With the innovation of laparoscopic instruments and the accumulation of minimally invasive experience of surgeons, laparoscopic surgery has evolved to become the approach of choice for many abdominal procedures[11]. LH has developed rapidly in the past few decades, which has shown much advantages over open hepatectomy in terms of short-term recovery, such as less intraoperative bleeding, less postoperative complications and shorter in-hospital stays[12, 13]. In addition, for diseases such as MCN-L, which almost exclusively occur in women (all patients in this series were female)[14], the cosmetic effect of laparoscopy can alleviate the patient's fear of surgery. Although MCN-L has the risk of malignant transformation and recurrence, MCN-L is considered as a benign tumor[4]. The European Guidelines Meeting acknowledge the advantages of laparoscopic liver surgery in liver benign disease in 2017[15]. Compared with laparotomy, laparoscopy can greatly relieve the preoperative abdominal symptoms. A systematic review included 4061 patients (87% open and 13% laparoscopic resections) with benign liver tumors requiring hepatectomy. Two studies of the review found significant better quality of life scores following laparoscopic compared to open surgery[16]. 74.6% of patients with MCN-L were symptomatic preoperatively[4]. Four patients in this series had abdominal pain. It can also be said that laparoscopy can relieve abdominal symptoms of benign tumors such as MCN-L compared with open surgery. The indications of laparoscopic hepatectomy for benign liver tumors have been expanding. Due to the extremely low incidence of MCN-L, it is not included in the guidelines as an indication for laparoscopic surgery. Many patients refuse surgery because of the huge scar of open surgery, leading to the progression of MCN-L to hepatic cystadenocarcinoma. For benign and indeterminate liver lesions, laparoscopic surgery is a safe choice, even if hepatectomy is required[11, 17–19]. There are few studies on the treatment of MCN-L with LH. Although the indicators of LH for the treatment of benign liver diseases are clear, the role of LH is still unclear for tumors like MCN-L that may become malignant. Therefore, this paper reviews and discusses the data and related literature.
The perioperative results and prognosis of this study suggest that LH for MCN-L is feasible and safe, and can provide a good prognosis. To ensure the safety of the surgery, the experience of this series is: 1) The integrity of the tumor must be guaranteed. This not only requires more than 5–10 years of experience in laparoscopic and open hepatectomy, but also careful operation throughout the procedure. When the specimen is taken out from the abdomen through trocar, the specimen bag should be used to avoid the cyst fluid flowing into the abdominal cavity due to the rupture of the tumor. 2) Ensure sufficient cutting edge. The principles of laparoscopic therapy should be consistent with open surgery. The resection line should be at least 1 cm outside the tumor to ensure the negative margin.
Table 2
LH for MCN-L in previous literatures
Author | Published year | case | Operating time(min) | Blood loss (mL) | Clavien-Dindo ≥ III(%) | LOS (days) | | Median PFS |
Ratti et al[20] | 2012 | 2 | NA | NA | 0 | NA | | NA |
Banerjee et al[21] | 2016 | 2 | NA | NA | NA | NA | | 34 |
Smerieri et al[22] | 2018 | 1 | NA | NA | 0 | 5 | | NA |
Kim et al[10] | 2019 | 1 | 240 | 70 | 0 | 7 | | NA |
Yang et al[9] | 2020 | 1 | NA | NA | NA | NA | | 6 |
This series | / | 6 | Mean 176.3 | Mean 102.5 | 0 | Mean5.8 | | 30.5 |
PFS: Progression-free survival; LOS: Length of hospital stay; NR: Not refered. |
In order to objectively summarize whether MCN-L can be used as an indication for laparoscopic surgery, we conducted a review of the literatures about LH for MCN-L (Table 2). Most of the literatures does not describe the operative, perioperative, and prognosis in detail. In 2012, Professor Ratti performed hepatectomy for 12 patients with MCN-L, including 2 cases of LH and 10 cases of open hepatectomy[20]. Unfortunately, the article does not provide specific data on LH for MCN-L. The hospital stay of 12 patients was 5 (4–8) days, the operation time was 209 ± 78 min, and the intraoperative blood loss was 260 ± 130 ml, which was similar to the data of this series. In the report of 2 cases of MCN-L treated with LH, both patients did not relapse after 28 months and 40 months of follow-up[21]. LH for MCN-L can obtain long-term good prognosis, which is consistent with our series. A case had a short-term recurrence after laparotomy cyst unroofing underwent laparoscopic left hepatectomy and was discharged 5 days after surgery[22]. A long-term and difficult adhesiolysis was performed, which also indicated the feasibility of LH for complex MCN-L. Based on the experience of our series, both laparotomy and laparoscopy are acceptable for MCN-L. The choice of surgical method depends on the patient's operation history, the location of the tumor, and whether the surgeon has the experience of LH and MCN-L.
To our knowledge, this study is the first case series of LH for MCN-L, with the largest number of cases. We combined the experience and reviewed the literatures, which may be an advantage of this series. However, because of the extremely low incidence rate of MCN-L, the number of cases in series is small which cannot be statistically analyzed. Retrospective review is another limitation.