1. Laparoscopic Liver Resections David A. Kooby, MD, FACS Associate Professor of Surgery Division of Surgical Oncology Emory University School of Medicine

2. Lap liver Abbreviations OLR; open liver resection LLR; laparoscopic liver resection mCRC; metastatic colorectal cancer

3. Lap liver Overview Brief history and technique Safety and efficacy (OLR vs LLR) Oncologic outcomes mCRC

4. History of Lap Liver Resection Open Lap 1987 2007 2002 1996 1992 Lap cholecystectomy 1 st report of major LLR 1 st large series of LLR 1 st large series of major LLR Comparative results to OLR 2009 1 st large series comparing cancer outcomes

5. Lap liver Laparoscopic hepatic resection of mCRC met.

6. Lap liver Technique

7. Lap liver Left lateral segmentectomy

8. Left hepatectomy

9. Incisions: partial right hepatectomy Lap liver

10. Partial right hepatectomy

11. Lap liver Laparoscopy for right sided lesions

12. mCRC – segment IVb Lap resection 115 minutes 100 ml EBL LOS 3 days R0 margins

13. Lap Ultrasound

14. Left Hepatectomy - Ports. 5 12 5 30° scope

15. Right Hepatectomy - Ports. 5 12 5 30° scope

16. Right Hepatectomy – Alternative Hand Port.

17. Lap liver Laparoscopic right hepatectomy VIDEO

18. Lap liver Perioperative concerns with LLR Hemorrhage Inadequate inflow/outflow control Staple line disruption Inadvertent vascular injury Difficult parenchymal transection Remnant failure Prolonged inflow occlusion Major venous thrombosis Other injuries Biliary tract Intestinal, other Gas embolus

19. Lap liver Literature Review of LLR 127 original reports (1994-2008) 2,804 cases Mortality 0.3% Morbidity 11% Nguyen and Gellar, Ann Surg, 2009;250:831-841 17% Major resections

20. Lap liver LLR for major (>3 segments) hepatectomy Pooled data from 6 HPB centers 3 European, 2 US, 1 Australian 210 cases: 65% right hepatectomies 35% left hepatectomies 43% total lap 12% conversion 2 (1%) 30d mortality 22% 30d morbidity Dagher and Buell, Ann Surg, 2009;250:856-860

21. Lap liver LLR vs. OLR Simillis, Surgery, 2007 141;203-211 Favors LLRFavors OLR Postoperative morbidity

22. Lap liver LLR vs. OLR perioperative outcomes Reference (Year) NEstimated blood loss LOS (days)Complications (%) LOLOLOLO Koffron et al (2007) 300100-↑1.95.49.322.0 Ito et al (2009) 65 -↑4.06.013.844.6 Topal et al (2008) 109250-↑6.08.07.828.9 Castaing et al (2009) 60 --101127.028.0

23. Lap liver The Louisville Statement, 2008 Consensus conference of 45 “experts” on LLR Terminology: pure lap, hand-assisted, hybrid Technique Efficacy and safety Conversion Benign liver tumors Malignant liver tumors Live donor hepatectomy Randomized trial vs. open registry Training and credentialing Buell et al, Ann Surg, 2008 250;825

24. Lap liver Learning curve FactorsA (n=58)B (n=58)C (n=58)P value Proportion lap (%) 182224 HCC (%) 182639<0.05 mCRC (%) 0713<0.05 Major LLR (%) 199<0.05 Conversions (%) 16103<0.05 Op time (min) 210180150<0.05 Blood loss (cc) 300200 <0.05 Morbidity (%) 17223<0.05 Vigano et al, Ann Surg, 2009:250;772 Learning curve levels out at 60 cases

25. Lap liver LLR for mCRC, largest series Variables N=109 Age (median) 63 yrs (32-88 yrs) Female 53 (51%) Site of Primary colon cancer Sigmoid/rectum 53 (48.6%) Right colon 23 (21.1%) Left colon 14 (12.8%) Transverse colon/splenic flexure 3 (2.8%) Unknown 16 (14.7%) Synchronous disease 12 (11.1%) Interval from primary cancer 12 mos (range 0 – 60) Chemo prior to LLR 69 (63.3%) Nguyen et al, Lap. resection mCRC, 6 centers, Ann Surg, 2009; 250:842-848

26. Lap liver LLR for mCRC, largest series Variables N=109 Operative approach Totally laparoscopic61 (56.0%) Hand-assisted44 (40.4%) Converted to open4 (3.7%) Type of resection Segmentectomy or wedge37 (33.9%) Left lateral sectionectomy29 (26.6%) Right lobectomy31 (28.4%) Left lobectomy10 (9.2%) Extended R. hepatectomy1 (0.9%) Caudate lobectomy1 (0.9%) Nguyen et al, Lap. resection mCRC, 6 centers, Ann Surg, 2009; 250:842-848

27. Lap liver LLR for mCRC, largest series Variables N=109 OR time (median) 234 min (60-555 range) Blood loss (median) 200 ml (200-2500 ml) Blood transfusion rate 11 (10.1%) ICU admission rate 34 (31.2%) Length of stay (median) 4 days (1-22 range) Mortality 0% Morbidity 13% Nguyen et al, Lap. resection mCRC, 6 centers, Ann Surg, 2009; 250:842-848

28. Lap liver LLR for mCRC, largest series Variables N=109 Tumor size (median) 30 mm (4 - 152 mm) Margin positive 5% Overall survival 1 year 88% 3 year 69% 5 year 50% Nguyen et al, Lap. resection mCRC, 6 centers, Ann Surg, 2009; 250:842-848

29. Lap liver LLR vs. OLR for mCRC Matched preoperative characteristics Demographics and extent of disease: Age, sex, number, distribution, and size of metastases, CRS, EHD, pre-hepatectomy chemotherapy 60 pts in each group Two separate centers, one for open case, one for laparoscopic Extent of liver resection was similar between groups Castaing, Ann Surg, 2009;250(5):849-855 All LLR were performed by one surgeon!

30. Lap liver LLR vs. OLR for mCRC Castaing, Ann Surg, 2009;250(5):849-855 LLROLR Inherent selection bias!

31. Lap liver Castaing, Ann Surg, 2009;250(5):849-855 Overall Survival Recurrence-free Survival p=0.32p=0.13 LLR vs. OLR for mCRC

32. Lap liver Concerns Inadequate training, experience, and mentorship Missed extrahepatic disease Render patient unresectable Hinder R0 resection Less parenchymal sparing

33. Small benign lesions DO NOT need treatment Malignant PotentialSpontaneous Hemorrhage FNHNO HemangiomaNORARE Simple cystsNOYES AdenomaYES

34. Lap liver Final judgment LLR for mCRC can be performed safely by experienced surgeons and may be appropriate for selected patients. Randomized trials for LLR vs. OLR may be impractical due to limited number of experienced surgeons and appropriate surgeons, and registry data may be the most powerful way to assess further questions

35. Lap liver Thank you ?