The international position on laparoscopic liver surgery: The Louisville Statement, 2008.
OBJECTIVE
To summarize the current world position on laparoscopic liver surgery.


BACKGROUND
Multiple series have reported on the safety and efficacy of laparoscopic liver surgery. Small and medium sized procedures have become commonplace in many centers, while major laparoscopic liver resections have been performed with efficacy and safety equaling open surgery in highly specialized centers. Although the field has begun to expand rapidly, no consensus meeting has been convened to discuss the evolving field of laparoscopic liver surgery.


METHODS
On November 7 to 8, 2008, 45 experts in hepatobiliary surgery were invited to participate in a consensus conference convened in Louisville, KY, US. In addition, over 300 attendees were present from 5 continents. The conference was divided into sessions, with 2 moderators assigned to each, so as to stimulate discussion and highlight controversies. The format of the meeting varied from formal presentation of experiential data to expert opinion debates. Written and video records of the presentations were produced. Specific areas of discussion included indications for surgery, patient selection, surgical techniques, complications, patient safety, and surgeon training.


RESULTS
The consensus conference used the terms pure laparoscopy, hand-assisted laparoscopy, and the hybrid technique to define laparoscopic liver procedures. Currently acceptable indications for laparoscopic liver resection are patients with solitary lesions, 5 cm or less, located in liver segments 2 to 6. The laparoscopic approach to left lateral sectionectomy should be considered standard practice. Although all types of liver resection can be performed laparoscopically, major liver resections (eg, right or left hepatectomies) should be reserved for experienced surgeons facile with more advanced laparoscopic hepatic resections. Conversion should be performed for difficult resections requiring extended operating times, and for patient safety, and should be considered prudent surgical practice rather than failure. In emergent situations, efforts should be made to control bleeding before converting to a formal open approach. Utilization of a hand assist or hybrid technique may be faster, safer, and more efficacious. Indications for surgery for benign hepatic lesions should not be widened simply because the surgery can be done laparoscopically. Although data presented on colorectal metastases did not reveal an adverse effect of the laparoscopic approach on oncological outcomes in terms of margins or survival, adequacy of margins and ability to detect occult lesions are concerns. The pure laparoscopic technique of left lateral sectionectomy was used for adult to child donation while the hybrid approach has been the only one reported to date in the case of adult to adult right lobe donation. Laparoscopic liver surgery has not been tested by controlled trials for efficacy or safety. A prospective randomized trial appears to be logistically prohibitive; however, an international registry should be initiated to document the role and safety of laparoscopic liver resection.


CONCLUSIONS
Laparoscopic liver surgery is a safe and effective approach to the management of surgical liver disease in the hands of trained surgeons with experience in hepatobiliary and laparoscopic surgery. National and international societies, as well as governing boards, should become involved in the goal of establishing training standards and credentialing, to ensure consistent standards and clinical outcomes.
Buell
Joseph F
JF
Department of Surgery, Director of Transplantation, Jewish Hospital Transplant Center, 200 Abraham Flexner Way, Louisville, KY 40202, USA. joseph.buell@louisville.edu
Cherqui
Daniel
D
Geller
David A
DA
O'Rourke
Nicholas
N
Iannitti
David
D
Dagher
Ibrahim
I
Koffron
Alan J
AJ
Thomas
Mark
M
Gayet
Brice
B
Han
Ho Seong
HS
Wakabayashi
Go
G
Belli
Giulio
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Kaneko
Hironori
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Ker
Chen-Guo
CG
Scatton
Olivier
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Laurent
Alexis
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Abdalla
Eddie K
EK
Chaudhury
Prosanto
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Dutson
Erik
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Gamblin
Clark
C
D'Angelica
Michael
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Nagorney
David
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Testa
Giuliano
G
Labow
Daniel
D
Manas
Derrik
D
Poon
Ronnie T
RT
Nelson
Heidi
H
Martin
Robert
R
Clary
Bryan
B
Pinson
Wright C
WC
Martinie
John
J
Vauthey
Jean-Nicolas
JN
Goldstein
Robert
R
Roayaie
Sasan
S
Barlet
David
D
Espat
Joseph
J
Abecassis
Michael
M
Rees
Myrddin
M
Fong
Yuman
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McMasters
Kelly M
KM
Broelsch
Christoph
C
Busuttil
Ron
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Belghiti
Jacques
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Strasberg
Steven
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Chari
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D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008107:Liver Diseases / Q000601:surgery*; D008113:Liver Neoplasms / Q000556:secondary / Q000601:surgery; D016031:Liver Transplantation; D019520:Living Donors; D019060:Minimally Invasive Surgical Procedures; D018579:Patient Selection; D020858:Tissue and Organ Harvesting