ORIGINAL ARTICLE

Pure Laparoscopic Versus Open Liver Resection

in Treatment of Hepatolithiasis Within the
Left Lobes: A Randomized Trial Study
Guoqian Ding, PhD, Wang Cai, PhD, and Mingfang Qin, PhD

The aim of this prospective randomized trial was to

Objective: The application of laparoscopic technology to liver find out a more effective technique of the management to
surgery has been developing rapidly, yet very few studies have been patients suffering from hepatolithiasis within the left lateral
conducted to compare the outcomes between open and laparo- lobes by comparing the operation time, the amount of
scopic liver resections. So little is known about their advantages
and disadvantages. The aim of this prospective randomized study
bleeding, the length of stay in hospital, and complications.
was to compare the outcomes between laparoscopic and open liver
resection in treatment of hepatolithiasis within the left lateral lobes. PATIENTS AND METHODS
Patients and Methods: Between January 2010 and May 2013, 98 From January 2010 to May 2013, patients diagnosed
patients with hepatolithiasis within the left lateral lobes diagnosed of hepatolithiasis within the left lateral lobes admitted to
by preoperative computed tomography and magnetic resonance our hospital were assessed for participating in this study.
cholangiopancreatography were randomized into open group and Written consent had been collected from the patients before
laparoscopic group. Each group had 49 patients. We compared the the study began. The criteria of choosing the participants
operation time, the amount of bleeding, the length of their stay in were age (between 16 and 70 y) as well as clinical, labo-
hospital, and complications. ratory, and radiologic assessment suggestive of hep-
Results: Of the laparoscopic group, 2 patients were converted to atolithiasis within the left lateral lobes. The patients who
open surgery. No fatal complication occurred in either the open met with the criteria for participating in the study under-
group or the laparoscopic group. There was no statistically sig- went MRCP and computed tomography. Only the patients
nificant difference in the complications between the 2 groups with computed tomography, MRCP evidence of hep-
(4.08% vs. 6.12%, P = 0.64), but the operating time, the amount of atolithiasis within the left lateral lobes were eligible for the
bleeding, and the length of stay in hospital were significantly study. Sealed envelopes were used to randomize the par-
shorter in the laparoscopic group than in the open group ticipants into open or laparoscopic group. The study pro-
(P < 0.05).
tocol was approved by the Ethics Committee. Written
Conclusions: Laparoscopic liver resection displays similar safety consent was collected from all the participating patients.
and feasibility for hepatolithiasis within the left lateral lobes, and Exclusion criteria included active acute pancreatitis, preg-
they were also similar with respect to the overall complications, but nancy, septic shock, pancreatic or bleary malignant dis-
the laparoscopic group has an advantage in the operating time, the orders, being unable to tolerate anesthesia or surgery, liver
amount of bleeding, and the length of their staying in hospital. It is, cirrhosis, previous history of abdominal surgery, and
however, agreed between the authors of this paper that further
studies with larger number of patients and longer follow-up
unwilling to provide written consent. The participating
observations are necessary to make a definitive conclusion. patients were randomized into 2 groups: open group and
laparoscopic group. The surgery in both groups was con-
Key Words: laparoscopic, liver resection, hepatolithiasis, open ducted by the same surgeon (the corresponding author)
group, laparoscopic group who has good experience in both open and laparoscopic
operations.
(Surg Laparosc Endosc Percutan Tech 2015;25:392–394)
Surgical Procedures
All the operations to the 2 groups of participants were

T he development and improvement of new instrumental

techniques enabled the performance of laparoscopic
liver resections to be performed in this area.1–3 There are
performed with general anesthesia and were conducted by
the same surgeon. Laparoscopic liver resections were con-
ducted respecting the rules dictated by traditional hepatic
more than 4000 worldwide published papers to date.4–7 The surgery,8 that is, the patient was positioned in a supine
approach to liver resection in the treatment of hep- position; and pneumoperitoneum was achieved with the
atolithiasis within the left lateral lobes, whether laparo- Hasan technique. The remaining ports were placed to
scopic or open, is changing and being discussed widely facilitate ergonomics and triangulation. Laparoscopic ports
among hepatobiliary surgeons. with balloons were used at the end to help increase the
working space. A 30-degree camera was used first to inspect
Received for publication April 12, 2014; accepted January 4, 2015.
the peritoneal cavity to rule out any extrahepatic disease.
From the Minimally Invasive Surgery Center of Tianjin Nankai Hos- Abdominal pressure was monitored that was maintained at
pital, Tianjin, China. 12 mm Hg. Four to 5 trocars were deployed along an ideal
The authors declare no conflicts of interest. semicircular line, with the concavity facing the right sub-
Reprints: Mingfang Qin, PhD, Minimally Invasive Surgery Center of
Tianjin Nankai Hospital, 122 Sanwei Road, Nankai District,
costal margin. Ultrasound knife was used to cut off the
300100 Tianjin, China (e-mail: 285932754@qq.com). round ligament and the left hepatic triangular ligament,
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. and dissected the left hepatic lobe vein segments with the

