Background: Liver resection remains the cornerstone for curative management in primary liver malignancies. Liver surgery ranges from simple wedge resections to complex hepatectomies involving vascular or biliary reconstructions. The anatomical complexity of the liver and these varied surgical approaches create challenges in assessing operative difficulty. This literature review explores the key factors influencing operative difficulty in liver resection for primary liver malignancy across surgical techniques. Methods: A broad literature review was conducted to determine the factors that were associated with increased operative difficulty in liver resection using the Embase, PubMed, and Cochrane databases for studies published between 2000 and 2025. Results: This review identifies several patient, tumor, and surgical factors that influence operative difficulty in liver resection. Numerous difficult scoring systems were identified, yet their applicability across different operative approaches remains uncertain. Across open and minimally invasive techniques, tumor size and location are commonly used to determine complexity. However, debate remains regarding the optimal cutoff for tumor diameter. Other identified factors include the extent of resection, patient-specific variables (e.g., cirrhosis, body mass index, previous surgeries), and surgical technique. In addition, liver resection procedures classified based on the 2000 Brisbane terminology have been stratified into three groups of increasing difficulty. Conclusion: The ability to predict operative difficulty is useful for case selection, surgical planning, and risk stratification for meaningful shared decision-making. Future research should focus on refining predictive models by integrating composite measures, including patient-reported outcomes and long-term survival. A unified, validated scoring system applicable across surgical techniques could enhance consistency in clinical practice and research to improve outcomes.

We aimed to investigate the differences in surgical difficulty between laparoscopic partial liver resections of segments 7 and 8.

We analyzed 173 patients who underwent partial liver resections of segments 7 or 8 between 2010 and 2022 at two institutions. We investigated differences in the surgical outcomes of each procedure using propensity score matching. We compared these outcomes with those of open partial liver resections for segments 7 and 8 to determine whether the differences were unique to the laparoscopic approach.

Thirty and 54 patients underwent laparoscopic partial liver resections of segments 7 and 8. In the matched cohort (22 in each group), the operation time was significantly longer (377 vs. 278 min, P = 0.020) and the proportion of postoperative complications significantly higher in segment 7 (27% vs. 0%, P = 0.008). Forty-one and 48 patients underwent open partial liver resections of segments 7 and 8, respectively. There were no significant differences in the surgical outcomes between the segments in the matched cohort (20 in each group).

Laparoscopic partial liver resections of segment 7 may be more challenging than that of segment 8. This difference in difficulty was not observed in open partial liver resections.

Despite technical advancements, minimally invasive liver surgery (MILS) for hepatocellular carcinoma (HCC) remains challenging. Nonetheless, effective tools to assess MILS complexity are still lacking. Machine learning (ML) models could improve the accuracy of such tools.

Patients who underwent curative-intent MILS for HCC were identified using an international database. An XGBoost ML model was developed to predict surgical complexity using clinical and radiological characteristics.

Among 845 patients, 186 (22.0 %) were classified as high-risk patients. In this subgroup, median Charlson Comorbidity Index (CCI) (5.0, IQR 3.0-7.0 vs. 2.0, IQR 2.0-5.0, p < 0.001) and tumor burden score (TBS) (median 4.12, IQR 3.0-5.1 vs. 4.22, IQR 3.2-7.1, p < 0.001) were higher. The model was able to effectively predict complexity of surgery in both the training and testing cohorts with high discriminating power (ROC-AUC: 0.86, 95%CI 0.82-0.89 vs. 0.73, 95%CI 0.65-0.81). The most influential variables were CCI, TBS, BMI, extent of resection, and sex. Patients predicted to have a complex surgery were more likely to develop severe complications (OR 4.77, 95%CI 1.82-13.9, p = 0.002). An easy-to-use calculator was developed.

Preoperative ML-prediction of complex MILS for HCC may improve preoperative planning, resource allocation, and patient outcomes.

Laparoscopic repeat liver resection (LRLR) is still a challenging technique and requires a careful selection of indications. However, the current difficulty scoring system is not suitable for selecting indications. The purpose of this study is to develop the indication model for LRLR using machine learning and to identify factors associated with open conversion (OC).

