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The International Position on Laparoscopic Liver Surgery: The Louisville Statement, 2008

Buell, Joseph F. MD, FACS*; Cherqui, Daniel MD; Geller, David A. MD; O’Rourke, Nicholas MD§; Iannitti, David MD; Dagher, Ibrahim MD; Koffron, Alan J. MD**; Thomas, Mark MD††; Gayet, Brice MD‡‡; Han, Ho Seong MD§§; Wakabayashi, Go MD¶¶; Belli, Giulio MD∥∥; Kaneko, Hironori MD***; Ker, Chen-Guo MD†††; Scatton, Olivier MD‡‡‡; Laurent, Alexis MD; Abdalla, Eddie K. MD§§§; Chaudhury, Prosanto MD¶¶¶; Dutson, Erik MD∥∥∥; Gamblin, Clark MD; D’Angelica, Michael MD****; Nagorney, David MD††††; Testa, Giuliano MD‡‡‡‡; Labow, Daniel MD§§§§; Manas, Derrik MD¶¶¶¶; Poon, Ronnie T. MD∥∥∥∥; Nelson, Heidi MD††††; Martin, Robert MD*; Clary, Bryan MD*****; Pinson, Wright C. MD†††††; Martinie, John MD; Vauthey, Jean-Nicolas MD§§§; Goldstein, Robert MD‡‡‡‡‡; Roayaie, Sasan MD§§§§; Barlet, David MD; Espat, Joseph MD§§§§§; Abecassis, Michael MD¶¶¶¶¶; Rees, Myrddin MD∥∥∥∥∥; Fong, Yuman MD****; McMasters, Kelly M. MD, PhD*; Broelsch, Christoph MD******; Busuttil, Ron MD****; Belghiti, Jacques MD††††††; Strasberg, Steven MD‡‡‡‡‡‡; Chari, Ravi S. MD§§§§

doi: 10.1097/SLA.0b013e3181b3b2d8
Original Articles From the 2008 International Laparoscopic Liver Resection Consensus Conference

Objective: To summarize the current world position on laparoscopic liver surgery.

Summary Background Data: Multiple series have reported on the safety and efficacy of laparoscopic liver surgery. Small and medium sized procedures have become commonplace in many centers, while major laparoscopic liver resections have been performed with efficacy and safety equaling open surgery in highly specialized centers. Although the field has begun to expand rapidly, no consensus meeting has been convened to discuss the evolving field of laparoscopic liver surgery.

Methods: On November 7 to 8, 2008, 45 experts in hepatobiliary surgery were invited to participate in a consensus conference convened in Louisville, KY, US. In addition, over 300 attendees were present from 5 continents. The conference was divided into sessions, with 2 moderators assigned to each, so as to stimulate discussion and highlight controversies. The format of the meeting varied from formal presentation of experiential data to expert opinion debates. Written and video records of the presentations were produced. Specific areas of discussion included indications for surgery, patient selection, surgical techniques, complications, patient safety, and surgeon training.

Results: The consensus conference used the terms pure laparoscopy, hand-assisted laparoscopy, and the hybrid technique to define laparoscopic liver procedures. Currently acceptable indications for laparoscopic liver resection are patients with solitary lesions, 5 cm or less, located in liver segments 2 to 6. The laparoscopic approach to left lateral sectionectomy should be considered standard practice. Although all types of liver resection can be performed laparoscopically, major liver resections (eg, right or left hepatectomies) should be reserved for experienced surgeons facile with more advanced laparoscopic hepatic resections. Conversion should be performed for difficult resections requiring extended operating times, and for patient safety, and should be considered prudent surgical practice rather than failure. In emergent situations, efforts should be made to control bleeding before converting to a formal open approach. Utilization of a hand assist or hybrid technique may be faster, safer, and more efficacious. Indications for surgery for benign hepatic lesions should not be widened simply because the surgery can be done laparoscopically. Although data presented on colorectal metastases did not reveal an adverse effect of the laparoscopic approach on oncological outcomes in terms of margins or survival, adequacy of margins and ability to detect occult lesions are concerns. The pure laparoscopic technique of left lateral sectionectomy was used for adult to child donation while the hybrid approach has been the only one reported to date in the case of adult to adult right lobe donation. Laparoscopic liver surgery has not been tested by controlled trials for efficacy or safety. A prospective randomized trial appears to be logistically prohibitive; however, an international registry should be initiated to document the role and safety of laparoscopic liver resection.

Conclusions: Laparoscopic liver surgery is a safe and effective approach to the management of surgical liver disease in the hands of trained surgeons with experience in hepatobiliary and laparoscopic surgery. National and international societies, as well as governing boards, should become involved in the goal of establishing training standards and credentialing, to ensure consistent standards and clinical outcomes.

An international panel was convened to discuss several pressing issues related to the relatively young and rapidly expanding field of laparoscopic liver surgery. The consensus position is that laparoscopic liver surgery is a safe and effective approach to the management of liver disease in the hands of trained surgeons with experience in both hepatobiliary and laparoscopic surgery. National and international societies, and governing boards, should work toward the goal of establishing training standards and credentialing to ensure consistent standards and to monitor clinical outcomes.

From the *University of Louisville, Louisville, KY; †Henri Mondor Hospital, Cretéil, France; ‡University of Pittsburgh, Pittsburgh, PA; §Royal Brisbane Hospital, Herston Queensland, Australia; ¶Carolinas Medical Center, Charlotte, NC; ∥Antoine Beclere Hospital, Clamart, France; **William Beaumont Hospital, Royal Oak, MI; ††University of Cincinnati, Cincinnati, OH; ‡‡Institut Mutualiste Montsouris, Paris; §§Seoul National University, Seoul, Korea; ¶¶Iwate Medical University, Iwate, Japan; ∥∥Loreto Nuovo Hospital, Naples, Italy; ***Toho University, Tokyo, Japan; †††Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; ‡‡‡Hospital Cochin, Paris, France; §§§The University of Texas, MD Anderson Cancer Center, Smithville, TX; ¶¶¶McGill University, Montreal, Quebec, Canada; ∥∥∥University of California-Los Angeles, Los Angeles, CA; ****Memorial Sloan Kettering, New York, NY; ††††Mayo Clinic, Rochester, MN; ‡‡‡‡University of Chicago, Chicago, IL; §§§§Mount Sinai Medical Center, New York, NY; ¶¶¶¶NHS, Newcastle, England; ∥∥∥∥Queen Mary Hospital, Pokfulam, Hong Kong; *****Duke University, Durham, NC; †††††Vanderbilt University Medical Center Nashville, TN; ‡‡‡‡‡Baylor, Houston, TX; §§§§§Roger Williams Medical Center, Providence, RI; ¶¶¶¶¶Northwestern University, Evanston, IL; ∥∥∥∥∥North Hampshire Hospital, Basingstoke, England; ******University Hospital, Essen, Germany; ††††††Hospital Beaujon, Clichy, France; and ‡‡‡‡‡‡Washington University, St. Louis, MO.

Reprints: Joseph F. Buell, MD, FACS, Department of Surgery, Director of Transplantation, Jewish Hospital Transplant Center, 200 Abraham Flexner Way, Louisville, KY 40202. E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.