| Introduction and ObjectiveModern surgery is trending towards minimally invasive surgery. As the representative of minimally invasive surgical procedure, laparoscopy has been widely used for surgical treatment of visceral diseases. Laparoscopic surgery has been proven to achieve the same therapeutic effect as open surgery and has advantages such as minimal trauma, quick recovery, and a cosmetic incision. Therefore, laparoscopic techniques have been developing rapidly and are now widely used in gastrointestinal surgery, biliary tract surgery, gynecologic surgery, and other fields in which technical specifications and treatment systems have been established. Because the liver is the largest solid organ in the abdominal cavity and has a complicated anatomical structure and important physiological function, laparoscopic liver resection is considered to be a particularly difficult and high-risk surgical procedure. The anatomical complexity of the intrahepatic duct system and highly sophisticated technical requirements have prompted resistance to the development of laparoscopic surgery. Therefore, the current international surgical community has attached great importance to laparoscopic liver surgery and identified new areas of concern associated with this procedure.With the gradual development of laparoscopic technology and constant updating of surgical equipment in recent years, laparoscopic liver resection has undergone rapid technological development worldwide. Advances include surgical sites away from the liver edge, superficial lesions from local excision extended to half of the liver, extended hemihepatectomy and resection of superior-posterior segment of the liver, and for living donor hepatectomy. The application of laparoscopy has been extended from marginal and local resection for benign hepatic diseases to major hepatectomy. Recent literature reports have shown a gradual increase in the number of cases of laparoscopic liver resection and the number of malignant liver tumors in cases of laparoscopic liver resection. The scope of laparoscopic techniques and treatment of liver disease is expanding, illustrating the potential for broad application of this technology.As in traditional open surgery, the dissection of porta hepatis and control of hepatic inflow are important aspects of laparoscopic hepatectomy. Recent studies worldwide have shown that the technical methods of laparoscopic anatomical liver resection are in accordance with those of open surgical procedures, under the laparoscopic dissection of Glissonian pedicle. To isolate and divide the branch of portal vein, hepatic artery and bile duct of the resected liver respectively, liver parenchyma transection was performed after ischemia boundary formed between resected and reserved liver surface.The advantage of this approach is dissected carefully clear for hepatic hilar duct, defect is restricted by vision and instruments operating flexibility. Laparoscopic dissection hepatic hilar duct is difficult, time-consuming, and strenuous, which can cause biliary tract injury, hemorrhage and other complications. In cases of adhesion,fibrosis and translocation in the liver and porta hepatis, the branch of portal vein, hepatic artery and bile duct often cannot isolated and the operation cannot be implemented, and therefore, needs to explore a kind of technique under a safe, feasible, simple, and quick method of porta hepatis dissection laparoscopically.The Glissonian pedicle transection approach in anatomical liver resection involves exposure of the outside aspect of the hepatic pedicle,isolate the portal vein triple structure (portal vein, hepatic artery, and bile duct) outside the sheath, liver parenchyma transection was performed after ischemia boundary formed between resected and reserved liver surface. This operative method was first described in 1986 by the Takasaki, who applied it to open anatomical liver resection. In 2007, Topal and Cho first performed laparoscopic anatomical liver resection by using this method and found it to be safe and feasible. Ikeda and Machado found that the Glissonian pedicle transection approach in laparoscopic liver resection has the advantages of being simple and quick. However, previous studies were either case reports or involved small samples. They therefore provided a low level of evidence in support of operative safety, feasibility, and possible advantages.In this prospective clinical trial, we compared the perioperative and follow-up results between laparoscopic anatomical liver resection by the Glissonian pedicle transection approach with traditional laparoscopic anatomical liver resection and evaluated the safety, effectiveness, feasibility, and possible advantages of the laparoscopic technique. Our objective was to study operative indications, contraindications, and complication-prevention measures; provide a high level of medical evidence for the popularization and application of laparoscopy; and comprehensively analyze this technology in terms of its scope of application and implementation specifications.MethodsIn this prospective, clinical randomized controlled trial, we evaluated patients who underwent laparoscopic anatomical left or right liver resection by either the Glissonian pedicle transection approach or traditional laparoscopic anatomical liver resection. In accordance with the inclusion and exclusion criteria, the data of 143 patients with lesions located in the left or right of the liver from January 2011 to November 2014 were retrieved. According to the surgical technique for the portal hepatis dissection, the patients were assigned to the Glissonian pedicle transection approach group (Glissonian group, n=74) and traditional laparoscopic anatomical liver resection group (traditional group, n= 69). Because extrahepatic bile duct exploration was required for patients with hepatolithiasis, the operating time in these patients was longer than that for patients with liver tumors. Moreover, the technical difficulty, risk, and operation time were different between patients who underwent left and right hemihepatectomy. Therefore, the