All About Laparoscopic Liver Resection

Podcast Transcript

Scott Steele:  Buts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Welcome to another episode of Buts and Guts. I'm your host Scott Steele, the chairman of Colorectal Surgery Chairman at the Cleveland Clinic in beautiful Cleveland, Ohio. Today, we're going to talk a little bit about a technical aspect in a disease process and that's laparoscopic liver resection. I'm absolutely thrilled to have Dr. David Kwon, who's the director of laparoscopic liver surgery within the Department of Surgery here at the Cleveland Clinic. David, welcome to Buts and Guts.

David Kwon:  Hi, Scott. Nice to meet you.

Scott Steele:  We always like to start out with all of our guests talking a little bit about where are you from, where were you born, where'd you train, and how did you come to the point that you're here at the Cleveland Clinic?

David Kwon:  Well, I have a relatively very different background. I had most of my education back in South Korea, and I developed my career back in South Korea because Korea is a region where we have a lot of liver diseases. I was exposed to a lot of liver diseases there and that's where I could develop a lot of my career. There I was exposed to a lot of liver resections and also a lot of living donor liver transplant. That is my training background. I was interested in laparoscopic approach since 2005. It came up to my mind that this is something that is beneficial to the patients and should be carried on to the next level. Back at those times, laparoscopic liver resection was something very bloody.

We didn't know how to control the bleeding. We used to have a lot of issues, but it was apparent that once the surgery was done clearly well, then the patients benefited a lot. I was able to integrate the laparoscopic surgery along with living donor liver transplant. I developed a program of laparoscopic approach to offer to living donor liver transplant donors of livers, and Cleveland Clinic wanted me to have that established share. That's how I came to be here. Currently I'm trying to establish a more extensive advanced laparoscopic liver resection program, as well as a laparoscopic living donor program.

Scott Steele:  Well, we're sure excited to have you here. Today, again, as we said, we're going to talk a little bit about a laparoscopic liver resection and a little bit about the living donor program. But before we dive in, let's just talk a little bit about the liver for the listeners out there that haven't had the knowledge of that. What's the liver? What's its primary function? Where does it sit?

David Kwon:  Well, the liver is the single largest organ within our body. It's around two kilograms in weight, which is around four or five pounds, and is so like considered like the factory. Everything you eat passes first through the liver. It detoxifies. It makes proteins into amino acids. It makes all the blocks that is necessary for your energy for your body building. It is fundamental to sustaining your healthy metabolism within your body.

Scott Steele:  What cases or disease process would a liver resection be required? Where do you come in?

David Kwon:  Well, in the U.S. most frequently, liver resection of all is carried out in patients with colorectal liver cancers, with liver metastasis. That is probably the highest incidences. The second largest is the primary liver tumor, so called the liver cancer. Those two would be the reason why usually the liver resection is done.

Scott Steele:  What type of tests are useful that you go into determining how much of the liver is involved and is it something that is amenable to a surgery on the liver? How do you figure that all out?

David Kwon:  Well, because liver is, as I said, one of the fundamental organs to sustain life, we cannot take too much of the liver out. Generally, we evaluate how much liver functions reserve you have before we consider any resection, and secondly, the extent of resection that we have to carry out. The extent is usually decided through a CT or an MRI, so we can see where the location of the tumor is, along with the proximity with the large vessels around, how much liver can we save and how much we should take out. That in addition to how much liver reserve you have is what determines whether you will be fit for liver resection or we'll have to have other choices on the table.

Scott Steele:  I'm a colorectal surgeon and I have patients all the time that may come and they may present with a metastasis to the liver. How do you make that determination whether that is a role of surgery in their care versus somebody here like, "You know what? You got disease that is not surgically amenable."

David Kwon:  Well, surgery offers the best survival rate. Surgery always comes... If it's operable, we do surgery. If it's not operable, we don't do surgery. Maybe we take the other measures. We put the surgery in the first on the treatment options. Whether this is amenable or not is depends on the size of the tumor you have, where it's located, how many you have. As I said, with the numbers and the size and the location, looking at the CT or an MRI, we generally can tell how much liver can we leave behind while taking out all the tumor necessary.

If we think we can take all the tumor out and you'll have enough liver function reserve, then we go for surgery. Whereas we think if the tumor is too big or there are too many and it's not possible to reset all the tumors, then we go for chemotherapy or radiation firsthand before going to surgery.

Scott Steele:  For patients that have other underlying diseases that may affect the liver such as a cirrhotic, how does that weigh into your thought process and disease management in terms of how surgically you can approach these patients or not approach these patients?

