Anatomical Liver Resection Research Articles

Indications for and limitations of laparoscopic anatomical liver resection: assessment of postoperative complications stratified by complexity of liver resection.

Although complex anatomical liver resections are more often being performed laparoscopically, the short-term outcomes following laparoscopic anatomical liver resection (LALR), its optimal indications, and limitations remain unclear. This study aimed to clarify the indications for and limitations of LALR by assessing the short-term outcomes. This retrospective study included 233 patients who underwent LALR. The complexity of LALR was categorized into three levels: Grade I (low), grade II (moderate), and grade III (high). Short-term outcomes were compared among these groups, and the risk factors for severe morbidity were identified. The patients' backgrounds were similar across the three groups. Intraoperative blood loss, Pringle maneuver time, and postoperative hospital stay were comparable between grade I (n = 59) and grade II (n = 65) LALR but were greater for grade III (n = 109). The transfusion and conversion rates were similar among the three groups. The operative time increased with the rise in difficulty grade. The rate of severe morbidity was 3.4% in grade I, 6.2% in grade II, and 16.5% in grade III LALR (P = 0.012). Multivariable analysis identified three perioperative risk factors for severe morbidity: Operative time of ≥ 540min (odds ratio [OR] = 4.762, P = 0.009), intraoperative blood loss of ≥ 350mL (OR = 3.982, P = 0.024), and preoperative serum albumin of ≤ 3.8g/dL (OR = 3.518, P = 0.035). Grade II LALR can be performed with the same level of safety as grade I LALR. However, grade III LALR has a higher complication rate than grades I and II LALR, and the risk increases further due to longer operative time and greater blood loss.

Does minimally invasive anatomical hepatectomy reduce surgical site infections?

Aim: This study aims to clarify the effectiveness of laparoscopic anatomical liver resections (ALRs) in surgical site infections (SSIs). Methods: We included 95 cases (44.0%) of laparoscopic ALRs (LALRs) and 121 (56.0%) of open ALRs (OALRs). Retrospective comparisons were performed between the two groups. Results: In preoperative factors, tumor size was significantly smaller in LALRs than in OALRs (34.4 ± 23.0 mm vs . 45.9 ± 35.7 mm, P = 0.007). The operative duration was longer in LALRs than in OALRs (523.0 ± 186.5 min vs . 356.3 ± 100.5 min, P < 0.001). However, the blood loss and the blood transfusion were fewer in LALRs than in OALRs (592.1 ± 911.7 mL vs . 1,240.6 ± 1,131.8 mL, P < 0.001, 26.3% vs . 48.8%, P = 0.001, respectively). Postoperative complications above the Clavien-Dindo grade IIIb were one case (1.1%) in LALRs and two in OALRs (P = 1.000). The postoperative hospital stay was shorter in LALRs than in OALRs (14.8 ± 16.5 days vs . 20.7 ± 18.9 days, P = 0.017). There was one (0.8%) postoperative death within 90 days in OALRs and none (0.0%) in LALRs (P = 1.000). Incisional SSIs (ISSIs) were significantly reduced in LALRs than in OALRs (1.1% vs . 7.4%, P = 0.045). Organ/space SSIs (OSSIs) were observed in five cases (5.3%) in LALRs and seven cases (5.8%) in OALRs (P = 1.000). A strong correlation between bile leakage and OSSIs was found. Although OSSIs (Odds ratio 31.200, P = 0.009) were the significant predictive factors for developing ISSIs in OALRs, no risk factors predicting ISSIs were found in LALRs using Multivariate logistic regression analyses. Conclusion: Although this is a limited study at a single institution, minimally invasive anatomical hepatectomy can reduce ISSIs.

