OriGiNAl ArTiClE
Twenty-four consecutive laparoscopic
hepatectomies in a tertiary care center
sergio renato Pais-Costa, sergio luiz Melo Araújo, Olímpia Alves Teixeira lima,
Victor Netto Figueiredo e Alexandre Chartuni Teixeira Pereira
ABsTrACT
Introduction. With the advances in minimally
invasive surgery, laparoscopic hepatectomy has
shown to be an interesting alternative in liver surgery. Laparoscopic liver resection presents many
advantages over an open surgery approach.
Objective. To evaluate early and late results of
laparoscopic hepatectomies in a tertiary hospital.
Methods. Authors reported on a series of twentyfour patients who underwent laparoscopic hepatectomy performed by a single surgical team at
Santa Lucia Hospital, Brasília, Brazil, from June
2007 to January 2012.
Results. The median age was 53 years (range: 2171 years). There were thirteen women and eleven
men. Thirteen patients presented with benign lesions, while eleven patients had malignant lesions.
The mean lesion size was 4.96 cm. There were
six major hepatectomy procedures and eighteen
minor hepatectomy procedures. The mean duration of operation was 205 minutes (range: 90-360
minutes). The mean intraoperative blood loss was
300 mL (range: 100-1500 mL). Two patients received transfusion (8%). There was one open conversion. There was no mortality or reoperation.
Postoperative morbidity rate was 11% (n = 2). One
patient presented lobar pneumonia, while another
presented intraoperative bleeding and incisional
hernia in the late postoperative period. The median hospital stay was four days (range: 2-11 days).
The median time needed for resuming daily activities was 13 days (range: 7-40 days). The median follow-up time was 18 months (range: 6-48 months),
and there was only one hepatic recurrence.
sergio renato Pais-Costa – MD, oncology surgeon, Santa Lucia Hospital,
Brasília, Distrito Federal, Brazil
sergio luiz Melo Araújo – MD, general surgeon, Santa Lucia Hospital,
Brasília, Distrito Federal, Brazil
Olímpia Alves Teixeira lima – MD, general surgeon, Santa Lucia Hospital,
Brasília, Distrito Federal, Brazil
Victor Netto Figueiredo – MD, general surgeon, Santa Lucia Hospital,
Brasília, Distrito Federal, Brazil
Alexandre Chartuni Teixeira Pereira – MD, general surgeon, Santa Lucia
Hospital, Brasília, Distrito Federal, Brazil
Mailing address. Sergio Renato Pais Costa. SEPS 710/910, conjunto D, sala 330, CEP 70.390-108, Brasília-DF, Brazil.
E-mail address: [email protected]
Received on October 16, 2012. Accepted on December 10, 2012.
No potential conflict of interest relevant to this article was
reported.
Conclusion. Laparoscopic hepatectomy is a safe
surgical approach for treating both benign and malignant hepatic lesions. This small series presented
no mortality and a low morbidity rate. There was
a low hepatic recurrence rate during a long-term
follow-up program.
Key words. Laparoscopy; hepatectomy; liver neoplasms; neoplasm metastasis.
Brasília Med 2012;49(4):233-241 • 233
ORIGINAL ARTICLE
RESUMO
iNTrOdUCTiON
Vinte e quatro hepatectomias laparoscópicas consecutivas em hospital terciário.
