Laparoscopic treatment of liver diseases in children

Abstract

Laparoscopic liver surgery has been increasingly used for the treatment of pediatric liver diseases over the past decade due to the development of special laparoscopic instruments and improvements in the technique. A number of factors are considered when electing to undergo the surgical process, including age, type of liver disease, and so on. Especially in children with liver masses, the number of trocars used and the position of their placement must be carefully designed to achieve successful outcomes. In the current review, the application of various laparoscopic instruments and the methods used for the laparoscopic treatment of liver diseases in children over the past decade are summarized.

Keywords

laparoscopic surgery / liver mass / pediatric

Introduction

Laparoscopic liver surgery has rapidly evolved over the last ten years. Laparoscopic surgery is used not only for the diagnosis of liver diseases, but also for their treatment; it is applicable to both benign and malignant cases. The current acceptable indication for laparoscopic liver resection is the presence of solitary lesions measuring 5 cm or less located in liver segments 2 to 6 [1].

In pediatric surgery, the role of laparoscopic procedures has been reevaluated along with the evolution and improvements in laparoscopic instruments and surgeon skills. Pediatric surgeons currently apply laparoscopic techniques in almost every field of pediatric surgery [2]. Nevertheless, the development of laparoscopic surgery for liver diseases in children is slow compared with that for adults. Pediatric laparoscopic hepatic surgery was initially limited to diagnostic laparoscopy and laparoscopic-guided liver biopsies. Over the past five years, however, laparoscopic surgeries for pediatric hepatic diseases have been performed successfully, and many case reports have been recently published.

Technical aspects

There are three types of laparoscopic liver resection: pure laparoscopy, hand-assisted laparoscopy, and the hybrid technique. European centers, especially in France, generally use pure laparoscopy. The technique was developed based on the experience obtained from 41 laparoscopic right hepatectomies performed in a tertiary care referral center for laparoscopic digestive surgery. Meanwhile, surgeons from North America have aggressively adopted either the hand-assisted or hybrid technique [3]. A total of 127 published articles of original series on laparoscopic liver resection were indentified, accounting for 2804 reported minimally invasive liver resections. Fifty percent of these articles were on malignant tumors, 45% were on benign lesions, 1.7% were on live donor hepatectomies, and the rest were of indeterminate diseases. Among the resections reported, 75% were performed via pure laparoscopic surgery, 7% were via hand-assisted, and 2% utilized the laparoscopic-assisted open hepatic resection (hybrid) technique. The remaining resections used other techniques or conversions to open hepatectomy. The most common laparoscopic liver resection is the wedge resection or segmentectomy (45%), followed by anatomic left lateral sectionectomy (20%), right hepatectomy (9%), and left hepatectomy (7%). Conversion from laparoscopic surgery to open laparotomy and that from laparoscopy to hand-assisted approach occurred in 4.1% and 0.7% of the reported cases, respectively. Overall, the mortality was 9 in 2 804 patients (0.3%), and morbidity was 10.5%, none of which were intraoperative deaths [4].

The application of 2.7-, 5-, 10-, and 12-mm trocars is common in pediatric laparoscopic surgery.

The main problem in laparoscopic liver resection is controlling the bleeding that occurs during liver parenchymal transactions, which is difficult in laparoscopy. As a solution, various laparoscopic instruments have been used for the safe dissection of the liver parenchyma, such as ultrasonic dissectors, ultrasound scissors, and water-jet dissections.

Carbon dioxide embolism is another potential complication that may be brought about by the creation of the pneumoperitoneum. Fors et al. [5] conducted research on gas embolism (GE) during laparoscopic liver resection in a pig model. They found that GE occurred in 10 of 15 piglets. In total, 33 separate GE episodes were recorded. A combination of several monitoring techniques with narrow limits as alarm settings could ensure accurate monitoring data of the complex physiological response to GE. This approach will ensure that data are revealed early enough to alert both the anesthetist and the surgeon of the impending problem. Surgical techniques, such as the abdominal-wall lifting method with or without creation of a pneumoperitoneum, have been developed in efforts to prevent surgical complications.

Prior to parenchymal division, the pneumoperitoneum is decreased to the minimum pressure that still allows adequate working space, which is between 8 and 10 mmHg in children, and 6 mmHg in infants. This is essential to minimize the risk of GE and postoperative liver dysfunction. Similarly, the central venous pressure (CVP) is decreased to minimize excessive bleeding from the parenchyma. Tissue dissection and hemostasis are performed using an ultrasonic dissector, while bipolar electrocautery forceps provide retraction.

