In This Article
- Massachusetts General Hospital's Liver Surgery Program uses a cohesive, multidisciplinary approach to improve liver patient care and expand treatment options
- The Minimally Invasive Hepatectomy Program has performed more than 300 laparoscopic liver resections since 2007, with a mortality rate of <1%. The surgeons are translating their laparoscopic experience to a robotic approach for some patients
- Advantages of laparoscopic hepatectomy include smaller hepatectomy incisions, a decreased risk for abdominal hernia and wound infection and a faster return to normal activities or chemotherapy if needed
- Mass General's Enhanced Recovery After Surgery (ERAS) Program and innovative multimodal prehabilitation study optimize surgical candidates to improve treatment outcomes
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Surgeons often use hepatectomy in the treatment of liver metastases, but partial or full hepatic resections may be curative for malignant and benign hepatic masses as well as cysts of the liver. Up to 80% of the liver can be removed in patients with healthy livers due to the organ's regeneration abilities.
While open hepatectomy remains the standard, laparoscopic liver resections continue to gain popularity as a viable alternative. Surgeons from the Minimally Invasive Hepatectomy Program at Massachusetts General Hospital are effectively utilizing laparoscopic and robotic liver resections to treat complex liver conditions, including primary liver cancers.
"As a tertiary or quaternary care institution, we really have an obligation to push the boundaries of what we can offer patients and how we can save lives while keeping them safe," says Cristina Ferrone, MD, surgical director of the Liver Surgery Program in the Division of General Surgery and gastroenterological surgeon in the Mass General Cancer Center. "We could not do the extent of the operations that we do or treat patients if we did not have this collaborative spirit and level of expertise."
Indications for Laparoscopic Hepatectomy
Since 2007, the Minimally Invasive Hepatectomy Program has performed more than 300 laparoscopic liver resections. "If you look at our mortality for those 350 resections, it's <1%," says Dr. Ferrone. "We've done a great job selecting the right patients for the right operation. A minimally invasive hepatectomy is not the right operation for everybody."
The best laparoscopic hepatectomy candidates tend to be patients who need segmentectomy or straightforward right or left hepatectomy.
"But it more depends on the location and size of the tumor and experience of the surgeon," Dr. Ferrone says.
Patients who are not good candidates include those with significant involvement or attachment of the mass to the vena cava, which increases the risk for clinically significant bleeding and carbon dioxide emboli. Patients with scar tissue from previous surgeries are also at higher risk for complications due to the amount of time needed to mobilize the liver.
Performing Minimally Invasive Hepatectomy
To perform a minimally invasive procedure, surgeons should not follow the standard steps of an open operation.
Dr. Ferrone says, "I always recommend starting off doing hand-assisted laparoscopic liver resections, especially when performing larger or more complex hepatic resections."
With the use of a hand port, surgeons can utilize their hand to apply pressure and stop any bleeding. The hand port can help the surgeon gain confidence/experience while keeping the patient safe and minimizing morbidity. This hand port can also be utilized as the extraction site for the specimen.
Laparoscopic Versus Open Hepatectomy
One significant benefit of the laparoscopic approach is a smaller incision. Open incisions start from the xiphoid, run down to the umbilicus and across the right side of the abdomen. These large incisions sometimes result in wound complications and can affect patients' core strength, mobility and balance because the rectus muscle has been divided.
"When you do it minimally invasively, the biggest port is where the mass is removed," says Dr. Ferrone. "As a result, patients have less pain, and we can discharge them from the hospital and get them back to normal activity faster."
Dr. Ferrone reports that discharges tend to be one to two days earlier for minimally invasive liver resections. A return to normal activity is approximately one to two weeks earlier, depending on the size of the resection. Reduced narcotic usage for post-operative pain is also an advantage for this patient cohort.
"Narcotics cause dizziness," says Dr. Ferrone. "We worry about patients falling because many are older."
Other advantages of a minimally invasive approach include:
- Better cosmetic result
- Decreased risk for abdominal hernia
- Decreased risk of wound infection
- Faster return to chemotherapy, if needed
Cancer outcomes have yet to be sufficiently studied in randomized trials comparing minimally invasive approaches to open resections of primary liver cancers.
"There was one study done in Norway for colorectal cancer, which showed that the results were equivalent," says Dr. Ferrone. "From a surgical standpoint, the reason people might see different results is because of limitations to individual physicians' technical abilities."
Optimizing Hepatic Resection Patients Before Surgery
Mass General's Enhanced Recovery After Surgery (ERAS) Program for liver patients helps optimize them one week prior to surgery. Clinicians share educational materials, advise patients about diet and exercise and help them mentally prepare for the operation.
A prehabilitation study provides an additional structure for a select group of laparoscopic liver resection candidates. Pancreatic and liver surgical oncologist Motaz Qadan, MD, PhD, is the principal investigator on the study, entitled Pilot Study of a Multimodal Prehabilitation Pancreatic Cancer Program. The program focuses on exercise and nutrition to improve treatment outcomes after open procedures and helps increase patients' ability to tolerate additional therapies, such as chemotherapy.
"We connect older patients or patients with multiple comorbidities to the prehab program so we can optimize their outcomes," Dr. Ferrone says.
Improving Care for Complex Liver Patients
Mass General's Liver Surgery Program utilizes a multidisciplinary approach to manage patients living with complex liver conditions. Patient populations include those with:
- Liver metastases
- Benign tumors such as hepatic adenomas and hepatic cysts
- Hepatocellular carcinomas with underlying cirrhosis resulting from:
- Alcohol use
- Other causes
"Each of those groups needs an active, dynamic team to care for them." says Dr. Ferrone. "We all have our own biases, but because our team of physicians discuss every new patient we can provide patients with the best care."
All new cancer patients at Mass General's liver program are seen by a team comprised of global experts in:
- Interventional gastroenterology
- Interventional radiology
- Medical oncology
- Radiation oncology
- Surgical oncology and general surgery
"We probably have the most collaborative and cohesive multidisciplinary liver program in the country," says Dr. Ferrone. "There are times when the interventional radiologists can do a procedure to help prep the patient so that I can do a bigger operation than I would normally be able to do. The only reason I can do it is because they have done a complex procedure safely."
This model of care decreases patient stress and frees physicians from redundant communications. "It allows us to design research questions and clinical trials through our academic collaboration," says Dr. Ferrone. Due to the extensive expertise and collaboration of world experts, patients with liver problems receive the best care possible.
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