Patients who underwent repeat hepatectomy (2017-2021) at Samsung Medical Center 2021 were investigated. Multiple indication models were developed using machine learning techniques (random forest, SVM, XGB) and logistic regression. The predictive performance of these models was compared, and risk factors associated with OC were analyzed.

Among 221 patients (110 LRLR, 111 ORLR), the ORLR group had a higher previous open approach rate (75.7% vs. 38.2%, p<0.001). Twice previous abdominal surgery was the only independent OC risk factor (OR 6.56, p=0.009). The indication model showed moderate predictive power (random forest AUC=0.779, logistic regression AUC=0.725, p=0.710). Important variables were previous laparoscopic approach, present subsegmentectomy, and left-sided tumor location.

The performance of the indication model for LRLR showed moderate predictive power in both machine learning and logistic regression. The important variables for LRLR were previous laparoscopic approach, present subsegmentectomy, and left side location.

In North America, the majority of hepatectomies are still performed in traditional open fashion. Robotic hepatectomy may facilitate a minimally invasive approach to liver resection.

We report a single-center experience with the wide adaptation of robotic hepatectomy over a 5-year period.

Retrospective analysis of a prospectively maintained database of all hepatectomies (n = 334) was performed at our institution from January 2018 to January 2023. This included 164 open, 18 laparoscopic, and 152 robotic hepatectomies. Propensity score matching (PSM) was used to match open (n = 100) to robotic (n = 100) hepatectomy cases by demographics and case complexity. Standard statistics were used to compare 90-day outcomes, including textbook outcome after liver surgery (TOLS), and cost. CUSUM curves were used to determine the learning curve for major hepatectomy.

During the study period, laparoscopic hepatectomy was phased out and robotic hepatectomy became the predominant approach. The median IWATE score for the robotic cases was 8 ± 2 and 39% were major hepatectomies. The learning curve for robotic right hepatectomy was 15 cases. When PSM cases were compared, while operative time was longer, blood loss and transfusion, intraoperative incidents, overall and major morbidity, bile leaks, post-hepatectomy liver failure, hypoxia requiring supplemental oxygen, reoperation, ICU utilization, and length of stay were significantly lower in the robotic group. There was no difference in positive margins or 90-day mortality. Robotic hepatectomy was associated with significantly higher TOLS compared to open hepatectomy (85% versus 64%, p < 0.001) and on multivariate analysis, only a robotic hepatectomy approach was independently associated with achieving TOLS (OR 3.3, (1.62-6.67) 95% CI)). The lower ICU utilization and length of stay accounted for a significantly lower overall hospital cost for robotic compared to open hepatectomy despite a higher operating room cost.

We describe the successful implementation of robotic hepatectomy at our institution with favorable outcomes and cost.

Laparoscopic liver resection (LLR) is a surgical procedure with varying degrees of difficulty depending on tumor status and surgical technique. Therefore, we aimed to evaluate the relationship between surgical difficulty levels and outcomes of LLR, particularly portal vein thrombosis (PVT).

We performed LLRs in 214 patients between January 2009 and December 2022. Among them, 200 patients who underwent pure LLR were allocated into three groups according to the Institut Mutualiste Montsouris (IMM) classification: Group I (n = 152), Group II (n = 26), and Group III (n = 22). The perioperative outcomes were also compared; risk factors for postoperative complications were evaluated.

The operation time was significantly longer (p < 0.001) and intraoperative blood loss was significantly higher (p < 0.001) in Group III than in Groups I and II. The rates of complications of Clavien-Dindo (CD) grade 2 or higher (19.1% vs. 34.6% vs. 63.6%, p < 0.001) and CD grade 3 or higher (5.3% vs. 11.5% vs. 22.7%, p = 0.015) were significantly higher and postoperative hospital stay (9 vs. 13 vs. 16 days, p < 0.001) was significantly longer in Group III than in Groups I and II. The IMM classification (odds ratio [OR], 5.727; 95% confidence interval [CI], 1.863-17.610; p = 0.002] and blood transfusion (OR, 6.410; 95% CI, 2.215-18.549; p < 0.001) were independent risk factors for CD grade 2 or higher complication using multivariate analysis. PVT was the most common complication in patients with CD of grade 2 or higher, occurring in 14 of 48 patients. Hepatitis viral status (OR: 7.552, p = 0.021 [non-B non-C for HCV]) and the IMM classification (OR: 58.767, p < 0.001[II vs. I]; OR: 40.535, p = 0.002 [III vs. I]) were independent risk factors for PVT using multivariate analysis.

