2007

Advances in Liver Surgery: Minimally Invasive Surgery for Liver Tumors and Cysts

• The liver is one of the last anatomic areas to be considered for laparoscopic surgical approaches because of technical complexities and the risk of bleeding.
• Improvements in laparoscopic surgical instruments and hemostatic devices and increased experience with minimally invasive approaches in liver surgery have reduced the risks.
• Primary benign and malignant liver tumors, metastatic lesions, and symptomatic cystic lesions of the liver can be safely removed or treated using innovative laparoscopic approaches.
• Advantages of laparoscopic surgery include reduced pain, hospital stay, wound complications, and recovery time.

The Challenge

Malignant tumors of the liver typically require resection for chance of cure. For both benign and malignant lesions, an uncomplicated and expedient recovery is desirable. In the past, hepatic resection required a large abdominal incision, frequently spanning the width of the abdomen. Expected hospital stays were 5 to 7 days, and recovery required an additional 6 weeks at home. These larger incisions pose a greater risk of wound complications such as infection, hernia, and chronic pain that has prompted the desire for minimally invasive approaches.

New Technology Leads to New Approaches

Over the past decade, improved surgical instrumentation and new hemostatic devices have allowed minimally invasive laparoscopic hepatic resection at Mayo Clinic and other multidisciplinary practices specializing in hepatic surgery. Primary benign and malignant liver tumors, metastatic lesions, and symptomatic cystic lesions of the liver can be safely removed by laparoscopy when deployed by experienced hepatic surgical teams. These minimally invasive approaches can also be combined with radiofrequency ablation techniques for the treatment of multiple tumors in selected patients.

Enlarge

Laparoscopic surgery requires 4 to 6 small (1.5 cm) incisions through which the laparoscope and other instruments are inserted. Extraction of larger specimens is accomplished through extension of one of these incisions or through lower abdominal surgical scars such as an appendectomy or cesarean delivery site. Initial results appear equal to those of open surgery with regard to efficacy. Advantages of laparoscopic approaches are reduced morbidity and improved quality of life, which may be particularly important in higher-risk patients. Hospital stays are typically shortened, and recovery time is reduced. Many patients have only minimal discomfort within a few days and typically resume normal activities within a few weeks. Because laparoscopic hepatic resection is fairly new, adequate trials evaluating outcomes are still under way. Results are expected in late 2007.

Indications for Laparoscopic Liver Surgery

Most patients considered for open hepatic resection are likely to be considered for laparoscopic resection as well. Optimal candidates for laparoscopic resection have had few previous upper abdominal operations, have more peripherally located hepatic tumors, and have no evidence of extrahepatic metastatic disease.

Patients with very large, deep, centrally located tumors and those with previous extensive upper abdominal or liver operations are poor candidates for laparoscopic hepatic resection. Importantly, patients with severe cardiopulmonary disease who are poor candidates for open hepatic resection are seldom candidates for laparoscopic approaches.