Laparoscopic liver resection (LLR) for lesions in the posterosuperior segments (PSS) is challenging. Identifying and minimizing risk factors for postoperative morbidity and mortality is crucial. This retrospective cohort study shares initial experiences with LLR of the PSS (VII, VIII, IVa) and wants to identify risk factors for clinically relevant postoperative complications (Clavien-Dindo grade ≥ III) in these patients.

We reviewed our prospective database for all patients who underwent LLR with at least one lesion in the PSS (April 2018-October 2022). Uni- and multivariate analyses were carried out using binary logistic regression analysis.

110 patients underwent LLR of the PSS. Median age was 67 years (IQR 59-76); 62% were male (n = 68), with a median BMI of 26 (IQR 23-30). The most frequent indications for LLR were primary liver cancer (37%) and colorectal liver metastasis (36%). Median operating time was 211 min (IQR 135-281) with a median blood loss of 460 mL (IQR 240-1200). Postoperative length of stay was 6 days (IQR 4-8). Clinically relevant postoperative complications were present in 20 patients (18%) with a 90-day mortality rate of 5% (n = 6). Multivariate analyses identified ASA ≥ III (OR 3.23 [95%CI 1.03-10.09]; p = 0.043), diabetes (OR 4.31 [95%CI 1.20-15.49]; p = 0.025), and intraoperative transfusion of packed red blood cells (PRBC) (OR 4.80 [95%CI 1.01-22.86]; p = 0.049) as risk factors for Clavien-Dindo grade ≥ III complications.

ASA ≥ III status, diabetes, and intraoperative PRBC transfusion are associated with an increased risk of Clavien-Dindo grade ≥ III complications in patients undergoing LLR in PSS. Preoperative optimization should include diabetes management, screening for anemia with appropriate supplementation, and comprehensive risk counseling for ASA ≥ III patients. Additionally, minimizing intraoperative PRBC transfusion should remain a key perioperative goal.

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.

Minimally invasive liver surgery (MILS) still appears to be adopted with significant variability. We aimed to investigate the diffusion, indications, and short-term outcomes of MILS compared to the open approach.

A prospective registry of all liver resections performed for any indication and using any technique between January 1, 2017, and December 31, 2019, was established (BReLLS) and analyzed.

A total of 1342 consecutive liver resections were included, 684 (51%) MILS and 658 (49%) open procedures. MILS was not attempted due to technical complexity in the 46.2% of cases, followed by previous abdominal surgery (22.5%). Patients undergoing MILS had a higher proportion of benign indications and of hepatocellular carcinomas, patients affected by liver cirrhosis with portal hypertension and a lower proportion of major hepatectomies (all p < 0.001). After propensity-score matching, MILS showed better results in terms of surgery duration (p < 0.001), blood loss (p = 0.015), complication rate (p < 0.001), rate of Clavien-Dindo grade ≥ 3 complications (p = 0.012), comprehensive complication index (p < 0.001), length of stay (p < 0.001), readmissions (p = 0.016). Centers performing over 50 liver resections per year had a higher proportion of overall MILS cases (p < 0.001), a similar proportion of major resections (p = 0.362), but a higher prevalence of MILS major resections (p = 0.004), lower 90-day mortality rates (p < 0.001), lower overall complication rates (p < 0.001), and shorter hospital length of stay (p < 0.001).

MILS was the preferred technique in half of the cases, particularly in patients with cirrhosis and portal hypertension, and benign lesions. It provided superior short-term outcomes compared to the open approach for both minor and major liver resections in selected patients.

We sought to define textbook outcome in liver surgery (TOLS) for intrahepatic cholangiocarcinoma (ICC) by considering the implications of perioperative outcomes on overall survival (OS).

Using a multi-institutional database, TOLS for ICC was defined by employing novel machine learning (ML) models to identify perioperative factors most strongly predictive of OS ≥ 12 months. Subsequently, clinicopathologic factors associated with achieving TOLS were investigated.

A total of 1556 patients with ICC were included. The ML classification models demonstrated that the absence of post-hepatectomy liver failure, intraoperative blood loss <750 mL, absence of major infectious complications, and R0 resection were the perioperative outcomes associated with prolonged OS, thereby defining TOLS for ICC. On multivariable analysis, older age, ASA class >2, lymph node metastasis, receipt of neoadjuvant therapy, advanced T status, poor histological grade and microvascular invasion were independently associated with lower odds of achieving TOLS (all p-values<0.05). Overall, 60.2 % (n = 936) of the patients achieved TOLS, demonstrating markedly improved OS and recurrence-free survival (RFS) than individuals who did not (both p < 0.05).

A standardized definition of TOLS for ICC was established that may be used to evaluate hospital performance at the patient level and help optimize surgical outcomes for patients with ICC.

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.

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.

Laparoscopic liver resection has advantages over open liver resection, including reduced blood loss and shorter hospital stays. Laparoscopic central hepatectomy (CH) is a highly challenging procedure, and such outcomes can only be achieved with a high level of expertise in laparoscopic liver surgery. Laparoscopic CH remains challenging, with safety and efficacy unclear. This study retrospectively evaluated the intra- and short-term outcomes of laparoscopic versus open CH and assessed safety and efficacy of laparoscopic surgery.

