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Journal of Minimally Invasive Surgery 2021; 24(4): 182-183
Published online December 15, 2021
https://doi.org/10.7602/jmis.2021.24.4.182
© The Korean Society of Endo-Laparoscopic & Robotic Surgery
How to minimize conversion to open surgery during laparoscopic liver resection: the point of view of hemostasis
Seunghwan Lee 
Correspondence to : Seunghwan Lee
Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 892 Dongnam-ro, Gangdong-gu, Seoul 05278, Korea
Tel: +82-2-440-6256
Fax: +82-2-440-7145
E-mail: histones@hanmail.net, histones1@khnmc.or.kr
ORCID: https://orcid.org/0000-0002-5516-0947
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
It has been 30 years since laparoscopic liver resection was first introduced, and, in the beginning, wedge resection or nonanatomical liver resection was mainly performed. With the development of surgical techniques and instruments, many centers are currently performing major liver resections and even difficult anatomical liver resections such as segment VI, VII, and VIII and caudate segment. However, laparoscopic surgery has limitations in instrument manipulation, and due to the nature of liver resection surgery, massive bleeding may occur. Therefore, it is necessary to make efforts to minimize the bleeding and reduce the conversion to laparotomy due to bleeding.
Keywords Laparoscopy, Hepatectomy, Hemostasis, Conversion to open surgery
Laparoscopic liver resection (LLR) has been widely performed recently. The difficulty of LLR is determined by the anatomical location of the liver to be resected, and, recently, many LLRs have been performed in difficult locations due to the increase in surgical experience [1,2].
As in this study [3], one of the most important reasons for conversion to open surgery is bleeding during surgery, and the causes of bleeding are various, such as the size, location, and number of tumors, and the degree of cirrhosis of the liver. Minimizing bleeding and, if there is bleeding, quick hemostasis can help to reduce unplanned conversion to open surgery [4–6]. In patients who are expected to have a high probability of conversion to open surgery, it is possible to minimize bleeding and reduce blood transfusion or operation time by making the decision to conversion to open surgery quickly [7].
It is necessary to accurately understand the intrahepatic location of the tumor and the vascular structures around it through images such as computed tomography before surgery; based on this, the surgical resection margin can be predicted. Exact placement of the trocar so that it can be resected comfortably along the predicted surgical margin allows the operator to operate in a comfortable position, which can help prevent bleeding [8].
In case of bleeding, inflow control by intracorporeally or extracorporeally Pringle maneuver is an established method to decrease bleeding during LLR and is widely used [9]. Outflow controls by Trendelenburg positioning, lower central venous pressure (<5 mmHg), slightly increasing intra-abdominal CO2 pressure (10–14 mmHg), or hanging maneuver are a helpful method to minimize bleeding and can be easily applied [7,10].
In addition, surgeons should be experienced with the use of all surgical devices for LLR and should be skillful in laparoscopic suture before starting LLR [10]. The technical limitations of LLR are continuously being overcome, and better instruments are expected to be developed in the future to help in the operation. More prospective data are required to confirm feasibility and safety of LLR.
Conflict of interest
The author has no conflicts of interest to declare.
Funding/support
None.
REFERENCES
- Cheung TT, Han HS, She WH, et al. The Asia Pacific Consensus Statement on Laparoscopic Liver Resection for Hepatocellular Carcinoma: a report from the 7th Asia-Pacific Primary Liver Cancer Expert Meeting held in Hong Kong. Liver Cancer 2018;7:28-39.
- Wakabayashi G, Cherqui D, Geller DA, et al. Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Ann Surg 2015;261:619-629.
- Shin H, Cho JY, Han HS, et al. Risk factors and long-term implications of unplanned conversion during laparoscopic liver resection for hepatocellular carcinoma located in anterolateral liver segments. J Minim Invasive Surg 2021;24:191-199.
- Lee JY, Rho SY, Han DH, Choi JS, Choi GH. Unplanned conversion during minimally invasive liver resection for hepatocellular carcinoma: risk factors and surgical outcomes. Ann Surg Treat Res 2020;98:23-30.
- Silva JP, Berger NG, Yin Z, et al. Minimally invasive hepatectomy conversions: an analysis of risk factors and outcomes. HPB (Oxford) 2018;20:132-139.
- Stiles ZE, Glazer ES, Deneve JL, Shibata D, Behrman SW, Dickson PV. Long-term implications of unplanned conversion during laparoscopic liver resection for hepatocellular carcinoma. Ann Surg Oncol 2019;26:282-289.
- Costi R, Scatton O, Haddad L, et al. Lessons learned from the first 100 laparoscopic liver resections: not delaying conversion may allow reduced blood loss and operative time. J Laparoendosc Adv Surg Tech A 2012;22:425-431.
- Takagi K, Kuise T, Umeda Y, et al. Laparoscopic liver resection of segment seven: a case report and review of surgical techniques. Int J Surg Case Rep 2020;73:168-171.
- Komeda K, Hayashi M, Inoue Y, et al. Clinical usefulness of endo intestinal clips during Pringle's maneuver in laparoscopic liver resection: a technical report. Surg Laparosc Endosc Percutan Tech 2013;23:e103-e105.
- Tranchart H, O'Rourke N, Van Dam R, et al. Bleeding control during laparoscopic liver resection: a review of literature. J Hepatobiliary Pancreat Sci 2015;22:371-378.
