Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Level 5, 20 College Road, Academia, Singapore, 169856, Singapore.
Duke-NUS Medical School, Singapore, Singapore.
Surg Endosc. 2018 Nov;32(11):4658-4665. doi: 10.1007/s00464-018-6310-1. Epub 2018 Jul 2.
BACKGROUND: Several studies published mainly from pioneers and early adopters have documented the evolution of minimally invasive hepatectomy (MIH). However, questions remain if these reported experiences are applicable and reproducible today. This study examines the changing trends, safety, and outcomes associated with the adoption of MIH based on a contemporary single-institution experience. METHODS: This is a retrospective review of 400 consecutive patients who underwent MIH between 2006 and 2017 of which 360 cases (90%) were performed since 2012. To determine the evolution of MIH, the study population was stratified into four equal groups of 100 patients. Analyses were also performed of predictive factors and outcomes of open conversion. RESULTS: Four hundred patients underwent MIH of which 379 (94.8%) were totally laparoscopic/robotic. Eighty-eight (22.0%) patients underwent major hepatectomy and 160 (40.0%) had resection of tumors located in the posterosuperior segments. There were 38 (9.5%) open conversions. Comparison across the four groups demonstrated that patients were older, had higher ASA score, and had increased frequency of previous abdominal surgery and repeat liver resections. There was also an increase in the proportion of patients who underwent totally laparoscopic/robotic surgery, major liver resection, resection of ≥ 3 segments, and multiple resections. Comparison of outcomes demonstrated that there was a significant decrease in open conversion rate, longer operation time, and increased use of Pringles maneuver. The presence of cirrhosis and institution experience (1st 100 cases) were independent predictors of open conversion. Patients who required open conversion had significantly increased operation time, blood loss, blood transfusion rate, morbidity, and mortality. CONCLUSION: The case volume of MIH performed increased rapidly at our institution over time. Although the indications of MIH expanded to include higher risk patients and more complex hepatectomies, there was a decrease in open conversion rate and no change in other perioperative outcomes.
背景：几项主要由先驱者和早期采用者发表的研究记录了微创肝切除术（MIH）的演变。然而，这些报告的经验是否适用于并可重现于今日仍存在疑问。本研究根据单一机构的当代经验，检查了与 MIH 采用相关的变化趋势、安全性和结果。
方法：这是一项回顾性研究，共纳入了 2006 年至 2017 年间接受 MIH 的 400 例连续患者，其中 360 例（90%）是在 2012 年后进行的。为了确定 MIH 的演变，将研究人群分为 4 个相等的 100 例患者组。还分析了开放转换的预测因素和结果。
结果：400 例患者接受了 MIH，其中 379 例（94.8%）为完全腹腔镜/机器人手术。88 例（22.0%）患者接受了大肝切除术，160 例（40.0%）患者切除了后上节段的肿瘤。有 38 例（9.5%）发生了开放转换。四个组之间的比较表明，患者年龄更大，ASA 评分更高，且有更多的腹部手术和再次肝切除术史。完全腹腔镜/机器人手术、大肝切除术、切除≥3 个节段和多次切除的比例也有所增加。比较结果表明，开放转化率、手术时间延长和普林格尔操作的使用增加显著。肝硬化和机构经验（前 100 例）是开放转换的独立预测因素。需要开放转换的患者手术时间、出血量、输血率、发病率和死亡率显著增加。
结论：随着时间的推移，本机构 MIH 的手术量迅速增加。尽管 MIH 的适应证扩大到包括高危患者和更复杂的肝切除术，但开放转化率下降，其他围手术期结果无变化。
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