Laparoscopic liver resection

# Guidance
Current evidence on the safety and efficacy of laparoscopic liver resection appears adequate to support the use of this procedure, provided that the normal arrangements are in place for consent, audit and clinical governance.
Patient selection for laparoscopic liver resection should be carried out by a multidisciplinary team. Surgeons undertaking laparoscopic liver resection should have specialist training and expertise both in laparoscopic techniques and in the specific issues relating to liver surgery.# The procedure

# Indications
A common indication for laparoscopic liver resection is a solitary liver metastasis from colorectal cancer, but it may also be used for hepatocellular carcinoma (HCC) and for benign liver tumours or cysts.
The early stages of primary and secondary liver cancer are often asymptomatic. As the tumour grows, symptoms may include jaundice, loss of appetite, loss of weight, nausea and tiredness. Benign liver tumours are usually small and asymptomatic, but if they become large they may cause symptoms such as pain, nausea and vomiting.
Open surgical resection is the standard treatment for patients with localised colorectal metastases of the liver or HCC. A number of alternative therapies have also been developed, including hepatic artery infusion chemotherapy, percutaneous ethanol injection, cryoablation, microwave coagulation therapy, laser-induced thermotherapy and radiofrequency ablation. Benign liver tumours are usually treated only if they are causing symptoms; the standard treatment is open surgical resection.

# Outline of the procedure
Laparoscopic liver resection is performed under general anaesthesia. The abdomen is insufflated with carbon dioxide and a number of small incisions are made to provide access for the laparoscope and surgical instruments. Diathermy is used to mark the line of transection on the liver surface. The hepatic parenchyma is then transected and the main blood vessels and bile ducts are divided and closed with clips or staples. The resected liver is enclosed in a bag and removed through a small incision in the umbilical area. Haemostasis of the transection line may be obtained by several techniques including cautery, haemostatic swabs and fibrin glue.
Hand-assisted laparoscopic liver resection allows the surgeon to place one hand in the abdomen while maintaining the pneumoperitoneum required for laparoscopy. An additional small incision is made which is just large enough for the surgeon's hand, and an airtight 'sleeve' device is used to form a seal around the incision.

# Efficacy
One study of 55 patients reported that there was no difference in the overall patient survival rate or disease-free survival rate between laparoscopic liver resection and open resection. In five studies (n = 217) that compared laparoscopic liver resection with open resection in patients with malignant tumours, there were no statistically significant differences in the extent of the resection margins.
Four of six non-randomised comparative studies reported that the postoperative hospital stay was significantly shorter after laparoscopic liver resection (mean stay ranged from 4 to 15 days) than after open liver resection (mean stay ranged from 8 to 22 days). For more details, refer to the Sources of evidence.
The Specialist Advisors noted that there were concerns that resection margins may be compromised which may put the patient at risk of increased local tumour recurrence.

# Safety
All of the studies reported the rate of conversion to laparotomy, which ranged from 0% (0/30) to 15% (2/13). Five of seven studies reported that blood transfusion was necessary during laparoscopic surgery in 0% (0/18) to 13% (4/30) of patients. Complications included chest infection in 15% (2/13), liver failure in 8% (1/13), ascites in 8% (1/13), atelectasis of the left lower pulmonary lobe in 8% (1/13) and biliary leak in 5% (1/21) of patients. For more details, refer to the Sources of evidence.
The Specialist Advisors stated that potential adverse effects included death due to uncontrollable haemorrhage, bile leakage, gas embolism, deep vein thrombosis and infection.# Further information
The Institute has issued guidance on radiofrequency ablation of hepatocellular carcinoma, radiofrequency ablation for the treatment of colorectal metastases in the liver and selective internal radiation therapy for colorectal metastases in the liver. The Institute has also published a cancer service guideline on improving outcomes in colorectal cancers.
Andrew DillonChief ExecutiveJuly 2005

# Sources of evidence
The evidence considered by the Interventional Procedures Advisory Committee is described in the following document.
'Interventional procedure overview of laparoscopic liver resection', January 2005.

# Information for patients
NICE has produced information on this procedure for patients and carers. It explains the nature of the procedure and the guidance issued by NICE, and has been written with patient consent in mind.# About this guidance
NICE interventional procedure guidance makes recommendations on the safety and efficacy of the procedure. It does not cover whether or not the NHS should fund a procedure. Funding decisions are taken by local NHS bodies after considering the clinical effectiveness of the procedure and whether it represents value for money for the NHS. It is for healthcare professionals and people using the NHS in England, Wales, Scotland and Northern Ireland, and is endorsed by Healthcare Improvement Scotland for implementation by NHSScotland.
This guidance was developed using the NICE interventional procedure guidance process.
It has been incorporated into the NICE pathway on colorectal cancer, along with other related guidance and products.
We have produced a summary of this guidance for patients and carers. Information about the evidence it is based on is also available.
Changes since publication
January 2012: minor maintenance.
Your responsibility
This guidance represents the views of NICE and was arrived at after careful consideration of the available evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
Copyright
 National Institute for Health and Clinical Excellence 2005. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.
Contact NICE
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