Since the performance of the first laparoscopic hepatectomy in 1992 by Gagner et al.,1 this approach
has become the treatment of choice for hepatic tumors in reference centers. Azagra et al.2 performed
the first anatomical laparoscopy, which consisted
of a successful left lateral sectionectomy or sectorectomy (segments II-III) in a patient with hepatic adenoma of segments II and III. Laparoscopic
hepatectomy should be used as a last resource in
laparoscopic surgery due to the anatomical complexity of this surgical approach and the lack of
surgeons with experience in both laparoscopy and
hepatic surgery. In general, like other laparoscopic
procedures, laparoscopic hepatectomy presents
many advantages over an open approach. Some
of its advantages are less postoperative pain, early
mobilization, minimal ileus, earlier resumption of
oral intake, and shorter hospital stay. At first, minor hepatectomy for superficial lesions was performed with great confidence. Nonetheless, the
advances in laparoscopic instruments and hepatic
transection devices as well as greater experience in
complex laparoscopic hepatobiliary resections have
allowed the use of both right and left major laparoscopic hepatic resection to increase.1-15
Introdução. Com a evolução da cirurgia minimamente
invasiva, as hepatectomias laparoscópicas têm se mostrado uma alternativa interessante para o cirurgião hepático. Hepatectomia por via laparoscópica apresenta
muitas vantagens sobre a abordagem aberta.
Objetivo. Avaliar os resultados precoces (morbidade e
mortalidade) e tardios (complicações tardias e recidiva
das lesões) das hepatectomias laparoscópicas em hospital terciário.
Método. Os autores relatam uma série de vinte e quatro
doentes submetidos à hepatectomia laparoscópica por
uma única equipe cirúrgica do Hospital Santa Lúcia,
Brasília-DF, Brasil, entre junho de 2007 e janeiro de 2012.
Resultados. A mediana de idade foi 53 anos (variou de
21 a 71 anos). Foram treze mulheres e onze homens. Treze
doentes tinham lesão hepática benigna, enquanto onze
tinham lesões malignas. A média do tamanho das lesões
foi 4,96 cm. Foram seis hepatectomias maiores e dezoito
hepatectomias menores. A média de tempo cirúrgico foi
205 minutos (variação de 90 a 360 minutos). A média de
sangramento intraoperatório foi 300 mL (variação de 100
a 1.500 mL). Dois doentes foram transfundidos. Houve uma
conversão. Não houve mortalidade, e nenhum doente foi
reoperado. A morbidade pós-operatória foi 8% (n = 2).
Um doente apresentou pneumonia lobar, enquanto outro
apresentou hemorragia intraoperatória e hérnia incisional
nos pós-operatório tardio. A mediana de internação foi 4
dias (variação de 2 a 11 dias). A mediana de retorno às
atividades cotidianas foi 13 dias (variação de 7 a 40 dias).
A mediana de seguimento foi 18 meses (variação de 4 a 38
meses), e houve apenas uma recidiva de lesão hepática.
Conclusão. A hepatectomia laparoscópica representa
um método cirúrgico seguro de tratamento para lesões
hepáticas. Esta pequena série apresentou mortalidade
nula e baixa morbidade. Houve baixa recorrência de lesão em longo prazo.
Palavras-chave. Laparoscopia; hepatectomia; neoplasias hepáticas; metástase neoplásica.
234 • Brasília Med 2012;49(4):233-241
Recently, laparoscopic hepatectomy has been performed with both minimal morbidity and no mortality in reference centers.3-7,15-17 In recent years,
some authors have taken the view that laparoscopic hepatectomy should be the preferred approach
in cases of both benign and malignant hepatic lesions.3-5,16,17 Even difficult-to-access lesions in the
right hepatic lobe may be resectable with great
confidence by the laparoscopic route, with low
conversion and morbidity rates.7,16 Thus, laparoscopic hepatectomy has started a new era in minimally invasive hepatobiliary surgery. It has been
established that, for specific patients and when
performed by a team with expertise in both hepatic and advanced laparoscopic surgery, laparoscopic
hepatectomy is safe and presents results identical
to those obtained with open operations.4,5,16,17-28 In
Brazil, however, there have been only some anecdotal case reports,19,20,25,26 and few small series have
been reported.21-23,27 Machado et al.23 and Pais-Costa
Sergio Renato Pais-Costa et al. • Laparoscopic hepatectomies
et al.27,28 showed that laparoscopic hepatectomy
was effective, with good results regarding either
malignant or benign hepatic lesions.