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Surg Laparosc Endosc Percutan Tech  Volume 25, Number 5, October 2015 Pure Laparoscopic Liver Resection

titanium clip clipping in the left sagittal portion notch of DISCUSSION OF THE STUDY RESULTS
liver round ligament. Selective hepatic vascular exclusion Since the introduction of laparoscopic chol-
was performed with LAPRO-CLIP. Apart from the second ecystectomy in 1987, the laparoscopic approach has been
hepatic portal, the left hepatic vein trunk branch was sep- applied to the full spectrum of abdominal procedures.
arated carefully with a titanium clip, and then the liver Nevertheless, the laparoscopic approach has not been fully
tissue was cut with an ultrasound knife. Finally, the speci- developed for liver resections. The reasons for this reluc-
men was extracted using a plastic bag through the tance are the presumed technical difficulties and concerns
Pfannestiel incision, with additional port-site enlargement if about the intraoperative hazards of bleeding and gas
required or by partial opening of a previous abdominal embolism.9 Because of the improvements in technologies
scar. and increasing surgeon’s experiences, the number of kera-
tectomy performed laparoscopically has increased expo-
nentially around the world in recent years.10
Statistical Analyses Three techniques have been utilized for the laparo-
Continuous data are reported as mean ± SD (range) scopic major keratectomy: pure laparoscopy (the pure
and compared using the 2-side Student t test for normally laparoscopic method), hand-assisted laparoscopy (the
distributed parameters. Continuous data non-normally hand-assisted method), and laparoscopy-assisted major
distributed are reported as median with an interquartile keratectomy (the laparoscopy-assisted method).11 The
range and were compared using the Wilcoxon Mann- method used for the current study this time was pure lap-
Whitney test. Comparisons between the 2 groups for cate- aroscopic method. Two cases in the laparoscopic group
gorical variables were done using the w2 test with the Yates were transferred to open surgery owing to abdominal
correction or the Fisher exact test when appropriate. Stat- adhesions. Many researchers have pointed out the reason
istical significance was set at P < 0.05. Statistical analysis for conversion to laparotomy, including bleeding, poor
was performed by IBM-SPSS Statistics 19.0 (SPSS Inc., progression during the parenchyma transaction, and
Chicago, IL). abdominal adhesions.12–15 The laparotomy was promptly
transferred and the patient recovered very well.
The landmark study showing the feasibility and safety
of laparoscopic liver resection was the investigation by
RESULTS Koffron et al16 in 2007. Their report describes the techni-
Ninety-eight patients participated in the study. They ques of both minor and major laparoscopic liver resection
were randomly divided into open group (n = 49) and lap- for 197 patients with benign lesions, including 20 right
aroscopic group (n = 49). There was not much difference in donor right hemihepatectomies and 103 patients with
ages, sex ratio, time of onset, the maximum size and malignant tumors. These types of operations were per-
number of the hepatolithiasis within the left lateral lobes, formed in our hospital in 2009. Initially we adopted only
the mass of removed liver tissue, and the clinical profile the hand-assisted method. However, this technology has
between the 2 groups (Table 1). been constantly improving with the increase in the number
In the laparoscopic group, 2 patients were converting of cases. At present, we perform the pure laparoscopic
to open surgery owing to abdominal adhesions. They were method skillfully.
converted to open surgery for the sake of safety. Otherwise As mentioned earlier, this study did not show stat-
no fatal complication occurred in either the open group or istically significant difference in the complications between
the laparoscopic group. In term of complications, 2 cases the groups (4.08% vs. 6.12%, P = 0.64), but the operating
occurred in the open group, one being postoperative bile time, the amount of bleeding and the length of the patients’
leakage, which was treated with drainage for 5 days. The staying in hospital was significantly shorter in the laparo-
other one is pneumonia, which was treated after antibiotic scopic group (P < 0.05). This suggests that the use of lap-
treatment. In the laparoscopic group, there were 3 cases of aroscopy results in clear and good benefits to the patients in
complications, one being of port wound infection and the shorter hospitalization time, less bleeding, better cosmetic
other 2 cases were converted to open surgery. There was no effect, earlier return to professional’s activities, and many
statistically significant difference in the complications others. The findings of the current study are consistent with
between the 2 groups (4.08% vs. 6.12%, P = 0.64) the findings discussed in other literatures reported in the
(Table 1), but the operating time, the amount of bleeding, past years.17,18
and the length of staying in hospital were significantly In conclusion, laparoscopic liver surgery is a safe and
shorter to the laparoscopic group (P < 0.05) (Table 1). feasible procedure to treat liver disease of hepatolithiasis

TABLE 1. The Situation of 2 Groups of Patients

Variables Open Group (n = 49) Laparoscopic Group (n = 49) P
Age (mean ± SD) (y) 58.42 ± 7.21 57.53 ± 6.31 0.77
Gender (female) [n (%)] 27 (55.1) 26 (53.06) 0.84
Time of onset (mean ± SD) (d) 6.21 ± 1.52 8.10 ± 2.52 0.34
Maximum size of hepatolithiasis (mean ± SD) (cm) 0.97 ± 0.21 0.96 ± 0.26 0.93
No. hepatolithiasis (3 or more) [n (%)] 7 (14.29) 5 (10.2) 0.54
Operating time (mean ± SD) (min) 97.1 ± 9.82 67.1 ± 8.36 0.02
Amount of bleeding (mean ± SD) (mL) 500 ± 22.3 380 ± 24.7 0.000
Length of stay (mean ± SD) (d) 5.8 ± 1.5 4.5 ± 2.0 0.004
Complications [n (%)] 2 (4.08) 3 (6.12) 0.64

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Ding et al Surg Laparosc Endosc Percutan Tech  Volume 25, Number 5, October 2015

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