title: Laparoscopic hepatectomy in cirrhotics: safe if you adjust technique.
abstract: Minimally invasive liver surgery is a growing field, and a small number of recent reports have suggested that laparoscopic liver resection (LLR) is feasible even in patients with cirrhosis. However, parenchymal transection of the cirrhotic liver is challenging due to fibrosis and portal hypertension. There is a paucity of data regarding the technical modifications necessary to safely transect the diseased parenchyma.
  
  
  
  Patients undergoing LLR by a single surgeon between 2008 and 2015 were reviewed. Patients with cirrhosis were compared to those without cirrhosis to examine differences in surgical technique, intraoperative characteristics, and outcomes (including liver-related morbidity and general postoperative complication rates).
  
  
  
  A total of 167 patients underwent LLR during the study period. Forty-eight (29 %) had cirrhosis, of which 43 (90 %) had hepatitis C. Most had Child-Pugh class A disease (85 %). Compared to noncirrhotics, patients with cirrhosis were older, had more comorbidities, and were more likely to have hepatocellular carcinoma. Precoagulation before parenchymal transection was used more frequently in cirrhotics (65 vs. 15 %, P < 0.001), and mean portal triad clamping time was longer (32 vs. 22 min, P = 0.002). There were few conversions to open surgery, though hand-assisted laparoscopy was used as an alternative to converting to open in three patients with cirrhosis. Blood loss was relatively low for both groups. Although there were more postoperative complications among cirrhotics (38 vs. 13 %, P = 0.001), this was almost entirely due to a higher rate of minor (Clavien-Dindo I or II) complications. Liver-related morbidity, major complications, and mortality rates were similar.
  
  
  
  LLR is safe for selected patients with cirrhosis. The added complexity associated with the division of diseased liver parenchyma may be overcome with some form of technique modification, including more liberal use of precoagulation, portal triad clamping, or a hand-assist port.
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Suite H3680C, Stanford, CA, 94305, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Worhunsky
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Suite H3680C, Stanford, CA, 94305, USA.
authors.forename: Monica M
authors.initials: MM
authors.lastname: Dua
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Suite H3680C, Stanford, CA, 94305, USA.
authors.forename: Thuy B
authors.initials: TB
authors.lastname: Tran
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Suite H3680C, Stanford, CA, 94305, USA.
authors.forename: Bernard
authors.initials: B
authors.lastname: Siu
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Suite H3680C, Stanford, CA, 94305, USA.
authors.forename: George A
authors.initials: GA
authors.lastname: Poultsides
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Suite H3680C, Stanford, CA, 94305, USA.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Norton
authors.affiliation: Division of Surgical Oncology, Department of Surgery, Stanford University Medical Center, 300 Pasteur Drive, Suite H3680C, Stanford, CA, 94305, USA. bvisser@stanford.edu.
authors.forename: Brendan C
authors.initials: BC
authors.lastname: Visser
mesh_terms: D000328:Adult; D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000601:surgery; D017115:Catheter Ablation; D018281:Cholangiocarcinoma / Q000601:surgery; D061887:Conversion to Open Surgery; D005260:Female; D058733:Hand-Assisted Laparoscopy; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008103:Liver Cirrhosis / Q000150:complications*; D008113:Liver Neoplasms / Q000601:surgery; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications
keywords: Cirrhosis; Hepatectomy; Laparoscopy; Technique