Laparoscopy uses elongated instruments (called "trocars") that are inserted through small incisions in the abdomen, usually 4 or 5, after insufflation of the abdomen with CO2 (pneumoperitoneum).
This technique can be used for benign and malignant tumors (primary and metastatic) and for the removal of the liver from a living donor.
In the case of malignant pathology, it has shown an oncological efficacy equal to that of the classic approach (open surgery), and it is the technique of choice in the case of small lesions located in easily accessible liver segments and in patients who cannot bear the surgical stress from a larger incision.
Major liver resections (e.g., right hepatectomy) have proven to be feasible but remain technically demanding procedures reserved for experienced surgeons. Patients with bilateral or central tumors near the hilum of the liver, the main hepatic veins, or the inferior vena cava are not standard candidates for a laparoscopic approach. However, in some more experienced centers, even these cases are treated laparoscopically for selected patients.
Laparoscopic access offers some advantages over conventional operations:
- A magnified view of the operative field allows for meticulous hemostasis.
- Positive pressure, induced by pneumoperitoneum, reduces intraoperative bleeding.
- significantly shorter hospital stay compared to an open approach and faster hospital discharge
- Early resumption of oral feeding
- early return of bowel activity
- less need for painkillers
An operation performed by laparoscopy can be performed according to three different approaches:
- Pure laparoscopy: the entire resection is performed through the laparoscopic ports, and an auxiliary incision is used for sample removal only.
- assisted laparoscopic surgery: in addition to the positioning of the classic trocars, the operator uses an auxiliary access, which also helps to extract the sample. If a purely laparoscopic procedure requires the insertion of a hand to overcome difficulties and complete the procedure, this should be considered a "conversion from pure laparoscopy to hand-assisted hepatectomy."
- Hybrid hepatectomy (also called "laparoscopic-assisted hepatectomy"): The operation begins with mobilization of the liver laparoscopically (with or without manual assistance), followed by a minilaparotomy to access the vascular pedicles (if necessary) and sectioning of the liver. parenchyma .
- Hand-assisted" and hybrid methods are generally adopted to perform complex resections or address localized lesions in inaccessible areas.
Sometimes, to complete the operation correctly (for example, in case of bleeding or unexpected intraoperative findings), conversion to laparotomy (classic or "open" approach) may be necessary.
In patients who do not tolerate pneumoperitoneum, either due to cardiopulmonary status or intraoperative complications, laparoscopy is contraindicated.