Hydatid cyst of liver

Hydatid disease is endemic in several countries. Although the disease can be asymptomatic for a long time, it is usually progressive, insidious, and can even require emergency diagnosis and treatment. A surgical approach is the most common treatment for the condition, with a tendency toward laparoscopic surgery.

Maazoun Kais et al. [6] reported a prospective study conducted between September 2001 and July 2004, which included 34 children who had undergone laparoscopic surgery for hydatid disease of the liver. Laparoscopic access to the abdominal cavity was achieved under a direct-vision vertical incision directly through the umbilicus using a 10 mm trocar. The CO₂ pneumoperitoneum pressure was maintained between 10 and 12 mmHg depending on the patient’s weight. Two other 5 mm trocars were introduced into the right and left hypochondria. In four cases, a third trocar was necessary to retract the liver. The cyst was protected by clean, sterile pads introduced through the umbilical trocar and filled with hypertonic saline solution. A puncture aspiration of the cyst followed, with its contents sterilized by infusion of hypertonic saline solution for 10 min. Reaspiration was then performed. The cyst was opened, and the proligerous membrane was removed and placed in a sack. Finally, the dome was resected and the biliary fistula was found. Laparoscopy was safely used in patients after improvements by Alebndazole [6,7].

Yagci Gokhan et al. [8] compared current therapeutic methods in the context of a 10 year single-institution experience. Between 1992 and 2003, 355 patients with 510 hydatid cysts of the liver were treated via open operation, laparoscopic surgery, or percutaneous treatment (PT). The preferred treatment modalities, perioperative complications, interventions, recurrences, and lengths of hospital stay were retrospectively analyzed. There were two postoperative deaths (1.08%) in the open surgery group, and biliary fistula was observed in 28 patients treated with open surgery, in 10 patients after PT, and in 2 patients after laparoscopic treatment. Recurrence rates were 16.2%, 3.3%, and 3.5% after open surgery, laparoscopic surgery, and PT, respectively.

The characteristics of the cyst, the presence of cystobiliary communications, and the availability of a multidisciplinary team are factors that could directly affect surgical results. Radical surgery can be done safely for suitable cases; conventional procedures are associated with greater morbidity. Laparoscopic surgery appears to be effective and safe, with low morbidity and recurrence rates, for cysts of types I–III in accessible localizations [8] (type I: pure fluid collection; type II: fluid collection with a split wall; and type III: fluid collection with septa).

Intraperitoneal rupture of a hydatid cyst is a life-threatening condition as it can bring about peritonitis, sometimes associated with hemoperitoneum, and allergic conditions, including anaphylaxis, thus requiring an emergency surgical operation. Moreover, there is always the risk of peritoneal recurrence owing to the implantation of scolices in the abdomen.

Laparoscopic surgery has yet to be applied in the treatment of intraperitoneal rupture of a hydatid cyst. However, if the general condition of the patient is not severe, it can be very useful and even more effective than traditional surgery. In particular, the procedure allows better irrigation of the entire peritoneal cavity. In fact, by changing the position of the operating table, it is easier to reach all the abdominal spaces using fiber optics, thus enabling better exploration and irrigation of the peritoneal cavity [9].

Solitary liver cysts

Liver cysts in children are rare. Many are solitary and simple and do not require intervention, but some of them are life-threatening [10]. Intervention is necessary in symptomatic cysts [11]. Laparoscopic surgery may be an appropriate treatment for some children with solitary liver cysts.

A healthy female neonate with a bodyweight of 3320 g at the gestational age of 38 weeks was found to have a 1.3 cm × 1.7 cm floating solitary nonloculated cyst [12]. Although the cyst grew to 2.1 cm × 5 cm within a week, the neonate remained asymptomatic. Considering that the presence of a duplication or pancreatic cyst could not be ruled out, a laparoscopy was performed on the 12th day after birth. The patient was placed in a supine position, and a semicircular incision was made in the left umbilical fold. The linea alba and peritoneum were incised using the open trocar placement technique to gain access to the abdomen. A purse-string suture was performed, through which a trocar was introduced under direct vision to create a pneumoperitoneum to a maximal pressure of 8 mmHg. A 2.7 mm 30° laparoscope was inserted into the abdomen and two 2.7 mm trocars were introduced: one in the left epigastrium for the cautery and the other in the right hypogastrium for the grasper. The solitary cyst was attached by a sessile stalk of approximate 2 cm to the right lobe of the liver just to the right side of the falciform ligament. Using a 2.7 mm grasper, the cyst was manipulated to reveal its attachment to the liver. A 2.7 mm hooked monopolar cautery was used to resect the stalk from the surface of the liver. After complete resection, the cyst was moved into the lower abdominal cavity. A needle was passed through the abdominal cavity and, under direct vision, the cyst was punctured and the contents aspirated. The shrunk cystic wall was removed through the work port. The procedure was completed within 90 min. There was no blood loss during the procedure and the postoperative course was uneventful. The neonate was discharged after 2 days. Histological examination showed a true simple liver cyst with a cuboidal epithelium, as well as a mesothelial lining and trabeculated hepatocyte residues along with small bile ducts. The cystic fluid showed the presence of inconspicuous monocytic cells. The cyst wall was delivered and subtotal excision was done.

