formed by 29 international experts of liver surgery and evidence-based medicine (EBM). Relevant literature was reviewed and analyzed by the evidence evaluation group. According to the WHO Handbook for Guideline Development, the Guidance Principles of Development and Amendment of the Guidelines for Clinical Diagnosis and Treatment in China 2022, a total of 14 recommendations were generated. Among them were 8 recommendations formulated by the GRADE method, and the remaining 6 recommendations were formulated based on literature review and experts' opinion due to insufficient EBM results. This international experts consensus guideline offered guidance for the safe and effective clinical practice and the research direction of RLR in future.
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Affiliation(s)
- Rong Liu
- Faculty of Hepato-Pancreato-Biliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing 100000, China
| | - Mohammed Abu Hilal
- Hepatobiliary Pancreatic, Robotic & Laparoscopic Surgery, Poliambulanza Foundation Hospital, Brescia 25100, Italy
| | - Go Wakabayashi
- Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Saitama 362-0075, Japan
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Chinnusamy Palanivelu
- GEM Hospital & Research Centre, GEM Hospital & Research Centre, Coimbatore 641045, India
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa 56126, Italy
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg 20251, Germany
| | - Hong-Jin Kim
- Department of Surgery, Yeungnam University Hospital, Daegu 42415, South Korea
| | - Xiao-Ying Wang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Ming-Gen Hu
- Faculty of Hepato-Pancreato-Biliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing 100000, China
| | - Gi Hong Choi
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University, College of Medicine, Seoul 03722, South Korea
| | - Fabrizio Panaro
- Department of Surgery/Division of Robotic and HBP Surgery, Montpellier University Hospital-School of Medicine, Montpellier 34090, France
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21218, United States
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Moscow 111123, Russia
| | - Xiao-Yu Yin
- Department of Pancreatobiliary Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510080, Guangdong Province, China
| | - Roland S Croner
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg 39120, Germany
| | - Yu-Man Fong
- Department of Surgery, City of Hope Medical Center, Duarte, CA 91010, United States
| | - Ji-Ye Zhu
- Department of Hepatobiliary Surgery, Peking University People’s Hospital, Beijing 100000, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Chuan-Dong Sun
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
| | - Jae Hoon Lee
- Division of Hepatobiliary & Pancreatic surgery, Asan Medical Center, University of Ulsan College of Medicine, Ulsan 682, South Korea
| | - Marco V Marino
- General Surgery Department, F. Tappeiner Hospital, Merano 39012, Italy
| | - Iyer Shridhar Ganpati
- Hepatobiliary and Pancreatic Surgery, National University Hospital, Singapore 189969, Singapore
| | - Peng Zhu
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
| | - Zi-Zheng Wang
- Department of Hepatobiliary Surgery, Senior Department of Hepatology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100000, China
| | - Ke-Hu Yang
- Evidence-Based Medicine Center, Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Jia Fan
- Zhongshan Hospital, Fudan University, Shanghai 200000, China
| | - Xiao-Ping Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
| | - Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong 999077, China
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Zhu P, Liao W, Zhang WG, Chen L, Shu C, Zhang ZW, Huang ZY, Chen YF, Lau WY, Zhang BX, Chen XP. A Prospective Study Using Propensity Score Matching to Compare Long-term Survival Outcomes After Robotic-assisted, Laparoscopic, or Open Liver Resection for Patients With BCLC Stage 0-A Hepatocellular Carcinoma. Ann Surg 2023; 277:e103-e111. [PMID: 35081573 DOI: 10.1097/sla.0000000000005380] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare the short- and long-term outcomes of robot-assisted (RALR), laparoscopic (LLR), or open liver resection (OLR) in the treatment of Barcelona Clinic Liver Cancer (BCLC) stage 0-A hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA Following the Balliol IDEAL classification, long-term oncological outcomes can be used to evaluate the value of minimally invasive techniques in the treatment of HCC, and to assess whether they should become a standard practice. METHODS Data from prospective cohorts of patients with BCLC stage 0-A HCC who underwent curative liver resection using OLR, LLR, or RALR at Tongji Hospital were reviewed. The short-term and long-term oncological outcomes of these 3 different surgical approaches after adequate follow-up were compared using propensity