Safety and feasibility of laparoscopic left hepatectomy for the treatment of hepatolithiasis in patients with previous abdominal surgery.

BACKGROUND: The aim of the study was to compare the benefits and drawbacks of laparoscopic left hepatectomy (LLH) in patients with previous abdominal surgery (PAS) with those in patients without PAS and confirm the safety and feasibility of LLH as a treatment for patients with hepatolithiasis and PAS.
MATERIALS AND METHODS: This retrospective comparative study included 111 patients who underwent LLH for hepatolithiasis (with PAS, n = 41; without PAS, n = 70) from August 2017 to August 2019. Patients' general information, surgical outcomes, hospital stay duration, hospitalisation cost, post-operative laboratory data and post-operative complications were evaluated.
RESULTS: No statistically significant difference was noted in the post-operative laboratory data between patients with and without PAS (P > 0.05). Longer operative times were required for patients with PAS than for those without PAS (P = 0.025). Hospitalisation cost, hospital stay duration, blood loss, open conversion and post-operative complications were not significantly different between patients with and without PAS (P > 0.05). No cases of mortality were noted.
CONCLUSIONS: LLH is a safe and feasible treatment for patients with hepatolithiasis and PAS.

INTRODUCTION

The left intrahepatic bile duct is the most commonly involved part of the liver in hepatolithiasis because of its unique anatomical structure that differentiates it from the right intrahepatic bile duct, and liver resection has been proven to be a curative therapy.[123] Several patients undergo reoperation for hepatolithiasis because of its high recurrence rate.[4] Laparoscopic left hepatectomy (LLH), including laparoscopic left hemihepatectomy (LLHH) and laparoscopic left lateral hepatectomy (LLLH), has been performed as a routine clinical treatment for patients with hepatolithiasis and has been proven to be safe and effective.[5] However, studies examining the use of LLH in patients with previous abdominal surgery (PAS) are limited.

In LLH for patients with PAS, the most significant challenge is the separation of adhesions.[67] First, in the process of placing the trocar in the abdominal cavity, organs, particularly the duodenum or colon with adhesions, are at a high risk of being damaged. Second, severe abdominal adhesions can hinder the border of the coronary ligament, falciform ligament, ligamentum teres hepatis and hilar area, among others, thereby increasing the difficulty of the surgery. In addition, the incidence of intraoperative bleeding increases in cases of dissection of vascular involved in adhesions. In recent years, laparoscopic hepatectomy (LH) has become a popular and effective therapy to cure hepatolithiasis.[8910] Laparoscopic cholecystectomy and laparoscopic exploration of the common bile duct (CBD) have successfully been performed in patients with PAS;[11] thus, LLH can inevitably be performed in patients with PAS. However, studies on the safety and feasibility of LLH in patients with PAS are limited.

MATERIALS AND METHODS

Patients and grouping

This retrospective clinical study was conducted at the Department of General Surgery and approved by the Institutional Review Board of The Second Affiliated Hospital of Nanchang University, China. The study was approved by the Ethics Committee of The Second Affiliated Hospital of Nanchang University. Informed consent was obtained from all patients. Overall, 111 patients with left hepatolithiasis who underwent LLH [Table 1] between August 2017 and August 2019 were included. Of these, 41 patients [Table 2] had undergone PAS and 70 had not. Table 3 shows the classification of PAS.

Table 1

Characteristics of patients performed laparoscopic left hepatectomy with and without previous abdominal surgery

	Group A* (n=41)	Group B† (n=70)	P
Gender (male/female)	8/33	21/49	0.382
Age (years)	55.0±10.1	52.8±10.2	0.279
Post-operative laboratory data
WBC (109/L)	13.2 (10.6-15.5)	11.7 (10.1-15.3)	0.125
TB (µmol/L)	20.5 (14.7-26.5)	22.5 (17.3-30.8)	0.141
DB (µmol/L)	5.9 (4.2-8.5)	6.4 (4.0-9.7)	0.514
IB (µmol/L)	13.5 (10.6-19.2)	15.5 (12.9-21.1)	0.051
AST (µmol/L)	140.4 (85.0-239.7)	131.9 (90.0-201.8)	0.957
ALT (µmol/L)	113.6 (73.2-197.6)	123.4 (86.8-187.4)	0.881
GGT (µmol/L)	93.8 (29.5-174.2)	63.7 (35.6-182.3)	0.709
Blood loss (ml)	200.0 (150.0-425.0)	200.0 (150.0-400.0)	0.607
Operative time (min)	334.3±72.0	295.0±92.0	0.025
Hospital stay duration (days)	16.5 (14.0-20.3)	16.0 (14.0-20.3)	0.752
Hospitalisation cost (WanRMB‡)	6.2 (5.4-7.2)	6.1 (5.1-7.3)	0.580
Open conversion	5	6	0.744
Post-operative complications
Bile leakage	3	3	0.670
Post-operative bleeding	1	0	0.375
Hepatic failure	0	0	-
Mortality	0	0	-