patients were further divided according to disease and operation method:those with stones, those with tumors, those who underwent left hemihepatectomy, and those who underwent right hemihepatectomy.All patients’ perioperative and postoperative follow-up data were collected. The Glissonian group and traditional group data were stratified and compared, and the perioperative and follow-up results were analyzed. The perioperative results included the overall operation time, portal hepatis dissection time, intraoperative blood loss, perioperative blood transfusion rate, surgical complications, mortality rate, length of hospital stay, postoperative laboratory index changes, and hospitalization expenses. The follow-up results included the rates of residual and recurrent calculi among patients with hepatoliththiasis and tumor metastasis and death among patients with malignant tumors. Survival was analyzed by the Kaplan-Meier method.ResultsOf the 143 patients,131 underwent laparoscopic anatomical liver resection; 12 patients were converted to laparotomy. Laparoscopic anatomical left hemihepatectomy was performed on 101 patients, and anatomical right hemihepateetomy was performed on 42 patients. The mean operation time, intraoperative blood loss, perioperative blood transfusion rate, postoperative gastrointestinal function recovery time, and hospital stay duration were 257± 45 min,370 ± 275 mL,9.1% (13/143),3.0 ± 0.8 days, and 10.9 ± 1.2 days, respectively. No perioperative death occurred. There were no statistically significant differences in the patients’ sex, age, Child-Pugh classification, white blood cell count, blood coagulation function, platelet count, preoperative liver function, or presence of liver cirrhosis between the two groups (P> 0.05). In the Glissonian and traditional groups, the overall operating time was 232 ± 38 vs 284 ± 35 min, respectively (P= 0.000); the portal hepatis dissection time was 28±4 vs 67 ± 10 min, respectively (P= 0.000); and the converting to open surgery rate was 3.96% vs 19.04%, respectively (P= 0.008). The following differences were not statistically significant between the Glissonian and traditional groups (P> 0.05):intraoperative blood loss (343±291 vs 399±256 mL, respectively; P= 0.232), perioperative blood transfusion rate (9.1%[6/74] vs 10.1%[7/69], respectively; P= 0.672), and the incidence of complications (22.97%[17/74] vs 27.54%[19/69], respectively; P= 0.530). The overall operation time and portal hepatis dissection time were shorter in the Glissonian group than in the traditional group. The times required to mobilize the liver, transect the liver parenchyma, remove the specimen, and place the drainage tube were not significantly different between the two groups (P> 0.05). The following variables were also not significantly different between the Glissonian and traditional groups:the postoperative gastrointestinal function recovery time (2.9±0.7 vs 3.0±0.7 days, respectively; P= 0.696), time to leaving the hospital bed (3.6± 1.2 vs 3.7±0.9 days, respectively; P= 0.884), abdominal cavity drainage tube removal time (5.0±0.8 vs 4.9±0.8 days, respectively; P= 0.737), and postoperative hospital stay (10.9± 3.7 vs 11.2±3.5 days, respectively; P= 0.767). In both groups, the postoperative liver function indices, white blood cell count, and blood coagulation function indices peaked on the first postoperative day; they then began to decline after the third postoperative day and recovered to preoperative levels to discharge from the basic. No significant differences were observed in the liver function indices, leukocyte/neutrophil ratio, or coagulation function indices between the two groups on postoperative days 1,3,5, or 7 (P> 0.05). The surgical cost was significantly higher in the Glissonian than the traditional group (62,838 vs 57,143, respectively; P= 0.013).Follow-up results:All patients were followed up until January 2015, and the median postoperative follow-up period was 19 months (range,7-48 months). The overall stone clearance rate was 93.8%(61/65), and the overall stone recurrence rate was 4.6% (3/65). There was no statistically significant difference between the Glissonian and traditional groups in the stone clearance rate (93.9%vs 93.6%, respectively; P= 0.534) or recurrence rate (3.0% vs 6.2%, respectively; P= 0.587). In total,8 of 52 (15.4%) patients developed tumor recurrence; 6 of 52 (4.2%) developed intrahepatic recurrence, and 2 of 52 (3.8%) developed extrahepatic recurrence. Three of 26 (11.5%) patients and 5 of 26 (19.2%) patients in the Glissonian and traditional groups developed tumor recurrence, respectively; the difference was not statistically significant (x2= 4.219, P= 0.062). Overall,5 of 143 (3.5%) patients died (2 of 74 [2.7%] in the Glissonian group and 3 of 69 [4.3%] in the traditional group); the difference was not statistically significant (%2= 0.864, P= 0.353). The 1-and 3-year overall survival rates in the Glissonian and traditional groups were 94.6% vs 84.6% and 92.3% vs 88.5%, respectively, with no statistically significant differences between the groups. The corresponding 1-and 3-year disease-free survival rates were 96.2% vs 84.6% and 88.5% vs 80.8%, respectively, with no statistically significant differences.Conclusions1.This study is the first to provide a high level of evidence that the Glissonian pedicle approach to laparoscopic anatomical liver resection is safe, feasible, simple, and rapid, supporting its future popularization and application.2.Laparoscopic anatomical hepatectomy via the Glissonian pedicle transection approach is suitable not only for left hemihepatectomy, but also for right hemihepatectomy, which requires high technical specification.3.Through a series of clinical cases, this study has demonstrated the indications, contraindications, and complication-prevention measures of the Glissonian pedicle transection approach to laparoscopic anatomical liver resection. This will allow for initial establishment of the applicability and implementation specifications of this operation. |
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