Efficacy and safety of indocyanine green-fluorescence imaging guided liver resection: a single-arm prospective cohort study

PurposeThis study aimed to evaluate the efficacy of indocyanine green (ICG)-fluorescence imaging for the identification of hepatic boundaries during liver resection and its advantages in surgical outcomes over conventional methods.MethodsThis prospective, exploratory, single-arm clinical trial included 47 patients with liver tumors who underwent liver resection using ICG-fluorescence imaging (ICG-LR) between 2019 and 2020. The primary outcome measure was the successful identification of hepatic boundaries during liver resection, from the perspective of both the hepatic surface and intrahepatic boundary, using ICG-fluorescence imaging. The secondary outcomes comprised surgical outcomes. Using propensity score matching (PSM), the surgical outcomes were subsequently compared between the ICG-LR group and patients who underwent conventional liver resection (C-LR, n = 100) between 2017 and 2018.ResultsHepatic boundaries were successfully identified in 28 patients (60%; 95% confidence interval, 45–72%), including 21 and 7 who underwent anatomical and non-anatomical liver resection, respectively. After PSM, 40 patients were included in each of the ICG-LR and C-LR groups. The surgical outcomes were similar between the groups. Subsequently, surgical outcomes were compared between the groups focusing on anatomical liver resection. After PSM, 21 patients were included in each group. The ICG-LR group had a lower rate of Clavien–Dindo grade ≥ IIIa complications (0% vs. 24%; P = 0.017), including ascites and bile leak, and a shorter hospital stay (12 vs. 14 days, P = 0.041) than the C-LR group did.ConclusionICG-fluorescence imaging could be used to recognize hepatic boundaries during liver transection. Additionally, ICG-LR may be useful in preventing severe liver-associated complications.Trial registration numberThis study is registered at the UMIN Clinical Trials Registry: UMIN0000180139 and Japan Registry of Clinical Trials: jRCT1051180070. The Registration Data Set is available at https://jrct.niph.go.jp/.

Technical tips for indocyanine green-guided minimally invasive anatomical liver resection

Minimally invasive anatomical liver resection is increasingly feasible due to the improved availability of preoperative 3-dimensional (3D) reconstruction of the liver as well as endoscopic cameras with near-infrared indocyanine green fluorescence overlay visualization. In this article, we share our experience and perceived benefits of anatomical liver resection with preoperative 3D liver reconstruction, provide technical tips to improve success at pedicle isolation and address common pitfalls that may be encountered by adopters early on their learning curve.

Laennec approach for anatomical liver resection assisted by laparoscopy or robotics: a multicenter cohort study.

Laennec's capsule serves as a critical anatomical landmark in anatomical liver resection. Despite its potential, a lack of large-scale prospective studies limits the widespread use of the Laennec approach for minimally invasive hepatectomy. This multicenter cohort study aimed to compare the outcomes of the traditional and Laennec approaches in minimally invasive anatomical hepatectomy across multiple centers in China. A total of 445 patients from 11 centers were included, with 339 undergoing the Laennec approach and 106 receiving the traditional approach. Intraoperative parameters such as the duration of hepatic pedicle isolation, hepatic vein exposure, parenchymal transection, and liver mobilization were analyzed. Postoperative outcomes, including recurrence-free survival (RFS) and R0 resection rates, were also assessed. Additionally, a series of subgroup analyses was conducted to evaluate the efficacy of the Laennec approach. The Laennec approach demonstrated notable intraoperative advantages, including reduced durations for hepatic pedicle isolation, liver mobilization, hepatic vein exposure, and parenchymal transection. Robotic-assisted procedures, in particular, showed superior outcomes when compared to laparoscopic platform. The Laennec approach proved highly effective across various liver diseases, particularly hepatocellular carcinoma (HCC), hemangioma, and hepatolithiasis. The Laennec gap, a distinct gap between the liver parenchyma and surrounding vasculature, played a key role in identifying candidates for Laennec approach. Subgroup analysis revealed that although the Laennec approach provides significant intraoperative benefits, these advantages seem not to translate into substantial postoperative improvements. The Laennec approach offers clear intraoperative advantages over the traditional approach when utilizing laparoscopic or robotic systems. These findings support the Laennec approach as a standardized technique for anatomical liver resection.

Novel techniques of liver segmental and subsegmental pedicle anatomy from segment 1 to segment 8.

