**4. Laparoscopic resection in cirrhotics**

As noted above, the cirrhotic patient represents a unique challenge to the laparoscopic liver surgeon. The possibility of postoperative liver failure resulting from inadequate remnant liver function is a dreaded complication to be avoided at all costs. One technique that can potentially prevent this problem is the use of preoperative portal vein embolization (PVE). The effectiveness of PVE is based on the remarkable regenerative capacity of the liver. The technique involves occlusion of the tumor bearing segments of the liver, which induces hypertrophy in the remaining hepatic segments. Generally, reimaging 6 weeks after PVE is performed to assess the adequacy of hypertrophy to provide an adequate future liver remnant. Failure to achieve adequate hypertrophy indicates a severely diseased liver that is not amenable to resection.

A meta-analysis of PVE has been found that the procedure is safe and able to induce adequate hypertrophy to reduce post resection liver failure in a considerable proportion of patients (Abulkhir, A et al 2008). Preoperative PVE is currently recommended in cirrhotic patients with predicted future liver remnant of less than 40%. For centers using ICG retention, values of 10-19% with a FLR of 40-60% also represents an indication for portal vein embolization (Rahbari, NN et al 2011).

For cirrhotic patients able to undergo liver resection, laparoscopy provides a number of unique benefits. The smaller incisions cause less disruption of the abdominal wall collateral circulation. As complete evacuation of ascites is not necessary for a laparoscopic procedure, intraoperative fluid shifts are lessened. This contributes to the reduction in postoperative ascites seen with laparoscopy compared to open hepatectomy (Dagher, I et al 2009; Gigot, JF et al 2002). Another unique benefit is the reduced adhesion formation following laparoscopic surgery. For patients undergoing resection of HCC, salvage transplantation remains an important option for recurrences that are within the Milan criteria. Laurent found that liver transplants following laparoscopic compared to open resection were performed in less time, with less blood loss and transfusion requirement (Laurent, A et al 2009). Similarly, Belli has found repeat hepatectomy following initial laparoscopic resection to be faster and safer, with less blood loss and risk of visceral injury (Belli, G et al 2009a).

#### **5. Development of a laparoscopic liver resection program**

The recent international consensus conference on laparoscopic liver surgery has developed guidelines for the establishment and credentialing of a laparoscopic liver surgery program

limited resection as been shown to be beneficial in the setting of cirrhosis (Rahbari, NN et al

Despite the limitations imposed by the greater difficulties in technical resection and patient selection, laparoscopic resection has proven to be a safe and effective alternative to open surgery in appropriately selected patients. Lai has demonstrated 5 year survival of 50%, with disease free survival of 36%, while Dagher has shown 5 year overall and disease free survival of 64.9% and 32.2%, respectively (Dagher, I et al 2010; Lai, EC et al 2009). Others have shown laparoscopic resection to be associated with lower morbidity and postoperative ascites compared to open resection (Belli, G et al 2009b). Although hepatocellular carcinoma in the setting of cirrhosis represents the most difficult of diseases to approach via laparoscopy, these results show that the technique is safe and effective when performed in

As noted above, the cirrhotic patient represents a unique challenge to the laparoscopic liver surgeon. The possibility of postoperative liver failure resulting from inadequate remnant liver function is a dreaded complication to be avoided at all costs. One technique that can potentially prevent this problem is the use of preoperative portal vein embolization (PVE). The effectiveness of PVE is based on the remarkable regenerative capacity of the liver. The technique involves occlusion of the tumor bearing segments of the liver, which induces hypertrophy in the remaining hepatic segments. Generally, reimaging 6 weeks after PVE is performed to assess the adequacy of hypertrophy to provide an adequate future liver remnant. Failure to achieve adequate hypertrophy indicates a severely diseased liver that is

A meta-analysis of PVE has been found that the procedure is safe and able to induce adequate hypertrophy to reduce post resection liver failure in a considerable proportion of patients (Abulkhir, A et al 2008). Preoperative PVE is currently recommended in cirrhotic patients with predicted future liver remnant of less than 40%. For centers using ICG retention, values of 10-19% with a FLR of 40-60% also represents an indication for portal

For cirrhotic patients able to undergo liver resection, laparoscopy provides a number of unique benefits. The smaller incisions cause less disruption of the abdominal wall collateral circulation. As complete evacuation of ascites is not necessary for a laparoscopic procedure, intraoperative fluid shifts are lessened. This contributes to the reduction in postoperative ascites seen with laparoscopy compared to open hepatectomy (Dagher, I et al 2009; Gigot, JF et al 2002). Another unique benefit is the reduced adhesion formation following laparoscopic surgery. For patients undergoing resection of HCC, salvage transplantation remains an important option for recurrences that are within the Milan criteria. Laurent found that liver transplants following laparoscopic compared to open resection were performed in less time, with less blood loss and transfusion requirement (Laurent, A et al 2009). Similarly, Belli has found repeat hepatectomy following initial laparoscopic resection to be faster and safer, with less blood loss and risk of visceral injury (Belli, G et al 2009a).

The recent international consensus conference on laparoscopic liver surgery has developed guidelines for the establishment and credentialing of a laparoscopic liver surgery program

**5. Development of a laparoscopic liver resection program** 

centers that have acquired the appropriate experience.

**4. Laparoscopic resection in cirrhotics** 

vein embolization (Rahbari, NN et al 2011).

not amenable to resection.

2011).

(Buell, JF et al 2009b). Prior to embarking upon beginning a program in laparoscopic liver surgery, it is necessary to acquire experience with both advanced laparoscopy and open hepatic surgery. These requirements have made the widespread adoption of laparoscopic liver surgery appropriately slow. As advanced laparoscopy becomes an increasingly important part of general surgery training programs, these prerequisites will become less of a hurdle, with the expected more rapid acceptance of laparoscopic liver surgery.

After establishing the necessary expertise in laparoscopy and open hepatic surgery, the ideal starting point is small, benign lesions in the periphery of the liver. Extensive use of hand assistance is also critical in reducing the learning curve. Koffron has described the hybrid technique, in which mobilization of the liver is performed laparoscopically, and parenchymal transection is then performed in an open fashion through the hand port incision (Koffron, AJ et al 2007). He has termed this approach "laparoscopic liver surgery for everyone," and we agree that this approach represents an ideal starting point for a laparoscopic liver program.

Once comfortable with performing more limited resections, the next step in development is the performance of major, anatomic resections. In this setting, the left lateral segmentectomy is the ideal starting point. Although much attention is given to the parenchymal transection phase, it should be noted that the greatest risk for vascular injury and subsequent conversion to an open procedure is actually during the mobilization phase. The most commonly injured vessel in this setting is the phrenic vein, which must be carefully identified and avoided. Conversion, as we have emphasized previously, should not be viewed as a failure or complication. Instead, the decision to convert to an open or hand assisted procedure rather than continue with a potentially unsafe situation laparoscopically is a mark of good surgical judgment.

Experience with resection of lesions located in the peripheral segments of the liver provides a foundation of skills, including mobilization, transection, hemostasis, and laparoscopic ultrasound. Once this fundamental skill set has been developed thoroughly, the surgeon is then able to proceed to more difficult lesions. At this point, malignant and/or large lesions located in the right and posterior segments of the liver can then be approached in the culmination of programmatic development. We have found that facility with minor resections can be achieved in 30 to 50 cases. More difficult resections such as formal lobectomy and right posterior resection require an additional 60 to 80 cases to master. Thus, the road to development of a laparoscopic liver resection program is long and often arduous, but is highly rewarding to both the surgeon and the patient when properly travelled.