score matching to reduce selection bias. RESULTS Of 369 patients included in this study (71, RALR; 141, LLR; and 157, OLR), 56 patients in each of the 3 groups were chosen for further comparison, after propensity score matching. In the minimally invasive group (RALR+LLR), both the operative time and duration of Pringle's maneuver were significantly longer than those in the OLR group; however, the length of hospital stay was significantly shorter. There were no significant differences in the other intraoperative parameters and the incidence of postoperative complications among the 3 groups. HCC recurrence in the minimally invasive group when compared with the OLR group was characterized by a significantly higher proportion of single lesion or early-stage HCC. However, there were no significant differences in the 5-year disease-free survival (63.8%, 54.4%, and 50.6%) or overall survival rates (80.8%, 78.6%, and 75.7%, respectively) among the 3 groups. Clinically significant portal hypertension was the only risk factor that negatively affected the 5-year disease-free survival rate. Multivariate Cox regression analysis showed that clinically significant portal hypertension, serum alpha-fetoprotein level (≥400 ng/mL), and Edmondson-Steiner grading (III+IV) were independent risk factors for poor long-term survival. CONCLUSION Both robotic and laparoscopic hepatectomies were safe and effective for patients with BCLC stage 0-A HCC when compared with open hepatectomy.
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Affiliation(s)
- Peng Zhu
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; and
| | - Wei Liao
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; and
| | - Wan-Guang Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; and
| | - Lin Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; and
| | - Chang Shu
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; and
| | - Zhi-Wei Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; and
| | - Zhi-Yong Huang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; and
| | - Yi-Fa Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; and
| | - Wan Yee Lau
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; and
- Faculty of Medicine, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Terriotories, Hong Kong SAR, China
| | - Bi-Xiang Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; and
- Faculty of Medicine, the Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, New Terriotories, Hong Kong SAR, China
| | - Xiao-Ping Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; and
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Steinkraus KC, Jötten L, Traub B, Zaimi M, Denzinger M, Michalski CW, Kornmann M, Hüttner FJ. Robotic Liver Surgery for Alveolar Echinococcosis: A Single-Centre Experience. Pathogens 2022; 11:1276. [PMID: 36365027 PMCID: PMC9698832 DOI: 10.3390/pathogens11111276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 10/20/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022] Open
Abstract
Alveolar echinococcosis (AE) is a rare disease caused by Echinococcosis multilocularis, which usually requires multidisciplinary management including surgery as the only curative approach. In recent years, minimally invasive strategies have been increasingly adopted for liver surgery. In particular, robotic surgery enables surgeons to perform even complex liver resections using a minimally invasive approach. However, there are only a few reports on robotic liver surgery for AE. Consecutive patients undergoing robotic liver surgery for AE were analysed based on the prospective database of the Interdisciplinary Robotic Centre of Ulm University Hospital. Between January 2021 and August 2022, a total of 16 patients with AE underwent robotic hepatectomy at our institution. Median age was 55.5 years (23−73), median body mass index (BMI) was 25.8 kg/m2 (20.2−36.8) and 12 patients (75%) were female. Anatomic resections were performed in 14 patients (87.5%), of which 4 patients (25%) underwent major hepatectomies (i.e., resection of >3 segments) including two right hemihepatectomies, one left hemihepatectomy and one extended right hemihepatectomy performed as associating liver partition with portal vein ligation staged (ALPPS) hepatectomy. There was no 90-day mortality, no postoperative bile leakage and no posthepatectomy haemorrhage. One patient developed posthepatectomy liver failure grade B after extended right hemihepatectomy using an ALPPS approach. One patient had to be converted to open surgery and developed an organ-space surgical site infection, for which he was re-admitted and underwent intravenous antibiotic therapy. Median length of postoperative hospital stay was 7 days (4−30). To our knowledge, this is the largest series of robotic liver surgeries for AE. The robotic approach seems safe with promising short-term outcomes in this selected cohort for both minor as well as major resections.