Laparoscopic anatomical liver resection has become more challenging because some subsegmental Glissonean pedicles are hard to dissect. Here, we introduce how to dissect every (sub) segmental Glissonean pedicle from the first porta hepatis and perform standardized (sub) segmentectomy [from segment 1 (S1) to S8]. To summarize our methods of laparoscopic anatomical segmental and subsegmental liver resection. The Glisson sheath and liver capsule were separated along the Laennec membrane. The Glissonean pedicle could be isolated and transected with little or no parenchymal damage through this extra-Glissonean dissection approach. The basin of the (sub) segment was determined by the ischemia demarcation line or indocyanine green staining. The hepatic vein or intersegmental vein was also used to guide the plane of parenchymal transection. All segmental or subsegmental pedicles or even the pedicle of the cone unit could be dissected along the Laennec membrane using our novel technique through the first porta hepatis. The dorsal branches of S8, the branches of S4a and the paracaval portion branches (b/c vein) of the caudate lobe were the most difficult to dissect. The novel techniques of liver segmental and subsegmental pedicle anatomy is feasible for laparoscopic liver resection and can help accurately guide (sub) segmentectomy from S1 to S8.

Application of indocyanine green–human serum albumin complex in fluorescence image-guided laparoscopic anatomical liver resection: study protocol for a randomized controlled trial

BackgroundIndocyanine green (ICG) is a near-infrared fluorescent dye widely used for intraoperative navigation during liver surgeries because of its non-radioactive nature, high safety, and minimal impact on liver function. However, variability in its dosage and concentration and its low imaging success rates have limited its widespread application. To address these issues, we developed a novel ICG–human serum albumin (ICG-HSA) complex to enhance fluorescence visualization during laparoscopic anatomical liver resection.MethodsThis prospective, double-blind, single-center, randomized controlled trial will compare the fluorescence navigation effects of the novel ICG-HSA complex with the guideline-recommended ICG administration scheme. The study will involve patients aged 18 to 75 years with malignant liver tumors. The participants will undergo evaluations at specified time points, and data will be collected using an internet-based electronic data capture system. The primary outcome will be the effectiveness of intraoperative fluorescence imaging, assessed by three independent experts. The secondary outcomes will be conversion to open surgery, the total operative time, intraoperative blood loss, and long-term survival rates.DiscussionThe aim of using this novel ICG-HSA complex will be to improve the success rate of fluorescence navigation in liver resection by ensuring better stability and a longer liver retention time compared with free ICG. This study seeks to validate the clinical value of ICG-HSA in enhancing surgical precision and outcomes, ultimately promoting its broader clinical application. The results are expected to provide high-level evidence supporting the safety and efficacy of this new fluorescence imaging agent.Trial registrationClinicalTrial.gov NCT06219096. Registered on 1 December 2024.

Evaluating microvascular invasion in hepatitis B virus-related hepatocellular carcinoma based on contrast-enhanced computed tomography radiomics and clinicoradiological factors.

Microvascular invasion (MVI) is a significant indicator of the aggressive behavior of hepatocellular carcinoma (HCC). Expanding the surgical resection margin and performing anatomical liver resection may improve outcomes in patients with MVI. However, no reliable preoperative method currently exists to predict MVI status or to identify patients at high-risk group (M2). To develop and validate models based on contrast-enhanced computed tomography (CECT) radiomics and clinicoradiological factors to predict MVI and identify M2 among patients with hepatitis B virus-related HCC (HBV-HCC). The ultimate goal of the study was to guide surgical decision-making. A total of 270 patients who underwent surgical resection were retrospectively analyzed. The cohort was divided into a training dataset (189 patients) and a validation dataset (81) with a 7:3 ratio. Radiomics features were selected using intra-class correlation coefficient analysis, Pearson or Spearman's correlation analysis, and the least absolute shrinkage and selection operator algorithm, leading to the construction of radscores from CECT images. Univariate and multivariate analyses identified significant clinicoradiological factors and radscores associated with MVI and M2, which were subsequently incorporated into predictive models. The models' performance was evaluated using calibration, discrimination, and clinical utility analysis. Independent risk factors for MVI included non-smooth tumor margins, absence of a peritumoral hypointensity ring, and a high radscore based on delayed-phase CECT images. The MVI prediction model incorporating these factors achieved an area under the curve (AUC) of 0.841 in the training dataset and 0.768 in the validation dataset. The M2 prediction model, which integrated the radscore from the 5 mm peritumoral area in the CECT arterial phase, α-fetoprotein level, enhancing capsule, and aspartate aminotransferase level achieved an AUC of 0.865 in the training dataset and 0.798 in the validation dataset. Calibration and decision curve analyses confirmed the models' good fit and clinical utility. Multivariable models were constructed by combining clinicoradiological risk factors and radscores to preoperatively predict MVI and identify M2 among patients with HBV-HCC. Further studies are needed to evaluate the practical application of these models in clinical settings.

