Recommendations for Laparoscopic Liver Resection
The use of laparoscopy for liver surgery is increasing rapidly. The Second International Consensus Conference on Laparoscopic Liver Resections (LLR) was held in Morioka, Japan, from October 4 to 6, 2014 to evaluate the current status of laparoscopic liver surgery and to provide recommendations to aid its future development. Seventeen questions were addressed. The first 7 questions focused on outcomes that reflect the benefits and risks of LLR. These questions were addressed using the Zurich-Danish consensus conference model in which the literature and expert opinion were weighed by a 9-member jury, who evaluated LLR outcomes using GRADE and a list of comparators. The jury also graded LLRs by the Balliol Classification of IDEAL. The jury concluded that MINOR LLRs had become standard practice (IDEAL 3) and that MAJOR liver resections were still innovative procedures in the exploration phase (IDEAL 2b). Continued cautious introduction of MAJOR LLRs was recommended. All of the evidence available for scrutiny was of LOW quality by GRADE, which prompted the recommendation for higher quality evaluative studies. The last 10 questions focused on technical questions and the recommendations were based on literature review and expert panel opinion. Recommendations were made regarding preoperative evaluation, bleeding controls, transection methods, anatomic approaches, and equipment. Both experts and jury recognized the need for a formal structure of education for those interested in performing major laparoscopic LLR because of the steep learning curve.
The First International Consensus Conference on Laparoscopic Liver Surgery was held in Louisville in 2008. Since then, the number of laparoscopic liver resections (LLRs) performed worldwide has increased exponentially, and LLR has expanded to include minor resection, major resection, robotic hepatectomy, anatomical resection, and donor hepatectomy. No randomized controlled trials (RCTs) have been published. The available data derive from multiple case series, case-control studies, reviews, and meta-analyses published over the last several years.
LLR has now entered the exploration and assessment phases of surgical innovation, particularly at highly specialized centers. For new surgical procedures to become widely adopted as standard operations, they should first be compared with established procedures and shown to be superior in at least some respects. However, acquiring surgical mastery in LLR is difficult and requires specific training. Furthermore, additional instruments are required, and these can add costs beyond those associated with open liver resection (OLR). Enthusiasm for new surgical technologies such as LLR should not stand in the way of proper comparative evaluation.
The Second International Consensus Conference on LLR (ICCLLR) was held from October 4 to 6, 2014, in Morioka, Iwate Prefecture, Japan, with the dual goal of defining the current role of LLR and developing recommendations and guidelines. This goal was to be achieved through analysis of the available literature and through expert presentations including videos in front of an independent Jury. The organizing committee invited 43 respected surgeons, that is, 34 expert panel members with demonstrated experience in LLR, plus 9 jury members, from 18 countries, to provide evidence and draw recommendations. The organizing committee formulated 17 questions in 2 categories—benefits and risks, and techniques of LLR. Each question was assigned a specific working group, composed of 3 to 7 expert panel members who were selected on the basis of their scientific and clinical activities. A search of the English language literature was performed through MEDLINE, EMBASE, and the Cochrane Library for articles published on LLR between 1991 and August 2014. The expert panel members were asked to add any missing relevant articles according to the questions, prepare reviews of the evidence, and draft recommendations in response to the questions. The jury provided recommendations on questions 1 to 7, which were related to benefits and risks of LLR. Basically, this part of the consensus meeting followed the independent jury-based consensus model (Zurich-Danish model). However, the experts provided recommendations on questions 8 to 17, which were related to technical aspects of LLR.
Approximately 240 individuals from 5 continents attended the ICCLLR. The audience consisted largely of surgeons involved or interested in LLR. State-of-the-art invited and competitive videos were presented that demonstrated many advanced LLR techniques. A member of each working group gave a 15-minute presentation covering their specific question, and each presentation was followed by questions from the jury, the expert panel, and the audience. Final statements and recommendations were presented by the primary author of each of the 17 working groups. The paper will be presented in 2 sections, the jury section followed by the expert technical section.
