The use of laparoscopy for liver surgery is increasing rapidly. The Second International Consensus Conference on Laparoscopic Liver Resections (LLR) was held in Morioka, Japan, from October 4 to 6, 2014 to evaluate the current status of laparoscopic liver surgery and to provide recommendations to aid its future development. Seventeen questions were addressed. The first 7 questions focused on outcomes that reflect the benefits and risks of LLR. These questions were addressed using the Zurich-Danish consensus conference model in which the literature and expert opinion were weighed by a 9-member jury, who evaluated LLR outcomes using GRADE and a list of comparators. The jury also graded LLRs by the Balliol Classification of IDEAL. The jury concluded that MINOR LLRs had become standard practice (IDEAL 3) and that MAJOR liver resections were still innovative procedures in the exploration phase (IDEAL 2b). Continued cautious introduction of MAJOR LLRs was recommended. All of the evidence available for scrutiny was of LOW quality by GRADE, which prompted the recommendation for higher quality evaluative studies. The last 10 questions focused on technical questions and the recommendations were based on literature review and expert panel opinion. Recommendations were made regarding preoperative evaluation, bleeding controls, transection methods, anatomic approaches, and equipment. Both experts and jury recognized the need for a formal structure of education for those interested in performing major laparoscopic LLR because of the steep learning curve.

Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka

Objective:The European Guidelines Meeting on Laparoscopic Liver Surgery was held in Southampton on February 10 and 11, 2017 with the aim of presenting and validating clinical practice guidelines for laparoscopic liver surgery.Background:The exponential growth of laparoscopic liver surgery in recent

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The Southampton Consensus Guidelines for Laparoscopic Liver Surgery: From Indication to Implementation.

The 2 nd International Consensus Conference on Laparoscopic Liver Resection (ICCLLR) was held 4 th –6 th October, 2014, in Morioka, Japan The level of evidence appears to be low in the field of laparoscopic liver resection (LLR) to create strong recommendations Therefore, an independent jury-based consensus model was applied to better define the current role of LLR and to develop internationally accepted recommendations The three-day conference was very intense with full of insightful discussions on assessment of LLR and its future directions The jury drew the statements based on the presentations and documents prepared by the expert LLR is theoretically superior to open liver resection (OLR) because the laparoscope allows better exposure with a magnified view, and the pneumoperitoneum pressure reduces hepatic vein bleeding from the cut surface During the ICCLLR, we shared these theoretical advantages in LLR and the conceptual change of liver resection After the ICCLLR, a couple of important studies have been published to prove this theoretical superiority of LLR over OLR in short-term outcomes without deteriorating long-term outcomes Another new concept was proposed at the ICCLLR: parenchyma sparing (limited) anatomical resection Review of the literature supports anatomical resection with parenchyma sparing strategy for LLR irrespective of hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM) Just after the ICCLLR, sensational news of clustered mortality after LLR was reported in the Japanese media and they impacted on daily practice of LLR in Japan The most important message from the ICCLLR is to protect patients from this new surgical procedure The ICCLLR recommended three actions for the protection of patients: (I) prospective reporting registry for transparency; (II) a difficulty scoring system to select patients; (III) creation of a formal structure of education The online prospective registry system including items to calculate the difficulty score has been created in Japan after the ICCLLR for the safe development of LLR

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What has changed after the Morioka consensus conference 2014 on laparoscopic liver resection

Laparoscopic versus open major hepatectomy: a systematic review and meta-analysis of individual patient data.

Six years have passed since the first International Consensus Conference on Laparoscopic Liver Resection was held. This comparatively new surgical technique has evolved since then and is rapidly being adopted worldwide. We compared the theoretical differences between open and laparoscopic liver resection, using right hepatectomy as an example. We also searched the Cochrane Library using the keyword "laparoscopic liver resection." The papers retrieved through the search were reviewed, categorized, and applied to the clinical questions that will be discussed at the 2nd Consensus Conference. The laparoscopic hepatectomy procedure is more difficult to master than the open hepatectomy procedure because of the movement restrictions imposed upon us when we operate from outside the body cavity. However, good visibility of the operative field around the liver, which is located beneath the costal arch, and the magnifying provide for neat transection of the hepatic parenchyma. Another theoretical advantage is that pneumoperitoneum pressure reduces hemorrhage from the hepatic vein. The literature search turned up 67 papers, 23 of which we excluded, leaving only 44. Two randomized controlled trials (RCTs) are underway, but their results are yet to be published. Most of the studies (n = 15) concerned short-term results, with some addressing long-term results (n = 7), cost (n = 6), energy devices (n = 4), and so on. Laparoscopic hepatectomy is theoretically superior to open hepatectomy in terms of good visibility of the operative field due to the magnifying effect and reduced hemorrhage from the hepatic vein due to pneumoperitoneum pressure. However, there is as yet no evidence from previous studies to back this up in terms of short-term and long-term results. The 2nd International Consensus Conference on Laparoscopic Liver Resection will arrive at a consensus on the basis of the best available evidence, with video presentations focusing on surgical techniques and the publication of guidelines for the standardization of procedures based on the experience of experts.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/jhbp.139

Laparoscopic hepatectomy is theoretically better than open hepatectomy: preparing for the 2nd International Consensus Conference on Laparoscopic Liver Resection.

Although minor laparoscopic liver resections (LLRs) appear as standardized procedures, major LLRs are still limited to few expert teams. The aim of this study was to report the combined data of 18 international centers performing major LLR. Variables evaluated were number and type of LLR, surgical indications, number of synchronous colorectal resections, details on technical points, conversion rates, operative time, blood loss and surgical margins. From 1996 to 2014, a total of 5388 LLR were carried out including 1184 major LLRs. The most frequent indication for laparoscopic right hepatectomy (LRH) was colorectal liver metastases (37.0%). Seven centers used hand assistance or hybrid approach selectively for LRH mostly at the beginning of their experience. Seven centers apply Pringle's maneuver routinely. The conversion rate for all major LLRs was 10% and mean operative time was 291 min. Mean estimated blood loss for all major LLR was 327 ml and negative surgical margin rate was 96.5%. Major LLRs still remain challenging procedures requiring important experience in both laparoscopy and liver surgery. Stimulating the younger generation to learn and accomplish these techniques is the better way to guarantee further development of this surgical field.

International experience for laparoscopic major liver resection.

Image guided surgery systems aim to provide navigation to surgeons in order to improve accuracy and safety of the procedures. Through stereo reconstruction algorithms, it is possible to generate 3D surfaces intra-operatively by means of a laparoscopic stereo-camera. This study aims to setup a simulation system and quantitatively validate a recent proposed reconstruction algorithm with application to laparoscopic liver resection surgery. The intra-operative surface will be used to guide model to patient registration. This will also improve accuracy of the navigation by correcting intra-operative deformations of the liver, such as those due to pneumoperitoneum. The accuracy results of the reconstruction method was found to be $3.7\pm 0.8$ mm in terms of Hausdorff distance. The validation therefore indicates the feasibility and accuracy of the surface reconstruction method.

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Edwin Bjorn

Papers

International experience for laparoscopic major liver resection.

Validation of stereo vision based liver surface reconstruction for image guided surgery