1. Results of minor and major hepatectomies by laparoscopy Brice Gayet, Vibert E, Kouider A Department of digestive pathology Montsouris Institute, Paris, France

2. Benefice and controversial SURGERY OF THE LIVER Exploration in malignancy Respect of abdominal wall Post-operative adhesions Immunological benefice ? Interface for computer Resection without reconstruction Malignancy Hepato-biliary surgeon RISKS OF LAP’ HEPATECTOMY Hemorrhage Poor exploration Gas embolism Technology and specific materials Progressive and specific learning

3. Technologies and experiences 131 Lap’ liver surgery 40 “easy” or resection < 3cm 53 Minor hepatectomies (≤ 2 segments) 38 Major hepatectomies (> 2 segments) Laparoscopic ultrasonography Parenchymal section devices Voice-controlled robot for camera Bipolar forceps

4. Materials and Methods 91 Hepatectomies in 86 patients (5 re-hepatectomies) Sex Ratio : M/F 1.3 – Median Age : 55 years (23-85) Benign lesions 19 diagnostic resections 5 resections for symptoms FNH 9 Others 7 Adenoma 3 24 Malignant lesions 43 colo-rectal metastases (CRM) 16 hepatocellular carcinomas (HCC) 3 neuroendocrine metastases 5 non neuroendoc non crm 67

5. 53 Minor Hepatectomies Wedge resections in all segments 28 Anatomical hepatectomies ( All segments excepted IVa ) 25 7 2 1 7 1 4 2 1

6. 38 Major hepatectomies 4 27 Plus 3 trisegmentectomies (II+III+IVb, V+VI+VII, V+VI+IVb 3 1

7. Post-operative results Morbidity : Abscess (n=2) - Biliary leak (reintervention) (n=1) - Hemorrhage (n=1 † ) – Hematoma (n=2) - Postoperative ileus (n=1) - Stroke (n=1) – Pleural effusion (n=2) 38 Major resections 7 Conversions (4 for hemorrhage) Duration: 5.5 hours (180-515) Mortality: 1 death at day 8 postop Morbidity: 11/38 (28%) 53 Minor resections 7 Major lap’ associated procedures 5 Conversions (0 for hemorrhage) Duration: 2.5 hours (60-390) Morbidity: 8/53 (15%) Transfusion: 8/91 patients (2 minor – 6 major) Morbidity : Biliary leak (reintervention) (n=2) – Hemorrhage (reintervention) (n=1) – Stump hematoma (n=2) – Liver abscess (n=1) – Abdominal abscess (n=2) 24 laparoscopic associated procedures

8. Results in CRM (n=43 in 38 pat) 18 Metachronous / 19 Synchronous / 1 Recurrences 5 Lap’ re-hepatectomies: Two steps (n=2) / Recurrence (n=2) Mean number: 2 (1-4) / Mean diameter: 3 cm (1-12) Associated lap’ colorectal resection: 7 patients Mean Follow-up: 30 months 1020304050600 20% 40% 60% 80% 100% 97% 87% 0102030405060 20% 40% 60% 80% 100% 74% 51% 8 RECURRENCES 3 intra-hepatic 5 re-hepatectomies Overall survival DFS

9. Results in HCC (n=16) Cirrhotic liver (n=7) Single nodule (n=14/15) Mean diameter 6.5 cm (1-18) 0 102030405060 20% 40% 60% 80% 100% 0 102030405060 20% 40% 60% 80% 100% Mean Follow-up: 40 months Overall survival Disease free survival 85% 66% 76% 68%

10. Conclusions Minor laparoscopic hepatectomies are feasible and safe for almost all hepatic segments Minor laparoscopic hepatectomies are feasible and safe for almost all hepatic segments Major laparoscopic hepatectomies are feasible but remain a demanding procedure which require a long training Major laparoscopic hepatectomies are feasible but remain a demanding procedure which require a long training Prognosis of liver malignant tumors does not seem to be modified by laparoscopic approach Prognosis of liver malignant tumors does not seem to be modified by laparoscopic approach This study suggests :