Long-Term Outcomes of Laparoscopic Anatomical versus Non-Anatomical Liver Resection for Hepatocellular Carcinoma.

The objective of this study was to investigate the long-term outcomes between laparoscopic anatomical liver resection (LAR) and laparoscopic non-anatomical liver resection (LNAR) in patients with hepatocellular carcinoma (HCC). In this single-center retrospective cohort study, 1773 patients, from January 2009 to December 2017, were assessed for inclusion. After exclusions, 661 patients were included: 304 patients received LAR and 357 patients received LNAR. Propensity score matching (PSM) with 1:1 ratio was used to eliminate the selection bias between LAR and LNAR groups. The Kaplan-Meier and Cox models were used for survival analysis. After PSM, 250 patients were in LAR or LNAR group, respectively. The overall survival (OS) had no significant difference between LAR and LNAR by Kaplan-Meier analysis. While, LAR had better disease-free survival (DFS) compared with LNAR (Log-rank P=0.035). The cumulative 5-year DFS rates were 48% for LAR, and 38% for LNAR. By Cox analysis, LAR was an independent risk factor of DFS (HR=1.308, P=0.030). In subgroup analysis for tumor size ≤ 5 cm, 207 patients were in LAR or LNAR subgroup after PSM. LAR had better DFS compared with LNAR (Log-rank P=0.033). LAR was an independent risk factor of DFS (HR=1.333, P=0.036). The cumulative 5-year DFS rates were 50% for LAR, and 39% for LNAR. In another subgroup analysis for tumor size > 5 cm, 43 patients were in LAR or LNAR subgroup after PSM. The DFS had no significant difference between LAR and LNAR (Log-rank P=0.912). LAR is preferred for HCC patients with tumor size ≤5cm compared with LNAR because of the better DFS. For patients with tumor size >5cm, LAR and LNAR might be alternative procedures with comparable long-term outcomes.

Laparoscopic central hepatectomy: Feasibility and safety.

Anatomical liver resection is the gold standard for hepatocellular carcinoma (HCC), enhancing survival and disease-free outcomes. For centrally located tumors, major resections are necessary but risky, especially for patients with liver disease. Central hepatectomy (CH) offers a parenchymal-sparing alternative to extended or hemihepatectomy (HH), reducing postoperative liver failure risk. However, its complexity and the large transection area make it challenging, especially with laparoscopic techniques. This study evaluates the feasibility and safety of laparoscopic CH for centrally located HCC, comparing surgical outcomes with those of the HH group. A total of 1592 laparoscopic hepatectomy cases from January 2011 to April 2023 were reviewed in a single institution. Patients undergoing laparoscopic CH were compared to those receiving HH during the same period. Exclusion criteria included non-HCC diagnosis, non-central tumors, and cases involving combined procedures. 70 cases of laparoscopic CH and 32 cases of laparoscopic HH were included. The CH and HH groups showed similar estimated blood loss (median 400ml vs. 290ml, p = 0.187) and intraoperative blood transfusion rates (10% vs. 15%, p = 0.413). Operation time did not significantly differ (median 330min vs. 360min, p = 0.862). Postoperative hospital stay was shorter in CH (median 6days vs. 9days, p = 0.018), with fewer ICU transfers (19% vs. 44%, p = 0.014) and lower 90-day mortality (1% vs. 9%, p = 0.055) compared to HH. Complication rates were similar overall (26% vs. 41%, p = 0.069), but HH had more Clavien-Dindo class I and II complications (13% vs. 19%, p = 0.040). Long-term survival did not significantly differ, but tended to favor the CH group. Despite the complexity, laparoscopic CH offers comparable perioperative outcomes and favorable long-term survival compared to HH. It can be considered a viable option for centrally located HCC, preserving liver function.