*Patients performed LLH with PAS, †Patients performed LLH without PAS, ‡Ten thousand renminbi. WBC: White blood cell, TB: Total bilirubin, DB: Direct bilirubin, IB: Indirect bilirubin, AST: Aspartate aminotransferase, ALT: Alanine aminotransferase, GGT: Gamma-glutamyl transferase, LLH: Laparoscopic left hepatectomy, PAS: Previous abdominal surgery, WanRMB: WanRenMinBi

Table 2

Classifications of previous abdominal operations

Incision	Surgical history	n
Only upper abdominal	Open CBD exploration	2
	Laparoscopic CBD exploration, cholecystectomy	3
	Open CBD exploration, cholecystectomy	2
	Open cholecystectomy	2
	Open hepatectomy, cholecystectomy	14
	Laparoscopic hepatectomy, cholecystectomy	3
	Laparoscopic cholangiojejunostomy, cholecystectomy	1
	Open gastrectomy, nephrectomy	1
Only lower abdominal	Open appendectomy	4
	Hysterectomy	1
	Caesarean	4
Both upper and lower abdominal	Open cholecystectomy, appendectomy	2
	Open cholecystectomy, caesarean	1
	Open hepatectomy, caesarean, hysterectomy	1

CBD: Common bile duct

Table 3

Characteristics of patients performed laparoscopic left hepatectomy with upper, lower and both upper and lower previous abdominal surgery compared with those who without previous abdominal surgery (data of patients performed laparoscopic left hepatectomy without previous abdominal surgery refer to [Table 1])

	Upper (n=28)	P*	Lower (n=9)	P †	Both upper and lower (n=4)	P ‡
Gender (male/female)	7/21	1.000	1/8	0.682	0/4	0.572
Age (years)	55.7±9.5	0.530	54.9±9.5	0.722	57.5±17.1	0.441
Post-operative laboratory data
WBC (109/L)	12.5 (10.5-15.4)	0.068	12.1 (8.9-13.3)	0.248	14.4 (13.2-16.5)	0.149
TB (µmol/L)	21.5 (16.3-29.3)	0.145	26.1 (12.9-33.4)	0.861	19.0 (14.5-32.0)	0.684
DB (µmol/L)	6.1 (4.1-9.4)	0.473	7.0 (3.1-12.4)	0.726	5.6 (4.0-10.4)	0.802
IB (µmol/L)	14.7 (12.2-19.4)	0.088	13.1 (9.8-23.4)	0.761	14.1 (9.7-21.8)	0.695
AST (µmol/L)	135.3 (87.1-215.2)	0.947	162.8 (82.4-261.6)	0.939	140.4 (83.5-222.0)	0.925
ALT (µmol/L)	121.6 (84.1-190.0)	0.593	133.5 (111.5-222.6)	0.283	92.3 (72.1-192.3)	0.520
GGT (µmol/L)	76.4 (35.2-175.9)	0.548	44.6 (24.1-91.5)	0.304	134.3 (119.4-191.4)	0.158
Blood loss (ml)	200.0 (150.0-400.0)	0.369	200.0 (125.0-750.0)	0.750	200.0 (87.5-200.0)	0.225
Operative time (min)	350.1±87.0	0.006	285.6±92.3	0.598	265.0±23.8	0.383
Hospital stay duration (days)	16.0 (14.0-20.0)	0.660	16.0 (15.0-20.0)	0.699	14.5 (10.5-23.0)	0.529
Hospitalisation cost (WanRMB)	6.2 (5.3-7.3)	0.241	5.9 (4.8-7.8)	0.916	5.4 (5.1-6.4)	0.294
Open conversion	3	1.000	2	0.211	0	1.000
Post-operative complication
Bile leakage	3	0.178	0	1.000	0	1.000
Post-operative bleeding	1	0.259	0	1.000	0	1.000
Hepatic failure	0	-	0	-	0	-
Mortality	0	-	0	-	0	-

*Statistically significant patients with PUAS versus without PAS, †Statistically significant patients with PLAS versus without PAS, ‡Statistically significant patients with PULAS versus without PAS. WBC: White blood cell, TB: Total bilirubin, DB: Direct bilirubin, IB: Indirect bilirubin, AST: Aspartate aminotransferase, ALT: Alanine aminotransferase, GGT: Gamma-glutamyl transferase, PAS: Previous abdominal surgery, PUAS: Previous upper abdominal surgery, PLAS: Previous lower abdominal surgery, PULAS: Previous upper and lower abdominal surgery, WanRMB: WanRenMinBi

Inclusion criteria

Patients who met the following criteria were included: Those with impacted stones associated with the dilation of intrahepatic duct (IHD) confined to the left hepatic bile duct, regardless of the presence of extrahepatic bile duct stones; those with left IHD associated with biliary strictures, atrophy or parenchymal fibrosis and those diagnosed using ultrasound, computed tomography or magnetic resonance cholangiopancreatography. Furthermore, patients with right IHD stones, hepatic abscess or cholangiocarcinoma were excluded.