David Kwon:  Well, patients with colorectal liver metastasis usually don't have background liver cirrhosis because the disease itself doesn't come from the liver, but from the colon or the rectum and the tumor has metastasize to the liver. However, the second most common incidents, which is the liver tumor, often have a background of hepatitis C or hepatitis B or NASH, nonalcoholic steatohepatitis. In that case, you have background cirrhosis. If you have background cirrhosis by lab tests that we do before surgery, we usually can tell how much reserve of the liver you will have after the operation. As I said, verify how much liver function you have and how much liver we have to take is what determines whether you will go for surgery or not.

Scott Steele:  Before we jump into the technical aspects of a liver resection, let's say I'm a patient out there listening to this podcast and I was just told by my primary care doc or even a surgeon that says, "You got to go visit a liver surgeon." What can they expect during that encounter in the outpatient clinic?

David Kwon:  The liver is a very specific field in which there are many ways to approach cases seen as inoperable by other surgeons could actually be thought to be as operable by a liver specialist. I think that is something that you have into consideration when you visit the office of any liver specialist surgeon.

Scott Steele:  When a patient comes into your office, do you review CAT scans with them? Do they get a sense of that examination? What's that type of visit because I can assure you that there's some trepidation or even fear with going to a liver surgeon. What is that office visit like?

David Kwon:  We usually evaluate first, as I said, the liver function. We draw blood there. We look at the CAT scan. We often nowadays because the MRI is a little bit more specific than CAT scan, we often if we think we'll have to resect, we do an MRI before we start designing the whole process of operation. Usually the MRI will be one additional test that you may have when you visit a clinic.

Scott Steele:  What is the laparoscopic liver resection? How is it performed and is it different than a robotic liver resection and are open? What is this all about?

David Kwon:  Laparoscopic and robotic are similar in the sense that they are both minimally invasive, which means that you're not opening the whole abdomen, putting a huge laparotomy to get access to the organs that you need to operate on, but rather putting little holes in the abdomen and operating with like long forceps, long sticks. By nature because you put three or four half inch size incisions and you do the whole operation with that. Because of that minimally invasive nature, the patients usually recover a lot faster. You experience a lot less pain.

However, the operation itself, like let's say we resect the left side of the liver, if you plan to resect the left side of the liver laparoscopically or either open, resection of the liver itself is the same, but it's just that you're not putting a big laparotomy, but you're doing the whole process through the small holes on your abdomen.

Scott Steele:  Do you have to make an incision to get a part of whatever you resected out?

David Kwon:  Well, it depends. If you're resecting a huge tumor out, we usually put an incision called the Pfannenstiel incision, which is incisions that the woman usually get when you have a C-sec. The size of the incision usually around 10 centimeter, around three inch, which is about I would say one-third to one-fourth of the normal incisions that we put when we need the same kind of operation. But when the tumor size is small and we only take a small part of deliver out, usually we extend one of the holes that we used to put the trocars in to do the operation and take it out through there. Actually you end up having very small scars and that's it. You don't have any big laparotomy scars.

Scott Steele:  You mentioned that the liver is an organ that sees a lot of the blood flow. I would imagine that there's some potential risks associated with a laparoscopic liver resection. How safe is it and what are some of those potential risks?

David Kwon:  Well, among every field in laparoscopic, liver resection has been one of the last field being explored. The main reason is because it's technically very, very difficult, and secondly, it's because it is associated with a lot of bleeding if done improperly. The bleeding control sometimes can be quite difficult if not done properly. That's why it took a long time for surgeons to adapt this new technique. However, if you look at the recent data, there has been a tremendous improvement in the techniques and the approach that actually a lot of recent data suggest that you have less bleeding doing laparoscopically. The overall complication rate is lower when you do a laparoscopically rather than you when you do it open.

I think we are entering now in a new era of liver surgery in which we can afford the patients with a lot less complication, much faster recovery than we used to say 10 years ago.

Scott Steele:  What is the recovery like from a laparoscopic liver resection?

David Kwon:  Compared to open, usually if you look at the data, they use about maybe one-third of the pain control that they usually need for a conventional laparotomy. Return to normal life is usually shortened down to 50%. Let's say if you do a conventional open liver resection, your patients usually take around three month to go back to work and not be too stressed working. Whereas when you use a laparoscopic approach, it usually takes one to maximum two month to go back to work and be okay while working.

Scott Steele:  When a patient wakes up from a laparoscopic liver resection, do they have a tube in their nose? They got a drain in their belly? Is there any of that stuff?

David Kwon:  Draining the belly depends on the extent of liver section being done. If you get a small wedge resection, we usually don't put drains. But if you get a major hepatectomy, major liver resection thing, then we put in a drain because you can have some complications related with liver resection. That's for safety reasons. Other than that, tubes usually we leave it there for two or three days and take it out. Tubes in the nose and all of that, that's old generation style operation. If we need a tube, we usually take it out during recovery room or in the OR before we wake you up. It's a lot easier to recover.