Abstract and Introduction
Abstract
The use of laparoscopy for liver surgery is increasing rapidly. The Second International Consensus Conference on Laparoscopic Liver Resections (LLR) was held in Morioka, Japan, from October 4 to 6, 2014 to evaluate the current status of laparoscopic liver surgery and to provide recommendations to aid its future development. Seventeen questions were addressed. The first 7 questions focused on outcomes that reflect the benefits and risks of LLR. These questions were addressed using the Zurich-Danish consensus conference model in which the literature and expert opinion were weighed by a 9-member jury, who evaluated LLR outcomes using GRADE and a list of comparators. The jury also graded LLRs by the Balliol Classification of IDEAL. The jury concluded that MINOR LLRs had become standard practice (IDEAL 3) and that MAJOR liver resections were still innovative procedures in the exploration phase (IDEAL 2b). Continued cautious introduction of MAJOR LLRs was recommended. All of the evidence available for scrutiny was of LOW quality by GRADE, which prompted the recommendation for higher quality evaluative studies. The last 10 questions focused on technical questions and the recommendations were based on literature review and expert panel opinion. Recommendations were made regarding preoperative evaluation, bleeding controls, transection methods, anatomic approaches, and equipment. Both experts and jury recognized the need for a formal structure of education for those interested in performing major laparoscopic LLR because of the steep learning curve.
Introduction
The First International Consensus Conference on Laparoscopic Liver Surgery was held in Louisville in 2008. Since then, the number of laparoscopic liver resections (LLRs) performed worldwide has increased exponentially, and LLR has expanded to include minor resection, major resection, robotic hepatectomy, anatomical resection, and donor hepatectomy. No randomized controlled trials (RCTs) have been published. The available data derive from multiple case series, case-control studies, reviews, and meta-analyses published over the last several years.
LLR has now entered the exploration and assessment phases of surgical innovation, particularly at highly specialized centers. For new surgical procedures to become widely adopted as standard operations, they should first be compared with established procedures and shown to be superior in at least some respects. However, acquiring surgical mastery in LLR is difficult and requires specific training. Furthermore, additional instruments are required, and these can add costs beyond those associated with open liver resection (OLR). Enthusiasm for new surgical technologies such as LLR should not stand in the way of proper comparative evaluation.
The Second International Consensus Conference on LLR (ICCLLR) was held from October 4 to 6, 2014, in Morioka, Iwate Prefecture, Japan, with the dual goal of defining the current role of LLR and developing recommendations and guidelines. This goal was to be achieved through analysis of the available literature and through expert presentations including videos in front of an independent Jury. The organizing committee invited 43 respected surgeons, that is, 34 expert panel members with demonstrated experience in LLR, plus 9 jury members, from 18 countries, to provide evidence and draw recommendations. The organizing committee formulated 17 questions in 2 categories—benefits and risks, and techniques of LLR. Each question was assigned a specific working group, composed of 3 to 7 expert panel members who were selected on the basis of their scientific and clinical activities. A search of the English language literature was performed through MEDLINE, EMBASE, and the Cochrane Library for articles published on LLR between 1991 and August 2014. The expert panel members were asked to add any missing relevant articles according to the questions, prepare reviews of the evidence, and draft recommendations in response to the questions. The jury provided recommendations on questions 1 to 7, which were related to benefits and risks of LLR. Basically, this part of the consensus meeting followed the independent jury-based consensus model (Zurich-Danish model). However, the experts provided recommendations on questions 8 to 17, which were related to technical aspects of LLR.
Approximately 240 individuals from 5 continents attended the ICCLLR. The audience consisted largely of surgeons involved or interested in LLR. State-of-the-art invited and competitive videos were presented that demonstrated many advanced LLR techniques. A member of each working group gave a 15-minute presentation covering their specific question, and each presentation was followed by questions from the jury, the expert panel, and the audience. Final statements and recommendations were presented by the primary author of each of the 17 working groups. The paper will be presented in 2 sections, the jury section followed by the expert technical section.
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