|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
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
|Dr. Conrad uses advanced parenchymal transection tools to minimize intraoperative blood loss during a laparoscopic resection of a hepatic lesion.
|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
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
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
|“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.”
information, contact Dr. Claudius Conrad at 713-745-1499 or Dr. Harmeet Kaur at 713-745-1519.
articles in OncoLog, March 2014 issue:
Home/Current Issue | Previous Issues
| Articles by
Topic | Patient
About Oncolog | Contact OncoLog | Sign
Up for E-mail Alerts
©2014 The University of
Texas MD Anderson Cancer Center
1515 Holcombe Blvd., Houston, TX 77030
1-877-MDA-6789 (USA) / 1-713-792-3245
Referral Legal Statements Privacy