The National Institute for Health and Clinical Excellence is examining laparoscopic liver resection and will publish guidance on its safety and efficacy to the NHS in England, Wales and Scotland. The Institute's Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisors, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about laparoscopic liver resection.

This document summarises the procedure and sets out the provisional recommendations made by the Advisory Committee. It has been prepared for public consultation. The Advisory Committee particularly welcomes:

• comments on the preliminary recommendations
• the identification of factual inaccuracies
• additional relevant evidence.

Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that the Institute will follow after the consultation period ends is as follows:

• The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.
• The Advisory Committee will then prepare draft guidance which will be the basis for the Institute's guidance on the use of the procedure in the NHS in England, Wales and Scotland.

For further details, see the Interventional Procedures Programme manual, which is available from the Institute's website (www.nice.org.uk/ipprogrammemanual).

Closing date for comments: 26 April 2005
Target date for publication of guidance: July 2005

Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation.

Current evidence on the safety and efficacy of laparoscopic liver resection appears adequate to support the use of this procedure provided that normal arrangements are in place for consent, audit and clinical governance.

Patient selection for liver resection should be carried out in the context of a multidisciplinary team. Laparoscopic liver resection requires specialist training and expertise both in laparoscopic techniques and in the specific issues relating to liver surgery.

A common indication for laparoscopic liver resection is a solitary liver metastasis from colorectal cancer, but it may also be used for hepatocellular carcinoma (HCC) and for benign liver tumours or cysts.

The early stages of primary and secondary liver cancer are often asymptomatic. As the tumour grows, symptoms may include jaundice, loss of appetite, weight loss, nausea and tiredness. Benign liver tumours are usually small and asymptomatic, but if they become large they may cause symptoms such as pain, nausea and vomiting.

Open surgical resection is the standard treatment for patients with localised colorectal metastases of the liver or HCC. A number of alternative therapies have also been developed, including hepatic artery infusion chemotherapy, percutaneous ethanol injection, cryoablation, microwave coagulation therapy, laser-induced thermotherapy and radiofrequency ablation. Benign liver tumours are usually treated only if they are causing symptoms: the standard treatment is open surgical resection.

Laparoscopic liver resection is performed under general anaesthesia. The abdomen is insufflated with carbon dioxide and a number of small incisions are made to provide access for the laparoscope and surgical instruments. Diathermy is used to mark the line of transection on the liver surface. The hepatic parenchyma is then transected and the main blood vessels and bile ducts are divided and closed with clips or staples. The resected liver is enclosed in a bag and removed through a small incision in the umbilical area. Haemostasis of the transection line may be obtained by several techniques including cautery, haemostatic swabs and fibrin glue.

One study of 55 patients reported that there was no difference in the overall patient survival rate or disease-free survival rate between laparoscopic liver resection and open resection. In five studies (n = 217) that compared laparoscopic liver resection with open resection in patients with malignant tumours, there were no statistically significant differences in the extent of the resection margins.

The Specialist Advisors noted that there were concerns that resection margins may be compromised which may put the patient at risk of increased local tumour recurrence.

All the studies reported the rate of conversion to laparotomy, which ranged from 0% (0/30) to 15% (2/13). Five of seven studies reported that blood transfusion was necessary during laparoscopic surgery in 0% (0/18) to 13% (4/30) of patients. Complications included chest infection in 15% (2/13), liver failure in 8% (1/13), ascites in 8% (1/13), atelectasis of the left lower pulmonary lobe in 8% (1/13), and biliary leak in 5% (1/21) of patients. For more details, refer to the sources of evidence (see Appendix).

The Specialist Advisors stated that potential adverse effects included uncontrollable haemorrhage, bile leakage, gas embolism, deep vein thrombosis and infection.

The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making its provisional recommendations.

Interventional procedures overview of laparoscopic liver resection, January, 2005

Available from: www.nice.org.uk/ip289overview