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Affiliation(s)
| | | | | | | | | | | | | | - Felix J. Hüttner
- Department of General and Visceral Surgery, Ulm University Hospital, Albert-Einstein-Allee 23, 89081 Ulm, Germany
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Marahrens N, Scaglioni B, Jones D, Prasad R, Biyani CS, Valdastri P. Towards Autonomous Robotic Minimally Invasive Ultrasound Scanning and Vessel Reconstruction on Non-Planar Surfaces. Front Robot AI 2022; 9:940062. [PMID: 36304794 PMCID: PMC9594548 DOI: 10.3389/frobt.2022.940062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/09/2022] [Indexed: 11/13/2022] Open
Abstract
Autonomous robotic Ultrasound (US) scanning has been the subject of research for more than 2 decades. However, little work has been done to apply this concept into a minimally invasive setting, in which accurate force sensing is generally not available and robot kinematics are unreliable due to the tendon-driven, compliant robot structure. As a result, the adequate orientation of the probe towards the tissue surface remains unknown and the anatomy reconstructed from scan may become highly inaccurate. In this work we present solutions to both of these challenges: an attitude sensor fusion scheme for improved kinematic sensing and a visual, deep learning based algorithm to establish and maintain contact between the organ surface and the US probe. We further introduce a novel scheme to estimate and orient the probe perpendicular to the center line of a vascular structure. Our approach enables, for the first time, to autonomously scan across a non-planar surface and navigate along an anatomical structure with a robotically guided minimally invasive US probe. Our experiments on a vessel phantom with a convex surface confirm a significant improvement of the reconstructed curved vessel geometry, with our approach strongly reducing the mean positional error and variance. In the future, our approach could help identify vascular structures more effectively and help pave the way towards semi-autonomous assistance during partial hepatectomy and the potential to reduce procedure length and complication rates.
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Affiliation(s)
- Nils Marahrens
- Storm Lab UK, Institute for Robotics, Autonomous Systems and Sensing, School of Electronic and Electrical Engineering, University of Leeds, Leeds, United Kingdom
- *Correspondence: Nils Marahrens,
| | - Bruno Scaglioni
- Storm Lab UK, Institute for Robotics, Autonomous Systems and Sensing, School of Electronic and Electrical Engineering, University of Leeds, Leeds, United Kingdom
| | - Dominic Jones
- Storm Lab UK, Institute for Robotics, Autonomous Systems and Sensing, School of Electronic and Electrical Engineering, University of Leeds, Leeds, United Kingdom
| | - Raj Prasad
- Department for Hepatobiliary Surgery, James’s University Hospital, Leeds Teachings Hospitals NHS Trust, Leeds, United Kingdom
| | - Chandra Shekhar Biyani
- Department for Urology, James’s University Hospital, Leeds Teachings Hospitals NHS Trust, Leeds, United Kingdom
| | - Pietro Valdastri
- Storm Lab UK, Institute for Robotics, Autonomous Systems and Sensing, School of Electronic and Electrical Engineering, University of Leeds, Leeds, United Kingdom
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You N, Wu K, Li J, Zheng L. Laparoscopic liver resection of segment 8 via a hepatic parenchymal transection-first approach guided by the middle hepatic vein. BMC Gastroenterol 2022; 22:224. [PMID: 35527252 PMCID: PMC9082856 DOI: 10.1186/s12876-022-02289-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 04/19/2022] [Indexed: 11/12/2022] Open
Abstract
Background Pure laparoscopic liver resection (LLR) of segment 8 (S8) is still rarely performed due to the lack of an appropriate surgical approach. This article discusses the technical tips and operation methods for LLR of S8 via a hepatic parenchymal transection-first approach. Methods Clinical data of 22 patients who underwent LLR of S8 via a hepatic parenchymal transection-first approach guided by the middle hepatic vein (MHV) in the Second Affiliated Hospital, Third Military Medical University (Army Medical University) from May 2017 to February 2020 were retrospectively analyzed. Results The mean age was 51.1 ± 11.6 years; mean operation time, 186.6 ± 18.4 min; median blood loss, 170.0 ml (143.8–205.0 ml); and median length of hospital stay, 8.0 days (7.0–9.0 days). There was no case of open conversion. Pathologic findings revealed all cases of hepatocellular carcinoma (HCC). Pathology showed free surgical margins. Post-operative complications included liver section effusion, pleural effusion, pneumonia, intra-abdomen bleeding and bile leak. All the complications responded well to conservative treatment. No other abnormality was noted during outpatient follow-up examination. All patients survived tumor-free. Conclusions LLR of S8 is still quite challenging at present, and it is our goal to design a reasonable procedure with accurate efficacy and high safety. We use hepatic parenchymal transection-first approach guided by the MHV for LLR of S8. This technique overcomes the problem of high technical risk, greatly reduces the surgical difficulty and achieves technological breakthroughs, but there are still many problems worth further exploration. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02289-8.