Laparoscopic left hepatectomy procedure

Pre-operative imaging was performed [Figure 1a]. The entire procedure was conducted under general anaesthesia by a senior staff surgeon. Patients were placed in the supine position and in a dorsal, elevated position (anti-Trendelenburg position) with both legs separated. Typically, five trocars were used for the working port and choledochoscope. The first trocar was inserted using the Hasson technique (if necessary), ensuring that it is far away from any abdominal scars surrounding the umbilicus if the patient had undergone PAS. Using the first trocar as a portal, pneumoperitoneum was established to maintain the intra-abdominal pressure at approximately 12 mmHg. Thereafter, a 30° oblique laparoscope was inserted. One 12-mm and one 5-mm operating trocars were placed approximately parallel to the umbilical cord at both midclavicular lines. The other 12-mm and 5-mm trocars were placed under the bilateral subcostals at the anterior axillary lines. An ultrasonic scalpel (Harmonic scalpel, Ethicon, Ciudad Juarez, Chihuahua, Mexico), an electronic coagulation device, non-traumatic forceps and an aspirator were used to dissect the adhesions [Figure 1b and c] and left perihepatic ligaments to expose operation horizon especially portal hilar, left coronary ligaments were dissected till root of the second portal hilar, then anatomically transecting the hepatic parenchyma. For LLLH, an ultrasonic scalpel was used to dissect the liver parenchyma along with the falciform ligament. Intrahepatic vascular and biliary structures were ligated using Hem-o-Lok clips (Teleflex, Morrisville, North Carolina, USA). For LLHH, the left hepatic artery [Figure 1d] and the left portal vein [Figure 1e] were ligated. We dissected the left hemiliver along the ischaemic line. The remaining liver parenchyma and root of left hepatic vein were transected with an endoscopic gastrointestinal anastomosis device [Figure 1f]. The main branch of portal vein control is not necessary during left liver resection[1213] unless confronting with uncontrolling bleeding which is always seen in hepatic vein damaged during operation or liver cirrhosis patients.

Figure 1

Pre-operative computed tomography film and surgical techniques. (a) The pre-operative computed tomography film of patient; (b) separating adhesion between liver visceral surface and stomach; (c) separating adhesion between liver diaphragmatic surface and abdominal wall; (d) ligating left hepatic artery; (e) ligating the left branch of the portal vein; (f) transecting last remaining liver parenchyma and root of left hepatic vein with an endoscopic gastrointestinal anastomosis device)

Statistical analysis

Statistical analysis was performed using SPSS software, version 24.0 (SPSS Inc., Chicago, IL, USA). Continuous variables were expressed as mean ± standard deviation or median (range), and categorical variables were expressed as numbers. Continuous variables were compared using the Student's t-test test or the Mann–Whitney U-test, and categorical variables were compared using the χ2 test or Fisher's exact test. We considered P < 0.05 as statistically significant.

RESULTS

We analysed outcomes for 111 patients who underwent LLH [Table 1], including 41 patients with PAS [Table 2] and 70 patients without PAS. No cases of hepatic failure and mortality were noted. Patients with PAS showed significantly longer LLH operative time than those without PAS (P = 0.025). There were no statistically significant differences in intraoperative blood loss, open conversion, hospital stay duration, hospitalisation cost or post-operative complications (P > 0.05). Moreover, no statistically significant differences were noted in the white blood cell (WBC) count and the total bilirubin (TB), direct bilirubin (DB), indirect bilirubin (IB), aspartate aminotransferase (AST), alanine aminotransferase (ALT) and gamma-glutamyl transferase (GGT) levels between patients with and without PAS (P > 0.05). Moreover, patients with PAS were stratified into groups of patients with previous upper abdominal surgery (PUAS) (28 patients), previous lower abdominal surgery (PLAS) (9 patients) and patients with both previous upper and lower abdominal surgery (PULAS) [28 patients; Table 3]. Longer operative times were required for patients with PUAS than for those without PAS (P = 0.006).

