ORIGINAL ARTICLES Laparoscopy-Assisted Major Liver Resections Employing A Hanging Technique The Original Procedure Hiroyuki Nitta, MD, Akira Sasaki, MD, Tomohiro Fujita, MD, Hidenori Itabashi, MD, Koichi Hoshikawa, MD, Takeshi Takahara, MD, Masahiro Takahashi, MD, Satoshi Nishizuka, MD, PhD, and Go Wakabayashi, MD, PhD Objective: To assess the feasibility, safety, and short-term outcomes of laparoscopy-assisted major liver resections. Summary of Background Data: The number of reports of laparoscopic major hepatectomies has gradually increased, and living donor hepatecto- mies for liver transplant have also recently been performed. However, because of the high degree of proficiency required, major hepatectomies have not been widespread. We developed an original procedure in which the liver is mobilized laparoscopically and resected by a hanging technique through a small incision. Methods: Between November 2002 and December 2008, 43 patients underwent laparoscopy-assisted major liver resections (LAMLRs) in our institution for hepatocellular carcinoma, metastatic liver cancer, and benign diseases. Results: LAMLRs were completed for 42 patients (97.7%). The median age was 62 years (range: 24 – 83 years). Preoperative diagnoses were hepatocel- lular carcinoma (n = 15), metastatic liver cancer (n = 19), and benign disease (n = 8). The types of liver resection consisted of the following: right trisectionectomy (n = 2), right hepatectomy (n = 14), left hepatectomy (n = 16), trisegmentectomy 4, 5, 8 (n = 2), right anterior sectionectomy (n = 4), and extended right posterior sectionectomy (n = 4). The median operating time was 317 minutes (range: 192–542 minutes) and median blood loss was 631 mL (range: 68 –2785 mL). There were neither perioperative deaths nor reoperations. Five patients (11.9%) experienced postoperative complications, 2 patients (4.8%) showed bile leakage, and 3 patients (7.1%) developed wound infections. The median postoperative hospital stay was 13.5 days (range: 6 –154 days). Conclusions: LAMLR with the hanging technique can be completed safely. The procedure can be performed by open liver surgeons; and thus may be widely performed in the future. (Ann Surg 2010;251: 000 – 000) L aparoscopic liver resection was first reported in the early 1990s, 1 and its usefulness has been documented. 2–11 Nonetheless, a series of previous reports have raised concerns about the safety and feasibility of laparoscopic minor liver resections. Comparative stud- ies between open and laparoscopic resections have shown that laparoscopic liver resection resulted in decreased intraoperative bleeding, 12–16 fewer complications, 12,13,15 lower analgesics con- sumption, 17 and shorter postoperative hospital stay. 12–16,18 Subse- quently, laparoscopic major hepatectomies have been reported, 4,6,19,20 and now even living donor hepatectomies for liver transplant can be performed with laparoscopy. 21,22 Compared with liver resection by laparotomy, the incision is much smaller and the degree of body wall damage is reduced. However, because a high degree of proficiency is required, major hepatectomies have not been widespread. A previous series of completely laparoscopic right hepatectomy have expressed concerns about a high rate (10%–17%) of conversion to laparotomy. 6,19,20 For laparoscopic major liver resections to be performed more broadly, it is necessary that the procedure be both safe and easy to perform. We developed a procedure in which the liver is mobilized laparoscopically and a parenchymal transection with a hanging technique through a small incision in the right subcostal region is made. Liver mobilization does not require any advanced laparo- scopic technique, and liver resection can be performed through a small laparotomy incision using the same surgical instruments now used for laparotomy. PATIENTS AND METHODS Between November 2002 and December 2008, 329 patients underwent liver resections at Iwate Medical University Hospital. Forty-three patients undergoing laparoscopy-assisted major liver resections (LAMLRs) with the hanging technique for HCC, meta- static liver cancer, and benign disease were identified from the patient database of the hospital. Each patient had tumors 10 cm in diameter and were not undergoing bile duct resection or lymph node dissection. Patients with lesions involving the diaphragm or inferior vena cava were excluded. Those receiving major hepatectomy for living donor liver transplantation were excluded because surgical procedures were slightly different. Statistical Analysis Variables analyzed included operation time, blood loss, re- sected tumor size, postoperative hospital stay, morbidity, and mor- tality. Morbidity and mortality were defined as those occurring within 1 month of surgery. Continuous data for each variable were represented by the median along with the range. To compare the groups, Student t test was applied to the continuous data and the  2 test to the categorical data. P  0.05 was considered to be statisti- cally significant. Surgical Procedure There are 2 stages to the present procedure. First, the liver is mobilized laparoscopically, followed by laparoscopic cholecystec- tomy. A laparoscopy-assisted parenchymal transection is then per- formed through a small laparotomy incision (Fig. 1). The patient is in the semi-left lateral decubitus position for right lobe mobilization. A trocar for a laparoscope is inserted from the umbilical area to induce CO 2 pneumoperitoneum (10 mm Hg). Trocar placement is shown in Figure 1. An intraoperative ultra- sonography is performed to ascertain the tumor’s location. During LAMLR of the right lobe, such as right hepatectomy, trisegmentec- From the Department of Surgery, Iwate Medical University School of Medicine, 19-1 Uchimaru, Morioka, Iwate, 020-8505, Japan. Reprints: Hiroyuki Nitta, MD. E-mail: hnitta@iwate-med.ac.jp. Copyright © 2010 by Lippincott Williams & Wilkins ISSN: 0003-4932/10/25103-0001 DOI: 10.1097/SLA.0b013e3181cf87da Annals of Surgery • Volume 251, Number 3, March 2010 www.annalsofsurgery.com | 1