The IMM classification could strongly predict postoperative complications, particularly PVT.

To assess technical difficulty scores for laparoscopic liver resections (LLR) in a large well-characterized cohort of low to high difficulty LLR.

Patients undergoing LLR and open liver resection (OLS) (2007-2022) at Massachusetts General Hospital were included. Patients were classified according to the technical difficulty scores Ban difficulty score, IWATE criteria, Hasegawa score, IMM score, and Southhampton score (SHH) and calibration of these scores in predicting postoperative outcome parameters was assessed.

301 patients underwent LLR. Median age was 59 years and 58.5% of the patients were female. Median lesion size was 42.2 mm, median operative time was 197.7 min, and median estimated blood loss was 400.5 ml. According to the different scoring systems, 18.9% (SHH) to 52.2% (IWATE) of the LLR were high difficulty. Overall intraoperative events according to the modified Satava classification grade II (6.6%) and grade III (2.7%) were low as was postoperative 90 days major morbidity (5.3%) and mortality (1.0%). The respective scores' calibration for predicting non-textbook outcomes, intraoperative events, operative time, major postoperative morbidity, blood transfusion rates, and length of hospital stay was moderate to good for the respective scores and best for the IWATE criteria.

Even high technical difficulty LLR can be performed with low postoperative morbidity and mortality rates. The scores evaluated performed well in predicting major liver surgery outome parameters. Among the different difficulty scoring systems, the IWATE criteria performed best.

Procedural techniques such as dissection and separation of blood vessels or nerves from the tumor for preserving limbs and functions involves high surgical difficulty. We hypothesized the relation of vessel and/or nerve preservation to surgical time and blood loss, accurately reflecting surgical difficulty. In this study, we elucidated the variables affecting surgical time and intraoperative bleeding in patients with malignant soft tissue tumors who did not undergo any reconstruction after tumor resection.

We included 153 patients with malignant oft tissue tumors in the trunk (n = 72), thigh (n = 68), and upper arm (n = 13) at nine institutions. We analyzed the possible predictive variables affecting surgical time and intraoperative bleeding.

Overall, the study included 153 patients (85 men and 68 women) with a mean age of 65 years. The tumors were primary soft tissue sarcoma (STS) (n = 114), local recurrent STS (n = 25), and soft tissue metastasis (n = 14). The median number of participating surgeons was three. The mean and median surgical time were 144.6 and 123 min, respectively. The mean and median intraoperative bleeding were 157.1 and 55 mL, respectively. Tumor size, depth, dissection and separation of blood vessels from the tumor, dissection and separation of nerve from the tumor, and the number of participating surgeons were significantly related to the surgical time and intraoperative bleeding.

The procedure of dissection and separation of blood vessels and nerves from the tumor were related to surgical time and intraoperative bleeding in patients with malignant soft tissue tumors, especially large and deep tumors.

Despite the growing adoption of laparoscopic hepatectomy (LH) for intrahepatic cholangiocarcinoma (ICC), there is no scoring system available designed to evaluate its surgical complexity. This paper aims to introduce a novel difficulty scoring system (DSS), designated as the Wei-DSS, exclusively tailored to assess the surgical difficulty of pure LH for ICC. We retrospectively collected clinical data from ICC patients who underwent pure LH at our institution, spanning from November 2018 to May 2024. Patients were categorized into two levels of Wei-DSS scores (low-difficulty [5-6], and high-difficulty [7-10]) determined by tumor characteristics, liver texture, resection extent and tumor marker levels. A total of 104 patients were enrolled in this study including a low-difficulty (LD) group comprising 47 patients and a high-difficulty (HD) group comprising 57 patients. Perioperative comparisons indicated that the HD group was significantly associated with a longer operation time (318.14 ± 125.89 min vs. 222.83 ± 119.03 min, P < 0.001), higher rates of intraoperative blood transfusions (59.6% vs. 27.7%, P = 0.001), and increased rates of postoperative complications (84.2% vs. 48.9%, P < 0.001) compared to the LD group. The receiver operating characteristic (ROC) curve analysis indicated that the Wei-DSS demonstrated superior predictive accuracy over the Major/Minor Classification for predicting postoperative complication rates (area under the curve [AUC] 0.702 vs. 0.622) and operating time (AUC 0.720 vs. 0.604 ). The Wei-DSS score may have the potential to assist surgeons in categorizing ICC patients with varying levels of surgical difficulty of LH, though it warrants further validations across multiple centers to solidify its efficacy and reliability.

