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Laparoscopic Two-stage Hepatectomy

dIscussIon comparable or slightly better in terms of intraoperative bleeding
In two-stage hepatectomy, complication rates have varied from 0 to and duration of hospital stay than the same measures in 61 patients
with an open approach.
1
30% 2,10,11 for the first stage and ranged up to 60% for the second. According to previous reports regarding laparoscopic
Higher complication rates after second-stage surgery are widely two-stage hepatectomy (Table 3), laparoscopic second-stage
acknowledged and likely are related to prolonged prehepatectomy hepatectomy was completed in 58 of 82 patients (70.7%). This
chemotherapy, complicated surgical procedures, and massive high completion rate for laparoscopic second resection could be
12
volumes of liver resection. Advantages of laparoscopic approach explained by the restriction of some studies to patients eligible
to liver resection have been well described, including less for laparoscopic resection at both stages and also by stringent
postoperative pain, fewer intra-abdominal adhesions, and shorter criteria, including a limited number of liver metastases. The
hospital stays. 13–15 Recently, laparoscopic approaches are gradually mean or median total number of metastatic tumors was about
being applied to two-stage hepatectomy, 16–20 offering the benefit 5 in these reported series; such a small number of metastases
of less invasiveness. However, overall surgical feasibility of two- might have been managed with only a single hepatectomy
stage hepatectomy using a laparoscopic approach remained an in some instances. Further, the mortality rate in two reports in
ongoing concern. Table 3 18,20 with a high completion rate for laparoscopic resections
In this study, the total number of metastases tended to be in both stages was about 3%, which is similar to or slightly greater
smaller in patients undergoing the laparoscopic approach than than mortality in open two-stage hepatectomy. 2,10,11,20 Based
in those treated with an open approach. However, as expected, on these results, laparoscopic second-stage resection should
laparoscopy decreased length of the operation and the hospital be limited to patients with relatively few remaining metastases.
stay and was associated with somewhat fewer postoperative General application of laparoscopic resection to both stages now
complications after first-stage hepatectomy. The laparoscopic first- remains an elusive goal.
stage approach provoked fewer adhesions, which should facilitate Given our small numbers of patients, long-term results would
the second stage. be difficult to generalize. However, at this writing, all three patients
Generally, inflammation of the portal pedicle after PVE is remain alive at 90, 445, and 1,345 postoperative days. Some
associated with dense abdominal and perihepatic adhesions, and controversy exists regarding the risk of compromising oncologic
anatomy is distorted by liver hypertrophy following the previous principles when a minimally invasive approach is adopted. However,
resection. As a result, laparoscopic second-stage hepatectomy recently reported long-term results for patients with laparoscopic
can be technically challenging, requiring exceptional expertise two-stage hepatectomy were comparable to results for open two-
in both laparoscopic maneuvers and hepatobiliary surgery. A stage hepatectomy. A laparoscopic approach might not adversely
20
hybrid procedure combining laparoscopic and open approaches affect the oncologic course of patients with two-stage hepatectomy
for the second hepatectomy is the least invasive strategy that we for bilobar colorectal liver metastases.
now can apply. Unfortunately, multiple small resections within
the deportalized liver in lieu of major hepatectomy via an open
approach were required in two patients with insufficient functional conclusIon
hypertrophy according to liver function parameters compromised Our preliminary data support the feasibility and safety of the
by perioperative chemotherapy. The other patient could not laparoscopic approach for first-stage liver resection. Advantages
tolerate right hemihepatectomy, so we performed posterior of first-stage laparoscopic hepatectomy include fewer adhesions
sectionectomy extended to segment 8 using a hybrid approach. and rapid postoperative recovery. This approach should be
In spite of these limitations, our short-term outcome was offered to patients with relatively small numbers of tumors who

Table 3: Reported series of laparoscopic two-stage hepatectomy
No. of Approach (pure/ Morbidity, Hospital stay,
patients conversion/open) Duration, minute Blood loss, mL % days Overall
First/ No. of PVE First/ First/ First/ First/ First/ mortality,
Authors Second tumors performed Second Second Second Second Second %
Di Fabio 16 8/8 4 (2–6) 7 8/0/0 139 ± 45/ 132 ± 103/ 0/50 6 (4–10)/ 0
2/1/5 243 ± 85 1,225 ± 468 15.5 (6–43)
Sandri 17 4/4 4 4/0/0 189/304 22/425 0 3.5/8 0
0/0/4 —
Fuks 18 34/26 6.0 ± 7.1 20 32/2/0 210 ± 114/ 150 ± 143/ 50/54 6.1 ± 5.2/ 3
22/4/0 250 ± 139 250 ± 203 9 ± 8.2
Kilburn 19 7/6 4 (3–10) 7 7/0/0 100 (60–170)/ 100 (50–400)/ 0/50 3 (2–5)/ 0
0/1/5 158 (120–220) 420 (100–600) 6.5 (5–23)
Okumura 20 38/38 6 (2–13) 25 37/1/0 159 (70–415)/ 50 (0–350)/ 16/26 6 (0–34)/ 2.6
34/4/0 305 (150–480) 225 (50–1,300) 9 (4–49)
No., number; PVE, portal vein embolization; pure, pure laparoscopic; conversion, conversion from laparoscopic to open surgery; open, open- abdomen;
first, first hepatectomy; second, second hepatectomy. Data are expressed as the mean ± standard deviation or the median followed by range in
parentheses

World Journal of Laparoscopic Surgery, Volume 14 Issue 2 (May–August 2021) 93