Development of a novel difficulty scoring system for laparoscopic liver resection procedure in patients with intrahepatic duct stones.

A difficulty scoring system (DSS) based on the extent of liver resection, tumor location, liver function, tumor size, and tumor proximity to major vessels was recently developed to assess the difficulty of various laparoscopic liver resection procedures. We validated DSS in patients who underwent laparoscopic left lateral sectionectomy (LLS). We reviewed the clinical data of 124 patients who underwent laparoscopic LLS between July 2003 and November 2015 and validated the DSS in 90 patients who underwent laparoscopic LLS for tumor according to their surgical outcomes. We also developed and evaluated the modified DSS in 34 patients who underwent LLS for intrahepatic duct (IHD) stones. The DSS score ranged from 3 to 6 in laparoscopic LLS for tumors. The median blood loss (P=0.002) was significantly different among patients divided into subgroups by DSS score. We made modified DSS for IHD stones using factors influencing longer operation time, including stone location (P=0.002), atrophy of liver parenchyma (P=0.012), ductal stricture <1cm from the bifurcation (P=0.047), and combined choledochoscopic examination for remnant IHD (P<0.001). The modified DSS score for IHD stones ranged from 3 to 7. Blood loss (P=0.02) and operation time (P<0.001) were significantly different among subgroups of patients divided by their difficulty scores. The median hospital stay (P=0.004) and operation time (P=0.039) were significantly longer and the complication rate (P=0.025) and complication grade (P=0.021) were significantly greater in patients with IHD stones than in patients with tumors. The surgical difficulty varies among patients undergoing the same laparoscopic LLS procedure. The modified DSS developed here can also be applied to patients with IHD stones.

A difficulty scoring system (DSS) based on the extent of liver resection, tumor location, liver function, tumor size, and tumor proximity to major vessels was previously developed to assess the difficulty of laparoscopic liver resection (LLR). Recently, we proposed a modified DSS for patients who undergo LLR for intrahepatic duct (IHD) stones. In this study, we validated the modified DSS for LLR for IHD stones. We reviewed the clinical data of 121 patients who underwent LLR for IHD stones between July 2003 and November 2015 and validated the modified DSS in patients who underwent LLR according to their surgical outcomes. We divided the patients into subgroups according to their scores and compared the surgical outcomes, including hospital stay, operation time, blood loss, transfusion rate, and the postoperative complication rate and grade, among the subgroups of patients. The DSS score ranged from 3 to 12 in LLR for IHD stones. The operation time (P < 0.001) significantly increased according to the DSS score. The median hospital stay after surgery (P = 0.024) and transfusion rate (P = 0.001) were significantly different among subgroups of patients divided by their difficulty scores. When we divided the patients into two groups based on the side of liver of resected, the operation time (P < 0.001), mean difficulty score (P < 0.001), and blood loss (P = 0.041) were greater in patients who underwent right liver resection. The surgical difficulty varies among patients undergoing the same LLR procedure for IHD stones. The modified DSS for IHD stones can effectively predict the surgery outcomes and complications of LLR.