CH included anterior sectionectomy (AS) and central bisectionectomy (CBS) (excluding cases with biliary reconstruction). The study comprised 38 patients receiving CH in our department from January 2010 to November 2023.

The laparoscopic group included 14 cases and the open group 24. AS/CBS was performed in 14/10 open group cases and 6/8 laparoscopic group cases. Short-term surgical outcomes showed no significant between-group difference in operative time, but the laparoscopic group lost significantly less blood (250 vs. 985 mL; p = 0.001) and the transfusion rate was lower (14% vs. 46%; p = 0.004). Among postoperative outcomes, incidence of bile leakage was not significantly different (33% vs. 42%; p = 0.42), but the laparoscopic group had significantly less postoperative ascites (0% vs. 17%; p = 0.047), fewer surgical site infections (SSI) (0% vs. 21%; p = 0.02), and shorter postoperative hospital stay (14 vs. 30 days; p = 0.005). The risk factor for bile leakage in CH by univariate and multivariate analysis was tumor proximity to the right anterior Glissonean pedicle (OR = 6.84; 95% CI = 1.67-32.7; p = 0.01).

Laparoscopic CH could be performed safely. Compared to open surgery, laparoscopic CH was effective in reducing blood loss, postoperative ascites, SSIs, and shortening postoperative hospital stay. However, tumors close to the root of the right anterior Glissonean pedicle were considered a risk factor for postoperative bile leakage and require caution.

Liver resection is the standard treatment for resectable hepatocellular carcinoma (HCC). The advent of robotic surgery has extended its application in liver surgery, reducing post-operative complications without compromising oncological safety. This study is a retrospective series with the aim of analyzing the preoperative patient's and tumor's characteristics and evaluating intraoperative and post-operative data in terms of hospital stay, complications, and oncological radicality.

Data were collected from a multicenter retrospective database that includes 1070 consecutive robotic liver resections (RLRs) performed in nine European hospital centers from 2011 to 2023. Of the entire series, 343 liver resections were performed for HCC.

A total of 247 patients (72.3%) had mono-focal lesions. Major hepatectomies and anatomical resections have been perfomed in 87% and 55% of patients, respectively. All 17 conversions (4.95%) were to the open approach. The operative mean time was 239.56 min and the estimated blood loss was 229.45 mL. The overall post-operative complication rate was 22.74%, but severe complications occurred in 4.08% of patients and one of them (0.29%) was reoperated on. The mean hospital stay was 5.82 days with a mean ICU stay of 0.9 days. Twenty-six resections (7.6%) were R1 parenchymal. Forty-six patients (4.08%) were readmitted to the hospital within 90 days after discharge and seventy-eight patients (22.74%) had disease recurrence. Total deaths included 36 (10.5%) patients with a 90-day mortality of 0.9%.

Robotic liver resection for HCC is feasible and safe when performed in experienced centers by surgeons who have completed the learning curve.

The Iwate difficulty scoring system (DSS) is one of the most widely validated DSS for laparoscopic liver resection (LLR). However, these studies only validated the 4 difficulty levels and did not validate the 12-point difficulty index of the system. To address current limitations in the studies validating the Iwate difficulty scoring system (DSS), we performed an international multicenter study to validate the Iwate DSS across both its four difficulty levels and 12-point difficulty index.

A retrospective cohort study of 22,252 patients undergoing LLR across 64 centers worldwide between 2005 and 2021 was performed. Baseline characteristics and perioperative outcomes were analyzed across the four difficulty levels and 12-point difficulty index of the Iwate DSS.

A total of 14,759 patients met the inclusion criteria. The main indications for LLR were hepatocellular carcinoma/intrahepatic cholangiocarcinoma (52.8 %), and metastatic tumors liver (26.5 %). In terms of underlying liver pathology, 5127 patients (34.8 %) had liver cirrhosis, and 1214 patients (8.3 %) had portal hypertension. Intraoperative outcomes (operation time, blood loss, blood transfusion, use of Pringles maneuver and open conversion) and postoperative outcomes (length of stay, morbidity, major complications, and 90-day mortality) significantly increased with stepwise increases across the four difficulty levels (P < 0.001) and 12-point difficulty index (P < 0.001). These trends remained significant following adjustment for baseline characteristics (P < 0.001).

The Iwate DSS 12-point difficulty index and four difficulty levels correlated well with LLR difficulty as determined by key surrogate perioperative measures.

