Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine, Idaigaoka 1-1, Hasama-machi, Oita, 879-5593, Japan.
Langenbecks Arch Surg. 2022 Aug;407(5):1961-1969. doi: 10.1007/s00423-022-02466-z. Epub 2022 Mar 6.
Laparoscopic liver resection (LLR) is possible in many patients, but pure LLR is sometimes difficult to complete, and unplanned intraoperative hand-assisted laparoscopic surgery (HALS) or open conversion is sometimes necessary. However, appropriate indications and timing for conversion are unclear. This study aimed to clarify the indications for HALS and open conversion from pure LLR.
We collected data from 208 patients who underwent LLR from January 2010 to February 2021 in our department. We retrospectively examined these data between cases of unplanned intraoperative HALS conversion, open conversion, and pure LLR, and clarified risk factors and indications for HALS or open conversion.
There were 191 pure LLRs, nine HALS conversions, and eight open conversions. In the HALS conversion group versus pure LLR group, body mass index (BMI) (27.0 vs. 23.7 kg/m, p = 0.047), proportions of patients with history of upper abdominal surgery (78% vs. 33%; p = 0.006), repeat hepatectomy (56% vs. 15%; p = 0.002), S7 or S8 tumor location (67% vs. 35%; p = 0.049), and difficulty score (DS) ≥ 7 (56% vs. 19%; p = 0.008) were significantly higher, and surgical time (339 vs. 239 min; p = 0.031) was significantly longer. However, postoperative states were not significantly different between the two groups. The BMI cutoff value for risk of unplanned intraoperative conversion determined by receiver operating characteristic curve analysis was 25 kg/m, and the proportion of patients with BMI ≥ 25 kg/m (89% vs. 31%, p < 0.001) was significantly higher in the HALS conversion versus pure LLR group. In the open conversion group, although there were no significant differences compared to the HALS group in clinicopathological factors except for sex, blood loss was greater (1425 vs. 367 mL; p < 0.001).
Risk factors for considering HALS during LLR were patients with a history of upper abdominal surgery including repeat hepatectomy, BMI ≥ 25 kg/m, S7 or S8 tumor location, DS ≥ 7, and prolonged surgical time. Furthermore, uncontrollable intraoperative bleeding was an indication for open conversion.
腹腔镜肝切除术（LLR）在许多患者中是可行的，但纯 LLR 有时难以完成，需要计划外的术中手助腹腔镜手术（HALS）或开放性转换。然而，转换的适当适应证和时机尚不清楚。本研究旨在阐明从纯 LLR 中转行 HALS 和开放性转换的适应证。
我们收集了 2010 年 1 月至 2021 年 2 月在我科接受 LLR 的 208 例患者的数据。我们回顾性地比较了计划外术中 HALS 转换、开放性转换与纯 LLR 病例的这些数据，并明确了 HALS 或开放性转换的危险因素和适应证。
纯 LLR 191 例，HALS 转换 9 例，开放性转换 8 例。HALS 转换组与纯 LLR 组相比，体重指数（BMI）（27.0 与 23.7kg/m，p=0.047）、有上腹部手术史的患者比例（78%与 33%；p=0.006）、再次肝切除术（56%与 15%；p=0.002）、肿瘤位于 S7 或 S8 （67%与 35%；p=0.049）和难度评分（DS）≥7（56%与 19%；p=0.008）的比例较高，手术时间（339 与 239min；p=0.031）较长。但两组术后状态无明显差异。通过受试者工作特征曲线分析确定术中计划外转换风险的 BMI 临界值为 25kg/m，HALS 转换组 BMI≥25kg/m 的患者比例（89%与 31%，p<0.001）明显高于纯 LLR 组。在开放性转换组，与 HALS 组相比，除性别外，临床病理因素无显著差异，但出血量更大（1425 与 367mL；p<0.001）。
考虑行 LLR 时行 HALS 的危险因素包括有上腹部手术史（包括再次肝切除术）、BMI≥25kg/m、肿瘤位于 S7 或 S8、DS≥7、手术时间延长。术中无法控制的出血是开放性转换的指征。
