Laparoscopic Liver Resections: A Feasibility Study in 30 Patients

Discussion

Prof. D. Jaeck (Strasbourg, France): First, Daniel, I congratulate you because I enjoyed your nice presentation. You showed that laparoscopic liver resection is feasible, and that in your hands it is safe! However, I would like to discuss the indications of this approach. It is clear that for benign lesions we are not allowed to have morbidity or any mortality. So we want to be sure to have at least the same results as in open surgery. For cancer, as you discussed particularly in the conclusion, you did not prove that it is as safe and as efficient as open surgery. So, which are the real advantages? Cost? Probably not, because we need more sophisticated instruments. Time? Certainly not, because you showed that hospital stay and duration of the procedure are the same as for open surgery. Blood loss is at least the same as with open surgery, perhaps even more. Morbidity seems to be the same, and your conclusion was that the potential benefit, if you do not consider the benign disease, could be obtained in case of hepatocellular carcinoma in cirrhotic patients. So I would like to ask if you could tell us more precisely for which type of tumor (location, stage) and in which kind (Child-Pugh stage) of cirrhotic patients you would propose a laparoscopic resection.

Prof. D. Cherqui (Créteil, France): Concerning benign lesions, I do not see that the risk has been increased in this study compared to open surgery. Indeed, there were no complications in patients with benign disease in this study. We did not perform these procedures until we were confident that we did not expose the patients to a higher risk. The operations were performed collaboratively by two surgeons, one expert in liver surgery and one expert in laparoscopic surgery. The patients were selected because they had a small and peripheral lesion. As soon as we felt that either exposure or minor bleeding was a problem, we converted to open surgery, and this occurred in two of the 30 cases.

Concerning patients with malignant lesions, who represent the majority of indications of liver resections, there is a concern about the possibility of tumor seeding. We chose to use laparoscopic resections in patients with hepatocellular carcinoma and cirrhosis with the aim of reducing morbidity, which is high in these patients. There is evidence that part of the morbidity is related to the abdominal wall incision, with division of collateral circulation. We anticipated that there would be less postoperative ascites, and indeed, although this is not controlled data, only one patient developed ascites. Ascites is usually reported in 30% to 50% of the cases, even after small resections by open surgery in cirrhotic patients. We excluded patients with colorectal metastases from this study because the use of laparoscopy is presently a controversial issue in colorectal cancer, even for the resection of the primary tumor. Patients with small colorectal metastases are operated on for cure, so at the present time we are waiting for the results of controlled studies in progress for laparoscopic resection of the primary colorectal tumors. However, patients with primary colorectal tumors may have peritoneal invasion, which has a higher risk of dissemination, while liver metastases are very rarely associated with peritoneal invasion. For patients with breast metastases, we used laparoscopy because these patients often have very small lesions that one cannot detect on preoperative imaging. Initial laparoscopy permitted us to avoid unnecessary laparotomy in such cases and to proceed with laparoscopic resection in other cases.

Prof. A. Johnson (Sheffield, United Kingdom): This is an interesting paper on technique, but the indications in about half the cases might be questioned (e.g., FNH with good MRI scans and secondary breast tumors). You state that the benefit is clear in young people, but I still think you have to prove that for the indications that would be generally agreed. The particular group in which this technique might be helpful are cirrhotic patients, but as you were only operating on grade A liver tissue, you would not expect much postoperative ascites. I wonder if you measured the metabolic response, because studies in gallbladder surgery show that the pneumoperitoneum itself produces a tremendous increase in antidiuretic and other hormones. The laparoscopic approach could actually be increasing, rather than decreasing, the problem of ascites. It is a very long operation, unnecessarily long for benign disease, and if you add up the length of all your incisions there is quite significant damage to the abdominal wall, 9 or 10 cm perhaps. One question about technique: you said you put a sling around the right hepatic and middle hepatic veins. If you did make a hole there, there is a real risk of a gas embolus with the pneumoperitoneum. Did you always do that, or was it only used on certain occasions? Two final questions: did you do any comparative costings, compared with the open procedure, and why did the patients stay in for so long after the laparoscopic resection?

Prof. D. Cherqui (Closing Discussion): Concerning the indications, I did not have time to show them to you here, but in our institution, many patients with benign lesions found incidentally at ultrasound are referred for diagnosis, and these include mainly young women. We see about 60 new cases of focal nodular hyperplasia (FNH) every year. Presently, noninvasive diagnosis is obtained in 80% of these patients just by CT and MRI scans. In the remaining 20%, diagnosis cannot be obtained by these means and a biopsy is required. Our previously reported policy is to undertake laparoscopic biopsy. The reason is that we get a large specimen for histologic diagnosis. In more than half of the cases, frozen-section study gives us the diagnosis. If it says FNH, we do not resect and the procedure is limited to laparoscopy, with the patient out of hospital the day after. So it is only a very small percentage of the patients with FNH that undergo resection, including the rare patients with symptoms and those in whom the pathologist cannot diagnose FNH. The latter are atypical FNHs that can only be diagnosed on the full specimen, therefore requiring resection for diagnosis.

For breast tumor metastases, there is no consensus so far as to the benefit of liver resection. However, in selected patients, the prognosis seems related to the liver lesions, and there are several articles in the literature advocating liver resection of isolated and limited breast metastases. Several cases are proposed every year. Only a few are operated on, but occasional long-term survival is observed. Indeed, we only operated on Child A patients because this is, for us, the only indication. In Child B patients with small hepatocellular carcinoma, we never consider resection and we would rather do transplantation. In Child A patients, there are several options. When the tumor is superficial, we believe that it is not an indication for percutaneous treatment because this would open the tumor in the peritoneum. So we propose resection of superficial tumors and do it by laparoscopy when feasible. The sling around the middle and left hepatic vein must be placed cautiously, and we did not observe any case of gas embolus. It is true that numerous port sites are required to perform this procedure, plus an extraction incision. However, this is the case for most complex laparoscopic procedures. I do not think that you can sum up all small incisions and say it is equal to one large laparotomy with fascia and muscle division. Finally, laparoscopic liver resection is certainly more expensive at the present time, but the primary goal is to be less invasive, and hopefully costs will be reduced in the future.