the liver is the most common site of hematogenous spread of primary colorectal carcinoma ( crc ) [ 1 , 2 ] and is affected in approximately 1025% of patients having surgery . surgical resection is the most effective and potential curative therapy for metastatic crc to the liver . the treatment strategies and outcomes for these patients have undergone many evolutionary changes [ 46 ] . minimally invasive laparoscopic surgery improves postoperative recovery , diminishes postoperative pain , reduces wound infections , shortens hospitalization , propagates rapid return to full activity , and yields superior cosmetic results , without compromising oncological outcome [ 7 , 8 ] . currently , laparoscopic resection of primary crc is performed in more than 40% of all patients in the netherlands according to the dutch surgical colorectal audit . however , the use of laparoscopy in liver surgery is still limited in the netherlands . there are several treatment options for crc patients presenting with synchronous liver metastases ( slms ) depending on primary tumor location ( rectum or colon ) and extent of hepatic disease . performing a simultaneous or staged resection of the primary tumor and liver metastasis is one of the items being discussed . recently , a systematic review showed that combined resection resulted in shorter hospitalization and fewer complications in comparison with staged resection although a tendency was seen towards a higher postoperative mortality after simultaneous resection . in contrast to the extensive literature on staged laparoscopic colorectal and laparoscopic liver surgery , there are only a few reports on combined laparoscopic colorectal and liver resection . the aim of this study is therefore to evaluate our initial experiences of simultaneous laparoscopic resection of primary crc and slm . five patients with primary crc and a clinical diagnosis of slm underwent combined laparoscopic colorectal and liver surgery between march 2011 and january 2012 in the academic medical center , amsterdam . treatment decisions in patients with crc and slm were based on location and complexity of resection of the primary tumor , extent of liver resection , feasibility of a laparoscopic approach , and physical condition of the patient . the institutional protocol of the academic medical center indicates that simultaneous resection is preferred in patients who require minor liver resection ( <3  segments ) independent of primary tumor location . neoadjuvant treatment preceding simultaneous resection is given for rectal primaries , consisting of short - course radiotherapy ( 5  5  gy ) followed by 3 to 6 courses of systemic chemotherapy ( capecitabine and oxaliplatin ) . if major hepatectomy is indicated , a  liver first approach  is preferred with neoadjuvant treatment consisting of 3 to 6 courses of systemic chemotherapy which is preceded by short - course radiotherapy in case of a rectal primary . systemic chemotherapy is completed in the adjuvant setting to a total number of 8 courses in patients with adequate clinical condition . all patients are discussed by the multidisciplinary team , and treatment is tailored to the individual patient with well - documented arguments for not following the institutional protocol ( i.e. , simultaneous right hemihepatectomy with right hemicolectomy in a fit young patient ) . laparoscopic colorectal surgery was performed using a medial to lateral approach with intracorporeal dissection and vascular control . for right hemicolectomy a pfannenstiel incision was used for specimen extraction in left - sided resections followed by an intracorporeal anastomosis using the double - stapling technique with circular stapler . complete laparoscopic liver resection was performed with the surgeon in between the patient 's legs . for metastasectomy in segments 7 and 8 , a hand - assisted laparoscopic approach was performed with the surgeon standing at the left side of the patient . total laparoscopic liver resection was started with insertion of a 10  mm trocar at the umbilicus followed by insufflation . for tumorectomy , two 5  mm trocars were positioned in the right and left upper abdomen . for left lateral sectionectomy , two 10/12 trocars were placed in each upper quadrant and an additional 5  mm trocar left subcostally . for tumorectomy in segments 7 and 8 , a hand port was placed via a vertical umbilical incision followed by a 10/12  mm trocar in the right lower quadrant and a 5  mm trocar in the midline above the hand port . in one patient , parenchymal transection was performed by using an ultrasonic dissection device with additional haemostasis using bipolar diathermy . the left segmental ( 2/3 ) portal pedicle and left hepatic vein were transected using a laparoscopic 60  mm stapler in case of left lateral sectionectomy . the liver specimen was put in a plastic bag in case of total laparoscopic resection and extracted via the umbilical or pfannenstiel incision . four men and one woman with a pathological diagnosis of crc and clinical or pathological diagnosis of slm were included . the average body mass index was 29.0 ( range 23.930.1 )  kg / m . one patient ( number  5 ) underwent laparoscopic resection of right - sided renal cell carcinoma two months earlier . during laparoscopy , a liver lesion was found and subsequent pet scanning and endoscopy revealed an additional sigmoid tumor . preoperative treatment of rectal cancer consisted of short - course radiotherapy ( 5 fractions of 5  gy ) followed by three to four courses of systemic chemotherapy ( oxaliplatin and capecitabine ) . the following procedures were performed : total laparoscopic right hemicolectomy with tumorectomy of segment 2 ( extraction via umbilical incision ) , total laparoscopic sigmoid resection with tumorectomy of segment 4/5 including the gallbladder and tumorectomy of segment 3 ( extraction via pfannenstiel ) , assisted laparoscopic low anterior resection and diverting ileostomy with total laparoscopic left lateral sectionectomy ( extraction via pfannenstiel ) , and two laparoscopic intersphincteric abdominoperineal excision with hand - assisted laparoscopic tumorectomy of segment 7 and segment 8 , respectively ( extraction via the umbilical hand port ) . the incision created for hand port and/or extraction of the specimen varied between 5 and 10  cm . median operation time was 303 minutes ( range 151384 ) with an estimated total blood loss of 700  ml ( range 200850 ) . intraoperative complications consisted of a small perforation of the right hepatic vein during liver mobilisation in one patient , which was sutured using an additional 