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Pulvirenti R, Tognon C, Bisoffi S, Ghidini F, De Corti F, Fascetti Leon F, Antoniello LM, Gamba P. Innovative Techniques Associated with Traditional Abdominal Surgery in Complex Pediatric Cases: A Tertiary Center Experience. CHILDREN-BASEL 2021; 8:children8100898. [PMID: 34682163 PMCID: PMC8534733 DOI: 10.3390/children8100898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/20/2022]
Abstract
Pediatric abdominal surgery is constantly evolving, alongside the advent of new surgical technologies. A combined use of new tools and traditional surgical approaches can be useful in the management of complex cases, allowing less invasive procedures and sometimes even avoiding multiple interventions. This combination of techniques has implications even from the anesthetic point of view, especially in post-operative pain control. Thereby, tertiary level centres, including highly-specialized professionals and advanced equipment, can maximize the effectiveness of treatments to improve the final outcomes. Our paper aims to present some possible combinations of techniques recently used at our institution to provide a one-session, minimally invasive treatment within different areas of abdominal surgery.
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Affiliation(s)
- Rebecca Pulvirenti
- Pediatric Surgery Unit, Women’s and Children’s Health Department, University Hospital of Padua, 35128 Padua, Italy; (S.B.); (F.G.); (F.D.C.); (F.F.L.); (L.M.A.); (P.G.)
- Correspondence: ; Tel.: +39-347-369-6172
| | - Costanza Tognon
- Anesthesiology Pediatric Unit, Women’s and Children’s Health Department, University Hospital of Padua, 35128 Padua, Italy;
| | - Silvia Bisoffi
- Pediatric Surgery Unit, Women’s and Children’s Health Department, University Hospital of Padua, 35128 Padua, Italy; (S.B.); (F.G.); (F.D.C.); (F.F.L.); (L.M.A.); (P.G.)
| | - Filippo Ghidini
- Pediatric Surgery Unit, Women’s and Children’s Health Department, University Hospital of Padua, 35128 Padua, Italy; (S.B.); (F.G.); (F.D.C.); (F.F.L.); (L.M.A.); (P.G.)
| | - Federica De Corti
- Pediatric Surgery Unit, Women’s and Children’s Health Department, University Hospital of Padua, 35128 Padua, Italy; (S.B.); (F.G.); (F.D.C.); (F.F.L.); (L.M.A.); (P.G.)
| | - Francesco Fascetti Leon
- Pediatric Surgery Unit, Women’s and Children’s Health Department, University Hospital of Padua, 35128 Padua, Italy; (S.B.); (F.G.); (F.D.C.); (F.F.L.); (L.M.A.); (P.G.)
| | - Luca Maria Antoniello
- Pediatric Surgery Unit, Women’s and Children’s Health Department, University Hospital of Padua, 35128 Padua, Italy; (S.B.); (F.G.); (F.D.C.); (F.F.L.); (L.M.A.); (P.G.)
| | - Piergiorgio Gamba
- Pediatric Surgery Unit, Women’s and Children’s Health Department, University Hospital of Padua, 35128 Padua, Italy; (S.B.); (F.G.); (F.D.C.); (F.F.L.); (L.M.A.); (P.G.)
