title: Hand-assisted laparoscopic management of liver tumors.
abstract: BACKGROUND
  Laparoscopy has clearly advanced the treatment of many diseases related to the liver and biliary tree. The addition of hand assistance can further facilitate minimally invasive liver surgery by providing tactile feedback, atraumatic and versatile retraction, finger-fracture parenchyma dissection, and more precise placement of probes and staplers.
  
  
  METHODS
  Over a 7-year period, 28 patients with liver tumors underwent 31 hand-assisted laparoscopic operations at a tertiary care center. The candidates for hand-assisted laparoscopic resection were patients with lesions involving two hepatic segments or fewer located at the inferior edge of the liver (segments 5 and 6), or confined to the left lateral segment (segments 2 and 3). Ablation was reserved for patients with poor functional status or limited hepatic reserve, and hand-assistance was added for laparoscopic ablation of centrally located tumors (segments 7, 8, and 4a).
  
  
  RESULTS
  The selection criteria were met by 52 patients, 6 of whom had benign lesions. The remaining 46 patients had malignant disease, and 15 of these patients (33%) were found to have extrahepatic disease: 11 at initial laparoscopy and 4 at hand-assisted abdominal exploration. Manual exploration also detected additional intrahepatic treatable lesions in two cases. A total of 19 patients (68%) had metastatic disease, and 3 (11%) had primary liver cancer. The most extensive resections were five left lateral segmentectomies. All margins were negative. The mean operative time was 2.75 h, and the mean blood loss was 230 ml. Two diaphragmatic injuries occurred during ablation of segment 8 lesions. Three cases were converted to open surgery because of adhesions. The mean hospital stay was 3.7 days. A group of 15 patients who had metastatic colorectal cancer treated with resection and/or ablation had a mean follow-up period of 24 months (range, 2-61 months) and a mean survival time of 36 months.
  
  
  CONCLUSIONS
  For selected patients, the hand-assisted technique can be applied safely and effectively to laparoscopic liver surgery and may identify the presence of previously undetectable intrahepatic or extrahepatic disease.
authors.affiliation: Connecticut Surgical Group, Hartford Hospital Transplant Program, Department of Surgery, Hartford Hospital, CT, USA. hhgpoul@ntplx.net
authors.forename: G
authors.initials: G
authors.lastname: Poultsides
authors.forename: M
authors.initials: M
authors.lastname: Brown
authors.forename: R
authors.initials: R
authors.lastname: Orlando
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008113:Liver Neoplasms / Q000401:mortality / Q000556:secondary / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D015996:Survival Rate