Department of Endocrine Surgery, Cleveland Clinic, 9500 Euclid Ave/F20, Cleveland, OH, 44195, USA.
Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA.
Surg Endosc. 2020 Feb;34(2):536-543. doi: 10.1007/s00464-019-06789-9. Epub 2019 Apr 8.
Laparoscopic liver resection (LLR) of posterosuperior (PS) segment liver tumors is technically challenging with confusion about optimal patient positioning and trocar placement (i.e., transabdominal vs. transcostal). The aim of this study is to describe our technique and outcomes with LLR of these tumors.
This is an IRB-approved retrospective review of a prospective database. Between 2005 and 2017, patients with benign and malignant lesions underwent LLR. Perioperative outcomes of PS (segments 4A, 7, and 8) and anterolateral (AL) resections were compared. All patients were operated through intra-abdominal trocars in the supine position.
304 patients underwent LLR for AL (n = 217) and PS (n = 87) segmental lesions. Minor liver resections were performed in 274 patients and major resections in 30. Groups were comparable for age, sex, pathology, and tumor size (mean 4.2 and 3.7 cm for AL and PS). Inflow occlusion was more frequently performed for PS resections, but precoagulation rates were similar. PS resections more frequently required hand assistance (50% vs. 20%, p < 0.001) and conversion to open (18% vs. 7%, p = 0.04). For PS versus AL resections, operative time (253 vs. 205 min, p ≤ 0.001) was longer and associated with more blood loss (307 vs. 211 mL, p < 0.001) and more frequent need for blood transfusion (15% vs. 7%, p = 0.04). However, the rate of negative resection margin, 90-day complication rates, and length of stay were similar between the two groups.
This study shows that LLR of PS located liver tumors is more challenging compared to AL lesions. Nevertheless, it can be performed successfully in the majority of patients with supine positioning and intra-abdominal trocar placement, without compromising oncologic principles. Liberal uses of hand assistance and inflow occlusion were the technical tips helping us to successfully resect these tumors laparoscopically.
腹腔镜下肝脏切除术（LLR）治疗后上（PS）段肝脏肿瘤具有一定的技术难度，尤其是在患者体位和套管位置（经腹腔 vs. 经胸壁）的选择方面存在混淆。本研究旨在描述我们采用 LLR 治疗这些肿瘤的技术和结果。
这是一项经机构审查委员会批准的回顾性分析，纳入了前瞻性数据库中的患者。2005 年至 2017 年间，良性和恶性病变患者接受了 LLR。比较 PS（段 4A、7 和 8）和前外侧（AL）切除的围手术期结果。所有患者均在仰卧位下通过腹腔内套管进行手术。
304 例患者接受了 AL（n=217）和 PS（n=87）段肝脏肿瘤的 LLR。274 例患者行小范围肝切除术，30 例患者行大范围肝切除术。两组患者在年龄、性别、病理和肿瘤大小方面具有可比性（AL 和 PS 组的平均肿瘤直径分别为 4.2cm 和 3.7cm）。PS 段切除术更常使用入肝血流阻断，但预凝率相似。PS 段切除术更常需要手助（50% vs. 20%，p<0.001），且更常需要转为开放性手术（18% vs. 7%，p=0.04）。与 AL 切除术相比，PS 切除术的手术时间更长（253min vs. 205min，p≤0.001），出血量更多（307ml vs. 211ml，p<0.001），输血需求更频繁（15% vs. 7%，p=0.04）。然而，两组的切缘阴性率、90 天并发症发生率和住院时间相似。
本研究表明，与 AL 病变相比，PS 段肝脏肿瘤的 LLR 更具挑战性。然而，在大多数患者中，采用仰卧位和腹腔内套管放置可以成功完成手术，而不会影响肿瘤学原则。广泛使用手助和入肝血流阻断是帮助我们成功进行腹腔镜下切除这些肿瘤的技术要点。