The relation between operative time and postoperative complications in liver surgery is unclear. The aim of this study is to assess the impact of operative time on the development of postoperative complications in patients who underwent minimally invasive or open liver resections of various anatomical extent and technical difficulty levels.

In this retrospective cohort study, patients that underwent a right hemihepatectomy (RH), technically major resection (anatomically minor resection in segment 1, 4a, 7 or 8; TMR) or left lateral sectionectomy (LLS) between 2000 and 2022 were extracted from a multicenter database comprising the prospectively maintained databases of 31 centers in 13 countries. Minimally invasive procedures performed during the learning curve were omitted. Logistic regression models, performed separately for 9 different groups based on stratification by procedure type and allocated surgical approach, were used to assess the association between the fourth quartile of operative time (25% of patients with the longest operative time) and postoperative complications.

Overall, 5424 patients were included: 1351 underwent RH (865 open, 373 laparoscopic and 113 robotic), 2821 TMR (1398 open, 1225 laparoscopic and 198 robotic), and 1252 LLS (241 open, 822 laparoscopic and 189 robotic). After adjusting for potential confounders (age, BMI, gender, ASA grade, previous abdominal surgery, disease type and extent, blood loss, Pringle, intraoperative transfusions and incidents), the fourth quartile of operative time, compared to the first three quartiles, was associated with an increased risk of postoperative complications after open, laparoscopic and robotic TMR (aOR 1.35, p = 0.031; aOR 1.74, p = 0.001 and aOR 3.11, p = 0.014, respectively), laparoscopic and robotic RH (aOR 1.98, p = 0.018 and aOR 3.28, p = 0.055, respectively) and solely laparoscopic LLS (aOR 1.69, p = 0.019).

A prolonged operative time is associated with an increased risk of postoperative complications, although it remains to be defined if this is a causal relationship.

For intrahepatic duct (IHD) stones, laparoscopic liver resection (LLR) is currently a reliable treatment. However, the current LLR difficulty scoring system (DSS) is only available for patients with hepatocellular carcinoma.

To explore the development of a DSS for IHD stone patients with LLR and the validation of its reliability.

We used clinical data from 80 patients who received LLR for IHD stones. Forty-six of these patients were used in multiple linear regression to construct a scoring system. Another 34 patients from different centers were used as external validation. The completeness of our DSS was then evaluated in patients with varying degrees of surgical difficulty based on documented surgical outcomes in the study group of patients.

The following five predictors were ultimately included and scored by calculating the weighted contribution of each factor to the prediction of operative time in the training cohort: Location of stones, number of stones ≥ 3, stones located in the bile ducts of several grades, previous biliary surgery less than twice, distal bile duct atrophy. Subsequently, the data set was validated using a DSS developed from the variables. The following variables were identified as statistically significant in external validation: Operative time, blood loss, intraoperative transfusion, postoperative alanine aminotransferase, and Clavien-Dindo grading ≥ 3. These variables demonstrated statistically significant differences in patients with three or more grades.

Patients with IHD stones have varying degrees of surgical difficulty, and the newly developed DSS can be validated with external data to effectively predict risks and complications after LLR surgery.

The evolution of laparoscopic liver surgery, originating in the 1990s, has been marked by significant advancements and milestones, overcoming initial technical hurdles and gaining widespread acceptance within the surgical community as a precise and safe alternative to open procedures. Along this journey, numerous challenges emerged, leading to the accumulation of evidence and the development of guidelines aimed at assisting surgeons in determining the safety, suitability, and complexity of laparoscopic liver resection. This chapter provides a thorough examination of key aspects of laparoscopic liver resection, including difficulty scoring systems, criteria for patient selection, technical considerations, outcomes across different types of liver lesions, and the innovative solutions developed to address challenges, thus offering a comprehensive overview of laparoscopic liver resection, and highlighting its evolving significance in modern hepatobiliary surgery.