The long-term impact of postoperative morbidity following laparoscopic liver resection for hepatocellular carcinoma is unclear. This study aimed to investigate whether the prognosis of hepatocellular carcinoma patients were affected by postoperative morbidity after laparoscopic liver resection. Hepatocellular carcinoma patients who underwent curative-intent laparoscopic liver resection were included. Risk factors of 30-day morbidity were identified using logistic regression analysis. Early (≤ 2 years) and late (> 2 years) recurrence rates, overall survival, and time to recurrence were compared among patients with and without postoperative morbidity. Independent prognostic factors of overall survival and time to recurrence of these patients were investigated using Cox regression analysis. This study included 420 patients, 147 (35%) of whom experienced postoperative morbidity. Diabetes mellitus, cirrhosis, portal hypertension, Child-Pugh grade B, multiple tumors, poor tumor differentiation and intraoperative blood transfusion were risk factors of postoperative morbidity. Patients with postoperative morbidity had higher early and late recurrence rates than those without postoperative morbidity (38.8% vs. 22.4%, P = 0.001; 50% vs. 25.5%, P = 0.001). Postoperative morbidity was associated with decreased overall survival (median: 54.5 months vs. not reached, P < 0.001) and time to recurrence (median: 36.4 vs. 68.2 months; P < 0.001). Postoperative morbidity resulted in a 43% and 92% higher risk of long-term mortality (HR 1.43; 95% CI 1-2.03; P = 0.048) and recurrence (HR 1.92; 95% CI 1.41-2.62; P < 0.001). For hepatocellular carcinoma patients undergoing laparoscopic liver resection, long-term oncologic outcomes are adversely affected by postoperative morbidity. Therefore, it is of great importance for surgeons to prevent and manage postoperative morbidity.

There is little information regarding the impact of the number of concurrent metabolic syndrome (MetS) risk factors on the textbook outcomes (TO) in patients with hepatocellular carcinoma (HCC) following liver resection.

Data from patients who underwent liver resection between 2015 and 2023 in a multicenter database were retrospectively reviewed (N = 3156). According to the guidelines, MetS risk factors include obesity, hypertension, diabetes, and dyslipidemia.

In this study, 2056 (65.1%) patients achieved TO. The incidence of TO was 63.1% in patients with ≥ 1 MetS risk factor, which was lower than that in patients without any MetS risk factors (67.5%, P = 0.011). As the number of MetS risk factors increased, the probability of not achieving TO gradually increased. The non-TO rates in patients with no, 1, 2, and ≥ 3 MetS risk factors were 32.5%, 35.9%, 37.6% and 40.2%, respectively (Ptrend = 0.005). Multivariate logistic regression confirmed that the number of MetS risk factors (0 as a reference; 1, OR 1.220, 95% CI 1.029-1.447, P = 0.022; 2, OR 1.397, 95% CI 1.113-1.755, P = 0.004; ≥ 3, OR 1.647, 95% CI 1.197-2.264, P = 0.002) independently contributed to non-TO in patients with HCC after liver resection. Both the 5-year recurrence-free survival (TO: 50.7% versus non-TO: 43.9%, P < 0.001) and overall survival rates (TO: 71.0% versus non-TO: 58.7%, P < 0.001) of TO patients were significantly better than those of non-TO patients.

Concurrent MetS risk factors can adversely impact TO achievement in patients with HCC after liver resection. The more risk factors patients have, the less likely they are to achieve TO.

Utilization of minimally invasive surgery (MIS) has become increasingly popular due to its potential benefits such as earlier recovery and reduced morbidity. We sought to characterize differences in 1-year healthcare costs and missed workdays among patients undergoing MIS and open surgery for a hepatic or pancreatic indication.

Data on patients who underwent hepatic and pancreatic resection were obtained from the IBM Marketscan database. Generalized linear models were utilized to compare healthcare costs and missed workdays among patients undergoing MIS versus open surgery.

Among 8705 patients, 85.0 % (n = 7399) and 15.0 % (n = 1306) of patients underwent an open or MIS HP procedure, respectively. In the unmatched cohort, patients who underwent MIS were more likely to be female (62.7 % vs. 54.6 %) and were less likely to have a Charlson Comorbidity Index score >2 (34.5 % vs. 49.6 %) (both p < 0.05). After entropy balancing, multivariable analysis demonstrated that MIS was associated with lower 1-year post discharge expenditures (mean difference -$9,739, 95%CI-$12,893, -$6585) and fewer missed workdays at 1-year post-discharge (IRR 0.84, 95%CI 0.81-0.87) (all p < 0.001).

At index hospitalization and 1-year post-discharge, an HP MIS approach was associated with lower healthcare expenditures versus open surgery for hepatic and pancreatic resection, as well as fewer missed workdays.

Laparoscopic hepatectomy has minimally invasive advantages, but reports on laparoscopic right anterior sectionectomy (LRAS) are rare. Herein, we try to explore the benefits and drawbacks of LRAS by comparing it with open right anterior sectionectomy (ORAS). Between January 2015 and September 2023, 39 patients who underwent LRAS (n = 18) or ORAS (n = 21) were enrolled in the study. The patients' characteristics, intraoperative details, and postoperative outcomes were compared between the two groups. No significant differences in the preoperative data were observed between the two groups. The LRAS group had significantly lesser blood loss (P = 0.019), a shorter hospital stay (P = 0.045), and a higher rate of bile leak (P = 0.039) than the ORAS group. There was no significant difference in the operative time (P = 0.156), transfusion rate (P = 0.385), hospital expenses (P = 0.511), rate of other complications, postoperative white blood cell count, and alanine aminotransferase and aspartate aminotransferase levels between the two groups (P > 0.05). Beside, there was no significant difference in disease-free survival (P = 0.351) or overall survival (P = 0.613) in patients with hepatocellular carcinoma between the two groups. LRAS is a safe and feasible surgical procedure. It may be preferred for lesions in the right anterior lobe of the liver.