Real-time indocyanine green fluorescence imaging and navigation for cone unit laparoscopic hepatic resection of intrahepatic duct stone: a case series study

Background Intrahepatic bile duct stones, although common and benign, require varying therapeutic strategies due to their recurrent nature. Inadequate management can escalate to liver cirrhosis or cholangiocarcinoma. A surgical method merging indocyanine green fluorescence imaging (ICG-FI) with liver cone unit resection is optimal, ensuring complete lesion removal and healthy liver tissue conservation. Method A retrospective descriptive study was conducted on 15 patients with intrahepatic bile duct stones who were admitted to Sichuan Provincial People’s Hospital from January 2021 to December 2023. All patients underwent laparoscopic anatomical liver resection guided by ICG-FI. Results Among the 15 patients included in the study, ten were male and five were female, with an average age of 52 years. All patients were free from underlying medical conditions. Intraoperatively, ICG-FI was good, with clear boundaries, and all patients successfully underwent surgery without any conversions to open surgery. The mean operative time was 236 ± 56 min, and the estimated blood loss was 320 ± 75 ml. Patients had a postoperative hospital stay of 5.5 ± 1.5 days. No severe complications occurred. Conclusions Real-time ICG-FI with anatomical liver resection is a safe and effective approach for managing intrahepatic bile duct stones.

Use of indocyanine green-human serum albumin complexes in fluorescence image-guided laparoscopic anatomical liver resection: a case series study (with video)

BackgroundThis study aimed to investigate the feasibility and efficacy of near-infrared fluorescence-guided laparoscopic anatomical hepatectomy (LAH) using a novel indocyanine green (ICG)-human serum albumin complex (HSA) in patients with hepatocellular carcinoma.MethodsClinical data of hepatocellular carcinoma patients who underwent ICG-HSA fluorescence-guided LAH at our center from January 2024 to April 2024 were prospectively collected and analyzed. Ultraviolet absorption spectroscopy was used to test the absorption and stability of ICG-HSA complex solutions under different conditions. After determining the optimal ratio, the complex was administered intravenously during surgery to perform negative staining via Glissonean pedicle isolation. LAH was performed along the fluorescence-demarcated boundaries.ResultsThirty-one patients were included (24 men; mean age, 54.61 ± 13.54 years). The median maximum tumor diameter was 2.80 (interquartile range [IQR], 2.00–4.00) cm. S8 segmentectomy (22.6%) and right posterior segmentectomy (19.4%) were the most common resections performed. Successful fluorescence negative staining was achieved in all patients using ICG and HSA at a 1:6 molar ratio at room temperature. Mean operation time was 297.58 ± 85.53 min, Median intraoperative blood loss was 100.0 mL (IQR, 50.0–200.0). The median surgical margin distance was 0.90 cm (IQR, 0.40–1.50). The postoperative complication rate was 45.2% (35.5% Clavien–Dindo grade I and 9.7% grade II). The median length of hospital stay was 5.0 days (IQR, 4.0–5.0).ConclusionICG-HSA-assisted LAH is safe and feasible. Compared with free ICG, the novel ICG-HSA complex exhibits better optical properties and in vivo stability, which can improve the accuracy of intraoperative liver segment localization and optimize the anatomical dissection plane. It has the potential to become an ideal fluorescent imaging agent for anatomical hepatectomy.Graphical abstractA In vitro binding experiments of indocyanine green (ICG) and human serum albumin (HSA) suggested that a 1:6 molar ratio and a configuration temperature of 37°C were optimal. B During surgery, after extrahepatic Glissonean isolation of the liver pedicle planned for resection, the ICG-HSA complex was administered through a peripheral vein using an infusion pump. C ICG-HSA metabolism comprises three stages: intravascular, liver, and systemic clearance. D The actual intraoperative fluorescence imaging and guidance effects of ICG-HSA in laparoscopic fluorescence negative-staining right hemihepatectomy.