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8
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Rocca A, Cipriani F, Belli G, Berti S, Boggi U, Bottino V, Cillo U, Cescon M, Cimino M, Corcione F, De Carlis L, Degiuli M, De Paolis P, De Rose AM, D'Ugo D, Di Benedetto F, Elmore U, Ercolani G, Ettorre GM, Ferrero A, Filauro M, Giuliante F, Gruttadauria S, Guglielmi A, Izzo F, Jovine E, Laurenzi A, Marchegiani F, Marini P, Massani M, Mazzaferro V, Mineccia M, Minni F, Muratore A, Nicosia S, Pellicci R, Rosati R, Russolillo N, Spinelli A, Spolverato G, Torzilli G, Vennarecci G, Viganò L, Vincenti L, Delrio P, Calise F, Aldrighetti L. The Italian Consensus on minimally invasive simultaneous resections for synchronous liver metastasis and primary colorectal cancer: A Delphi methodology. Updates Surg 2021; 73:1247-1265. [PMID: 34089501 DOI: 10.1007/s13304-021-01100-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 05/12/2021] [Indexed: 12/17/2022]
Abstract
At the time of diagnosis synchronous colorectal cancer, liver metastases (SCRLM) account for 15-25% of patients. If primary tumour and synchronous liver metastases are resectable, good results may be achieved performing surgical treatment incorporated into the chemotherapy regimen. So far, the possibility of simultaneous minimally invasive (MI) surgery for SCRLM has not been extensively investigated. The Italian surgical community has captured the need and undertaken the effort to establish a National Consensus on this topic. Four main areas of interest have been analysed: patients' selection, procedures, techniques, and implementations. To establish consensus, an adapted Delphi method was used through as many reiterative rounds were needed. Systematic literature reviews were conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses instructions. The Consensus took place between February 2019 and July 2020. Twenty-six Italian centres participated. Eighteen clinically relevant items were identified. After a total of three Delphi rounds, 30-tree recommendations reached expert consensus establishing the herein presented guidelines. The Italian Consensus on MI surgery for SCRLM indicates possible pathways to optimise the treatment for these patients as consensus papers express a trend that is likely to become shortly a standard procedure for clinical pictures still on debate. As matter of fact, no RCT or relevant case series on simultaneous treatment of SCRLM are available in the literature to suggest guidelines. It remains to be investigated whether the MI technique for the simultaneous treatment of SCRLM maintain the already documented benefit of the two separate surgeries.
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Affiliation(s)
- Aldo Rocca
- Department of Medicine and Health Sciences "V. Tiberio", University of Molise, Campobasso, Italy.
- Center for Hepatobiliary and Pancreatic Surgery, Pineta Grande Hospital, Castel Volturno, Italy.
| | - Federica Cipriani
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Giulio Belli
- Department of General and HPB Surgery, Loreto Nuovo Hospital, Naples, Italy
| | - Stefano Berti
- Department of Surgery, Hospital S Andrea La Spezia, La Spezia, Italy
| | - Ugo Boggi
- Division of General and Transplant Surgery, Pisa University Hospital, Pisa, Italy
| | - Vincenzo Bottino
- Department of Obesity and Metabolic Surgery, Ospedale Evangelico Betania, Naples, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padua, Italy
| | - Matteo Cescon
- General Surgery and Transplant Unit, IRCCS AOU Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Matteo Cimino
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center, IRCCS, Humanitas University, Rozzano, MI, Italy
| | - Francesco Corcione
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Luciano De Carlis
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, School of Medicine, University of Milano-Bicocca, Milan, Italy
| | - Maurizio Degiuli
- Department of Oncology, Digestive and Surgical Oncology, San Luigi University Hospital, University of Torino, Orbassano, Italy
| | - Paolo De Paolis
- General Surgery Department, Ospedale Gradenigo, Turin, Italy
| | - Agostino Maria De Rose
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Domenico D'Ugo
- General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Ugo Elmore
- Vita-Salute San Raffaele University, Milan, Italy
- Division of Gastrointestinal Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Giorgio Ercolani
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Forli, Italy