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Editorial
Journal of Minimally Invasive Surgery 2021; 24(4): 182-183
Published online December 15, 2021 https://doi.org/10.7602/jmis.2021.24.4.182
Copyright © The Korean Society of Endo-Laparoscopic & Robotic Surgery.
How to minimize conversion to open surgery during laparoscopic liver resection: the point of view of hemostasis
Seunghwan Lee
Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
Correspondence to:Seunghwan Lee
Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, 892 Dongnam-ro, Gangdong-gu, Seoul 05278, Korea
Tel: +82-2-440-6256
Fax: +82-2-440-7145
E-mail: histones@hanmail.net, histones1@khnmc.or.kr
ORCID: https://orcid.org/0000-0002-5516-0947
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
It has been 30 years since laparoscopic liver resection was first introduced, and, in the beginning, wedge resection or nonanatomical liver resection was mainly performed. With the development of surgical techniques and instruments, many centers are currently performing major liver resections and even difficult anatomical liver resections such as segment VI, VII, and VIII and caudate segment. However, laparoscopic surgery has limitations in instrument manipulation, and due to the nature of liver resection surgery, massive bleeding may occur. Therefore, it is necessary to make efforts to minimize the bleeding and reduce the conversion to laparotomy due to bleeding.
Keywords: Laparoscopy, Hepatectomy, Hemostasis, Conversion to open surgery
Body
Laparoscopic liver resection (LLR) has been widely performed recently. The difficulty of LLR is determined by the anatomical location of the liver to be resected, and, recently, many LLRs have been performed in difficult locations due to the increase in surgical experience [1,2].
As in this study [3], one of the most important reasons for conversion to open surgery is bleeding during surgery, and the causes of bleeding are various, such as the size, location, and number of tumors, and the degree of cirrhosis of the liver. Minimizing bleeding and, if there is bleeding, quick hemostasis can help to reduce unplanned conversion to open surgery [4–6]. In patients who are expected to have a high probability of conversion to open surgery, it is possible to minimize bleeding and reduce blood transfusion or operation time by making the decision to conversion to open surgery quickly [7].
It is necessary to accurately understand the intrahepatic location of the tumor and the vascular structures around it through images such as computed tomography before surgery; based on this, the surgical resection margin can be predicted. Exact placement of the trocar so that it can be resected comfortably along the predicted surgical margin allows the operator to operate in a comfortable position, which can help prevent bleeding [8].
In case of bleeding, inflow control by intracorporeally or extracorporeally Pringle maneuver is an established method to decrease bleeding during LLR and is widely used [9]. Outflow controls by Trendelenburg positioning, lower central venous pressure (<5 mmHg), slightly increasing intra-abdominal CO2 pressure (10–14 mmHg), or hanging maneuver are a helpful method to minimize bleeding and can be easily applied [7,10].
In addition, surgeons should be experienced with the use of all surgical devices for LLR and should be skillful in laparoscopic suture before starting LLR [10]. The technical limitations of LLR are continuously being overcome, and better instruments are expected to be developed in the future to help in the operation. More prospective data are required to confirm feasibility and safety of LLR.
NOTES
Conflict of interest
The author has no conflicts of interest to declare.
Funding/support
None.
References
- Cheung TT, Han HS, She WH, et al. The Asia Pacific Consensus Statement on Laparoscopic Liver Resection for Hepatocellular Carcinoma: a report from the 7th Asia-Pacific Primary Liver Cancer Expert Meeting held in Hong Kong. Liver Cancer 2018;7:28-39.
- Wakabayashi G, Cherqui D, Geller DA, et al. Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Ann Surg 2015;261:619-629.
- Shin H, Cho JY, Han HS, et al. Risk factors and long-term implications of unplanned conversion during laparoscopic liver resection for hepatocellular carcinoma located in anterolateral liver segments. J Minim Invasive Surg 2021;24:191-199.
- Lee JY, Rho SY, Han DH, Choi JS, Choi GH. Unplanned conversion during minimally invasive liver resection for hepatocellular carcinoma: risk factors and surgical outcomes. Ann Surg Treat Res 2020;98:23-30.
- Silva JP, Berger NG, Yin Z, et al. Minimally invasive hepatectomy conversions: an analysis of risk factors and outcomes. HPB (Oxford) 2018;20:132-139.
- Stiles ZE, Glazer ES, Deneve JL, Shibata D, Behrman SW, Dickson PV. Long-term implications of unplanned conversion during laparoscopic liver resection for hepatocellular carcinoma. Ann Surg Oncol 2019;26:282-289.
- Costi R, Scatton O, Haddad L, et al. Lessons learned from the first 100 laparoscopic liver resections: not delaying conversion may allow reduced blood loss and operative time. J Laparoendosc Adv Surg Tech A 2012;22:425-431.
- Takagi K, Kuise T, Umeda Y, et al. Laparoscopic liver resection of segment seven: a case report and review of surgical techniques. Int J Surg Case Rep 2020;73:168-171.
- Komeda K, Hayashi M, Inoue Y, et al. Clinical usefulness of endo intestinal clips during Pringle's maneuver in laparoscopic liver resection: a technical report. Surg Laparosc Endosc Percutan Tech 2013;23:e103-e105.
- Tranchart H, O'Rourke N, Van Dam R, et al. Bleeding control during laparoscopic liver resection: a review of literature. J Hepatobiliary Pancreat Sci 2015;22:371-378.
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