The aim of this study was to describe both the short
and long-term results of laparoscopic hepatectomies to treat benign and malignant liver diseases,
performed by a single surgical team in a private
reference hospital in Brasília, Brazil.
accordance with the surgeon’s preference and location of the lesion.
Either intra-hepatic Glissonian approach
(Figures 1 and 2) or extra-hepatic Glissonian approach (laparoscopic dissection of both hepatic
pedicles and the major biliary tree) was performed in accordance with the surgeon’s choice.
Liver transection was preferably performed
METHOds
Between June 2007 and January 2012, 24 consecutive laparoscopic hepatectomies were done at
Santa Lucia Hospital, Brasília, Brazil. All resections
were performed by a single surgical team. The indications for laparoscopic resection of benign liver
tumors were the following: preoperative diagnosis
of hepatic adenoma with 5 cm or more in diameter;
cystadenoma; uncertain diagnosis based on imaging or biopsy findings; and presence of symptoms.
The laparoscopic approach was chosen because of
the size and location of the lesions. Large tumors,
tumors close to major vascular structures, and tumors located in central positions were excluded
from this sample.
Liver resections were defined in accordance with the
International Hepato-Pancreato-Biliary Association
(IHPBA) terminology, derived from the Couinaud
classification. Subsequently, major hepatectomy
was defined as resection of three or more segments.
Ultrasonography, computed tomography, and magnetic resonance were performed on all patients.
When the radiological diagnosis was uncertain, liver
biopsy was performed by the percutaneous route.
Radio-guided percutaneous drainage was tried to
treat all diagnosed hepatic abscesses.
The surgical technique for laparoscopic hepatic
resection was determined case by case, in accordance with previously described technical principles.6,7,18,20-23,27 In general, the procedures were performed with carbon-dioxide-pressure control over
the pneumoperitoneum, with a positive pressure of
12 mmHg. A 30-degree laparoscope was used with
four or five port sites, depending on the case and in
Figure 1. Liver evaluation for intrahepatic Glissonian
approach – large focal nodular hyperplasia in the
left hepatic lobe (segments II-III)
Figure 2. Laparoscopic left lobectomy – intrahepatic
Glissonian approach. Sectioning through hilar
structures by means of vascular stapler after two
hepatotomy procedures
Brasília Med 2012;49(4):233-241 • 235
ORIGINAL ARTICLE
using Ligasure Device (10 mm size, Covidien,
US), as shown in Figure 3. More rarely, in two
cases of this series, liver transection was done
by Ultracision shears (Ethicon-Endosurgery, US).
Small vascular or biliary ducts were sealed using
ultrasonic devices, while major structures were
sealed using metal clips or Hemo-o-lock clips.
Portal pedicles and hepatic veins were divided
using a linear stapler (Endogia – 30 or 45 mm
– vascular type), in accordance with Gumbs et
al.13 Except for two cases in which the patients
presented an abdominal incision due to previous
open surgery (one case of right subcostal and one
case of median laparotomy), the surgical specimen was resected by means of a Pfannenstiel
incision. The surgical specimen was moved into
a plastic bag or glove. Abdominal drainage was
generally not performed. When necessary, suction drains were used (in three cases).
Figure 3. Right hemi-hepatectomy – transection of
hepatic parenchyma with Ligasure 10 mm
rEsUlTs
Thirteen laparoscopic hepatectomy procedures
were performed to treat benign hepatic lesions,
while eleven were performed because of malignant lesions. There were thirteen women and
eleven men. The median age was 53 (range: 2171 years). Fifteen patients presented solitary
236 • Brasília Med 2012;49(4):233-241
lesions, while nine presented multiple lesions.
The right hepatic lobe was compromised in
thirteen cases, while the left hepatic lobe was
compromised in eleven cases. Only two patients
presented bilateral lesions (both malignant).