Furthermore, we stratified patients based on those who underwent LLHH and LLLH. Longer operative times were required for patients with PAS who underwent LLHH than for those without PAS (P = 0.042). However, no statistically significant difference was observed between patients with and without PAS with respect to hospitalisation cost and blood loss (P > 0.05). Longer operative times were required for patients with PUAS who underwent LLHH than for those with PLAS (P = 0.028). Adhesions in different parts seemed to have no effect on LLLH.

DISCUSSION

The first LH was performed in 1992,[14] a laparoscopic left lateral hepatectomy was carried out as the first anatomic LH by Azagra.[15] With laparoscopic technique improvement, LH has widely proven to be a safe and effective treatment for hepatolithiasis and liver tumour.[1617] It is cautionary that LH requires expertises skilling in open hepatectomy, laparoscopic surgery and ultrasonography after long learning curve.[1418] Cipriani et al.[19] and Cherqui[20] also supposed in their previous studies that laparoscopic liver resection was so complicated that needs hepatobiliary experts with long training process in order to reduce the incidence of intraoperative accidents on account of complex adhesiolysis. Performing LH in patients with PAS remains a cause of concern to surgeons.

Although percutaneous transhepatic cholangioscopy can be performed for IHD stones, it is not a radical method for patients with liver atrophy or ductal stricture.[21] In addition, compared with conventional laparotomy, laparoscopic liver resection results in lower hospitalisation costs, shorter hospital stay durations, lesser intrasurgical blood loss, earlier recovery and lesser pain.[2223] However, few studies have evaluated the safety and feasibility of LLH in patients with PAS. The present study was conducted to explore this issue by comparing the outcomes of patients with and without PAS who underwent LLH.

Our results showed that longer operative times were required for patients with PAS than for those without PAS. However, there was no difference in blood loss and hospitalisation cost between patients with and without PAS. This result is justified because in patients with PAS, abdominal adhesions require additional time for separation to expose the surgical region. Regarding blood loss, the blood vessels involved in adhesions were typically ligated using an ultrasonic scalpel or Hem-o-Lok clips, thereby reducing the rate of bleeding. Hospitalisation costs included the cost of the surgery as well as post-operative expenses, which can be influenced by patient age, body mass index, organ function and other factors. Therefore, hospitalisation costs varied based on the individual.

For further analysis, we divided the PAS group into those with PUAS, PLAS and PULAS. We observed that relatively longer operative times were required for patients with PUAS (350.1 ± 87.0 min) than for those with PLAS (285.6 ± 92.3 min) and PULAS (265.0 ± 23.8 min). Our study results were consistent with those of a prior study conducted by Karayiannakis et al.[24] who found that patients with PUAS exhibited more extensive and denser adhesions than those with PLAS. Adhesiolysis was required more frequently in patients with PUAS than in those with PLAS.[11] In addition, considering the high rate of the occurrence of upper abdominal adhesions, it is not surprising that open conversion and post-operative complications occurred in patients with PUAS because adhesions frequently hinder critical surgical incisions and increase operative difficulty. Moreover, our results showed no statistically significant differences in the rates of bile leakage, post-operative bleeding between patients with and without PAS. No cases of hepatic failure and mortality were noted. Finally, no statistically significant differences were noted in the WBC count and the TB, DB, IB, AST, ALT and GGT levels, suggesting that there is no difference in the rates of perioperative liver injury or functional outcomes between patients with and without PAS. We believe that there was no greater systemic risk in patients with PAS.

For patients with PAS, the most critical technical difficulty was the establishment of pneumoperitoneum and dissection of adhesions.[252627] When performing an LLH, the surgical approach to the abdomen must follow the strict application of technical principles. The first trocar (observation port) site should be placed as far away as possible from the original surgical scar. If necessary, pneumoperitoneum should be established using the Hasson technique to effectively avoid an organ injury. We found that most adhesions were present between the colon, stomach and perihepatic ligament [Figure 1b] as well as between the liver diaphragmatic surface and abdominal wall [Figure 1c]. Therefore, we attempted to free the adhesions using a harmonic scalpel to distinguish the normal structure of the liver and its surrounding organs. Another difficulty was with regard to locating the CBD and portal vein; we always exposed the Winslow hole by dissecting downward from the hepatic flexure along the left lateral side of the hepatogastric ligament, followed by dissecting the Glisson pedicle and separating the cavity between the CBD and portal vein using forceps. In cases where it was difficult to assess the liver area because of severe adhesions or bleeding, we switched to laparotomy. Laparoscopy has the advantage of wide surgical vision, provided that there are no intestinal canals involved in the adhesions.

CONCLUSIONS

LLH for patients with PAS is safe and effective. Therefore, when left hepatectomy is considered for patients with a prior surgical history, the laparoscopic approach can be a good alternative.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.