Despite the increasing widespread adoption and experience in minimally invasive liver resections (MILR), open conversion occurs not uncommonly even with minor resections and as been reported to be associated with inferior outcomes. We aimed to identify risk factors for and outcomes of open conversion in patients undergoing minor hepatectomies. We also studied the impact of approach (laparoscopic or robotic) on outcomes.

This is a post-hoc analysis of 20,019 patients who underwent RLR and LLR across 50 international centers between 2004-2020. Risk factors for and perioperative outcomes of open conversion were analysed. Multivariate and propensity score-matched analysis were performed to control for confounding factors.

Finally, 10,541 patients undergoing either laparoscopic (LLR; 89.1%) or robotic (RLR; 10.9%) minor liver resections (wedge resections, segmentectomies) were included. Multivariate analysis identified LLR, earlier period of MILR, malignant pathology, cirrhosis, portal hypertension, previous abdominal surgery, larger tumor size, and posterosuperior location as significant independent predictors of open conversion. The most common reason for conversion was technical issues (44.7%), followed by bleeding (27.2%), and oncological reasons (22.3%). After propensity score matching (PSM) of baseline characteristics, patients requiring open conversion had poorer outcomes compared with successful MILR cases as evidenced by longer operative times, more blood loss, higher requirement for perioperative transfusion, longer duration of hospitalization and higher morbidity, reoperation, and 90-day mortality rates.

Multiple risk factors were associated with conversion of MILR even for minor hepatectomies, and open conversion was associated with significantly poorer perioperative outcomes.

Although various difficulty scoring systems have been proposed for laparoscopic liver resection (LLR), details remain uncertain regarding distance between the tumor and vessels as a factor of difficulty. We aimed to examine the risk factors for conversion to open hepatectomy in LLR, including distance between tumor and vessels.

Between January 2012 and December 2022, 118 patients who underwent LLR were retrospectively enrolled and their perioperative characteristics were evaluated.

A total of 10 cases (8.5%) were converted to open hepatectomy during LLR. The conversion group had lower platelet count, shorter distance between the tumor and a medium vessel (defined as diameter of 5-10 mm), and greater tumor depth compared with the pure LLR group. Receiver-operating characteristic curve analysis identified 10 mm as the optimal cutoff value of tumor proximity to a medium vessel (sensitivity, 80.0%, specificity, 78.7%, AUC 0.817) for predicting conversion. In multivariate analysis, lower platelet count (p = .028) and tumor proximity within 10 mm to a medium vessel (p = .001) were independent risk factors for conversion in LLR.

Our study suggests tumor proximity within 10 mm to a medium vessel and lower platelet count as predictors of unfavorable intraoperative conversion in LLR.

Severe bleeding remains a significant concern in laparoscopic resection for hepatic hemangioma. It is rarely reported that how the degree of major vessels involvement impacts on severe bleeding. The present study primarily aimed to analyze the impacts of the number of involved major vessels (NIMV) during laparoscopic surgery for hepatic hemangioma and evaluate the risk factors associated with increased bleeding.

A database search was carried out for consecutive patients who underwent laparoscopic resection for liver hemangiomas at our department from January 2018 to December 2023. The collected data included demographics, characteristics of the hemangiomas, laboratory data, operation method, surgical and postoperative variables.

A total of 72 patients were enrolled in the study. 42 patients were categorized into the group with NIMV < 2, while 30 patients were divided into the group with NIMV ≥ 2. The group with NIMV ≥ 2 demonstrated a significant correlation with special segments, involved multiple segments and diameter of the hemangiomas (P < 0.01). And the perioperative variables including the extent of resection, operative time, blood loss, Pringle maneuver times, postoperative stay, drainage tube duration, and postoperative liver function (ALT, AST) also showed significant differences between the two groups (P < 0.05). Notably, NIMV ≥ 2 was identified as the most important independent risk factor for intraoperative blood loss ≥ 500 ml in laparoscopic surgery for hepatic hemangioma (P = 0.011). For NIMV ≥ 2, the independent risk factor was special segments in multivariate analysis (P = 0.000).

