By Victoria Stern

Surgeons have been performing laparoscopic liver resections since the late 1980s, but the standard approach to managing liver malignancies is still open surgery.

“Liver resection has been one of the last areas where we’ve applied minimally invasive techniques,” said T. Peter Kingham, MD, Department of Surgery, Hepatopancreatobiliary Service, Memorial Sloan-Kettering Cancer Center, New York City. “It’s a challenge to safely perform the same liver resection laparoscopically, as open, in all segments of the liver.”

Surgical glove port for single-port surgery.

A new study, led by Mitsuhiro Asakuma, MD, Department of General and Gastroenterological Surgery, Osaka Medical College, Takatsuki City, Japan, demonstrated the safety and feasibility of single-port laparoscopic liver resection using a surgical glove port in 19 patients, all of whom recovered quickly and experienced minimal postoperative pain. The new research, presented at the 21st International Congress of the European Association for Endoscopic Surgery (EAES) in June, won the Olympus EAES Award for best oral presentation on single-port surgery.

“I think this is a well-done study,” said Dr. Kingham, who was not involved in this research. “The surgeons’ surgical glove method, in particular, is novel and applicable in most hospitals because it does not require any extra equipment.”

Other recent efforts have shown promise for a single-port approach to liver resection in selected patients. In 2011, Dr. Kingham and his colleagues published information on a small series of single-port liver resections, in which they reported the safety and feasibility of left-liver wedge resection through a single port (Surg Endosc 2011;25:1489-1494). Research by surgeons in Japan showed the success of single-port laparoscopic hepatectomy in eight patients, none of whom experienced wound pain or liver dysfunction after a two-week follow-up (Surg Endosc 2012;26:1696-1701). Another recent study from Korea found single-port laparoscopic liver resection to be feasible in “well-selected cases” (Surg Endosc 2012;26:1602-1608). In this study, of the 24 patients with hepatocellular carcinoma who underwent the single-port procedure, two were converted to multiport laparoscopic hepatectomy due to limitations of the instrument length and four were converted to open surgery.

In the current prospective study, Dr. Asakuma and his colleagues completed 339 single-port surgeries from June 2009 to May 2013 at their hospital, 19 of which were single-port hepatectomies—eight partial resections, seven lateral sectionectomies, three fenestrations and one mast cell tumor. (The series also included 293 cholecystectomies, three cholecystectomies with common bile duct stones, 12 appendectomies, five colectomies and three additional operations.)

Dr. Asakuma’s team performed the procedures using a surgical glove port, which they previously found was an effective and low-cost tool to facilitate single-port surgery (World J Surg 2010;34:2487-2489). During the surgery, the team created a 2-cm incision along the umbilicus to insert the port and extract the specimens. The resection surface was a flat plane in nine cases and a curved plane in six. All but three patients had malignancies on the left side of the liver.

Of the eight patients undergoing partial resection, operative time ranged from 60 to 225 minutes and bleeding occurred in one patient (800 mL). For the seven patients undergoing lateral sectionectomy, operative time ranged from 50 to 155 minutes and bleeding was minimal, also occurring in only one patient (330 mL). No blood transfusions were needed and the resection margins remained clear. Patients resumed an oral diet and regained full mobility on postoperative day 1.

The authors concluded that the single-port liver resection is an achievable technique, especially for lateral segments, and comes with several benefits to patients. “The estimated advantages of the [single-port approach] are less postoperative pain, better cosmetic results and greater patient satisfaction,” said Dr. Asakuma. “Potential disadvantages are sacrifices to safety, which we aim to eliminate.”

According to Dr. Asakuma, the next step is to conduct a randomized controlled trial comparing the single-port approach to liver resection with laparoscopic and open approaches. Dr. Asakuma believes that, although single-port surgery for liver resection was born just three years ago, it has the potential to replace laparoscopic or open techniques through patient demand.

However, Dr. Kingham is more skeptical of the benefits of single-port liver resection beyond cosmesis.

“The single-port technique is very limited to the superficial left sides of the liver,” Dr. Kingham noted. “Our team, for instance, is focusing more on developing laparoscopic techniques that we can use anywhere in the liver, including the harder-to-reach right side.”

As instrumentation improves and allows for more maneuverability, single-site liver resection may be applied to more parts of the liver, but is unlikely to become the standard of care, Dr. Kingham added. “I believe, however, that it’s important to show that single site is possible. That is how the field of surgery truly advances.”

No relevant conflicts of interest were reported.