The etiology of the lesions were adenoma (n =
4), metastasis (n = 9), hepatocellular carcinoma
(n = 2), focal nodular hyperplasia (n = 4), hepatic
abscess (n = 2), hemangioma (n = 2), and biliary
cystadenoma (n = 1). The main symptoms were
pain (n = 10), palpable mass (n = 8), discomfort (n
= 7), and early satiety (n = 6). The lesion diameter
ranged from 1.8 to 12 cm (mean: 4.96 cm).
All patients underwent preoperative radiological
investigations through abdominal ultrasound,
computed tomography, and nuclear magnetic
resonance. These examinations showed that
twenty-one patients presented a solid liver tumor (87.5%), while three patients presented a
cystic lesion (12.5%). For malignant lesions, PETScan was also performed. The tumor markers
carcinoembryonic antigen, alpha-fetoprotein,
and carbohydrate antigen (CA 19.9) were assayed
in all cases. Eight of the twenty-four patients
underwent tumor biopsy (by the percutaneous
route in six cases, by laparoscopy in two cases).
In this series, tumor biopsy allowed us to obtain
a certain diagnosis in four cases (50%, i.e. four
out of eight biopsies).
In twelve patients, the surgical indication was malignant or premalignant disease. There were two
cases of hepatocellular carcinoma, three of noncolorectal non-neuroendocrine metastasis, six of
colorectal cancer liver metastasis, and one of hepatic cystadenoma. In the non-colorectal non-neuroendocrine metastasis group, the primary origin
was the following: kidney = 1, small intestine = 1,
pelvic soft tissue sarcoma =1. In the other twelve
patients with benign disease, the most common
indications were the following: presence of symptoms, hepatic adenoma (diameter > 5 cm), uncertain preoperative diagnosis, or failure of percutaneous treatment of hepatic abscesses.
Among the benign solid tumors (n = 10), preoperative typical features of hepatic adenoma,
Sergio Renato Pais-Costa et al. • Laparoscopic hepatectomies
focal nodular hyperplasia, and hemangioma were
found in almost all of these patients (n = 8). Eight
of them presented symptoms such as pain and
discomfort. One case presented multiple adenomatosis with three lesions. This patient reported
abusive use of anabolic steroids. Uncertain diagnoses were the surgical indication in the case of
two patients (focal nodular hyperplasia = 1 and
hemangioma = 1). Histological examination confirmed the preoperative diagnosis in all these patients. One case of focal nodular hyperplasia was
diagnosed preoperatively, while three cases presented atypical radiological findings. The indication for liver resection in these patients was an
uncertain diagnosis (differential diagnosis with
hepatocellular carcinoma) in one case and right
upper quadrant pain due to a bulky hanging tumor located in the V hepatic segment in the other case. Both cases of hepatic abscesses had been
previously unsuccessfully treated by percutaneous drainage. Subsequently, laparoscopic hepatectomy was performed because both lesions presented central locations within the hepatic lobe,
with partial destruction of the adjacent liver parenchyma. Two patients who presented bilateral
metastasis successfully underwent “two-stage”
laparoscopic hepatectomy.
The laparoscopic procedure was completed in
23 patients (95%). One patient who presented a
giant hemangioma (10 cm) underwent open conversion due to massive intraoperative bleeding.
There were six major hepatectomy procedures
and eighteen minor hepatectomy procedures
(Figure 5). The distribution of hepatectomies
were as follows: right hepatectomy (n = 2), left
hepatectomy (n = 4), lateral left segmentectomy
or bisegmentectomy II-III (n = 6), right posterior
sectionectomy or bisegmentectomy VI-VII (n =
8), bisegmentectomy V-VI (n=1), monosegmentectomy V (n = 2), and monosegmentectomy VI
(n = 1). The surgical features of the hepatectomies are shown in Table 1. Twenty hepatic resections were performed by an intra-hepatic
Glissonian approach, while four hepatectomies
(all of them major hepatectomies) were done
through an extra-hepatic Glissonian approach
(with dissection of both main hepatic pedicles
and the major biliary tree). Two patients required postoperative blood transfusions. Three
patients underwent surgical drainage of the liver
bed using suction drains. The drains were taken out on the fourth or fifth postoperative day.