The involvement of multiple major vessels (NIMV ≥ 2) was significantly associated with special segments, resulting in increased intraoperative blood loss, operation difficulty, and delayed postoperative recovery. Moreover, it was identified as the single independent risk factor with a considerable risk for increased blood loss during laparoscopic resection for hepatic hemangioma.

In the last three decades, minimally invasive liver resection has been replacing conventional open approach in liver surgery. More recently, developments in neoadjuvant chemotherapy have led to increased multidisciplinary management of colorectal liver metastases with both medical and surgical treatment modalities. However, the impact of neoadjuvant chemotherapy on the surgical outcomes of minimally invasive liver resections remains poorly understood.

A multicenter, international, database of 4998 minimally invasive minor hepatectomy for colorectal liver metastases was used to compare surgical outcomes in patients who received neoadjuvant chemotherapy with surgery alone. To correct for baseline imbalance, propensity score matching, coarsened exact matching and inverse probability treatment weighting were performed.

2546 patients met the inclusion criteria. After propensity score matching there were 759 patients in both groups and 383 patients in both groups after coarsened exact matching. Baseline characteristics were equal after both matching strategies. Neoadjuvant chemotherapy was not associated with statistically significant worse surgical outcomes of minimally invasive minor hepatectomy.

Neoadjuvant chemotherapy had no statistically significant impact on short-term surgical outcomes after simple and complex minimally invasive minor hepatectomy for colorectal liver metastases.

Laparoscopic anatomical resection of segment 7 (LARS7) remains a technically challenging procedure due to the deep anatomical location and the potential risk of injury to the right hepatic vein (RHV). Herein, we initiated an innovative technique of caudo-dorsal approach combined with the occlusion of the RHV and Pringle maneuver for LARS7 and presented the outcomes of our initial series.

Since January 2021, the patients who underwent LARS7 by using this novel technique were enrolled in this study. The critical aspect of this technique was the interruption of communication between the RHV and the inferior vena cava. Meanwhile, the Pringle maneuver was adopted to control the hepatic inflow.

A total of 11 patients underwent LARS7 by using this novel technique, which included 8 hepatocellular carcinoma, 2 bile duct adenocarcinoma and one focal nodular hyperplasia. The median operative time was 199 min (range of 151-318 min) and the median blood loss was 150 ml (range of 50-200 ml). The main trunk of the RHV was fully exposed on the cutting surface in all cases and no patient received perioperative blood transfusion. No procedure was converted to open surgery. Of note, no indications of CO2 gas embolism were observed in these cases after the introduction of double occlusion. Only one patient suffered from postoperative complications and healed after treatment. The median postoperative stay was 5 days (range of 4-7 days). The 90-day mortality was nil. At a median follow-up period of 19 months, all of the patients were alive without any evidence of tumor recurrence.

The caudo-dorsal approach combined with the occlusion of RHV and the Pringle maneuver may be a feasible and expected technique for safe exposure of RHV in LARS7. Further validation of the feasibility and efficacy of this technique is needed.

There are no data to evaluate the difference in populations and impact of centers with liver transplant programs in performing laparoscopic liver resection (LLR).

This was a multicenter study including patients undergoing LLR for benign and malignant tumors at 27 French centers from 1996 to 2018. The main outcomes were postoperative severe morbidity and mortality.

A total of 3154 patients were included, and 14 centers were classified as transplant centers (N = 2167 patients, 68.7 %). The transplant centers performed more difficult LLRs and more resections for hepatocellular carcinoma (HCC) in patients who more frequently had cirrhosis. A higher rate of performing the Pringle maneuver, a lower rate of blood loss and a higher rate of open conversion (all p < 0.05) were observed in the transplant centers. There was no association between the presence of a liver transplant program and either postoperative severe morbidity (<10 % in each group; p = 0.228) or mortality (1 % in each group; p = 0.915).

Most HCCs, difficult LLRs, and cirrhotic patients are treated in transplant centers. We show that all centers can achieve comparable safety and quality of care in LLR independent of the presence of a liver transplant program.

Laparoscopic liver resection (LLR) of high difficulty score is technically challenging. There is a lack of clinical evidence to support its applicability in terms of the long-term survival benefits. This study aims to compare clinical outcomes between LLR and the open liver resection of high difficulty score for hepatocellular carcinoma (HCC).