Jain Prashant et al. [13] reported that a 1-day-old female infant with a congenital liver cyst 9 cm × 7 cm in size underwent laparoscopic deroofing surgery at day 16 of life. Using a 5 mm umbilical trocar, a pneumoperitoneum was created by maintaining an abdominal pressure of 6 mmHg and a flow rate of 1 L/min. Approximately 100 ml of pale yellow serous fluid was aspirated with the aid of another 3 mm trocar in the right hypochondrium. The cyst wall was delivered through the right hypochondriac port, and subtotal excision was done. A drain was inserted though the same trocar.

Cyst puncture and aspiration give good access to the cyst and delineate its relation to the liver parenchyma. However, Tim N. Rogers et al. [10] reported that an 8-year-old girl with a large cystic had undergone laparoscopy and drainage of the cystic mass before referral, but the fluid rapidly reaccumulated.

Complete excision of the liver cyst is recommended with careful follow-up because of the risk of malignant transformation [14].

Benign tumor

Laparoscopic liver resection for benign diseases can be recommended for patients with peripheral lesions requiring limited resection. Major resections may be performed in strictly selected patients, but further evaluation is required. Specific training is also necessary. The indications for laparoscopic resection of benign liver diseases must be the same as those for open surgery. The reduction of abdominal wall damage and cosmetic advantages of the laparoscopic approach present clear benefits in patients with benign liver diseases [15].

Dutta Sanjeev et al. [16] reported a case of nonanatomical laparoscopic hepatic resection of a large mesenchymal hamartoma in a 2-year-old boy. The child presented with a large asymptomatic abdominal mass extending from the right upper quadrant down into the pelvis. A CT scan showed an 11 cm × 10 cm × 7 cm tumor arising from the right hepatic lobe, involving segments V and IVb. The lesion extended posterior to the gallbladder bed. A biopsy of the lesion was performed through a mini subcostal incision, which identified it as a mensenchymal hamartoma. Under general anesthesia, the patient was positioned supine. A pneumoperitoneum was established and maintained at 15 mmHg during tumor assessment and reduced to 12 mmHg during tumor resection. No attempt was made at vascular control; however, low central venous pressures were maintained throughout the case. This is, in addition to the counterpressure provided by the pneumoperitoneum, minimized intraoperative ooze. Four radially expanding trocars were inserted into the abdomen, including a 5 mm trocar in the umbilicus, a 5 mm trocar in the right mid-abdomen, a 12 mm trocar in the left hyperchondrium, and a 5 mm assistant trocar in the left mid-abdomen. The incision from the previous biopsy was avoided during trocar placement to avoid dense adhesions. The mass occupied approximately 50% of the abdominal cavity. Omental and abdominal wall adhesions to the old biopsy site were divided using hook electrocautery. A laparoscopic ultrasound probe was introduced into the abdomen, and the dimensions of the tumor were extrapolated relative to the surface anatomy. An intraoperative laparoscopic ultrasound probe showed that the tumor extended only a short distance posterior to the left gallbladder bed. Hence, the gallbladder was preserved by performing limited mobilization from its bed. Ultrasound guidance was used to direct the diathermy scoring of the liver capsule in preparation for nonanatomical resection. The liver parenchyma was then dissected using the laparoscopic Helix Hydro-Jet in a medial to lateral direction. At regular intervals, the vessels and ducts were sealed and transected using a 10 mm Ligasure Atlas device. Once resection of the tumor was complete, the raw surface was coagulated using short bursts of the laparoscopic Argon Beam Coagulator. Fibrin sealant was then applied. The largest bag available could neither accommodate the specimen nor be maneuvered within the limited abdominal space. A small Pfannenstiel incision was thus made to remove the specimen, which was compressed to accommodate the small incision without difficulty. The total operative time was 2.5 h.