Introduction: Laparoscopic liver resection is a challenging procedure, yet it is increasingly applied in the treatment of hepatocellular carcinoma (HCC), including our center. Our aim is to evaluate the impact of laparoscopic hepatectomy for hepatocellular carcinoma regarding the long-term outcomes. Patients and Methods: A combined retrospective-prospective cohort study of 41 HCC patients who underwent laparoscopic hepatectomy at the Organ Transplantation Center, Viet Duc University Hospital from January 2019 to December 2023. Results: Liver resection for tumors &gt;5 cm accounted for 24.4%, with 63.4% of cases classified as high difficulty (Ban Daisuke score). The mean operative time was 192 minutes, and the intraoperative blood transfusion rate was 18.9%. The mean disease-free survival was 44.5 ± 3.19 months, with 1-, 2-, 3-, and 4-year rates of 94.4%, 87.2%, 70.6%, and 70.6%, respectively. The mean overall survival was 50.0 ± 2.30 months, with corresponding rates of 96.7%, 92.9%, 86.8%, and 86.8%. Preoperative AFP 0.5 cm were favorable prognostic factors. Conclusions: Laparoscopic hepatectomy is a safe and effective treatment option for hepatocellular carcinoma offering significant survival benefits. Keywords: Laparoscopic hepatectomy, Difficulty Scoring System, Hepatocellular carcinoma. References GLOBOCAN 2020. Cancer fact sheet: Vietnam fact sheet. Accessed April 29, 2023. https://gco.iarc.fr/today/data/factsheets/populations/704-viet-nam-fact-sheets.pdf Balzan S, Belghiti J, Farges O, et al. The “50-50 Criteria” on Postoperative Day 5 An Accurate Predictor of Liver Failure and Death After Hepatectomy. Annals of Surgery. 2005;242(6):824-829. doi:10.1097/01.sla.0000189131.90876.9e Dindo D, Demartines N, Clavien PA. Classification of Surgical Complications. Annals of Surgery. 2004;240(2):205-213. doi:10.1097/01.sla.0000133083.54934.ae Johnson PJ, Berhane S, Kagebayashi C, et al. Assessment of Liver Function in Patients With Hepatocellular Carcinoma: A New Evidence-Based Approach—The ALBI Grade. Journal of Clinical Oncology. 2015;33(6):550-558. doi:10.1200/jco.2014.57.9151 Ban D, Tanabe M, Ito H, et al. A novel difficulty scoring system for laparoscopic liver resection. J Hepatobiliary Pancreat Sci. 2014;21(10):745-753. doi:10.1002/jhbp.166 Tran Cong Duy Long. Evaluation of the Role of Laparoscopic Liver Resection in the Treatment of Hepatocellular Carcinoma. Doctoral Thesis in Medicine. University of Medicine and Pharmacy at Ho Chi Minh City; 2016. Nguyen Dinh Hieu, Nguyen Quang Nghia, Pham Van Binh. Result of laparoscopic liver resection for hepatocellular carcinoma in Nghe An oncology hospital. VMJ. 2024;536(1B). doi:10.51298/vmj.v536i1B.8822 Yoon YI, Kim KH, Cho HD, et al. Long-term perioperative outcomes of pure laparoscopic liver resection versus open liver resection for hepatocellular carcinoma: a retrospective study. Surg Endosc. 2019;34(2):796-805. doi:10.1007/s00464-019-06831-w Yamamoto M, Kobayashi T, Oshita A, et al. Laparoscopic versus open limited liver resection for hepatocellular carcinoma with liver cirrhosis: a propensity score matching study with the Hiroshima Surgical study group of Clinical Oncology (HiSCO). Surg Endosc. 2020;34(11):5055-5061. doi:10.1007/s00464-019-07302-y Ghielmetti M, Ramser M, Oertli D. Laparoscopic liver resection: a single-centre experience. Swiss Med Wkly. 2021;151:w20391. doi:10.4414/smw.2021.20391 Ruzzenente A, Bagante F, Poletto E, et al. A machine learning analysis of difficulty scoring systems for laparoscopic liver surgery. Surg Endosc. 2022;36(12):8869-8880. doi:10.1007/s00464-022-09322-7 Tsai KY, Chen HA, Wang WY, Huang MT. Long-term and short-term surgical outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma: might laparoscopic approach be better in early HCC? Surg Endosc. 2019;33(4):1131-1139. doi:10.1007/s00464-018-6372-0 Soubrane O, Goumard C, Laurent A, et al. Laparoscopic resection of hepatocellular carcinoma: a French survey in 351 patients. HPB. 2014;16(4):357-365. doi:10.1111/hpb.12142 Cheng CH, Lai Y, Hung HC, et al. Recurrence Patterns After Hepatectomy With Very Narrow Resection Margins for Hepatocellular Carcinoma. Front Surg. 2022;9:926728. doi:10.3389/fsurg.2022.926728. Download file PDF

