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From OncoLog, March 2014, Vol. 59, No. 3

Photo: Dr. Claudius Conrad performs liver resection
Dr. Claudius Conrad (right) performs a laparoscopic liver resection. The two-dimensional image provided by the laparoscope is supplemented with images from preoperative computed tomography and intraoperative ultrasonography.

Expanding the Use of Laparoscopic Liver Resection

By Bryan Tutt 

Minimally invasive surgical resection of liver tumors once was used only in select patients with easily accessible lesions located in the anterior parts of the liver. However, recent improvements in surgical techniques and the use of preoperative imaging have made laparoscopic approaches possible for even complex liver resections.

“Procedures that until recently could only be performed as open surgery are now being performed laparoscopically,” said Claudius Conrad, M.D., Ph.D., an assistant professor in the Department of Surgical Oncology at The University of Texas MD Anderson Cancer Center.

Dr. Conrad explained that the increased use of laparoscopic surgery for primary liver tumors and metastatic tumors to the liver is the result not of a single technological advance but rather of collaborative efforts by multidisciplinary team members to apply multiple advances in imaging technology, surgical tools, and surgical technique.

“In the past 3 years, we have performed over 100 minimally invasive liver resections at MD Anderson with very good outcomes,” said Thomas Aloia, M.D., an associate professor in the Department of Surgical Oncology. An increasing number of minimally invasive pancreatic procedures also are being performed (see “Minimally Invasive Pancreatic Surgery,” below).

Overcoming challenges


Advanced laparoscopic liver resection presents challenges that open surgery does not, and overcoming these challenges requires teamwork and planning. “More than in open surgery, the complexity of laparoscopic surgery requires close collaboration between all members of the operative team,” Dr. Conrad said.

The laparoscope provides the surgeon a clear view, but the image is two-dimensional. The surgical team supplements this view with preoperative images and intraoperative ultrasonography. “Preoperative cross-sectional imaging and intraoperative ultrasonography not only help identify lesions and critical structures but also facilitate the conversion of the two-dimensional image of the laparoscope into the three-dimensional motor performance of the surgery,” Dr. Conrad said.

A limitation of laparoscopic surgery has been the ability to adequately control intraoperative bleeding, as compression and suturing are technically more difficult. However, Dr. Conrad said, advanced parenchymal transection devices allow the surgeon to divide liver tissue in such a way that bleeding is minimized. “Most importantly,” he said, “bleeding is minimized through accurate preoperative imaging and careful planning, as these allow the surgeon to avoid major vessels in the liver and optimize the transection plane.”

Preoperative imaging and surgical planning


Computed tomography (CT) is the mainstay of preoperative imaging for liver resections and plays a central role in planning laparoscopic procedures. “In the past 5 years, CT scanners have gotten faster, which enables us to scan the liver in multiple phases of contrast enhancement,” said Harmeet Kaur, M.D., an associate professor in the Department of Diagnostic Radiology. Dr. Kaur said that CT is not only fast and reliable but also more likely than other modalities to detect extrahepatic lesions. She added that the ability to scan thin cross-sections, which enables two- or three-dimensional reconstructions in different planes, makes CT useful for visualizing a patient’s anatomy.
Photo: Dr. Claudius Conrad
Dr. Conrad uses advanced parenchymal transection tools to minimize intraoperative blood loss during a laparoscopic resection of a hepatic lesion.
Photo: Intraoperative ultrasonography
During a laparoscopic liver resection, intraoperative ultrasonography helps the surgical team locate lesions and avoid critical structures.

In fact, incremental advances in technology are making possible increasingly detailed reconstructions from CT. MD Anderson’s Department of Diagnostic Radiology is developing a system of three-dimensional vascular reconstruction that will allow surgeons to rotate the image of a patient’s hepatic vascular structure on screen so that it can be viewed from any perspective.

CT is supplemented by magnetic resonance imaging in a growing number of patients, according to Dr. Kaur. The spatial resolution of CT allows radiologists to see the liver anatomy and vasculature, while the contrast resolution of magnetic resonance imaging enables radiologists to detect small lesions that may be missed by CT.

“To succeed in doing laparoscopic liver surgery, you need radiologists who are dedicated to understanding the liver anatomy and who are familiar with all the variants of the hepatic and portal veins and the hepatic arteries,” Dr. Kaur said.

At MD Anderson, surgeons and medical oncologists work closely with radiologists to understand each patient’s anatomy and determine the best surgical approach as well as the timing of neoadjuvant and adjuvant chemotherapy. Dr. Kaur said this collaborative approach also helps select patients who would benefit most from liver resection.