There was no gas embolism in this series.
Table 1. Surgical features
rEsUlTs
Vascular clamping – n (%)
1 (18)
Intraoperative blood loss –
mean (range)
300 mL (100-1500)
Blood transfusion – n (%)
2 (18)
Duration of surgery –
mean (range)
240 min (90-360)
Weight of the specimen –
mean (range)
285 g (57-1040)
n = number of patients
The mean duration of the operation was 205
minutes. For the initial cases (n = 5), the mean
duration of the operation was greater than
in the subsequent operations (257 versus 197
min). However, most of the major hepatectomy
procedures (80%) were performed in the later
cases. There was no mortality in this series.
Postoperative complications occurred in two
patients who underwent one right hemi-hepatectomy and one left hemi-hepatectomy (8%)
(Table 2). One patient presented infectious left
lobar pneumonia, which was treated with antibiotics. Another patient presented intraoperative bleeding and underwent open conversion.
This patient presented incisional hernia at the
postoperative period, which was laparoscopically treated. There was neither biliary leakage
nor hepatic insufficiency. There was no reoperation in this series. Oral intake was resumed on
the first postoperative day in all but one patient
who underwent open conversion. The median
hospital stay was four days (range: 2-11 days).
All patients but one used low doses of common
analgesics such as dipyrone during the postoperative course. One patient used narcotic analgesia during the postoperative course. The median
time needed for the patients to return to their
Brasília Med 2012;49(4):233-241 • 237
ORIGINAL ARTICLE
daily activities was 13 days (range: 7-40 days).
Characteristics of the postoperative course are
shown in Table 2.
Table 2. Postoperative course
rEsUlTs
Morbidity – n (%)
Reoperation – n (%)
2 (11)
0
Specific liver resection
complications* – n (%)
1 (5.5)
Nonspecific complications – n (%)
1 (5.5)†
Mortality – n (%)
Hospital stay – median (range)
Return of normal activities –
median (range)
0
4 d (2-11)
13 d (7-30)
Oral intake (hours)
6
10 (52)
12
4 (23)
24
3 (17)
> 24
1 (7)
*Intraoperative bleeding. †lobar pneumonia.
The mean follow-up time in this series was 24
months (median: 18 months; range: 4-39 months).
All the symptomatic patients achieved complete
symptom relief. Among the cancer patients, all
but one patient with non-colorectal non-neuroendocrine metastasis (adenocarcinoma of the small
intestine) did not experience recurrence. All of
them present good quality of life.
disCUssiON
Laparoscopic hepatectomy is an advance in the
continuing development of minimally invasive surgery in general and laparoscopic liver surgery in
particular. Advances in expertise related to laparoscopic procedures, ongoing technological advances in laparoscopic devices, and increased patient
awareness of the availability of these techniques
238 • Brasília Med 2012;49(4):233-241
have created growing interest in the application
of these techniques to laparoscopic hepatectomy.16
The surgical skills required for laparoscopic hepatectomy have evolved in parallel with the adaptation of laparoscopic techniques to procedures in
hepatectomy. Hilar dissection, biliary or vascular
repair, mobilization of the liver, and transection
of the parenchyma are more technically demanding and potentially more dangerous than other
laparoscopic procedures that have been previously reported. Anatomical hemi-hepatectomy
requires a clear understanding of general liver
anatomy, experience in advanced hepatobiliary
surgery, and, additionally, the ability to dissect
major vascular and biliary structures using a laparoscopic approach.10,14,16, 21,23
Despite the various obstacles and challenges, laparoscopic hepatectomy presents great advantages
over open hepatectomy. The major advantages of
laparoscopic hepatectomy are those of all laparoscopic surgical procedures. Laparoscopic hepatectomy causes less tissue damage, and this has
been associated with lower levels of postoperative
pain, fewer peritoneal adhesions, shorter hospital
stay, and an earlier return to daily activities.3,4,7,11
Moreover, two recently published case-control
studies16,17 and one cohort study5 have shown that
laparoscopic hepatectomy provided lower blood
loss, reduced morbidity, fewer overall operative
complications and, especially with regard to malignant disease, no significant difference either in
tumor recurrence or in long-term survival.15,16,17,29,30
Furthermore, the cosmetic advantages are excellent when laparoscopic hepatectomy is performed.
