This document summarizes new advances in laparoscopic resection for liver tumors. It discusses the historical challenges of open liver surgery and improved outcomes with laparoscopic techniques. Specific cases are presented of laparoscopic resection for benign cysts and tumors as well as malignant hepatocellular carcinoma and colorectal cancer metastases. The theoretical advantages and solutions for challenges of the laparoscopic approach are reviewed.

1. New Advances in the Treatment of Liver Tumors: Laparoscopic Resections Cancer Care Innovations Dorothy E. Schneider Cancer Center Mills-Peninsula Hospital April 23, 2011 Kimberly Moore Dalal, MD, FACS Surgical Oncology and General Surgery Peninsula Medical Clinic Bruce Allen, MD; Aziz Ahmad, MD; Dirk Baumann, MD; John Beare, MD; Pamela Foster, MD; Stephanie Lin, MD; Andrea Metkus, MD; John Rosenman, MD; Randolph Wong, MD; Albert Wetter, MD

4. OR Team, Bagram, Afghanistan 2007 Liver cancer

5. MASCAL, October 14, 2007 19 Americans injured Liver cancer

8. Anatomy Liver cancer

9. Benign Hepatic Lesions Liver cancer Tumor Malignant Potential Spontaneous Hemorrhage Focal nodular hyperplasia No No Hemangioma No Rare Cystadenoma Yes No Adenoma Yes Yes

11. Ultrasound Complex cystic structure of liver with layering Liver cancer

12. Triple phase liver CT: Cystic lesion, Seg 4, 6x8x6 cm Liver cancer

14. Liver cancer Triple phase liver CT: Seg 7, 4x2x2 cm

15. Traditional Open “Chevron” Incision Liver cancer

16. Exposure in an Open Resection Liver cancer

17. Laparoscopic Port Placement for Right Liver Lesions Cho JY, et al. , Arch Surg 2009; 144(1):25-29. Liver cancer

18. Laparoscopic View of the Liver Liver cancer Machado MA, et al ., Surg Endosc, 2009; 23:2615-2619.

19. Case 2: Hepatic Adenoma, Segment 7 Laparoscopic Resection…9 Months Later Liver cancer

27. 23 pts: Negative margins (100%). No local recurrence. Laparoscopic Hepatectomy MSKCC Results (n=44) Liver cancer D’Angelica, MD, et al ., AHPBA 2006 Benign 21 pts (47%) Malignant 23 pts (53%) 1 tumor 36 pts (81%) > 1 tumor 8 pts (18%)

28. Operative Outcome Laparoscopic Hepatectomy MSKCC Results: Comparison to Open Liver cancer D’Angelica, MD, et al ., AHPBA 2006 LLR (n=44) OLR (n=91) p OR time (minutes) 199 161 0.01 Pringle time (minutes) 31 22 0.04 Pringle 45% 75% <0.01 EBL (ml) 161 521 <0.01 Transfusion 2.2% 26% <0.01

29. Laparoscopic Hepatectomy MSKCC Results: Comparison to Open Post-operative Outcome Liver cancer D’Angelica, MD, et al ., AHPBA 2006 LLR (n=44) OLR (n=91) p Length of stay (days) 5.1 6.7 <0.01 Morbidity 13% 28% 0.08 Regular diet (days) 3 3 0.7 Oral analgaesia (days) 3.1 3.5 0.1 Mortality 0% 0% 0

34. Child-Pugh Class A Patients are Candidates for Resection Liver cancer Class A = 5-6 points Good operative risk Class B = 7-9 points Moderate operative risk Class C = 10-15 points Poor operative risk 1 2 3 Encephalopathy None 1-2 3-4 Ascites None Slight Moderate Albumin (g/dL) >3.5 2.8-3.5 <2.8 Prothrombin time (sec) 1-4 4-6 >6 Bilirubin (mg/dL) 1-2 2-3 >3

36. Triphasic Liver CT: Segment III 3.5 cm mass Liver cancer

46. Radiofrequency Ablation Liver cancer

47. Radiofrequency Ablation Pre-ablation 3-days post 2 months post Liver cancer

50. Microwave Ablation Liver cancer

52. Resectability of Colorectal Cancer Metastases Liver cancer

53. After portal vein embolization, left liver hypertrophied and right liver atrophied Metastases resected Staged Resections

56. Local Recurrence Rates for RFA Mulier S, et al ., Ann Surg. 2005 Aug;242(2):158-71. Liver cancer

57. Liver cancer