FAQ

Consensus on technical standards for laparoscopic anatomical liver resection surgery has been released

The consensus on technical standards for laparoscopic anatomical liver resection surgery has been released. Specifically, on July 20, 2023, the Chinese Journal of Digestive Surgery published the "Chinese Expert Consensus on the Operation Procedure and Technical Standards for Laparoscopic Anatomical Liver Resection (2023 Edition)". This consensus aims to standardize the surgical methods and techniques of laparoscopic anatomical liver resection to ensure that it achieves the expected safety and effectiveness during development and promotion.

Laparoscopic anatomical liver resection has undergone a process of exploration, development and optimization from simple to complex and then to precise, overcoming the dual barriers of technology and concepts, and forming a preliminary process-based, standardized and standardized operation system. However, the overall development and promotion still face great difficulties and challenges.

In addition, on September 28, 2023, the Chinese Journal of Digestive Surgery also published a related article, further emphasizing that surgical planning should fully consider preoperative imaging and three-dimensional visualization evaluation, and at the same time combine the patient's liver basic function and liver reserve function to formulate an individualized and optimized LALR surgical plan.

The consensus on the technical standards for laparoscopic anatomical liver resection has been released in 2023, and has been discussed and promoted in detail on multiple platforms to standardize the surgical operation process and technical standards to ensure the safety and effectiveness of the operation.

What are the specific contents and requirements of the consensus on the technical standards for laparoscopic anatomical liver resection?

The specific contents and requirements of the consensus on the technical standards for laparoscopic anatomical liver resection mainly include the following aspects:

ALR theory and technical system: The ALR (Adequate Lobe Resection) theory and technical system was proposed by Makuuchi in the 1980s, including the following four aspects of standards:

Mark the boundaries of the liver segments on the surface of the liver by staining or blood flow blocking.

Under the guidance of ultrasound examination, the liver parenchyma is cut off with the landmark veins of the liver segment as the boundary.

The hepatic veins of great significance in the liver section are fully exposed.
The Glissonean system near the root of the segment is cut off.

Glissonean pedicle transection method: Takasaki proposed the Glissonean pedicle transection method in 1998, and defined a new anatomical segmentation and the smallest resection unit-the cone unit. When performing ALR, the Glissonean pedicle that controls the target liver segment is found and severed through extrathecal dissection, and the Couinaud liver segment or combined resection based on the cone unit is completed according to the liver ischemic zone.

Anatomical liver resection in the portal vein basin: With the help of modern three-dimensional reconstruction basin analysis technology and indocyanine green fluorescence navigation system, the tumor-bearing portal vein basin can be completely resected with higher quality to obtain the surgical oncology and perioperative efficacy of hepatocellular carcinoma. This consensus aims to improve and standardize the theory and technical system of laparoscopic portal vein basin anatomical liver resection, and lay the foundation for more in-depth exploration of scientific problems in this field and safe and standardized promotion.

Clinical pathological characteristics: For hepatobiliary stones and intrahepatic bile duct dilatation, anatomical resection based on liver segments, liver regions, and liver lobes should also be selected during surgical treatment. This is the key to reducing residual stones and lesions and reducing the recurrence rate.

How to achieve an effective combination of preoperative imaging and three-dimensional visualization in laparoscopic anatomical liver resection?

In laparoscopic anatomical liver resection, the effective combination of preoperative imaging and three-dimensional visualization can be achieved through the following steps:

Preoperative enhanced CT examination: First, a preoperative enhanced CT examination is performed to obtain detailed imaging data of the liver. This step is basic and critical because it provides detailed anatomical information required for surgery.

Application of three-dimensional visualization technology: The enhanced CT images obtained before surgery are processed and reconstructed using three-dimensional visualization technology to generate a three-dimensional model of the liver. This process can be completed through professional software, such as medical image processing software, which can convert two-dimensional imaging information into three-dimensional images, accurately and intuitively showing the spatial structure and anatomical variations of the liver.

Individualized surgical planning: Based on the three-dimensional model, doctors can make more accurate surgical plans. This includes determining the best incision location, evaluating the relationship between the tumor and surrounding tissues, and predicting possible bleeding risks. The three-dimensional model can also help doctors simulate the surgical process to better understand the surgical path and potential challenges.

Intraoperative real-time navigation: During the operation, ultrasound or other real-time imaging technologies can be used to merge with the three-dimensional model to provide real-time navigation support. This technology can help doctors accurately locate lesions and important structures during surgery, reducing uncertainty and risks during surgery.