| | - Giuseppe M Ettorre
- Department of General Surgery and Transplantation, San Camillo-Forlanini General Hospital, Rome, Italy
| | - Alessandro Ferrero
- Department of HPB and Digestive Surgery, Ospedale Mauriziano Umberto I, Turin, Italy
| | - Marco Filauro
- General and Hepatobiliopancreatic Surgery Unit, Department of Abdominal Surgery, E.O. Galliera Hospital, Genoa, Italy
| | - Felice Giuliante
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Salvatore Gruttadauria
- Abdominal Surgery and Organ Transplantation Unit, Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, ISMETT, Palermo, Italy
| | - Alfredo Guglielmi
- Unit of HPB Surgery, Department of Surgery, GB Rossi University Hospital, Verona, Italy
| | - Francesco Izzo
- Divisions of Hepatobiliary Surgery, Istituto Nazionale Dei Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Elio Jovine
- Department of Surgery, AOU Sant'Orsola Malpighi, IRCCS, Bologna, Italy
| | - Andrea Laurenzi
- General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Forli, Italy
| | - Francesco Marchegiani
- Hepatobiliary Surgery and Liver Transplantation Unit, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padua, Italy
| | - Pierluigi Marini
- The Department of General and Emergency Surgery, San Camillo-Forlanini Regional Hospital, Rome, Italy
| | - Marco Massani
- Department of Surgery, Regional Hospital of Treviso, Treviso, Italy
| | - Vincenzo Mazzaferro
- Department of Gastrointestinal Surgery and Liver Transplantation, Fondazione IRCCS Istituto Nazionale Tumori di Milano, Milan, Italy
| | - Michela Mineccia
- Department of General Surgery and Transplantation, San Camillo-Forlanini General Hospital, Rome, Italy
| | - Francesco Minni
- Division of Pancreatic Surgery, Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Andrea Muratore
- General Surgery Unit, E. Agnelli Hospital, Pinerolo, TO, Italy
| | - Simone Nicosia
- Department of Surgery, AOU Sant'Orsola Malpighi, IRCCS, Bologna, Italy
| | - Riccardo Pellicci
- General Surgery Unit, Santa Corona Hospital, Pietra Ligure, SV, Italy
| | - Riccardo Rosati
- Vita-Salute San Raffaele University, Milan, Italy
- Division of Gastrointestinal Surgery, San Raffaele Scientific Institute, Milan, Italy
| | - Nadia Russolillo
- Department of HPB and Digestive Surgery, Ospedale Mauriziano Umberto I, Turin, Italy
| | - Antonino Spinelli
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090, Pieve Emanuele, MI, Italy
- Division of Colon and Rectal Surgery, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Gaya Spolverato
- Surgery Unit, Department of Surgical Oncology and Gastroenterology Sciences (DiSCOG), University of Padua, Padua, Italy
| | - Guido Torzilli
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center, IRCCS, Humanitas University, Rozzano, MI, Italy
| | - Giovanni Vennarecci
- Laparoscopic, Hepatic, and Liver Transplant Unit, AORN A. Cardarelli, Naples, Italy
| | - Luca Viganò
- Division of Hepatobiliary and General Surgery, Department of Surgery, Humanitas Clinical and Research Center, IRCCS, Humanitas University, Rozzano, MI, Italy
| | - Leonardo Vincenti
- Medical Oncology Unit, National Cancer Research Centre, Istituto Tumori Giovanni Paolo II, Bari, Italy
| | - Paolo Delrio
- Colorectal Surgical Oncology-Abdominal Oncology Department, Istituto Nazionale per lo Studio e la Cura dei Tumori, 'Fondazione Giovanni Pascale' IRCCS, 80131, Naples, Italy
| | - Fulvio Calise
- Center for Hepatobiliary and Pancreatic Surgery, Pineta Grande Hospital, Castel Volturno, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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9
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Hiroyoshi J, Ishizawa T, Abe H, Arita J, Akamatsu N, Kaneko J, Ushiku T, Hasegawa K. Identification of Glisson's Capsule Invasion During Hepatectomy for Colorectal Liver Metastasis by Contrast-Enhanced Ultrasonography Using Perflubutane. World J Surg 2021; 45:1168-1177. [PMID: 33392704 DOI: 10.1007/s00268-020-05883-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Glisson invasion by CLM is associated with a risk of margin-positive resection, leading to poor long-term outcomes after hepatectomy. This study was performed to evaluate the efficacy of intraoperative ultrasonography (IOUS) for the diagnosis of Glisson's capsule invasion by colorectal liver metastasis (CLM). METHODS This prospective study involved 50 consecutive patients undergoing hepatectomy for CLM. Preoperatively, all patients had undergone gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI). During