Patients and inclusion/exclusion criteria
The Institutional Review Board at Sun Yat-sen University Cancer Center approved this prospective study, and the methods were carried out in accordance with approved guidelines (ClinicalTrials.gov ID: NCT02613156).
The inclusion criteria were as follows: (1) recurrent HCC after open surgery; (2) recurrent HCC located in any part of the left lateral lobe or the diaphragm side of the right lobe and near the surface of the liver, without noteworthy surgical contraindications; (3) no major vessel or bile duct tumor invasion or metastasis; (4) grade A or B liver function or grade C liver function that recovered to grade A after liver-protective treatment; and (5) a signed informed consent form from the patient. The exclusion criteria were as follows: (1) major vessel or bile duct tumor invasion; (2) recurrent HCC located in the right liver parenchyma and near secondary vessels and bile ducts; (3) extrahepatic metastasis; (4) grade C liver function; (5) noteworthy surgical contraindications; or (6) patient refusal to undergo laparoscopic hepatectomy.
Observation indicators and detection methods
Routine biochemical tests were conducted as part of the postoperative re-examination, and changes in alanine aminotransferase and aspartate aminotransferase levels were used to assess postoperative liver function changes. The severity of adhesions was assessed using the modified American Fertility Society (mAFS) classification scoring system. Pain scores were evaluated using a visual analogue scale (VAS) after surgery (the 1st day). Patients were followed up every 2 or 3 months after discharge from the hospital.
The surgical instruments used for patients in the laparoscopic group included conventional laparoscopic instruments (three 5-mm trocars, two 10-mm trocars, and two damage-free laparoscopic clamps), the STORZ high-resolution laparoscopic operating system (Mittelstraße, Tuttlingen, Germany), the GEN300 ultrasonic scalpel system (Johnson and Johnson, New Brunswick, NJ, USA), a laparoscopic linear cutter stapler (Johnson and Johnson, New Brunswick, NJ, USA), a laparoscopic ultrasound device, LigaSure, bipolar coagulation, titanium laparoscopic clips, and absorbable hemostatic gauze.
The surgical instruments used for patients in the control group included conventional laparotomy instruments, an electric scalpel, an intraoperative B-mode ultrasound device, proline tubing, gelatin sponges, and absorbable hemostatic gauze.
All patients received general anesthesia and intubation. Based on the tumor location, patients in the laparoscopic group were placed in the supine position, with their legs spread apart or horizontally; patients in the control group were positioned horizontally. Moreover, in the laparoscopic group, if the tumor was in the right lobe, a five-way-access approach was used, in which the surgeon stood on the same side as the tumor, the laparoscope-supporting assistant stood between the patient’s legs, and the surgical assistant stood on the other side of the tumor. A small incision (1.5 cm in diameter) was made along the upper navel edge, and a Veress needle was inserted to establish pneumoperitoneum. Next, a 10-mm trocar was inserted, and then the laparoscope was inserted to explore the liver tumor and peritoneal adhesions. Pressure was maintained at 8–12 mmHg. Next, a small incision (0.5 cm in diameter) was made 2 cm underneath the right costal margin, and a 5-mm trocar was inserted for auxiliary surgical access. Another small incision (1.0 cm in diameter) was made laterally and inferiorly, and a 10-mm trocar was inserted and used as the main surgical access. A small incision (0.5 cm in diameter) was then made underneath the left costal margin, and a 5-mm trocar was inserted for auxiliary surgical access. These access points were located as far away from the adhesions as possible. If it was impossible to circumvent peritoneal adhesions, laparoscopic separation of the adhesions was performed first. If the tumor was in the S2 or S3 segment, a four-way-access approach was used: the surgeon stood on the right side of the patient, and the first assistant stood on the left side of the patient. Only one access point underneath the left costal margin was required. During resection of tumor lesions and liver segments from the right lobe, the surgeon separated adhesions in the operating field that were near the abdominal wall using an ultrasonic scalpel and then determined the location and incision edges of the tumor under the guidance of laparoscopic ultrasound. Next, the surgeon used an ultrasound-guided scalpel to separate the liver parenchyma, followed by the use of LigaSure coagulation to stop bleeding from small vessels. Groups of titanium clips were used to stop the bleeding if the LigaSure coagulation was ineffective. The surgeon resected the tumor after separating the liver parenchyma. If the tumor was in the S2 or S3 segment, the surgeon performed laparoscopic resection of the left lateral lobe. After separating the adhesions, the surgeon cut the left coronary ligament and the left triangular ligament. The assistant pulled the left lobe upward and to the right, and the surgeon separated the hepatogastric ligament and verified that the incision edge was more than 2 cm away from the tumor (guided by laparoscopic ultrasound). Next, the surgeon separated the liver parenchyma along the incisions on the surface of the liver until reaching the vascular pedicle of the S2 and S3 segments and then used a laparoscopic linear cutter stapler to cut the residual liver tissue and vessels to resect the left lobe. A gelatin sponge was used to stop minor bleeding in the operating field. After the wound was checked for active bleeding, the surgeon expanded the incision at the navel edges to remove the specimen. Next, the surgeon placed an abdominal drainage tube according to standard procedures. For patients in the control group, if the tumor was in the left lateral lobe or the right anterior lobe, an incision was made along the midline of the abdominal wall; if the tumor was in the right lobe, an oblique incision was made underneath and along the costal margin. Adhesions were separated after the abdominal wall was opened, and intraoperative B-mode ultrasound was used to determine the location of the tumor and incision lines. A conventional surgical approach was used for local resection or segmental resection of the HCC. If the tumor was in the S2 or S3 segment, the left lateral lobe was resected with an open lobectomy, and an abdominal drainage tube was placed according to standard procedures.
SPSS 21.0 software was used to process all data. Measurement data are expressed as the mean ± standard deviation and were analyzed with an independent-sample t test. Count data were analyzed with the χ
2 test. Relapse-free survival was analyzed using the Kaplan–Meier method. P < 0.05 were considered statistically significant.