Yoon Yoo-Seok et al. [17] reported that total laparoscopic left lateral sectionectomy was performed on a 5-year-old girl who had a cystic tumor of the liver. A 10 cm multiseptated cystic mass was identified on the CT. The patient was placed in a supine position with a 30° reverse Trendelenburg adjustment. A 10 mm umbilical trocar was introduced via the open method, after which a pneumoperitoneum was made. A second 10 mm trocar was inserted 2 cm left of the midline, a third 10 mm trocar was inserted at the anterior axillary line below the right costal margin, and a fourth 12 mm trocar was inserted between the second and third trocars about 3 or 4 cm caudal to the third trocar. Applying traction to the right side of the divided round ligament, the liver parenchyma was superficially dissected lateral to the falciform ligament toward the cephalic direction with a Harmonic scalpel. Then, Gilisson’s pedicles were transected to segments II and III along with the liver parenchyma using a 45 mm endovascular gastrointestinal anastomosis (Endo-GIA) for the division of the left hepatic vein and the remaining liver parenchyma. Postoperative pathology confirmed the presence of mesenchymal hamartoma of the liver with a disease-free resection margin.

Yeung Chung Kwon et al. performed an operation on a 4-year-old girl with a symptomatic tumor in the liver. A CT scan showed a 3 cm × 4cm lesion confined to segments II and III and mostly covered by a small rim of normal tissue that was enhanced in the arterial phase. Given that the tumor was confined to the left lobe, a diagnostic laparoscopic surgery was performed. After induction of general anesthesia, the patient was placed in a supine position with a 20° elevation of the right side. A 30° telescope was introduced through a 5 mm transumbilical trocar. No lesion was visible on the surface of the liver and no features of metastases were observed. Three additional 5 mm trocars were inserted into the right and left upper quadrants. An additional liver retractor was placed through a stab incision in the epigastrium. A flexible laparoscopic 5 MHz ultrasound probe was used as the initial step through the 5 mm working port to localize the tumor and define the intrahepatic vascular anatomy. Applying a 5 mm electrohook, the left triangular ligament was incised and the diaphragmatic attachment of the left lobe was released. The round ligament was used for traction of the upper left lobe to define the venous anatomy including the inferior vena cava and hepatic vein confluence. A TissueLink radiofrequency probe was used to mark the proposed line of incision on the surface of the liver to the left of the falciform ligament and continue parenchymal resection with simultaneous saline irrigation, hemostatic sealing, and coagulation of soft tissue. LigaSure was used to coagulate the small vessels or bile ducts. Finally, linear Endo GIA was used to staple off the specimen from the left portal vein and branch of the left hepatic artery. The resected specimen was placed in a plastic bag and delivered though an extension of the transumblical wound. No drain was left. Estimated blood loss during the procedure was 10 ml. Histological examination revealed fibrous nodular hyperplasia. The postoperative course was uneventful and the girl was discharged on postoperative day 5 [18].

Other studies, however, have shown that most benign lesions can be morcellated and removed through a 12 mm port site.

Blunt liver trauma

The management of blunt liver trauma has progressed over the last two decades with the adoption of conservative non-operative practices. Meanwhile, conservative management has resulted in an increased incidence of late complications, such as persistent hemorrhage, fistulas, and bile leaks, as well as hepatic necrosis or abscess. These complications can be managed secondarily using planned interventions via laparoscopy or other techniques [19]. In select cases, laparoscopy could be proposed as both a diagnostic and therapeutic tool.

Feleppa Cosimo et al. reported the case of an 8-year-old Albanian boy who was admitted to the emergency care of the surgical department of a healthcare institution with the diagnosis of suspected hemoperitoneum caused by mild liver trauma. Abdominal laparoscopic exploration showed, besides peritoneal free blood, a ruptured hepatic cystic lesion involving the left liver, which was completely excised [20]. In cases like this, laparoscopy can be useful for both successful diagnosis and disease management.

In contrast to the findings above, Schmidit et al. [21] reported on eight cases of liver trauma/disease that were diagnosed based on exploratory laparotomy, two cases based on sonography and laparoscopy, one case based on laparoscopy only, and another case based on sonography only. Recent papers indicate that laparoscopy is no longer very valuable either for determining indications for surgery or as a supplement to imaging modalities.

Liver abscesses

Liver abscess is a common disease in children in developing countries. Percutaneous drainage along with antimicrobial drug therapy is the general treatment used for the condition, but surgery still plays a significant role in selected patients.