It is particularly important when performed to
treat benign disease.3,14,24 Earlier resumption of oral
intake is also a great advantage, considering that
hepatectomy is a major surgical procedure. For
these reasons, the laparoscopic approach should
be taken into account in the management of both
benign and malignant liver disease.4,5,8,12,16,17,23
According to some authors,3,11,14,17,23 the use of the
laparoscopic route should not modify or broaden
the indications for either benign or malignant
liver disease. The same principles applied to open
Sergio Renato Pais-Costa et al. • Laparoscopic hepatectomies
hepatic surgery must be respected. Therefore, especially in the case of benign disease, it should be
reserved for symptomatic lesions, specific complications or even uncertain diagnosis (differential
with primary or metastatic neoplasms). Patients
should be offered more liberal surgical resection,
especially for hepatic adenoma, because of the
high risk of rupture and malignant degeneration.14
Despite the initial skepticism about the use of
laparoscopic hepatectomy to treat malignant
neoplasms, it is nowadays frequently performed,
since this procedure is secure and effective. Some
authors4,11,15-17 have taken the view that laparoscopic hepatectomy is as safe as conventional
open hepatectomy.
series, there was one perioperative complication
(intraoperative bleeding), and only two patients
received transfusions (in a case of major right
hepatectomy due to a large cystadenoma of 12 cm
in diameter and a case of left hemi-hepatectomy
due to giant hemangyoma). Although the rate of
conversion to open surgery has ranged from 0 to
15%,14,23 it depends on the resection type, experience of the team, and volume of the lesion. The
present open conversion rate is similar to that
found in the literature.
For left lesions, some authors have considered laparoscopic hepatectomy to be the initial approach
in reference centers, performed by surgeons with
high levels of expertise.3-5,15,17 Campos et al.4 recently published a single series of left laparoscopic resections in which the clear advantages of the laparoscopic approach were observed. More recently,
in a cohort study that compared laparoscopy and
open left lateral segmentectomy, Carswell et al.5
observed that laparoscopy was superior because
there is less need for postoperative opiate analgesia
and because postoperative hospital stay is shorter.
In this study, it was observed that there was no
use of opiates and none of the patients presented
complications on the third postoperative day, especially regarding left lateral segmentectomy procedures. It was also observed in this series that the
results were similar, without postoperative opiate
administration, for all but one patient who underwent open conversion (left hemi-hepatectomy for
giant hemangioma). With especial regard to left resections, only one patient presented complications
(intraoperative bleeding and incisional hernia). In
Brazil, we had previously reported the safety of the
left lateral segmentectomy by an intrahepatic approach for treating left side lesions in the liver.30
Although the initial experiences with right liver
resection were technically demanding, some authors5,16,21,22,27 have taken the view that the laparoscopic approach should be the preferred choice,
even for posterior right lesions (segments VI-VII).
In this series, despite the fact that it was a small
sample, there were more cases of right resections,
including two cases of formal right hepatectomy,
five cases of posterior right sectionectomy (SVIVII), two cases of monosegmentectomy of segment
V, and one case of segmentectomy of segment VI.