5  mm trocar . one patient had surgery - related complications with perineal wound infection and delayed gastric emptying ( patient number 3 ) . other complications consisted of postoperative myocardial infarction necessitating reanimation and angioplasty ( patient number 1 ) , and pneumonia with delirium managed by intravenous antibiotics and haloperidol ( patient number 2 ) . an r0 resection of the primary tumor and liver lesions was achieved in all patients . definitive pathology of the liver in the patient with renal cell carcinoma and sigmoid carcinoma showed an adenocarcinoma originating from the upper gastrointestinal tract . at present , the origin of this third primary tumor is unknown and this patient receives palliative chemotherapy because of progressive liver disease . in two of the three patients who already had induction chemotherapy , systemic treatment the patient with myocardial infarction did not receive any ( neo)adjuvant systemic chemotherapy because of his poor physical condition . the advantages of performing laparoscopic colorectal   or hepatic resections   by experienced surgeons have led to a prominent increase for these operative approaches in recent years . separately for primary crc and crc liver metastases , laparoscopic resection has been shown to result in enhanced recovery and reduced morbidity with similar oncological outcome [ 7 , 8 ] . this suggests that a laparoscopic combined approach will also benefit patients who are candidates for simultaneous resection . open resection of both primary tumor and synchronous liver metastases often requires an extensive incision , especially if the location of the liver metastasis is opposite to the primary tumor location ( i.e. , right liver lobe and rectum ) . using a laparoscopic approach , exposure can be improved due to a magnified visualization from different angles , even in the narrow pelvis or not easily accessible places of the upper abdomen . the feasibility of a simultaneous laparoscopic approach has been demonstrated by our initial experience in five patients , and the results presented confirm findings from the limited literature on this topic ( table 4 ) . patients with a solitary , peripherally located metastasis in segments 26 are the most ideal candidates for simultaneous laparoscopic resection . two additional trocars can provide adequate access to the liver besides the standard trocar placement for the colorectal procedure . two patients in this series were diagnosed with a peripheral lesion in the posterior segments 7 and 8 , requiring full mobilization of the right liver . both liver mobilization and parenchymal transection could be accomplished in these patients using an umbilical hand port . others also described the use of a hand port placed in an upper midline incision for liver mobilization [ 12 , 17 ] . if major hepatectomy is indicated , the midline incision can subsequently be used for vascular control and parenchymal transection . but even total laparoscopic major hepatectomy in combination with colorectal resection has been shown to be feasible in three patients ( table 4 ) [ 23 , 25 ] . this allows for a small pfannenstiel incision to extract the specimens , which has been proven to result in the lowest incidence of incisional hernia . there are no randomized controlled trials comparing simultaneous and staged resections and the existing comparative studies are obviously difficult to interpret due to selection bias . theoretical arguments against simultaneous resection are the combination of a clean and contaminated procedure , and the impaired protein synthesis of the liver increasing the risk of infection and compromising anastomotic healing . however , according to a systematic review based on 14 comparative studies , combined resection was associated with lower morbidity . this led the authors to conclude that simultaneous resection can be undertaken in selected patients by surgeons specialized in both fields of colorectal and hepatobiliary surgeries . patient selection and expertise are essential for this complex type of surgery , and the multidisciplinary team should decide on optimal timing within multimodality treatment schedules . life expectancy of patients with liver metastasis from colorectal origin has been increasing as a result of improvements in liver surgery and systemic chemotherapy . repeat surgery for recurrent liver metastasis has been shown to have similar outcome compared with the first liver resection [ 2729 ] . an initial laparoscopic approach reduces adhesion formation and facilitates repeat resection , which has also been shown to be beneficiary in patients who need subsequent liver transplantation in case of patients with hcc . given the improved oncological outcome , quality - of - life issues related to abdominal wall integrity and cosmesis become more important , underlining the potential benefits of laparoscopy . in conclusion , our initial experience in combination with the previously published data indicate that simultaneous laparoscopic resection of primary crc and synchronous liver metastases is feasible and advisable in selected patients , provided that appropriate expertise is available .
introduction . simultaneous resection of primary colorectal carcinoma ( crc ) and synchronous liver metastases ( slms ) is subject of debate with respect to morbidity in comparison to staged resection . 
 the aim of this study was to evaluate our initial experience with this approach . 
 methods . 
 five patients with primary crc and a clinical diagnosis of slm underwent combined laparoscopic colorectal and liver surgery . 
 patient and tumor characteristics , operative variables , and postoperative outcomes were evaluated retrospectively . results . 
 the primary tumor was located in the colon in two patients and in the rectum in three patients . 
 the slm was solitary in four patients and multiple in the remaining patient . 
 surgical approach was total laparoscopic ( 2 patients ) or hand - assisted laparoscopic ( 3 patients ) . 
 the midline umbilical or transverse suprapubic incision created for the hand port and/or extraction of the specimen varied between 5 and 10  cm . 
 median operation time was 303 ( range 151384 ) minutes with a total blood loss of 700 ( range 200850 )  ml . 
 postoperative hospital stay was 5 , 5 , 9 , 14 , and 30 days . 
 an r0 resection was achieved in all patients . 
 conclusions . from this initial single - center experience , simultaneous laparoscopic colorectal and liver resection appears to be feasible in selected patients with crc and slm , with satisfying short - term results .