An initial report of robotic-assisted anatomical liver resection with indocyanine green fluorescence navigation using the ultrasound-guided preoperative positive staining technique.

Robotic-assisted surgery has become increasingly popular because of its potential benefits. Anatomical liver resection (ALR) is a valuable strategy in hepatocellular carcinoma (HCC) management. ALR with indocyanine green (ICG) fluorescence navigation was reported as an effective solution for segment identification. We reported a simple and convenient "preoperative positive staining technique" for laparoscopic ALR to overcome some limitations. To our knowledge, this is the first report of robotic-assisted surgery in which ALR was performed using this technique. A 69-year-old man presented with a 12-mm HCC in segment 8. Preoperative three-dimensional simulation images showed that the fourth-order branch of the portal vein was a tumor-bearing portal pedicle. After anesthesia induction, 1 mL of 0.025 mg/mL ICG was injected percutaneously into this branch under B-mode ultrasound guidance before pneumoperitoneum. A robotic laparoscope was inserted. The preoperative positive staining area was clearly stained on the liver surface with the Firefly mode on the da Vinci Xi system. Based on the demarcation line, the liver parenchymal resection was started. The ICG fluorescence staining area was checked frequently on the resected side of the liver transection plane. Subsequently, the fourth-order portal branch was identified with the ICG fluorescence technique and ligated. Finally, the specimen was resected. The operation took 352 min, with 10 mL of blood loss, and was completed without any operative problems. Although many cases are required, the proposed preoperative positive staining technique appears useful for accurate and precise surgery given the increasing application of robotic-assisted hepatectomy.

The Usefulness of Fluorescence Imaging in Laparoscopic Liver Resection

AbstractIndocyanine green (ICG) has been used extensively in medical applications after being approved by the Food and Drug Administration (FDA) in 1954. In the beginning, this substance was originally employed for evaluating cardiac output and quantifying liver function. The widespread acceptance of the technique was delayed until the early 2000s, when advancements in digital imaging resolution provided more satisfactory images compared with those of film-based photography. ICG-based fluorescence imaging has since been used in various aspects of liver surgery. In 2008, Aoki et al first reported an intraoperative technique for subsegmental and segmental fluorescent staining during open hepatectomy, achieving a success rate of 93% in identifying the anatomical plane. At about the same time, laparoscopic liver resections (LLRs) were increasingly used for liver malignancies but were still in a developmental phase with yet to be standardized surgical protocols. Combined ICG fluorescence imaging in LLR has since been developed to improve the quality and precision of anatomical liver resections. This article is a case presentation and review of the clinical applications of ICG fluorescence imaging in liver surgery.

Safety and Feasibility of Laparoscopic Anatomical Liver Resection for Hepatocellular Carcinoma: A Propensity Score-matched Study.

Laparoscopic anatomical liver resection (LAR) for hepatocellular carcinoma (HCC) is technically demanding. Therefore, this study aimed to compare the perioperative and long-term oncological outcomes of LAR and open anatomical liver resection (OAR) for HCC. We retrospectively analyzed 460 consecutive patients who underwent anatomical liver resection as the initial treatment for primary HCC between January 2010 and February 2024. Patients were categorized into the LAR and OAR groups, and surgical outcomes between the groups were compared using 1:1 propensity score matching (PSM). After PSM, the LAR and OAR groups included 100 patients each. The LAR group exhibited significantly less blood loss (80 vs. 436 ml; p<0.0001), lower transfusion rates (0% vs. 12%; p=0.0002), shorter operative time (345 vs. 398 min; p=0.0009), lower postoperative morbidity rates (6% vs. 34%; p<0.0001), and shorter postoperative hospital stay (8 vs. 15 days; p<0.0001) than the OAR group. The 1-, 3-, and 5-year overall survival rates were 97.7%, 96.2%, and 89.7%, respectively, in the LAR group and 98.0%, 92.7%, and 88.4%, respectively, in the OAR group (p=0.5874). The 1-, 3-, and 5-year recurrence-free survival rates were 93.2%, 75.7%, and 60.7%, respectively, in the LAR group and 86.0%, 64.5%, and 59.1%, respectively, in the OAR group (p=0.2314). LAR showed improvements in perioperative complications, reduced postoperative hospital stay, and comparable recurrence-free and overall survival rates with those of OAR. Therefore, LAR for HCC is considered safe, feasible, and oncologically acceptable in selected patients.