hepatectomy, a contrast agent (perflubutane) was intravenously injected and Glisson invasion was estimated based on three characteristic findings: a tumor thrombus, peripheral dilatation, and border irregularity/caliber change. The diagnostic abilities of the preoperative and intraoperative imaging studies were evaluated based on pathological examinations of resected specimens. RESULTS Among 187 CLMs resected, pathological examinations proved Glisson invasion in 24 tumors (13%). IOUS revealed a tumor thrombus in 3 tumors (1.6%), peripheral dilatation in 4 (2.1%), and border irregularity and/or caliber change in 24 (12.8%). The sensitivity and specificity of IOUS with any of the above three findings for diagnosis of Glisson invasion was 79% and 96%, respectively, while preoperative EOB-MRI detected Glisson invasion in only four tumors (sensitivity/specificity, 17%/100%). The cutoff value of caliber change for diagnosis of Glisson invasion was set at 140% by receiver operating characteristic analysis. The R0 resection rates were not significantly different between patients with (82%) and without (85%) Glisson invasion. CONCLUSIONS Identification of characteristic findings (tumor thrombus, peripheral dilatation, and border irregularity/caliber change) by contrast-enhanced IOUS is useful for the prediction of Glisson invasion by CLM.
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Affiliation(s)
- Junko Hiroyoshi
- Department of Surgery, Graduate School of Medicine, Hepato-Biliary-Pancreatic Surgery Division, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takeaki Ishizawa
- Department of Surgery, Graduate School of Medicine, Hepato-Biliary-Pancreatic Surgery Division, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Hiroyuki Abe
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Junichi Arita
- Department of Surgery, Graduate School of Medicine, Hepato-Biliary-Pancreatic Surgery Division, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Nobuhisa Akamatsu
- Department of Surgery, Graduate School of Medicine, Hepato-Biliary-Pancreatic Surgery Division, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Junichi Kaneko
- Department of Surgery, Graduate School of Medicine, Hepato-Biliary-Pancreatic Surgery Division, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Tetsuo Ushiku
- Department of Pathology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Department of Surgery, Graduate School of Medicine, Hepato-Biliary-Pancreatic Surgery Division, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
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10
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Comparison of laparoscopic ultrasound and liver-specific magnetic resonance imaging for staging colorectal liver metastases. Surg Endosc 2020; 35:3547-3553. [PMID: 32710215 DOI: 10.1007/s00464-020-07817-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/10/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Intraoperative liver ultrasound appears superior to liver-specific contrast-enhanced magnetic resonance imaging (MRI) to stage colorectal liver metastases (CRLMs). Most of the data come from studies on open surgery. Laparoscopic ultrasound (LUS) is technically demanding and its reliability is poor investigated. Aim of the study was to assess the accuracy of LUS staging for CRLMs compared to MRI. METHODS All patients with CRLMs scheduled for laparoscopic liver resection (LLR) between 01/2010 and 06/2019 who underwent preoperative MRI were considered for the study. LUS and MRI performance was compared on a patient by patient basis. Reference standards were final pathology and 6 months follow-up results. RESULTS Amongst 189 LLR for CRLMs, 146 met inclusion criteria. Overall, 391 CRLMs were preoperatively detected by MRI. 24 new nodules in 16 (10.9%) patients were found by LUS and resected. Median diameter of new nodules was 5.5 mm (2-10 mm) and 10 (41.6%) were located in the hepatic dome. Pathology confirmed 17 newly detected malignant nodules (median size 4 mm) in 11 (7.5%) patients. Relationships between intrahepatic vessels and tumours differed between LUS and MRI in 9 patients (6.1%). Intraoperative surgical strategy changed according LUS findings in 19 (13%) patients, requiring conversion to open approach in 3 (15.8%) of them. The sensitivity of LUS was superior to MRI (93.1% vs 85.6% whilst specificity was similar (98.6% MRI vs 96.5% LUS). CONCLUSIONS Laparoscopic liver ultrasound improves liver staging for CRLMs compared to liver-specific MRI.