Postoperative effect evaluation and feedback: After the operation, the surgical effect can be evaluated by comparing the three-dimensional models before and after the operation. At the same time, the patient's clinical data (such as recovery status, complication rate, etc.) can also be collected to further optimize future surgical plans.

How is the individualized and optimized LALR surgical plan formulated in laparoscopic anatomical liver resection?

In laparoscopic anatomical liver resection (LALR), the formulation of an individualized and optimized surgical plan requires comprehensive consideration of multiple factors. First, non-anatomical or anatomical liver resection is performed according to the patient's degree of cirrhosis, tumor size, proximity to important blood vessels, and remaining liver volume. Second, accurate positioning of the tumor during surgery and establishment of an operable surgical space are key steps.

In addition, the choice of surgical approach is also an important part of formulating an individualized surgical plan. The individualized selection of surgical approach and the establishment of an operable surgical space are the basis for the smooth implementation of laparoscopic liver resection. For example, the 4/5-hole method is used for individualized design. The principle of arranging the operation holes is to be fan-shaped around the lesion liver focus, with the principle of fully exposing the cutting edge and not hindering the operation. The position of the main operation hole is as consistent as possible with the planned liver section plane.

What are the main difficulties and challenges encountered in the actual operation of laparoscopic anatomical liver resection?

The main difficulties and challenges encountered in the actual operation of laparoscopic anatomical liver resection include the following aspects:

Perspective and exposure problems: Due to the limitation of the perspective of the laparoscope, the surgical field of view is limited, resulting in increased complexity of the operation. Especially in difficult parts such as the right posterior lobe of the liver, segment VII, and segment VIII, the field of view is poor, which increases the difficulty of the operation.

Mechanical activity space limitation: The activity space of laparoscopic surgical instruments is limited, which makes the operation more difficult.

Lack of tactile feedback: Compared with traditional laparotomy, laparoscopic surgery lacks tactile feedback. Doctors cannot perceive the texture and position of the tissue by touch, which increases the risk of surgery.

Difficulty in bleeding control: Intraoperative bleeding is one of the main reasons for conversion to laparotomy in laparoscopic anatomical liver resection. Especially in some difficult parts (such as S7 segment), bleeding control is more difficult.

Complexity of liver anatomy: The liver anatomy is complex, and the origin, number and course of the portal vein in each liver segment vary from person to person, resulting in unclear boundaries between liver segments. The Glisson pedicle of some liver segments is deep, and it is easy to accidentally damage the intrahepatic duct when separating and dissecting the target blood vessels through the portal approach.

Technical challenges: Laparoscopic hepatectomy has high technical challenges, especially for inexperienced doctors, with a long learning curve, high conversion rate, and relatively high complication rate and mortality rate.

Handling of important blood vessels and structures: The surgical operation is difficult when dissecting and handling the vascular pedicles of liver segments II and III and the left hepatic vein.

What are the latest research advances on laparoscopic anatomical liver resection mentioned in other related articles published in the Chinese Journal of Digestive Surgery?

According to the relevant articles published in the Chinese Journal of Digestive Surgery, the latest research progress on laparoscopic anatomical liver resection mainly includes the following aspects:

Indocyanine green fluorescence guidance technology: The application of this technology in laparoscopic anatomical liver segment resection can improve the accuracy and safety of the operation. By using indocyanine green fluorescent dye, doctors can more clearly identify and separate the blood vessels and nerves of the liver, thereby reducing intraoperative bleeding and postoperative complications.

3D printing technology assisted surgery: The application value of 3D printing technology in laparoscopic anatomical liver segment VIII resection has been further studied and verified. Through 3D printing preoperative models, doctors can have a more intuitive understanding of the anatomical structure of the liver before surgery, thereby improving the accuracy and safety of the operation.

Chinese Expert Consensus (2023 Edition): In 2023, the Chinese Journal of Digestive Surgery published the "Chinese Expert Consensus on the Operation Procedure and Technical Standards of Laparoscopic Anatomical Liver Resection (2023 Edition)", which provides standardized operation procedures and technical guidance for laparoscopic anatomical liver resection, which helps to improve the quality and safety of surgery.

These research advances indicate that laparoscopic anatomical liver resection surgery has been continuously improving in technology and methods, especially in the application of fluorescence guidance technology and 3D printing technology, which has significantly improved the accuracy and safety of the surgery.

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