Laparoscopic hepatectomy has been widely accepted owing to its advantages as a minimally invasive surgery; however, laparoscopic segment 7 (S7) hepatectomy (LSH) has been rarely reported. We aimed to explore the safety and feasibility of LSH by comparing it with open surgical approaches.

Twenty-nine patients who underwent S7 hepatectomy between January 2016 and January 2023 were enrolled in this study. The patients' characteristics, intraoperative details, and postoperative outcomes were compared between the 2 groups.

No significant differences were observed in the preoperative data. The patients who underwent LSH had significantly shorter hospital stays ( P =0.016) but longer operative times ( P =0.034) than those who underwent open S7 hepatectomy. No significant differences in blood loss ( P =0.614), transfusion ( P =0.316), hospital expenses ( P =0.391), surgical margin ( P =0.442), rate of other complications, postoperative white blood cell count, and alanine aminotransferase and aspartate aminotransferase levels were noted between the 2 groups ( P >0.05). For hepatocellular carcinoma, the results showed no differences in either disease-free survival ( P =0.432) or overall survival ( P =0.923) between the 2 groups.

LSH is a safe and feasible surgical procedure that is efficient from an oncological point of view. It may be the preferred technique for lesions in the S7 of the liver.

Laparoscopic hepatectomy for colorectal liver metastases (CRLM) is performed worldwide. However, owing to a lack of palpatory information and difficulties associated with accurate intraoperative ultrasonographic diagnosis, the tumor may be exposed at the hepatic transection margin. This study aimed to investigate the pathological significance of near-infrared (NIR) fluorescence imaging with indocyanine green (ICG)-guided laparoscopic hepatectomy and determine its usefulness in securing the resection margin for CRLMs.

Fifty-nine patients who underwent laparoscopic hepatectomy for CRLM using NIR fluorescence imaging between February 2017 and June 2021 at Sapporo Medical University Hospital were included. Generally, all patients received intravenous ICG (2.5 mg/body) as a fluorescence agent 1 to 2 days before surgery. During the surgical procedure, real-time NIR fluorescence imaging was repeatedly performed to assess the surgical margins.

Of the 94 tumors in 59 patients, laparoscopic NIR fluorescence imaging identified 56 tumors (59.6%) on the liver surface. Pathological analysis indicated clear margins in 96.6% (57/59) of patients. Examination of paraffin-embedded sections, which were successful in only 20 of 94 cases (21.3%), revealed that there were no tumor cells positive for NIR fluorescence, and the median distance of the continuous fluorescent signal from the tumor margin was 1.074 mm.

We demonstrated a high R0 rate using NIR fluorescence-guided hepatectomy. This technique has the potential to improve intraoperative tumor identification and tumor margin assurance and reduce the rate of positive resection margins in patients with CRLMs.

A single metric does not sufficiently capture the multidimensional and complex perioperative nature of treatment for patients with gastric cancer. There is a newly developed composite indicator, called textbook outcome, that reflects the "ideal" surgical outcome. However, limited evidence exists for the long-term prognosis of textbook outcome in patients with gastric cancer. Thus, this study was aimed at assessing the association between textbook outcome and long-term oncologic prognosis after gastrectomy.

In total, 2,658 consecutive patients who underwent gastrectomy between January 2004 and December 2017 were included. The primary endpoint was 5-year conditional survival (if the patient survived the first 30 days after surgery). Textbook outcome was defined as retrieved ≥15 lymph nodes, pR0 resection, complete-potentially curative resection during operation, hospitalization ≤21 days, no reinterventions, no severe postoperative complications, no hospital readmission ≤30 days after discharge, no unplanned intensive care unit treatment, and no 30-day postoperative mortality. Multivariable analysis was performed to evaluate the adjusted predictors of textbook outcome. A Cox regression analysis was used to analyze the relationship between achieving textbook outcome parameters and long-term oncologic prognosis.

A total of 1,770 (66.6%) of the 2,658 patients achieved all textbook outcome metrics in this study. The textbook outcome group displayed a greater 5-year conditional overall survival than the nontextbook outcome group (64.7% vs 40.2%, P < .001). The 5-year conditional disease-free survival of the patients with textbook outcomes was strongly superior to that of the patients without textbook outcomes (63.1% vs 37.6%, P < .001). Textbook outcome was independently associated with longer 5-year conditional overall survival and disease-free survival (hazard ratio 0.494 [0.439-0.557] and hazard ratio 0.487 [0.433-0.547], respectively).

Attaining textbook outcome is strongly related to an improved long-term oncologic prognosis for patients with gastric cancer, underscoring the need for continued efforts to enhance surgical care quality.

Numerous surgical techniques are currently available for minimally invasive left hepatic resection, each offering its own advantages and disadvantages.

This multimedia manuscript delves into the primary approaches for minimally invasive left hepatectomy, with a focus on particular topics such as left hepatic vein approach, transection and middle hepatic vein exposure, and Glissonean approach. We examine key factors that surgeons should consider when choosing among these methods and provide practical recommendations.

To enhance understanding, our article includes video footage from multiple centres, showcasing expertly executed surgeries for each approach along with their main considerations.

This multimedia resource will serve as a valuable guide for surgeons, aiding in the selection of the most suitable strategy for minimally invasive left hepatectomies, tailored to the specific needs of the patient and the characteristics of the lesion.