In deciding whether laparoscopic surgery is appropriate for a patient, Dr. Conrad said, “Most important are safety and the oncologic aspects; we have to minimize the risk of complications, and we want to remove all the cancer and suspected lymph nodes. Only secondary is whether the laparoscopic or open approach is best for the patient’s recovery.”

When planning a laparoscopic procedure, the surgeon will also plan for performing open surgery if needed. “We are always prepared to complete the operation through a traditional incision if safety or oncologic aspects dictate that this is best for the patient. However, preoperative imaging and collaborative planning make conversion from the laparoscopic to the traditional approach a rare event,” Dr. Conrad said.

The multidisciplinary approach allows minimally invasive surgery to be considered for even complex procedures. As an example, Dr. Conrad described a patient with lesions in the posterosuperior segments of the liver, which were once considered inaccessible by a laparoscopic approach. But Dr. Conrad was able to perform a minimally invasive resection by inserting the trocars through the chest and diaphragm. “We removed the lesions laparoscopically, and the patient had an excellent outcome,” he said.

Benefits of laparoscopy

“Laparoscopic surgery provides comparable long-term oncologic outcomes to open surgery and can help to improve resectability in patients with recurrent disease,” Dr. Conrad said.

The chief advantages of laparoscopic surgery over open surgery are reduced pain, blood loss, morbidity, risk of surgical site infection, and length of hospital stay. According to Dr. Conrad, the faster recovery time from laparoscopic surgery can enable some cancer patients to begin adjuvant therapy sooner and perhaps tolerate it better.

Many patients with multiple bilateral liver tumors require a two-stage resection, in which tumors are removed from one side of the liver and portal vein embolization is used to help the rest of that side of the liver regenerate before a second surgery is done to remove disease from the other side. This concept has been advanced by Jean-Nicolas Vauthey, M.D., a professor and chief of the liver and pancreas section in the Department of Surgical Oncology. Between 2003 and 2011, 134 patients had a planned two-stage hepatectomy, and the two-step liver resection sequence was successfully completed in 112 of these patients.

If the first stage of a two-stage resection is performed laparoscopically, the reduced scarring facilitates the second surgery after the portal vein embolization. The liver tumor study group at MD Anderson is currently investigating the outcomes of patients who underwent two-stage resections with the first stage performed laparoscopically.

An important benefit from the reduced pain and recovery time of the laparoscopic approach is better quality of life. “Many of our patients lead active lives,” Dr. Conrad said. “They are not only asking if we can remove the tumor; they are also asking how soon they can get back to their normal daily activities.”

Fortunately, the minimally invasive laparoscopic approach is successful in more and more patients as physicians gain experience in planning and performing such procedures. Dr. Kaur said, “More than new technology, the key to success is having a multidisciplinary team dedicated to understanding the liver anatomy.”

Minimally Invasive Pancreatic Surgery

Photo: Dr. Claudius Conrad
“Minimally invasive surgical therapy requires unique skill sets.”
– Dr. Jason Fleming

Not only can the laparoscopic approach be used to perform complex hepatobiliary procedures, it can be used in pancreatic surgery. Even an extremely difficult procedure such as a pancreaticoduodenectomy can be performed using a laparoscopic approach.

“We routinely remove lesions in the pancreatic body and tail laparoscopically or robotically, and we’re beginning to develop a laparoscopic program for lesions located in the pancreatic head,” said Claudius Conrad, M.D., Ph.D., an assistant professor in the Department of Surgical Oncology.

Matthew Katz, M.D., an assistant professor in the Department of Surgical Oncology, pointed out the challenges of caring for patients with pancreatic neoplasms. “These are complex clinical problems that require a thoughtful approach,” he said. “Through carefully integrated care, we have achieved excellent outcomes.”

Dr. Conrad said, “To date, there are no published randomized controlled trials comparing minimally invasive—either robotic or laparoscopic—pancreaticoduodenectomies to open procedures, nor are there any registered trials ongoing, to my knowledge.” He added that although the published data suggest that minimally invasive pancreaticoduodenectomy is safe and has short-term benefits, “the findings of low operative blood loss and high rate of negative-margin resection must be viewed in the setting of highly selected patients with significantly smaller-than-usual tumors.”

Nevertheless, for this select group of patients, the benefits of advanced laparoscopic pancreatic surgery are very important. “Minimally invasive surgical therapy requires unique skill sets, and we have recruited outstanding surgeons with specific expertise in this area,” said Jason Fleming, M.D., a professor in and deputy chair of the Department of Surgical Oncology and service chief of pancreas surgery. “Moving forward, we will investigate these new approaches and hope to integrate them into our existing clinical strategies to further improve the survival of our patients with these aggressive malignancies.”

For more information, contact Dr. Claudius Conrad at 713-745-1499 or Dr. Harmeet Kaur at 713-745-1519.

Other articles in OncoLog, March 2014 issue:

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