Cipriani Federica, Ratti Francesca, Fiorentini Guido, Catena Marco, Paganelli Michele, Aldrighetti Luca
Hepatobiliary Surgery Division, San Raffaele Hospital , Milan, Italy .
J Laparoendosc Adv Surg Tech A. 2018 Jul;28(7):785-791. doi: 10.1089/lap.2018.0071. Epub 2018 Mar 28.
Previous abdominal surgery has traditionally been considered an additional element of difficulty to later laparoscopic procedures. The aim of the study is to analyze the effect of previous surgery on the feasibility and safety of laparoscopic liver resection (LLR), and its role as a risk factor for conversion.
After matching, 349 LLR in patients known for previous abdominal surgery (PS group) were compared with 349 LLR on patients with a virgin abdomen (NPS group). Subgroup analysis included 161 patients with previous upper abdominal surgery (UPS subgroup). Feasibility and safety were evaluated in terms of conversion rate, reasons for conversion and outcomes, and risk factors for conversion assessed via uni/multivariable analysis.
Conversion rate was 9.4%, and higher for PS patients compared with NPS patients (13.7% versus 5.1%, P = .021). Difficult adhesiolysis resulted the commonest reason for conversion in PS group (5.7%). However, operative time (P = .840), blood loss (P = .270), transfusion (P = .650), morbidity rate (P = .578), hospital stay (P = .780), and R1 rate (P = .130) were comparable between PS and NPS group. Subgroup analysis confirmed higher conversion rates for UPS patients (23%) compared with both NPS (P = .015) and PS patients (P = .041). Previous surgery emerged as independent risk factor for conversion (P = .033), alongside the postero-superior location and major hepatectomy.
LLR are feasible in case of previous surgery and proved to be safe and maintain the benefits of LLR carried out in standard settings. However, a history of surgery should be considered a risk factor for conversion.
传统上，既往腹部手术一直被视为后续腹腔镜手术难度增加的一个因素。本研究旨在分析既往手术对腹腔镜肝切除术（LLR）可行性和安全性的影响，及其作为中转开腹危险因素的作用。
经过匹配，将349例有既往腹部手术史的患者行LLR（PS组）与349例初次接受腹部手术的患者行LLR（NPS组）进行比较。亚组分析包括161例有既往上腹部手术史的患者（UPS亚组）。通过中转率、中转原因和结局评估可行性和安全性，并通过单因素/多因素分析评估中转的危险因素。
中转率为9.4%，PS组患者的中转率高于NPS组患者（13.7%对5.1%，P = 0.021）。粘连松解困难是PS组中转的最常见原因（5.7%）。然而，PS组和NPS组之间的手术时间（P = 0.840）、失血量（P = 0.270）、输血情况（P = 0.650）、发病率（P = 0.578）、住院时间（P = 0.780）和R1切除率（P = 0.130）相当。亚组分析证实，UPS组患者的中转率高于NPS组（P = 0.015）和PS组患者（P = 0.041）。除了肝后上区位置和肝大部切除术外，既往手术是中转的独立危险因素（P = 0.033）。
既往有手术史的情况下LLR是可行的，且被证明是安全的，并能保持在标准情况下进行LLR的益处。然而，手术史应被视为中转的危险因素。
