Laparoscopic liver resection

More than 3,000 laparoscopic liver resections (LLR) are performed worldwide for benign disease, malignancy, and living donor hepatectomy. Minimally invasive hepatic resection approaches include pure laparoscopic, hand-assisted laparoscopic, and a laparoscopic-assisted open "hybrid" approach, where the operation is started laparoscopically to mobilize the liver and begin the dissection, followed by a small laparotomy for completion of the parenchymal transection. Surgeons should have an advanced understanding of hepatic anatomy, extensive experience in open liver surgery, and technical skill to control major vascular and biliary structures laparoscopically before embarking on LLR. Although there is no absolute size criterion, smaller, peripheral lesions (<5 cm) that lie far from major vessels and anticipated transection planes are most amenable to LLR. Although the majority of reported LLR are non-anatomic resections or segmentectomies, several surgical groups are now performing laparoscopic major hepatic resections with excellent safety profiles. Patient benefits from LLR include less operative blood loss, less postoperative pain and narcotic requirement, and a shorter length of hospital stay, with comparable postoperative morbidity and mortality to open liver resection. Comparison studies between LLR and open resection have revealed no differences in width of resection margins for malignant lesions or overall survival after resection for hepatocellular cancer or colorectal cancer liver metastases. Advantages of LLR for HCC in particular include avoidance of collateral vessel ligation, decreased postoperative hepatic insufficiency, and fewer postoperative adhesions, all of which are features that enhance subsequent liver transplantation.