Scott Steele:  David, one of the other things that you spoke about was the living donor for the liver. Can you talk a little bit about that program and who's it for? How would you get involved if you’re interested in it? How do you guys go about that program? How safe is it? Just some of the generalizations there.

David Kwon: For living donor liver transplant, you need a living donor. Usually living donors, you take about 60% to 40% of your liver out and you donate it to the recipient. The good thing about the liver is that it regenerates. It's like if you start with 100% of liver, you split it to two, you give the 60% of the recipient, actually in about a year, your 40% that you have grows back to 100 and the 60% that was given to the recipient grows to 100. You divide the 100 into two and it becomes 200. That's the beauty of living donor liver transplant. Now the laparoscopic approach, after I started the program, it was very clear and evident that it's very good for the patient.

The patients love it. One of the things because I used to do a lot of donor surgery also, one of the things was that usually donors are... They're very altruistic. They want to save someone's life. They want to sacrifice themselves to do all of that. It always was in my mind that I should afford the donors one of the best recovery options that is available surgically. But the main thing with living donor is that you cannot have any accidents on donors because your patients were healthy before. The number one principle in living donor liver transplant is that we have to have their donor back healthy and safe and back to work in whatever he used to do or she used to do is number one principle in living donor liver transplant.

Because laparoscopic itself is more technically challenging than open surgery and it was perceived to be more dangerous before, a lot of surgeons used to be very skeptical that laparoscopic approach could be performed on donors because there has been donor death after operation being reported. We used to have a perception that it's more dangerous. It's not good for donors. However, I learned through my course of laparoscopic liver resections that a lot of the things previously thought to be very dangerous, you actually can do it very safely laparoscopically. When I realized that is when I started my laparoscopic donor program back in South Korea and that program now is the largest program in the world.

But throughout that experience, I learned that by affording a laparoscopic approach to donors, actually the donors recover a lot faster. The cosmetics that that you have after the operation is a lot better. They are so much more satisfied, and they end up still saving someone's life after all that big operation.

Scott Steele:  What's on the horizon for the future of laparoscopic liver resection surgery?

David Kwon:  The laparoscopic liver resection used to be for small lesions. Very easy to take for wedges. If you look at the U.S. data, it's out of 100 liver resections performed every year, barely 10%, barely 10 cases are done laparoscopically and the remaining 90% are done by open method. However, that can be expanded a lot. I think surgery is like a right hepatectomy, which is like a very large operation that a lot of surgeons have hard time to do and used to be thought as very, very difficult and dangerous laparoscopically. Nowadays, we are able to do it relatively safe in a very relatively short operative time. I think this horizon will expand even more.
The right hepatectomy can become right extended, central. A lot of difficult operations that once was perceived that it's too difficult to do laparoscopically, now I think we can perform it laparoscopically. We have a lot more choice of having the laparoscopic approach in diseases once that we thought would only have the open option.

Scott Steele:  Well, that's fantastic and we're sure glad to have you here at the Cleveland Clinic. We like to end up all of our guests with a little bit more about you and go over a couple of quick hitters. What's your favorite meal?

David Kwon:  My favorite meal is bibimbap. It's a Korean dish. It's a mixture of rice and a lot of fresh vegetables and some meat. It's very healthy, and it's also very yummy.

Scott Steele:  What's your favorite sport?

David Kwon:  My favorite sport, I used to like tennis. I used to like a lot of sports, but nowadays, I guess it's bicycling. I think Cleveland is a very nice place to bike.

Scott Steele:  What's the last nonmedical book that you've read?

David Kwon:  The last nonmedical book that I've read, it's Switch. It's a book by Chip and Dan Heath. I'm an avid fan of them. They have very nice books that they write. It's about changing the culture of an organization or it can be of a person and there are little steps. There are a little important steps that you need to have there in order to have a change. If anyone is interested in changing their organization's culture or their habits, it's a book that I would recommend to everyone.

Scott Steele:  Then also considering your background and your relative newness to Cleveland, what's one thing that you like here about living in Cleveland?

David Kwon:  Cleveland, it's not too busy. It's not like New York or LA, but you still have the city vibe. You still have very nice restaurants. You still have a fantastic orchestra. You still have rock and roll, but still you don't have the traffic. That's what I love most about Cleveland.

Scott Steele:  Well, that's fantastic. To learn more, please visit clevelandclinic.org/liver. That's clevelandclinic.org/liver. To schedule an appointment with a Cleveland Clinic Liver Specialist, please call (216) 444-7000. That's (216) 444-7000. David, thanks for joining us on Buts and Guts.

David Kwon:  Thanks so much.

Scott Steele:  That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Buts and Guts.