The major advantage of laparoscopic hepatectomy
for resecting posterior right lesions is that it avoids
the large open incision that is generally necessary
to access posterior pedicles.7,27 Right-side hepatic resections are not only technically more difficult, but
also present higher conversion rates than left resections do.11,16,19,23 Laparoscopic hepatectomy for right
lesions can be considered feasible and safe, as Cho et
al.7 have shown in a recent study. For the posterior
right sectionectomy in this series, an intra-hepatic
approach was preferred, as already described in
Brazil by Machado et al.22 Like Machado’s series,
we reported the high efficacy of this technique for
treating posterior lesions in the right lobe.27 This approach avoids large incisions, which tend to cause
pain. Moreover, it is safe and may decrease intraoperative bleeding as seen in this study, in which
the five patients who underwent posterior right sectionectomy S received no transfusions and showed
minimal intraoperative bleeding.
In a series of 78 patients, Zhang et al.24 observed
totally successful laparoscopic liver resections,
with no conversion to open procedures and only four patients receiving transfusions. In this
In one of the largest series of 300 minimally invasive liver resections, which were compared with
open procedures, Koffron et al.16 observed that the
laparoscopic approach was superior to the open
Brasília Med 2012;49(4):233-241 • 239
ORIGINAL ARTICLE
technique. The advantages were related to the
duration of the operation, blood loss, transfusion
requirement, length of hospital stay, overall operative complications, and local malignant recurrence. These authors concluded that the outcomes
from minimally invasive liver resections compared
favorably with those from the standard open operation. In a study previously published by the
present author29 on a single series of cases of open
hepatectomy due to metastasis (n = 30 cases), in
which almost all of the patients were operated by
the senior author (Costa SRP), the overall mortality was 3%, while the morbidity rate was 46%. The
reoperation rate was 16%, and 44% of the patients
received transfusions. The median blood loss was
800 ml. Although it was difficult to compare the
outcomes of the laparoscopic series and those
of a contemporary open series, given the higher
proportion of major hepatic resections (66% vs.
25%) and greater severity of metastatic disease
(age, nutritional state, and associated diseases) in
the open series, in addition to the lack of a specific statistical test to compare those samples,
the laparoscopic series presented some advantages. There was less mortality, morbidity, blood
loss, and fewer transfusions and reoperations. In
Brazil, a few authors18-23,25-27 have published studies on laparoscopic hepatectomy. Machado et al.21
observed both low morbidity and zero mortality in
laparoscopic hepatectomy procedures performed
due to colorectal cancer liver metastasis, and their
results were similar to those found in this series.
This has also been observed in more recent studies, in which mortality was generally zero, while
general morbidity ranged from 0% to 10%.3,4,16,17,21,27
However, with regard to right resections, morbidity is proportionally higher than in left resections,
as described by Koffron et al.,16 who suggest that
right lesions may be more difficult to treat. Cho
et al.7 observed an overall morbidity rate of 28%,
when considering only right liver resections. In
this series, there was no reoperation, which differs
from what some authors had previously reported.23
However, major hepatectomy only accounted for
25 % (n = 6) of this series, which may have contributed to the low morbidity rate in this study.7
240 • Brasília Med 2012;49(4):233-241
To date, with regard to malignant disease, studies
have suggested that there is no difference between
laparoscopic hepatectomy and open hepatectomy
in relation to port-site metastasis, free margins, local-systemic recurrence or even survival rates.11,12,
16,17,21,29-32
However, there have only been a few
match-controlled studies, with no ideal level of
evidence. Historical series have shown no difference between laparoscopic hepatectomy and open
hepatectomy performed on malignant disease.
Nevertheless, such findings should be viewed with
caution, and new studies need to be conducted in
order to answer these unresolved questions.
In conclusion, laparoscopic hepatectomy is a safe surgical approach to treating focal hepatic lesions consisting of either benign or malignant disease. In this
small series, both zero mortality and low morbidity
were associated with low late tumor recurrence.
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