Laparoscopic right posterior anatomic resection (LRPAR) presents challenges due to uncontrollable hemorrhage from the inferior vena cava and the risk of carbon dioxide (CO2) gas embolism. However, there is a lack of research specifically addressing the safe exposure of right hepatic vein (RHV). Herein, we introduced a novel technique of combining occlusion of the RHV with the Pringle maneuver and presented the outcomes of our initial series.

All consecutive patients who underwent LRPAR using this novel technique were enrolled in this study from March 2021 to January 2024. The demographic characteristics, perioperative outcomes and follow-up data were collected and analyzed.

A total of 12 patients underwent LRPAR using the technique of double occlusion during study period. All the procedures were performed laparoscopically, with no conversions to open surgery. The median operative time was 203 min (range of 172-279 min) and the median blood loss was 200 ml (range of 50-280 ml). No patient received a blood transfusion during the perioperative period. Of note, the main trunk of the RHV was fully exposed on the cutting surface in all cases, and no evidence of CO2 gas embolism was observed following double occlusion. None of the patients suffered from Clavien-Dindo grade II or higher postoperative complications, and the perioperative mortality was nil. The median postoperative stay was 5 days (range of 5-7 days). The median hospitalization cost was 43,048.5 RMB (40,240.35-57,921.53 RMB). At a median follow-up period of 24 months (range of 4-35 months), all patients were alive with normal daily living and no disease recurrence was observed.

Combining occlusion of the right hepatic vein with the Pringle maneuver appears to be a feasible and expected technique for securing the exposure of RHV in LRPAR. Further follow-up and well-designed prospective comparative studies are needed to validate the feasibility and efficacy of this technique.

Laparoscopic hepatectomy (LH) for hepatocellular carcinoma (HCC) has been well known for its advantages in the past 10 years, but little is known regarding its oncologic outcomes while the technique is being developed at an institution. This study aimed to evaluate the safety and effectiveness of LH for patients with primary HCC at favorable locations, focusing on postoperative short- and long-term outcomes during the development period.

We retrospectively reviewed patients diagnosed with primary HCC who underwent hepatectomy between January 2013 and December 2019 at Hualien Tzu Chi Hospital. Patients with HCC at favorable locations (anterolateral segments) were collected and divided into laparoscopic and open hepatectomy (OH) groups. The data for long-term outcomes, as the primary endpoint, and postoperative outcomes, as the secondary endpoint, were collected.

The review included 159 patients, among which 42 and 44 patients in favorable locations underwent open and laparoscopic hepatectomies, respectively. There were no significant differences in intraoperative blood loss, major complication rate, and 90-day mortality rate between the two groups. The laparoscopic group had a lower transfusion rate, shorter postoperative hospital stay, and lower 90-day readmission rate. There were no significant differences in 12-, 36-, and 60-month overall survival and disease-free survival.

LH for favorably located HCC is the preferred surgical approach compared to OH due to the decreased transfusion rate, shorter postoperative hospital stay, and lower 90-day readmission rate. LH did not compromise the 90-day mortality rate with sustained long-term overall and disease-free survival. LH for favorably located HCC is a safe and effective surgical approach even during the development period.

Perihilar cholangiocarcinoma, intrahepatic cholangiocarcinoma (IHCC), and gall bladder cancer are difficult malignancies to treat and are characterized by a tendency for local recurrence and a generally unfavorable prognosis. Surgical resection offers the only potential cure, conventionally performed via the open approach. Although minimally invasive approaches show promise, data remain limited.

With the institutional review board's approval, we prospectively followed 100 patients between 2013 and 2023 who underwent robotic surgical resection for perihilar, IHCC, and gallbladder cholangiocarcinoma. Data are presented as median (mean ± SD). Significance was accepted at P ≤ .05.

The median patient age was 70 years, and the median operative duration was 333 min, with an estimated blood loss of 200 mL. Importantly, no unplanned conversions occurred, and only 1 intraoperative complication occurred within the IHCC cohort. The median length of stay was 4 days. There were a total of 19 postoperative complications and 19 readmissions within 30 days. Additionally, there were 3 in-hospital mortalities and 5 90-day mortalities. R0 resection was achieved in 87% of patients and R1 resection in 13%. At a median follow-up of 36 months, 62% of patients demonstrated disease-free survival, whereas 6% continued to live with the disease, and 32% did not survive.

Our experience demonstrates the feasibility and safety of robotic resection for these complex malignancies, yielding promising short-term outcomes. Further investigation is required to ascertain the long-term oncologic outcomes.

Laparoscopic simultaneous resection (LSR) of primary colorectal tumors and synchronous colorectal liver metastases (sCRLM) has been recently performed. This study aimed to evaluate the postoperative outcomes after LSR and determine the risk factors for resection surface-related complications (RSRC), such as postoperative biliary fistula and liver-transection surface abscess.

Between 2009 and 2022, consecutive patients with sCRLM who underwent LSR were included. We retrospectively analyzed clinicopathological data, including intraoperative factors and postoperative outcomes. The difficulty level of all liver resections was classified according to the IWATE difficulty scoring system (DSS). We then performed univariate and multivariate analyses to identify the risk factors for RSRC.