Robotic caudo-peripheral approach for liver parenchymal transection in anatomical liver resections for hepatocellular carcinoma

Liver parenchymal transection is a challenging step during hepatic resection, particularly when using robotic platforms that require specific skills to optimize this phase. Pedicle division at the beginning of the liver parenchyma helps to better identify the resection plane and minimizes blood loss. The three-dimensional (3D) high-definition vision and the robotic Maryland allow for clear identification of the hepatic pedicles that could be dissected or divided without the need for a laparoscopic ultrasonic dissector. The caudo-peripheral technique, combined with the Maryland bipolar Kelly clamp crushing technique, is a useful approach to complete parenchymal transection and achieve safe anatomical resections in cases of hepatocellular carcinoma (HCC) with multi-pronged bleeding control. This is essential for expediting the procedure, reducing the number of intermittent clamping times, and minimizing the risk of ischemia-reperfusion injury. In this setting, perfect synchronization between the surgeon operating at the console and the bedside assistant is crucial. Advances in artificial intelligence (AI) systems have shown great potential to redefine clinical care management, preoperative planning, and intraoperative decision making for patients with HCC. This paper describes the most relevant details of our technique, its theoretical background, advantages, and limitations. Moreover, minimally invasive surgery offers the opportunity to share surgical experiences and technical progress through multimedia videos. This represents a modern and effective teaching tool to accelerate the learning process and overcome the challenges of the most complex procedures by offering surgeons various solutions to common technical problems.

Persistent hyperbilirubinemia following preoperative biliary stenting in patients undergoing anatomic hepatectomy predicts serious complications.

Biliary obstruction before liver resection is a known risk factor for post-operative complications. The aim of this study was to determine the impact of persistent hyperbilirubinemia following preoperative biliary drainage before liver resection. The ACS-NSQIP (2016-2021) database was used to extract patients with cholangiocarcinoma who underwent anatomic liver resection with preoperative biliary drainage comparing those with persistent hyperbilirubinemia (> 1.2mg/dL) to those with resolution. Patient characteristics and outcomes were compared with bivariate analysis. Multivariable modeling evaluated factors including persistent hyperbilirubinemia to evaluate their independent effect on serious complications, liver failure, and mortality. We evaluated 463 patients with 217 (46.9%) having hyperbilirubinemia (HB) despite biliary stenting. Bivariate analysis demonstrated that patients with HB had a higher rate of serious complications than those with non-HB (80.7% vs 70.3%; P = 0.010) including bile leak (40.9% vs 31.8%; P = 0.045), liver failure (26.7% vs 17.9%; P = 0.022), and bleeding (48.4% vs 36.6%; P = 0.010). Multivariable analysis demonstrated that persistent HB was independently associated with serious complications (OR 1.88, P = 0.020) and mortality (OR 2.39, P = 0.049) but not post-operative liver failure (OR 1.65, P = 0.082). Failed preoperative biliary decompression is a predictive factor for post-operative complications and mortality in patients undergoing hepatectomy and may be useful for preoperative risk stratification.

A pilot study of virtual liver segment projection technology in subsegment-oriented laparoscopic anatomical liver resection when indocyanine green staining fails (with video).

