Major hepatectomy is a high-risk procedure used to remove
approximately half of a patient's liver and is the treatment of choice
for many cancers involving the liver.
For patients who may benefit from this major liver operation to treat
cancer, an open abdominal procedure is often the only option. However, a
minimally invasive approach that avoids the large open incision may
soon be a viable alternative, revealed the results from a multicenter
study presented at the 2016 Clinical Congress of the American College of
‘The odds of serious morbidity, including major bleeding, serious infections, organ failure, and death, were significantly lower after major liver resection performed by minimally invasive surgery.’
The researchers evaluated 1,015 major liver resections
(hepatectomies) performed in 2014 at 65 hospitals that participate in
the American College of Surgeons National Surgical Quality Improvement
Program (ACS NSQIP®) Hepatopancreaticobiliary Collaborative. Of those
procedures, 13%, or 132, were performed using minimally invasive
surgery (MIS), the rest were performed using open operations. This
research is the largest multicenter study to date evaluating outcomes
after MIS major liver resection.
Lucas W. Thornblade, a general surgery resident at the University of
Washington, Seattle, said, "Our study results showed that the odds of
serious morbidity, including major bleeding, serious infections, organ
failure, and death, were significantly lower after major liver resection
performed by MIS."
In this study, the odds of death or serious complications in the
short term for liver cancer patients who had MIS was about half that of
those who had the conventional open procedure. Risk of bile leak, liver
failure, a second operation, or readmission were similar between the
two types of operations.
Dr. Thornblade and his coauthors undertook the study to evaluate
the use of MIS in more challenging cases. "There has not been
convincing evidence to support the routine use of MIS in these more
challenging liver resections," Dr. Thornblade said. "But the ACS NSQIP
registry recently began collecting data on hepatectomies. This new data
presented a unique opportunity to look at a larger group of patients
who are having these more challenging operations," he explained.
During MIS, the surgeon inserts instruments through small
incisions, or ports, and with the guidance of a camera, controls the
surgical instruments inside the abdominal cavity to perform the steps of
The advantages of MIS are well known. While the carbon dioxide
gas used to inflate the abdominal cavity during MIS helps to lessen
blood loss, MIS liver resection has some inherent challenges, according
to Dr. Thornblade. "When performing MIS, the surgeon has limited access
to control the blood vessels and that limitation certainly presents a
risk of major bleeding," he said. "Also, the ability to expose the
targeted part of the organ during MIS is different than it is with an
open liver procedure."
The location of the tumor and its relationship to major blood
vessels are factors the surgeon takes into consideration when deciding
if MIS is feasible. Hence, depending on the surgeon's experience and
comfort level, MIS may only be an option when the tumor is accessible
with the surgical instruments.
Another challenge is that MIS liver procedures are not widely
available. "One factor that may limit the ability of a patient to
undergo MIS liver resection is access to a surgeon who is trained in
this procedure," Dr. Thornblade said. "There is a significant learning
curve to mastering MIS approaches to liver resection, and in order to
see enough cases to become skillful in MIS resection, liver surgeons
need to practice in a high-volume setting."
In 2015, an expert panel on minimally invasive surgery, the
Second International Consensus Conference on Laparoscopic Liver
Resection, issued a statement that MIS for major liver resection is
still considered an innovative procedure. "Our study helps to
contribute to that fund of knowledge," Dr. Thornblade said. "Our
findings indicate that the odds of a favorable outcome for MIS major
liver resection are significantly better, in selected cases, among
surgeons who participate in NSQIP."
"However, more information is needed on long-term disease
recurrence and survival after MIS liver procedures," Dr. Thornblade
said. "There may come a time in the United States when we are
interested in developing a trial to look at long-term outcomes with MIS