Of the 112 patients, 94 (83.9%) underwent partial hepatectomy and colorectal surgery. The median DSS score was 5 points (1-11), with 12 (10.7%) patients scoring ≥ 7 points. Postoperative complications were observed in 41 (36.6%) patients, of whom 16 (14.3%) experienced severe complications classified as Clavien-Dindo grade IIIa or higher. There was no postoperative mortality. The most common complication was RSRC (19 patients, 17.0%). Multivariate analysis identified American Society of Anesthesiologists (ASA) classification ≥ 3 [odds ratio (OR) 10.3, 95% confidence interval (CI) 1.37-77.8; P = 0.023], DSS score ≥ 7 points (OR 5.08, 95% CI 1.17-20.0; P = 0.030), and right-sided colectomy (OR 4.67, 95% CI 1.46-15.0; P = 0.009) as independent risk factors for RSRC. Postoperative hospital stays were significantly longer for patients with RSRC than for those without RSRC (22 days vs. 11 days; P < 0.001).

Short-term outcomes of LSR for patients with sCRLM were acceptable in an experienced center. RSRC was the most common complication, and high-difficulty hepatectomy, right-sided colectomy, and ASA classification ≥ 3 were independent risk factors for RSRC.

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.

The objective of this study was to evaluate the clinical effects of perioperative steroid hormone usage in hepatectomy patients through a comprehensive systematic review and meta-analysis. Prospective randomized controlled trials (RCTs) investigating the perioperative use of steroid hormones in hepatectomy patients were systematically searched using various databases, including PubMed, Medline, Embase, the Cochrane Library, the Chinese Biomedical Literature Database, Wanfang Data, and the CNKI database. Two researchers independently screened and extracted data from selected studies. Data analysis was performed using RevMan 5.3 software. The results revealed significantly lower levels of total bilirubin (standard mean difference [SMD] = -0.7; 95% CI: -1.23 to -0.18; and p = 0.009), interleukin-6 (SMD = -1.02; 95% CI: -1.27 to -0.77; and p < 0.001), and C-reactive protein (SMD = -0 .65; 95% CI: -1 .18 to -0.11; and p = 0.02) on postoperative day 1 (POD 1), as well as a reduced incidence of postoperative complications in the steroid group compared to the placebo group. No significant differences were observed between the two groups regarding alanine aminotransferase (ALT) levels, aspartic aminotransferase (AST) levels, or specific complications such as intra-abdominal infection (p = 0.72), wound infection (p = 0.1), pleural effusion (p = 0.43), bile leakage (p = 0.66), and liver failure (p = 0.16). The meta-analysis results indicate that perioperative steroid usage can effectively alleviate liver function impairment and inflammation response following hepatectomy while improving patient prognosis.

This research is the first study in the United States to document more than a decade of experience with 530 patients who underwent robotic hepatectomy at a single high-volume institution.

With institutional review board approval, a prospectively collected database of consecutive patients who underwent robotic hepatectomy from 2012 to January 2024 was reviewed. Data are presented as median (mean ± SD).

Of the 530 robotic hepatectomies, 231 (44.0%) were minor resections, 133 (25.0%) were technically major resections, and 166 (31.0%) were major resections. The patients were aged 63.0 (61.0 ± 14.7) years with a body mass index of 28.0 (29.0 ± 7.9) kg/m2. Cirrhosis was present in 80 patients (19.0%), with an American Society of Anesthesiologists score of 3.0 (3.0 ± 0.5) and a Model for End-Stage Liver Disease score of 7.0 (8.0 ± 3.0). Of note, 280 patients (53.0%) had previous abdominal operations, and 44 patients (8%) had previous liver resections. The operative time was 233.0 (260.0 ± 130.7) minutes, and the estimated blood loss was 100.0 (165.0 ± 205.0) mL. Moreover, 353 patients (66%) had hepatectomies for neoplastic disease, and 500 patients (95%) had an R0 resection margin. The tumor size was 4.0 (5.0 ± 3.6) cm. The total 90-day postoperative complications were 45 (8%), of which 21 (4%) were classified as major complications (Clavien-Dindo score of >III). The length of stay was 3.0 (4.0 ± 3.7) days, and the 30-day readmission rate was 86 (16%). The overall survival rates at 1, 3, and 5 years were 82%, 65%, and 59% for colorectal liver metastases, 84%, 68%, and 60% for hepatocellular carcinoma, and 79%, 61%, and 50% for intrahepatic cholangiocarcinoma, respectively.

After a decade of application and optimization at a high-volume institution, the robotic approach has been demonstrated to be a safe and effective approach to liver resection.

This study comprehensively compared laparoscopic liver resection (LLR) to open liver resection (OLR) in treating colorectal cancer liver metastasis (CRLM).

A systematic review of relevant literature was conducted to assess a range of crucial surgical and oncological outcomes.

Findings indicate that minimally invasive surgery (MIS) did not significantly prolong the duration of surgery compared to open liver resection and notably demonstrated lower blood transfusion rates and reduced intraoperative blood loss. While some studies favored MIS for its lower complication rates, others did not establish a statistically significant difference. One study identified a lower post-operative mortality rate in the MIS group. Furthermore, MIS consistently correlated with shorter hospital stays, indicative of expedited post-operative recovery. Concerning oncological outcomes, while certain meta-analyses reported a lower rate of cancer recurrence in the MIS group, others found no significant disparity. Overall survival and disease-free survival remained comparable between the MIS and open liver resection groups.

