title: Experience with more than 500 minimally invasive hepatic procedures.
abstract: OBJECTIVE
  To evaluate our experience with more than 500 minimally invasive hepatic procedures.
  
  
  BACKGROUND
  Recent data have confirmed the safety and efficacy of minimally invasive liver surgery. Despite these reports, no programmatic approach to minimally invasive liver surgery has been proposed.
  
  
  METHODS
  We retrospectively reviewed all patients who underwent a minimally invasive procedure for the management of hepatic tumors between January 2001 and April 2008. Patients were divided into 3 groups: laparoscopy with intraoperative ultrasound and biopsy only, laparoscopic radiofrequency ablation (RFA), and minimally invasive resection. To compare the various forms of surgery, we analyzed the incidence of complications, tumor recurrence, mortality, and cost. Statistical analysis was performed using chi(2) analysis, Student t test, Kaplan-Meier survival analysis with the log-rank test, and multivariable Cox models.
  
  
  RESULTS
  A total of 590 minimally invasive hepatic procedures were performed during 489 operative interventions. The representative tumor histologies were: hepatocellular carcinoma (HCC; N = 210), colorectal carcinoma (N = 40), miscellaneous liver metastases (N = 42), biliary cancer (N = 20), and benign tumors (N = 176). Thirty-five patients underwent laparoscopic ultrasound and confirmatory biopsy alone; 201 patients underwent 240 laparoscopic RFAs, and 253 patients underwent 306 minimally invasive resections. Conversion rates to open surgery for the RFA and resection group were 2% overall. One hundred ninety-nine (40.6%) patients were cirrhotic; 31 resections were performed in cirrhotic patients. Complication and mortality rates for RFA and resection were comparable (11% vs. 16%, and 1.5% vs. 1.6%). However, complication rates (14% vs. 29%; P = 0.02) and mortality (0.3% vs. 9.7%; P = 0.006) rates were higher in the cirrhotic versus noncirrhotic resection group. Overall recurrence rates for RFA and resection groups were 24% and 23%, respectively. Local recurrence rates were higher in the RFA group (6.3% versus 1.5%; P < 0.06). Overall patient survival differed between HCC patients receiving RFA alone and those receiving RFA and OLT (P < 0.0001). Overall survival for cancer patients receiving RFA versus resection differed significantly when unadjusted for other covariates (P = 0.01), and remained marginally significant in a multivariable model (P = 0.056).
  
  
  CONCLUSIONS
  Minimally invasive hepatic surgery has become a viable alternative to open hepatic surgery. Our present data are equivalent or superior to those encountered in any large open series. Our experience with RFA confirms a low local recurrence rate and an excellent technique for bridging patients to transplantation. Morbidity and mortality rates for minimally invasive hepatic resections in cirrhotics, is similar to other reported open resection series. This series confirmed excellent interim survival rates after laparoscopic HR and superiority over RFA in the treatment of cancer, with significantly lower local tumor recurrence rate.
authors.affiliation: Jewish Transplant Center, Division of Transplantation, Department of Surgery, University of Louisville, Louisville, KY 40202, USA. joseph.buell@louisville.edu
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Buell
authors.forename: Mark T
authors.initials: MT
authors.lastname: Thomas
authors.forename: Steven
authors.initials: S
authors.lastname: Rudich
authors.forename: Michael
authors.initials: M
authors.lastname: Marvin
authors.forename: Ravi
authors.initials: R
authors.lastname: Nagubandi
authors.forename: Kadiyala V
authors.initials: KV
authors.lastname: Ravindra
authors.forename: Guy
authors.initials: G
authors.lastname: Brock
authors.forename: Kelly M
authors.initials: KM
authors.lastname: McMasters
mesh_terms: D017115:Catheter Ablation / Q000706:statistics & numerical data; D006498:Hepatectomy / Q000009:adverse effects / Q000191:economics / Q000379:methods / Q000706:statistics & numerical data*; D006801:Humans; D010535:Laparoscopy / Q000706:statistics & numerical data; D008113:Liver Neoplasms / Q000601:surgery*; D019060:Minimally Invasive Surgical Procedures / Q000706:statistics & numerical data*; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology; D012189:Retrospective Studies; D014463:Ultrasonography / Q000706:statistics & numerical data