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11
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Troisi RI, Pegoraro F, Giglio MC, Rompianesi G, Berardi G, Tomassini F, De Simone G, Aprea G, Montalti R, De Palma GD. Robotic approach to the liver: Open surgery in a closed abdomen or laparoscopic surgery with technical constraints? Surg Oncol 2020; 33:239-248. [PMID: 31759794 DOI: 10.1016/j.suronc.2019.10.012] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 10/24/2019] [Indexed: 02/07/2023]
Abstract
The application of the minimally invasive approach has shown to be safe and effective for liver surgery and is in constant growth. The indications for laparoscopic surgery are steadily increasing across the field. In the early 2000s, robotic surgery led to some additional improvements, such as tremor filtration, instrument stability, 3D view and more comfort for the surgeon. These techniques bring in some advantages compared to the traditional OLR: less blood loss, shorter admissions, fewer adhesions, and a faster postoperative recovery and better outcomes in case of further hepatectomy for tumor recurrence has been shown. Concerning which is the best minimally invasive approach between laparoscopic and robotic surgery, the evidence is still conflicting. The latter shows good potential, since the endo-wristed instruments work similarly to the surgeon's hands, even with an intact abdominal wall. However, the technique is still under development, burdened by important costs, and limited by the lack of some instruments available for the laparoscopic approach. The paucity of universally accepted and proven data, especially concerning long-term outcomes, hampers drawing univocal acceptance at present. Furthermore, the number of variables related both to the patient and the disease further complicates the decision leading to a treatment tailored to each patient with strict selection. This review aims to explore the main differences between laparoscopic and robotic surgery, focusing on indications, operative technique and current debated clinical issues in recent literature.
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Affiliation(s)
- Roberto Ivan Troisi
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy; Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium.
| | - Francesca Pegoraro
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | | | - Giammauro Berardi
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium
| | - Federico Tomassini
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium
| | - Giuseppe De Simone
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | - Giovanni Aprea
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | - Roberto Montalti
- Department of Public Health, Federico II University Naples, Italy
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
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12
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Guilbaud T, Marchese U, Gayet B, Fuks D. Highlights, limitations and future challenges of laparoscopic resection for colorectal liver metastases. J Visc Surg 2019; 156:329-337. [PMID: 31101548 DOI: 10.1016/j.jviscsurg.2019.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The liver is the most common site for metastatic colorectal cancer (CRLM). Despite advances in oncologic treatment, resection of metastases is still the only curative option. Although laparoscopic surgery for primary colorectal cancer is well documented and widely used, laparoscopic surgery for liver metastases has developed more slowly. However, in spite of some difficulties, laparoscopic approach demonstrated strong advantages including minimal parietal damage, decreased morbidity (reduced blood loss and need for transfusion, fewer pulmonary complications), and simplification of subsequent iterative hepatectomy. Up to now, more than 9 000 laparoscopic procedures have been reported worldwide and long-term results in colorectal liver metastases seem comparable to the open approach. Only one recent randomized controlled trial has compared the laparoscopic and the open approach. The purpose of the present update was to identify the barriers limiting widespread acceptance of laparoscopic approach, the benefits and the limits of laparoscopic hepatectomies in CRLM.
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Affiliation(s)
- T Guilbaud
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, 42, boulevard Jourdan, 75014 Paris, France; Université Paris Descartes, 15, rue de l'école de médecine, 75005 Paris, France.
| | - U Marchese
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, 42, boulevard Jourdan, 75014 Paris, France; Université Paris Descartes, 15, rue de l'école de médecine, 75005 Paris, France
| | - B Gayet
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, 42, boulevard Jourdan, 75014 Paris, France; Université Paris Descartes, 15, rue de l'école de médecine, 75005 Paris, France
| | - D Fuks
- Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste Montsouris, 42, boulevard Jourdan, 75014 Paris, France; Université Paris Descartes, 15, rue de l'école de médecine, 75005 Paris, France
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