Laparoscopy was initially used for diagnosis after its discovery in the 1960s [13]. It was gradually applied to the evolution of surgical procedures. This surgical method was quickly accepted due to its clinical experience with less pain and quick recovery, as well as its cosmetic advantages [14]. Since then, laparoscopic surgery has rapidly expanded to encompass more complex abdominal procedures. Furthermore, laparoscopic liver resection (LLR) was developed. The magnified view of laparoscope and the compression effect of pneumoperitoneum on the hepatic vein enables the surgeon to obtain a clear and dry operation field. It has a limited effect on surrounding tissues, and the application of intraoperative ultrasound and indocyanine green (ICG) fluorescence imaging technology help shape the landmark of intrahepatic vessels and tumor edge, increasing the preservation of functional liver parenchyma and reducing the effect of surgery on liver function [15, 16]. With its numerous advantages, the application of LLR in the treatment of benign and malignant liver tumors has grown steadily.
FNH is a benign liver tumor with a higher prevalence in females. According to the literature, the etiology and pathogenesis are not well understood. The current prevailing theory is that arterial malformations, coupled with changes in perfusion, cause a regenerative, hyperplastic response of the normal hepatocyte [4, 17]. Most patients are identified through physical examination, and some have abdominal discomfort or psychological stress. Imaging examination plays a vital role in diagnosis. FNH < 5 cm must be differentiated from HCA and hemangioma, but few FNHs have typical imaging features. This is also one of the reasons why preoperative FNH diagnosis is difficult.
Observation and follow-up were previously recommended as the primary treatment strategy. However, whether surgery is necessary remains debatable [18]. Laparoscopy accounted for 83% of our cases, including five cases of right posterior lobe tumor wedge resection. Simultaneously, we successfully performed three cases of single-port left lateral lobectomy. For young female patients, MIS considers both treatment and cosmetic requirements and is more consistent with the current theme of precision medicine. We reviewed surgical resection experiences of multiple clinical centers for benign liver tumors in addition to our data.
Table 4
Author | Benign tumor | LS/OS | FNH | Minor resection | Major resection | Mean operative time (min) | Complications(≥ gradeⅢ) (%) | Mortality (%) | Mean PHS (days) |
Deha Erdogan et al. (2008) | 70 | 0/70 | 12 | 46 | 24 | 200.9 | N/A | 0 | 13.2 |
Hans Michael Hau et al. (2017) | 100 | 14/86 | 100 | 68 | 32 | 163 | 7 | 0 | 16 (LOS) |
Katrin Hoffmann et al. (2015) | 79 | 9/70 | 38 | 18 | 61 | N/A | N/A | 0 | 8 |
Carsten Kamphues et al. (2011) | 146 | N/A | 45 | 85 | 61 | 200 | 6 | 0 | 9 |
Francesco Ardito et al. (2019) | 173 | 173/0 | 23 | 147 | 26 | N/A | 3 | 0 | 4.9 |
Cheng-Gang Li et al. (2020) | 23 | 23/0 | 23 | 22 | 1 | 120 | 2 | 0 | 5 |
Yang Shi et al. (2021) | 29 | 6/23 | 29 | 27 | 2 | 184 | 1 | 0 | 5.3 |
*LS/OS: Laparoscopic surgery/Open surgery |
Major resection: more than three Couinaud segments.
Minor resection: up to three Couinaud segments, including wedge/partial resection.
PHS: Postoperative hospital stay; LOS: length of hospital stay.
N/A: not available.
Each set of data in Table 4 includes both open and laparoscopic surgeries. Our center also has data on robot-assisted surgery, as Li [19] performed all surgeries with the assistance of the Da Vinci robot. When combined with the literature on benign liver tumor surgical resection, we observe a gradual reduction in the surgery duration, intraoperative blood loss, complications, and PHS. Li [19] performed all 23 surgeries using robot-assisted laparoscopy, and its surgical trauma and postoperative hospital stay significantly differ from traditional open and laparoscopic techniques. Subsequently, with the support of modern technology and the accumulation of surgical experience, it is safe and feasible to perform laparoscopic surgery on FNH patients who meet the surgical indications.
Our group proposes that patients meeting the following criteria must undergo surgery. (1) Diagnosis is clear and tumor enlargement (> 3–4 cm, 0.5 cm per year) during follow-up; (2) patients with specific progressive abdominal/psychological symptoms related with FNH; (3) existing tests cannot distinguish benign from malignant tumors [8, 18, 20]. We added three additional surgical indications based on our clinical observations.
ⅠAsymptomatic with obvious anxiety: Almost all patients diagnosed with FNH experience anxiety/depression (SCL-90 ≥ 2.0), with varying degrees of impact on their daily life and work. One of our patients was diagnosed with depression during the follow-up period after FNH diagnosis and required oral medication to control it. A recent follow-up revealed that he gradually reduced psychoactive drug dosage after surgery.
ⅡLesion is subcapsular or in the left lateral lobe of liver, and wedge/partial resection is sufficient for benign lesions. Furthermore, FNH patients often lack basic liver diseases and have good surgical tolerance. Intraoperative ultrasound, fluorescent navigation, 3D printing technology, and Da Vinci robot have all contributed to the safe and effective performance of liver resection [16, 21, 22]. Therefore, we recommend preventive resection for easily resectable tumors under the supervision of professional medical staff and advanced technologies. Surgery after the onset of symptoms will undoubtedly increase difficulty and trauma to prevent the tumor from growing and compressing the Glisson sheath and hepatic veins.
Ⅲ Kim and Ashbab reported that while FNH remains stable during pregnancy, tumor growth can still be detected in some patients, which increases the difficulty of surgery and the risk of pregnancy[3, 23, 24]. This will increase the psychological burden of pregnancy. Simultaneously, the diagnosis is strait due to the limitation of imaging examinations during pregnancy and the confusing symptoms (nausea and vomiting during pregnancy). Furthermore, the physiological increase of alpha-fetoprotein during pregnancy makes it difficult to distinguish between benign and malignant ones [25]. Therefore, we recommend preventive resection for reproductive women diagnosed with FNH.