From 2010 to 2020, using Iwate criteria, 424 patients underwent liver resection of high difficulty score by the laparoscopic (n = 65) or open (n = 359) approach. Propensity score (PS) matching was performed between the two groups. Short-term and long-term outcomes were compared between PS-matched groups. Univariate and multivariate analyses were performed to identify prognostic factors affecting survival.

The laparoscopic group had significantly fewer severe complications (3% vs. 10.8%), and shorter median hospital stays (6 days vs. 8 days) than the open group. Meanwhile, the long-term oncological outcomes were comparable between the two groups, in terms of the tumor recurrence rate (40% vs. 46.1%), the 5-year overall survival rate (75.4% vs. 76.2%), and the 5-year recurrence-free survival rate (50.3% vs. 53.5%). The high preoperative serum alpha-fetoprotein level, multiple tumors, and severe postoperative complications were the independent poor prognostic factors associated with worse overall survival. The surgical approach (Laparoscopic vs. Open) did not influence the survival.

LLR of high difficulty score for selected patients with HCC has better short-term outcomes than the open approach. More importantly, it can achieve similar long-term survival outcomes as the open approach.

Minimally invasive liver resections (MILR) offer potential benefits such as reduced blood loss and morbidity compared with open liver resections. Several studies have suggested that the impact of cirrhosis differs according to the extent and complexity of resection. Our aim was to investigate the impact of cirrhosis on the difficulty and outcomes of MILR, focusing on major hepatectomies.

A total of 2534 patients undergoing minimally invasive major hepatectomies (MIMH) for primary malignancies across 58 centers worldwide were retrospectively reviewed. Propensity score (PSM) and coarsened exact matching (CEM) were used to compare patients with and without cirrhosis.

A total of 1353 patients (53%) had no cirrhosis, 1065 (42%) had Child-Pugh A and 116 (4%) had Child-Pugh B cirrhosis. Matched comparison between non-cirrhotics vs Child-Pugh A cirrhosis demonstrated comparable blood loss. However, after PSM, postoperative morbidity and length of hospitalization was significantly greater in Child-Pugh A cirrhosis, but these were not statistically significant with CEM. Comparison between Child-Pugh A and Child-Pugh B cirrhosis demonstrated the latter had significantly higher transfusion rates and longer hospitalization after PSM, but not after CEM. Comparison of patients with cirrhosis of all grades with and without portal hypertension demonstrated no significant difference in all major perioperative outcomes after PSM and CEM.

The presence and severity of cirrhosis affected the difficulty and impacted the outcomes of MIMH, resulting in higher blood transfusion rates, increased postoperative morbidity, and longer hospitalization in patients with more advanced cirrhosis. As such, future difficulty scoring systems for MIMH should incorporate liver cirrhosis and its severity as variables.

We performed this study in order to investigate the impact of liver cirrhosis (LC) on the difficulty of minimally invasive liver resection (MILR), focusing on minor resections in anterolateral (AL) segments for primary liver malignancies.

This was an international multicenter retrospective study of 3675 patients who underwent MILR across 60 centers from 2004 to 2021.

1312 (35.7%) patients had no cirrhosis, 2118 (57.9%) had Child A cirrhosis and 245 (6.7%) had Child B cirrhosis. After propensity score matching (PSM), patients in Child A cirrhosis group had higher rates of open conversion (p = 0.024), blood loss >500 mls (p = 0.001), blood transfusion (p < 0.001), postoperative morbidity (p = 0.004), and in-hospital mortality (p = 0.041). After coarsened exact matching (CEM), Child A cirrhotic patients had higher open conversion rate (p = 0.05), greater median blood loss (p = 0.014) and increased postoperative morbidity (p = 0.001). Compared to Child A cirrhosis, Child B cirrhosis group had longer postoperative stay (p = 0.001) and greater major morbidity (p = 0.012) after PSM, and higher blood transfusion rates (p = 0.002), longer postoperative stay (p < 0.001), and greater major morbidity (p = 0.006) after CEM. After PSM, patients with portal hypertension experienced higher rates of blood loss >500 mls (p = 0.003) and intraoperative blood transfusion (p = 0.025).