A 28-day-old preterm neonate at the gestational age of 34 weeks was admitted with symptoms of refusal to feed, high fever, distension in the epigastric region, and lethargy [22]. An ultrasonogram of the abdomen revealed the following finding: multiple abscesses in the right lobe of liver, 3 abscesses of 31, 15, and 18 mm in segment 4 of the left lobe, an abscess of 8 mm in segment 2 of the left lobe, a large subphrenic abscess of 37 mm × 19 mm between segment 4 and the diaphragm, a large subphrenic abscess of 40 mm between segment 2 and the anterior abdominal wall, and a tract leading from the abscess cavity of the left lobe of the liver to the pericardium, resulting in pyo-pericardium. Three 5 mm trocars were inserted into the abdomen: one in the umbilicus for the 5 mm telescope and two 5 mm trocars along the midclavicular line, in line with the umbilicus. The liver abscesses were punctured and the pus was aspirated using a suction cannula. Blunt dissection was made between the left lobe of the liver and the diaphragm. The suction cannula proved to be a very useful instrument for blunt dissection as it caused minimal trauma to the tissues and maximum dissection. Staphylococcus aureus grew on the culture. The baby was given the necessary antibiotics and discharged after 5 days. Thus, it can be seen that laparoscopy is also an excellent procedure for draining multiple liver abscesses.

Malignant liver tumor

A recent retrospective multicenter European study analyzed the feasibility, safety, and late outcome of patients after laparoscopic resection of either hepatocellular carcinoma or liver metastases [23]. This study demonstrated the efficacy and safety of laparoscopic resection of small malignant tumors located in the left lateral or anterior segments of the right liver. There was no reported morbidity, and the complication rate was low (22%). An updated meta-analysis of relevant studies published between January 1, 1998 and May 1, 2009 showed that laparoscopic hepatic resection for malignant tumors is associated with a long-term survival rate that is at least comparable to open hepatic resection [24]. The research of Kararyan et al. [25] also indicated that perioperative morbidity and mortality and long-term survival after the laparoscopic resection of colorectal metastases appear to be comparable with those after open resection. However, few papers reported the use of laparoscopic surgery in pediatric malignant solid tumors. Chan et al. [26] reported on 38 children who had undergone minimally invasive surgery for tumor resection, including one case with a liver mass, but found that the role of minimally invasive surgery techniques in resecting malignant tumors is uncertain.

Conclusions

With the continuous development of laparoscopic instruments and techniques, children with solid tumors, such as ovarian, adrenal, kidney, and liver tumors, have been able to undergo laparoscopic surgery safely over the past decade. However, laparoscopy is applied less in cases of pediatric liver disease than in other diseases. Patient bleeding and CO₂ embolism complicate pediatric laparoscopic hepatectomy. Fortunately, a number of surgeons have already solved the problems inherent in the procedure, thus allowing the safe and successful completion of such surgeries (Table 1). Based on the size and position of the liver diseases, varied forms of trocars could be inserted into the abdomens of children. While large, solid, benign tumors in pediatric patients could be resected completely using laparoscopic techniques and no recurrence is expected, laparoscopic surgery remains most often used for hydatid cysts of the liver.

A meta-analysis on laparoscopic hepatectomy showed that the operative time was not significantly different between these two approaches [27]. Patient bleeding in the laparoscopic group was significantly lower than in the open surgery group. Complications with laparoscopy patients were significantly less frequent, and the duration of hospital stay of laparoscopy patients was significantly shorter than that of open surgery patients. Simillis et al. [28] reported a comparative study on works published between 1998 and 2005, including evaluated endpoints of operative, functional, and adverse events. Laparoscopic resection resulted in reduced operative blood loss and earlier recovery, with oncologic clearance comparable with open surgery. If performed by experienced surgeons in selected patients, laparoscopic resection may be a safe and feasible option compared with other surgical procedures.

Patients must be carefully selected for laparoscopic liver resection because adult studies have shown that not all tumors can be easily removed via laparoscopic resection. Large tumors, especially those close to the hepatic veins or the cavohepatic junction and centrally or posteriorly located tumors in the right part of the liver, are not ideal candidates for laparoscopic resection; the major hepatic vessels are difficult to control laparoscopically and the application of the total vascular isolation technique further complicates the procedure [29]. As such, it is dangerous to overuse these procedures. Conversion should be performed for difficult resections requiring extended operating times to ensure the safety of patients; it should be considered a prudent surgical practice rather than a failure.

After extensive development, laparoscopy has become a standard for several procedures, particularly for benign diseases. The use of laparoscopy in the management of malignant diseases or for complex procedures that require resection and reconstruction remains controversial.

Laparoscopic liver surgery is a safe and effective approach for the management of surgical liver disease in the hands of trained surgeons with experience in hepatobiliary and laparoscopic surgery. Therefore, national and international societies should become involved in the goal of establishing training standards to ensure consistent application and clinical outcomes.

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