We report our experience with laparoscopic major liver resection in Korea based on a multicenter retrospective study. Data from 1,009 laparoscopic liver resections conducted from 2001 to 2011 were retrospectively collected. Twelve tertiary medical centers with specialized hepatic surgeons participated in this study. Among 1,009 laparoscopic liver resections, major liver resections were performed in 265 patients as treatment for hepatocellular carcinoma, metastatic tumor, intrahepatic duct stone, and other conditions. The most frequently performed procedure was left hemihepatectomy (165 patients), followed by right hemihepatectomy (53 patients). Pure laparoscopic procedure was performed in 190 patients including 19 robotic liver resections. Hand-assisted laparoscopic liver resection was performed in three patients and laparoscopy-assisted liver resection in 55 patients. Open conversion was performed in 17 patients (6.4 %). Mean operative time and estimated blood loss in laparoscopic major liver resection was 399.3 ± 169.8 min and 836.0 ± 1223.7 ml, respectively. Intraoperative transfusion was required in 65 patients (24.5 %). Mean postoperative length of stay was 12.3 ± 7.9 days. Postoperative complications were detected in 53 patients (20.0 %), and in-hospital mortality occurred in two patients (0.75 %). Mean number and mean maximal size of resected tumors was 1.22 ± 1.54 and 40.0 ± 27.8 mm, respectively. R0 resection was achieved in 120 patients with hepatic tumor, but R1 resection was performed in eight patients. Mean distance of safe resection margin was 14.6 ± 15.8 mm. Laparoscopic major liver resection has become a reliable option for treatment of liver disease in Korea.

Laparoscopic liver resection (LLR) is a high-risk and difficult minimally invasive surgery that requires a comprehensive preoperative evaluation and strict technical training. The Ban Difficulty Scoring System (DSS-B) and the Difficulty Scoring System Based on the Extent of Resection (DSS-ER) are difficulty scoring systems used in LLR. The aim of this study was to explore the clinical practicality of the DSS-B and DSS-ER in LLR. Differences in perioperative data were compared among different difficulty groups. The DSS-B and DSS-ER were used to evaluate the difficulty of LLR in 199 patients with tumors. Furthermore, the DSS-ER was used to evaluate the difficulty of LLR in 50 patients with intrahepatic bile duct stones (IBDSs). Finally, the correlation between the DSS-B and DSS-ER were explored. In 199 patients who underwent LLR for tumors, the results of an intergroup comparison using the DSS-B groupings showed that operation time, intraoperative blood loss, the intraoperative blood transfusion rate, hepatic portal blockage, conversion to open surgery rate, and the postoperative hospital stay were significantly different among the groups (P < .05). Differences in perioperative data among the difficult groups were similar between the DSS-ER and DSS-B groups. A total of 50 patients who underwent LLR for IBDS were grouped based on the DSS-ER, and intergroup comparisons showed that operation time, intraoperative blood loss, the intraoperative blood transfusion rate, and the hepatic portal block rate were significantly different among the groups (P < .05). Moreover, there was a significant difference in DSS-B scores among the DSS-ER groups (P < .001). The DSS-B and DSS-ER accurately classify the degree of difficulty in LLR and therefore provide significant guidance to clinical doctors working and training in LLR.

BackgroundThis study aimed to externally validate and upgrade the recent difficulty scoring system (DSS) proposed by Halls et al. to predict intraoperative complications (IOC) during laparoscopic liver resection (LLR).MethodsThe DSS was validated in a cohort of 128 consecutive patients undergoing pure LLRs between 2008 and 2019 at a single tertiary referral center. The validated DSS includes four difficulty levels based on five risk factors (neoadjuvant chemotherapy, previous open liver resection, lesion type, lesion size and classification of resection). As established by the validated DSS, IOC was defined as excessive blood loss (> 775 mL), conversion to an open approach and unintentional damage to surrounding structures. Additionally, intra- and postoperative outcomes were compared according to the difficulty levels with usual statistic methods. The same five risk factors were used for validation done by linear and advanced nonlinear (artificial neural network) models. The study was supported by mathematical computations to obtain a mean risk curve predicting the probability of IOC for every difficulty score.ResultsThe difficulty level of LLR was rated as low, moderate, high and extremely high in 36 (28.1%), 63 (49.2%), 27 (21.1%) and 2 (1.6%) patients, respectively. IOC was present in 23 (17.9%) patients. Blood loss of >775 mL occurred in 8 (6.2%) patients. Conversion to open approach was required in 18 (14.0%) patients. No patients suffered from unintentional damage to surrounding structures. Rates of IOC (0, 9.5, 55.5 and 100%) increased gradually with statistically significant value among difficulty levels (P < 0.001). The relations between the difficulty level, need for transfusion, operative time, hepatic pedicle clamping, and major postoperative morbidity were statistically significant (P < 0.05). Linear and nonlinear validation models showed a strong correlation (correlation coefficients 0.914 and 0.948, respectively) with the validated DSS. The Weibull cumulative distribution function was used for predicting the mean risk probability curve of IOC.ConclusionThis external validation proved this DSS based on patient’s, tumor and surgical factors enables us to estimate the risk of intra- and postoperative complications. A surgeon should be aware of an increased risk of complications before starting with more complex procedures.

