Liver Cancer
Reasoning
The prognosis of patients with hepatocellular carcinoma (HCC) may be improved with the appropriate selection of treatment, which depends on the accurate identification of all hepatic lesions, including size, number, and location. Non-therapeutic laparotomy and its associated morbidity may be prevented by the detection of unresectable disease with staging laparoscopy. Since peritoneal disease is uncommon with HCC, surface laparoscopy may be less valuable compared with laparoscopic ultrasound.
Indications
Patients with primary hepatic tumors who are candidates for curative resection based on preoperative identification of size and location of disease with adequate hepatic reserve.
Contraindications
Patients with known unresectable hepatic disease such as major vessel or organ invasion are not candidates for surgery
Technique
The patient is placed in the supine position, and pneumoperitoneum is established. A 30-degree laparoscope through an umbilical port is recommended for optimal visualization of the entire liver. Additional ports can be placed in the right anterior axillary line and epigastric area as needed. A standard laparoscopic ultrasound probe is used to systematically examine the entire liver identifying all lesions suspected to be malignant. Ultrasound-guided core biopsy should be used for suspicious lesions that are unresectable or preclude curative resection. Biopsy of resectable lesions need not be performed.
Evidence
The quality and amount of the available literature for staging laparoscopy in primary hepatic tumors is limited, and no randomized trials exists. The designs of these studies differ. Some compare staging laparoscopy with laparoscopic ultrasound to preoperative imaging while others compare it to exploratory laparotomy. There is also inconsistency in the type of preoperative imaging and the specific CT scan techniques used. In addition, the impact of each surgeon’s expertise in laparoscopic ultrasound on the diagnostic accuracy of the procedure remains unknown. Lack of Laparoscopic ultrasound facility and skill in most of the centers is a major limitation. These limitations make firm recommendations difficult.
The identification of hepatic tumors using triphasic CT scan is less sensitive than laparoscopic ultrasound in correlation studies and is highly dependent on tumor size: 0-1 cm (71%), 1-2 cm (84%), 2-3 cm (96%), and greater than 3 cm (100%). Laparoscopic ultrasound can detect 9.5% more tumors than CT alone, most of which are less than 1 cm. Staging laparoscopy correctly identifies 63-67% of patients with unresectable disease. The most common reasons that staging laparoscopy missed unresectable disease were vascular invasion, lymph node metastases, and adjacent organ invasion. With the combination of staging laparoscopy and laparoscopic ultrasound, 16-25% of patients may avoid open laparotomy.
Procedure-related complications are uncommon, and no mortality has been reported. Bleeding, infection, bowel injury, bile leak, and anesthesia-related complications may occur. Compared with open exploration, patients undergoing Staging laparoscopy with laparoscopic ultrasound have been reported to have shorter hospital stay (9 vs. 2.2 – 5 days, respectively) and earlier time to adjuvant therapy (23 vs. 6 days, respectively) (level II, III) [2-3]. No adverse oncologic effects of the procedure have been described.
References
Foroutani A, Garland AM, Berber E, et al. Laparoscopic ultrasound vs triphasic computed tomography for detecting liver tumors. Arch Surg 2000;135:933-938.
Jarnagin WR, Bodniewicz J, Dougherty E, Conlon K, Blumgart LH, Fong Y. A prospective analysis of staging laparoscopy in patients with primary and secondary hepatobiliary malignancies. J Gastroint Surg 2000; 4:34-43.
Lo CM, Lai EC, Liu CL, Fan ST, Wong J. Laparoscopy and laparoscopic ultrasonography avoid exploratory laparotomy in patients with hepatocellular carcinoma. Ann Surg 1998;227:527-532.