The analysis emphasizes the potential advantages of LLR in terms of surgical outcomes and aligns with existing literature findings in this field.

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This study evaluated the cost-effectiveness of open, laparoscopic, and robotic liver resection.

A comprehensive literature review and Bayesian network meta-analysis were conducted. Surface under cumulative ranking area values, mean difference, odds ratio, and 95% credible intervals were calculated for all outcomes. Cluster analysis was performed to determine the most cost-effective clustering approach. Costs-morbidity, costs-mortality, and costs-efficacy were the primary outcomes assessed, with postoperative overall morbidity, mortality, and length of stay associated with total costs for open, laparoscopic, and robotic liver resection.

Laparoscopic liver resection incurred the lowest total costs (laparoscopic liver resection versus open liver resection: mean difference -2,529.84, 95% credible intervals -4,192.69 to -884.83; laparoscopic liver resection versus robotic liver resection: mean difference -3,363.37, 95% credible intervals -5,629.24 to -1,119.38). Open liver resection had the lowest procedural costs but incurred the highest hospitalization costs compared to laparoscopic liver resection and robotic liver resection. Conversely, robotic liver resection had the highest total and procedural costs but the lowest hospitalization costs. Robotic liver resection and laparoscopic liver resection had a significantly reduced length of stay than open liver resection and showed less postoperative morbidity. Laparoscopic liver resection resulted in the lowest readmission and liver-specific complication rates. Laparoscopic liver resection and robotic liver resection demonstrated advantages in costs-morbidity efficiency. While robotic liver resection offered notable benefits in mortality and length of stay, these were balanced against its highest total costs, presenting a nuanced trade-off in the costs-mortality and costs-efficacy analyses.

Laparoscopic liver resection represents a more cost-effective option for hepatectomy with superior postoperative outcomes and shorter length of stay than open liver resection. Robotic liver resection, though costlier than laparoscopic liver resection, along with laparoscopic liver resection, consistently exceeds open liver resection in surgical performance.

Minimally invasive liver resection (MILR) is performed for other gastrointestinal applications. At our centre, all liver resections are systematically performed using a minimally invasive approach. This study aimed to describe our experience in minimising open surgery and emphasised the importance of minimally invasive surgery.

We retrospectively reviewed 260 patients who underwent liver surgery and compared the surgical outcomes between the open and MILR groups.

A total of 154 patients (68%) underwent MILR. The proportion of patients who underwent prior abdominal surgery and resection was higher in the open surgery group. However, the proportion of patients with liver cirrhosis was similar between the two groups. The MILR group was superior in terms of operative time, blood loss, Pringle manoeuvre rate and mean hospital stay. In addition, major complication and bile leak rates were lower in the MILR group. No significant differences in the tumour size, number of lesions or underlying liver pathology were observed between the two groups.

Acceptable outcomes can be achieved even when the minimally invasive approach is considered the primary option for all patients who require liver resection. Minimally invasive tools are necessary for the modern practice of liver surgery; therefore, laparoscopic or robotic surgery should be included in the armamentarium of liver surgeons.

Laparoscopic liver surgery has advanced significantly, offering benefits, such as reduced intraoperative complications and quicker recovery. However, complex laparoscopic hepatectomy (CLH) is technically demanding, requiring skilled surgeons. This study aims to share technical aspects, insightful tips, and outcomes of CLH at our center, focusing on the safety and learning curve.

We reviewed all patients undergoing liver resection at our center from July 2017 to December 2023, focusing on those who underwent CLH. Of 135 laparoscopic liver resections, 63 (46.7%) were CLH. The learning curve of CLH was also assessed through linear and piecewise regression analyses considering the operation time and intraoperative blood loss.

Postoperative complications occurred only in 4.8% of patients, with a 90-day mortality rate of 3.2%. The mean operation time and blood loss significantly decreased after the first 20 operations, marking the learning curve's optimal cut-off. Significant improvements in R0 resection (p = 0.024) and 90-day mortality (p = 0.035) were noted beyond the learning curve threshold.

CLH is a safe and effective approach, with a relatively short learning curve of 20 operations. Future large-scale studies should further investigate the impact of surgical experience on CLH outcomes to establish guidelines for training programs.

The aim was to analyze the learning curves of minimal invasive liver surgery(MILS) and propose a standardized reporting.

MILS offers benefits compared to open resections. For a safe introduction along the learning curve, formal training is recommended. However, definitions of learning curves and methods to assess it lack standardization.

A systematic review of PubMed, Web of Science, and CENTRAL databases identified studies on learning curves in MILS. The primary outcome was the number needed to overcome the learning curve. Secondary outcomes included endpoints defining learning curves, and characterization of different learning phases(competency, proficiency and mastery).