Laparoscopic right-sided liver resection may be feasible and safe. Retrospective analysis. Department of surgery at a university hospital. Of 103 consecutive laparoscopic liver resections performed from May 1, 2003, to April 30, 2007, 46 patients underwent a right-sided laparoscopic liver resection. Six operations required conversion (13%) to open surgery. Overall, data from 40 patients with benign liver tumors (n = 2), intrahepatic duct stones (n = 3), liver metastasis from colorectal cancer (n = 8), and hepatocellular carcinomas (n = 27) were analyzed. Feasibility and operative outcome. The operations included 12 major resections (5 right hemihepatectomy and 7 right posterior sectionectomy) and 28 minor resections (14 segmentectomy and 14 tumorectomy). No operative mortality, subsequent operation, or life-threatening complications occurred. Overall, 11 patients (28%) experienced complications; 2 had bile leakage, 6 had perihepatic fluid collection, 2 had prolonged ascites, and 1 had pleural effusion. All recovered after conservative management. The mean operation time was 300 minutes, the mean blood loss was 620 mL, and the mean hospital stay was 11 days. For lesions located at segment VII or VIII (n = 15), the mean operation time and amount of blood loss in those receiving a minor liver resection were similar to those who received a major resection (P = .21 and .88, respectively). Although greater technical refinement is required for a minor resection in the superior part of the right side of the liver, laparoscopic right-sided liver resection is feasible and safe.

Validation of a Difficulty Scoring System for Laparoscopic Liver Resection: A Multicenter Analysis by the Endoscopic Liver Surgery Study Group in Japan

Ban- Iwate difficulty scoring system for laparoscopic liver resection- Validation in a Single centre UK cohort

Aim. To compare survival after open liver resections and laparoscopic liver resection based on the experience of two large Russian surgical centers using the propensity score matching. Material and methods. The primary point of the study was the assessment of long-term overall and disease-free survival after laparoscopic and open liver resection. The secondary point were immediate outcomes. Propensity score matching was used for balancing covariates and reducing the drawbacks of observational study. Results. The study included data from 185 patients after 93 laparoscopic liver resection and 92 open liver resection. The immediate outcomes of 176 patients (95%) were analyzed. Long-term results were evaluated in 157 patients (85%) with propensity score based analysis. Forty-three pairs were matched. The blood loss and the hospital stay were less in the group of laparoscopic liver resection before matching. After matching, the blood loss was equal in both groups. The length of hospital stay remained significantly shorter in laparoscopic liver resection group after matching. No differences in severe morbidity was observed between groups. No death was registered after open and laparoscopic liver resection. The overall 5-year survival rate in the laparoscopic and open liver resection groups did not differ before and after matching (56%/68% and 72%/76%, respectively). Disease-free 5- and 4-year survival did not differ either, but revealed the trend to be longer after laparoscopic liver resection before and after matching (52%/10% and 58%/28%, respectively). Conclusion. Laparoscopic liver resection for colorectal liver metastases reduced the hospital stay. The overall survival of patients did not depend on the type of approach. Disease-free survival discovered the trend to improve after laparoscopic liver resection.