The presence and severity of LC affect and compound the difficulty of MILR for minor resections in the AL segments. These factors should be considered for inclusion into future difficulty scoring systems for MILR.

Laparoscopic anatomical Segment 8 (S8) resection is a highly challenging hepatectomy. Augmented reality navigation (ARN), which could be combined with indocyanine green (ICG) fluorescence imaging, has been applied in various complex liver resections and may also be applied in laparoscopic anatomical S8 resection. However, no study has explored how to apply ARN plus ICG fluorescence imaging (ARN-FI) in laparoscopic anatomical S8 resection, or explored its accuracy.

This study is a post hoc analysis that included 31 patients undergoing laparoscopic anatomical S8 resection from the clinical NaLLRFI trial, and the resected liver volume was measured in each patient. The perioperative parameters of safety and feasibility, as well as the accuracy analysis outcomes were compared.

There were 16 patients in the ARN-FI group and 15 patients underwent conventional laparoscopic hepatectomy without ARN or fluorescence imaging (non-ARN-FI group). There was no significant difference in baseline characteristics between the two groups. Compared with the non-ARN-FI group, the ARN-FI group had lower intraoperative bleeding (median 125 vs. 300 mL, P = 0.003). No significant difference was observed in other postoperative short-term outcomes. Accuracy analysis indicated that the actual resected liver volume (ARLV) in the ARN-FI group was more accurate.

ARN-FI was associated with less intraoperative bleeding and more accurate resection volume. These techniques may address existing challenges and provide rational guidance for laparoscopic anatomical S8 resection.

Background: Laparoscopic liver resection (LLR) has become a widely used standardized operation for patients with hepatocellular carcinoma (HCC) in the field of hepatic surgery. However, the risk factors and long-term implications associated with unplanned conversion to an open procedure during the LLR have not been adequately studied. Methods: The study incorporated 96 patients with HCC. Risk factors of conversion and their prognosis were analyzed by comparing patients who successfully underwent LLR with those who required unplanned conversion. Results: In this study, the unplanned conversion rate for laparoscopic hepatectomy was 42.7%. Patients who underwent conversion had longer length of stay (8 versus 7 days, P < .001), longer operation time (297.73 versus 194.03 minutes, P = .000), a higher transfusion rate (29.3% versus 5.5%, P < .001), and more postoperative complications compared with patients who successfully underwent LLR. The two surgical maneuvers did not show substantial disparities in terms of total survival and disease-free survival rates. Risk factors of unplanned conversion contained tumor location (odds ratio [OR], 3.129; 95% confidence interval [CI]: 1.214-8.066; P = 0.018) and tumor size (OR, 2.652; 95% CI: 1.039-6.767; P = 0.041). Conclusions: The unplanned conversion during LLR for HCC was linked to unfavorable short-term prognosis, yet it did not influence long-term oncologic outcomes. Moreover, preoperative evaluation of tumor size and location may effectively reduce the probability of unplanned conversion during LLR.

A high body mass index (BMI) generally increases the risk of postoperative complications because of the intraperitoneal adipose tissue. Robotic gastrectomy (RG) decreases the surgical difficulty of conventional laparoscopic gastrectomy (LG) for these patients. We conducted the present study to identify the advantages of RG over LG for overweight patients.

We reviewed clinical data on patients who underwent either LG or RG at the National Cancer Center Hospital East between January, 2014 and May, 2022.

The 1298 patients eligible patients were divided into a non-overweight cohort (n = 996) (LG, n = 818; RG, n = 178) and an overweight cohort (n = 302) (LG, n = 250; RG, n = 52) according to a BMI cut-off of 25 kg/m2. In the overweight cohort, the RG group had a lower incidence of grade ≥ III postoperative complications (0.0 vs. 8.8%, p = 0.01) and grade ≥ II postoperative complications (11.5 vs. 22.0%, p = 0.12) than the LG group. Multivariate analysis identified that RG was significantly associated with a lower incidence of grade ≥ II postoperative complications in the overweight cohort (odds ratio, 0.33; 95% confidence interval, 0.12-0.87; p = 0.02).

RG may reduce the risk of postoperative complications, compared with conventional LG, in overweight patients.