Precision surgery for liver tumors favors laparoscopic anatomical liver resection (LALR), involving the removal of specific liver segments or subsegments. Indocyanine green (ICG)-negative staining is a commonly used method for defining resection boundaries but may be prone to failure. The challenge arises when ICG staining fails, as it cannot be repeated during surgery. In this study, we employed the virtual liver segment projection (VLSP) technology as a salvage approach for precise boundary determination. Our aim was to assess the feasibility of the VLSP to be used for the determination of the boundaries of the liver resection in this situation. Between January 2021 and June 2023, 12 consecutive patients undergoing subsegment-oriented LALR were included in this pilot series. The VLSP technology was utilized to define the resection boundaries at the time of ICG-negative staining failure. Routine surgical parameters and short-term outcomes were evaluated to assess the safety of VLSP in this procedure. In addition, its feasibility was assessed by analyzing the accuracy between the predicted resected liver volume (PRLV) and actual resected liver volume (ARLV). Of the 12 enrolled patients, the mean operation time was 444.58 ± 101.70min (range 290-570min), with a mean blood loss of 125.00 ± 96.53ml (range 50-400mL). One patient (8.3%) was converted to laparotomy for subsequent parenchymal transection, four (33.3%) received blood transfusions and four (33.3%) had postoperative complications. All patients received an R0 resection. The Pearson correlation coefficient (r) between PRLV and ARLV was 0.98 (R2 = 0.96, p < 0.05), and the relative error (RE) was 8.62 ± 6.66% in the 12 patients, indicating agreement. Failure of intraoperative ICG-negative staining during subsegment-oriented LALR is possible, and VLSP may be an alternative to define the resection boundaries in such cases.

Impact of anatomical liver resection for hepatocellular carcinoma in preventing early-phase local recurrence after surgery.

The superiority of anatomical liver resection (AR) for localized hepatocellular carcinoma (HCC) over nonanatomical liver resection (NR) remains controversial. This study aimed to investigate the impact of AR in preventing local and early HCC recurrence. A total of 280 patients who underwent initial liver resection for solitary HCC ≤5 cm in diameter were categorized into the AR and NR groups and compared using propensity score matching analysis. Between the matched pairs (n = 87 in each group), the incidence rates of local and early (recurrence within 2 years after surgery) recurrences in the AR group were significantly lower than those in the NR group (13.8% vs. 28.7%, p = .025; 20.7% vs. 35.6%, p = .028, respectively). The overall survival in the AR group was better than that in the NR group (median: 13.4 vs. 7.6 years, p = .003). NR was among independent risk factors for early recurrence (odds ratio: 1.98, 95% CI: 1.1-3.6, p = .023) and prognostic factors for local recurrence (hazard ratio: 2.44, 95% CI: 1.4-4.4, p = .003). AR is superior in controlling local and early recurrence postoperatively for solitary HCC ≤5 cm in diameter compared with NR.

Which Surgical Technique for Liver Resection is Favourable in Patients with Colorectal Liver Metastases?

Abstract Background The liver is the most common metastatic site after curative treatment for colorectal cancer (CRC). Around 50% of all patients with CRC will develop colorectal liver metastases (CRLM). Liver resection (LR) represents a curative treatment option. Benefits of anatomic (ALR) versus non-anatomic liver resection (NALR) show a lack of consistent evidence. While ALR seems to be associated with a higher postoperative complication rate, NALR could lead to more recurrences. Aims We investigated complication and survival rates of patients with CRLM after both resection types. Methods This is a multicentre cohort study using retrospectively and prospectively collected data. All patients undergoing LR for CRLM between 2009 and 2020 from 3 specialised centres in Switzerland and Germany were included. Complication and survival rates after ALR versus NALR were analysed using uni- and multivariate Cox regression models. Results 624 patients were included. Median follow-up time was 25.49 months. In 292/624 patients (47%) ALR was performed, while 53% underwent NALR. Complications according to the Clavien-Dindo classification have been observed significantly more often in the ALR group (p=0.001). Especially severe complications grade III and IV have been more present after ALR (36/292 vs. 26/332 and 13/292 vs. 11/332, respectively). Both, length of ICU and postoperative hospital stay have been significantly longer in the ALR group (p&amp;lt;0.001 each). The uni- and multivariate models have shown no significant differences in overall survival (OS) and recurrence free survival rates (RFS) between both groups (for OS adjusted HR of 0.84 (95% CI 0.59 - 1.21; p=0.35) and for RFS adjusted HR 0.92 (95% CI 0.69 - 1.22, p=0.56)). Conclusion This multicentre prospective study investigating ALR versus NALR for CRLM has shown no significant differences in OS and RFS. However, postoperative complications have been reported significantly more often after ALR. NALR seems to be the better choice for patients with CRLM undergoing LR.