60 articles with 12'241 patients and 102 learning curve analyses were included. The laparoscopic and robotic approach was evaluated in 71 and 18 analyses and both approaches combined in 13 analyses. Sixty-one analyses (60%) based the learning curve on statistical calculations. The most often used parameters to define learning curves were operative time (n=64), blood loss (n=54), conversion (n=42) and postoperative complications (n=38). Overall competency, proficiency and mastery were reached after 34 (IQR 19-56), 50 (IQR 24-74), 58 (IQR 24-100) procedures respectively. Intraoperative parameters improved earlier (operative time: competency to proficiency to mastery: -13%, 2%; blood loss: competency to proficiency to mastery: -33%, 0%; conversion rate (competency to proficiency to mastery; -21%, -29%), whereas postoperative complications improved later (competency to proficiency to mastery: -25%, -41%).

This review summarizes the highest evidence on learning curves in MILS taking into account different definitions and confounding factors. A standardized three-phase reporting of learning phases (competency, proficiency, mastery) is proposed and should be followed.

Despite evidence of benefits on postoperative outcomes, minimally invasive liver surgery (MILS) had a very low diffusion up to 2014, and recent evolution is unknown. Our aim was to analyze the recent diffusion and adoption of MILS and compare the trends in indications, extent of resection, and institutional practice with open liver surgery (OLS).

We analyzed the French nationwide, exhaustive cohort of all patients undergoing a liver resection in France between January 1, 2013 and December 31, 2022. Average annual percentage changes (AAPC) in the incidence of MILS and OLS were compared using mixed-effects log-linear regression models. Time trends were analyzed in terms of extent of resection, indication, and institutional practice.

MILS represented 25.2% of 74,671 liver resections and year incidence doubled from 16.5% in 2013 to 35.4% in 2022. The highest AAPC were observed among major liver resections [+ 22.2% (19.5; 24.9) per year], primary [+ 10.2% (8.5; 12.0) per year], and secondary malignant tumors [+ 9.9% (8.2; 11.6) per year]. The highest increase in MILS was observed in university hospitals [+ 14.7% (7.7; 22.2) per year] performing 48.8% of MILS and in very high-volume (> 150 procedures/year) hospitals [+ 12.1% (9.0; 15.3) per year] performing 19.7% of MILS. OLS AAPC decreased for all indications and institutions and accelerated over time from - 1.8% (- 3.9; - 0.3) per year in 2013-2018 to - 5.9% (- 7.9; - 3.9) per year in 2018-2022 (p = 0.013).

This is the first reported trend reversal between MILS and OLS. MILS has considerably increased at a national scale, crossing the 20% tipping point of adoption rate as defined by the IDEAL framework.

Laparoscopic treatment has been increasingly adopted for giant hepatic hemangioma (HH), but the role of liver resection or enucleation remains uncertain. The aim of this study is to compare the laparoscopic resection (LR) with laparoscopic enucleation (LE) for HH, and to provide evidence on how to choose the most suitable approach for HH.

A retrospective analysis of HH patients underwent laparoscopic treatment between March 2015 and August 2022 was performed. Perioperative outcomes were compared based on the surgical approaches, and risk factors for increased blood loss was calculated by logistic regression analysis.

A total of 127 patients in LR group and 287 patients in LE group were enrolled in this study. The median blood loss (300 vs. 200 mL, P < 0.001) was higher in LE group than that in LR group. Independent risk factors for blood loss higher than 400 mL were tumor size ≥ 10 cm, tumor adjacent to major vessels, tumor occupying right liver or caudate lobe, and the portal phase enhancement ratio (PER) ≥ 38.9%, respectively. Subgroup analysis showed that LR was associated with less blood loss (155 vs. 400 mL, P < 0.001) than LE procedure in patients with high PER value. Both LR and LE approaches exhibited similar perioperative outcomes in patients with low PER value.

Laparoscopic treatment for HH could be feasibly and safely performed by both LE and LR. For patients with PER higher than 38.9%, the LR approach is recommended.

Our clinical practice of laparoscopic liver resection (LLR) had achieved better short-term and long-term benefits for patients with hepatocellular carcinoma (HCC) over open liver resection (OLR), but the underlying mechanisms are not clear. This study was to find out whether systemic inflammation plays an important role.

A total of 103 patients with early-stage HCC under liver resection were enrolled (LLR group, n = 53; OLR group, n = 50). The expression of 9 inflammatory cytokines in patients at preoperation, postoperative day 1 (POD1) and POD7 was quantified by Luminex Multiplex assay. The relationships of the cytokines and the postoperative outcomes were compared between LLR and OLR.

Seven of the circulating cytokines were found to be significantly upregulated on POD1 after LLR or OLR compared to their preoperative levels. Compared to OLR, the POD1 levels of granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-6 (IL-6), IL-8, and monocyte chemoattractant protein-1 (MCP-1) in the LLR group were significantly lower. Higher POD1 levels of these cytokines were significantly correlated with longer operative time and higher volume of blood loss during operation. The levels of these cytokines were positively associated with postoperative liver injury, and the length of hospital stay. Importantly, a high level of IL-6 at POD1 was a risk factor for HCC recurrence and poor disease-free survival after liver resection.

Significantly lower level of GM-CSF, IL-6, IL-8, and MCP-1 after liver resection represented a milder systemic inflammation which might be an important mechanism to offer better short-term and long-term outcomes in LLR over OLR.