The aim of this study is to analyze our experiences with laparoscopic surgery for treating intrahepatic duct (IHD) stones and to evaluate its role for the management of IHD stone. Until now, laparoscopic surgery for IHD stone has been rarely reported. From October 1998 to June 2007, we performed 76 cases of laparoscopic surgery for treating IHD stones [30 laparoscopic IHD explorations (LIHDE) and 46 laparoscopic hepatectomy (LH)]. The choice between LIHDE and LH was based on the severity of the IHD stricture, the presence of parenchymal atrophy, and the impaction of stones, as determined by the preoperative radiologic images or intraoperative choledochoscopy. Retrospective analysis was done on the clinical outcomes of the 76 patients. Conversion to open surgery was needed in 6 patients (7.9%). The mean operation time (LIHDE vs. LH) was 278.4 and 344.3 minutes, respectively. The mean postoperative hospital stay was 14.6 and 12.8 days, respectively. Postoperative complications occurred in 28 patients (36.8%), and all of them responded to the conservative management. There was 1 case of postoperative mortality in the LH group because of sepsis. The overall initial success rate of removing the stones by laparoscopic surgery in our intention-to-treat analysis was 78.9% (60 of 76). The reasons for treatment failure included remnant stones (n = 9), conversion to open surgery (n = 6), and postoperative mortality (n = 1). For the 69 patients who had laparoscopic surgery successfully preformed without mortality, the initial success rate of stone clearance was 87.0% (60 of 69) and the final clearance rate after additional choledochoscopic stone removal was 92.8% (64 of 69). This study demonstrates that laparoscopic surgery can be an effective option for managing IHD stones and it also suggests the potential role of laparoscopic surgery for treating IHD stones in the era of laparoscopy.

Despite several attempts to treat intrahepatic duct (IHD) stones by laparoscopy, most cases have been limited to left-sided IHD stones. The aim of this study was to evaluate the therapeutic feasibility and effectiveness of a laparoscopic approach for right-sided IHD stones compared with the open approach for this disease. This study included 34 consecutive patients who underwent laparoscopic (n = 17) and open (n = 17) treatment for right-sided IHD stones from March 2005 to December 2011. Clinical data including the operative time, intraoperative blood loss, postoperative hospital length of stay, postoperative complications, stone clearance, and recurrence rate were retrospectively analyzed and compared between the two groups. Of the 17 patients who underwent laparoscopic treatment, three were treated using laparoscopic intrahepatic duct exploration alone and 14 patients were treated using laparoscopic liver resection. The operative time in the laparoscopic group was longer than that in the open group (432 ± 158 vs. 335 ± 85 min, p = 0.03). The laparoscopic group showed a lower postoperative complication rate than the open group (29 vs. 64 %, p = 0.039). There were no significant differences in intraoperative blood loss (988 ± 929 vs. 879 ± 942 ml, p = 0.737) or postoperative length of hospital stay (16 ± 22 vs. 12 ± 14 days, p = 0.221). This study demonstrated that laparoscopic treatment could be an effective and safe therapeutic modality in selected patients with right-sided IHD stones.

Validation of the Iwate scoring system for the stratification of laparoscopic liver resections: An international multicenter study.

Background: The difficulty scoring system based on the extent of resection (DSS-ER) is a common tool for assessing the difficulty and risk of laparoscopic liver resection (LLR), but DSS-ER fails to comprehensively and accurately assess low level for beginners. Methods: The 93 cases of LLRs for primary liver cancer in the general surgery department of the Second Affiliated Hospital of Guangxi Medical University from 2017 to 2021 were retrospectively analyzed. The low level of DSS-ER difficulty scoring system was reclassified into three grades. The intraoperative and postoperative complications were compared among different groups. Results: There were significant differences in the operative time, blood loss, intraoperative allogeneic blood transfusion, conversion to laparotomy, and allogeneic blood transfusion among the different groups. Meanwhile, the postoperative complications were mainly pleural effusion and pneumonia, and the incidence of grade III was higher compared with other two grades. No significant difference existed in the postoperative biliary leakage and liver failure among three grades. Conclusions: This reclassified low level of DSS-ER difficulty scoring system has certain clinical value for LLR beginners to complete the corresponding learning curve.

Laparoscopic liver resection for centrally located tumors close to the hilum, major hepatic veins, or inferior vena cava