Anterior Sectionectomy Research Articles

Modified liver hanging maneuvers to facilitate various difficult types of hepatectomy: A single center experience

The liver hanging maneuver (LHM) is a useful technique enabling a safe anterior approach. Since the first time described by Belghiti, it has been modified many times by different surgeons to be more effective. Thus, we aim to evaluate the short term results of using some modified liver hanging maneuvers (mLHM) for difficult types of hepatectomy. From February 1 to September 30, 2020, we perform 3 modified techniques of LHM for 4 patients with liver's tumors. mLHM 1: A tape was placed upon the fossa ductus venosi, its cranial tip was passed to the right behind the common trunk of left hepatic vein and middle heptic vein, and its caudal tip passed behind the left Glissonean pedicle to the hepatic hilum. mLHM 2: After transect the caudal part of S1R about 2 cm, a tape was passed through the hepatic hilum and the right hepatic vein - middle hepatic vein pocket along the right border of the paracaval portion. mLHM 3: Instead of a tape, we used 2 fingers to create the tunnel and push the liver forward. Among 4 patients, there were 2 right hepatectomy and caudate lobectomy, 1 left hepatectomy and caudate lobectomy, 1 right anterior sectionectomy with reconstruction right hepatic vein for huge tumor. The modified LHMs were performed successfully in all patients, provide adequate cut planes without complications. The LHM is a safe and effective technique which can be modified to adapt with many types of hepatectomy.

Setting up a division of HBP surgery at a local university hospital

Setting up a division of HBP surgery at a local university hospital

Perioperative and oncologic outcomes of right anterior sectionectomy for liver disease: A single-center experience with 415 patients

Right anterior sectionectomy (RAS) is technically difficult and performed infrequently, so there were a few reports of small numbers about this surgery. We described large number of clinicopathologic and oncologic outcomes associated with RAS. We retrospectively reviewed the medical records of 415 patients treated with RAS for hepatic tumors located at segment 5 and/or 8 between January 2008 and December 2017. All patients underwent RAS with the alternative Glissonean pedicle clamp and Kelly clamp-crushing methods for transection. The mean operative time was 165 minutes and the mean transection time was 28 minutes. Major morbidities (≥ grade III) occurred in 28 cases (6.7%). Bile leakage occurred in 63 patients (15.1%), but no patients required reoperation. Grade A/B/C post-hepatectomy liver failure occurred in 39/7/0 (9.4%/1.7%/0.0%) patients, respectively. There were no in-hospital mortality caused by postoperative complications. The mean hospital stay was 13.3 days. The most common diagnosis was hepatocellular carcinoma (HCC; n = 361, 87.0%), followed by intrahepatic cholangiocarcinoma (n = 15, 3.6%), mixed HCC and cholangiocarcinoma (n = 17, 4.1%), colorectal cancer liver metastasis (n = 12, 2.9%). The mean tumor size was 3.8 cm. Among HCC patients, the 5- and 10- year overall survival (OS) rate was 78.3%, 64.4%, and 5- and 10- year disease-free survival (DFS) rate was 57.2%, 37.7%, respectively. Operative time, tumor size, and vessel invasion were factors significantly associated with OS and DFS for HCC patients. RAS was associated with acceptable procedure-related morbidity and mortality as well as appropriate oncologic outcomes for HCC patients.

Laparoscopic major hepatectomy using dorsal approach to the major hepatic veins

Dorsal approach of right and middle hepatic veins lets their exposure from root to periphery, minimizing venous bleeding. Usefulness of this approach is shown to tradiitional major hepatectomies (right and left hemihepatectomies) as well as tecchnicaly major hepatectomies (anterior and posterior sectionectomies).

Laparoscopic Extended Anterior Hepatic Sectionectomy with Right Hepatic Venous Tumor Thrombectomy (with Video).

Laparoscopic Extended Anterior Hepatic Sectionectomy with Right Hepatic Venous Tumor Thrombectomy (with Video).

Hepatocellular adenoma initially diagnosed as hepatocellular carcinoma with resistance to proton beam radiotherapy - A case report.

Introduction and importanceHepatocellular adenoma (HCA) is a rare liver tumor. We report a case of a radio-resistant liver tumor that was removed surgically and found to be HCA.Case presentationA 37-year-old Japanese man was incidentally diagnosed with a liver tumor. He had no history of viral hepatitis nor metabolic disorders. MRI revealed a tumor enhancing in arterial phase, followed by washout in late phase, and hypointensity in hepatobiliary phase. A diagnosis of hepatocellular carcinoma (HCC) was made and surgery was advised. However, the patient chose proton beam radiotherapy. Although the tumor initially shrunk, it increased in size thereafter. Therefore, anterior sectionectomy was performed. Histology revealed proliferation of hepatocytes without cytologic atypia. On immunohistochemistry, CRP, SAA, GS, L-FABP, and nuclear expression of β-catenin were positive. A final diagnosis of mixed inflammatory and β-catenin activated HCA was made.Clinical discussionHCA is associated with obesity. The present case was a slightly obese man without history of viral hepatitis. In such cases, HCA should be considered. In the present case, proton beam radiotherapy was performed for a diagnosis of HCC. However, the tumor was radio-resistant.ConclusionHCA shows an almost equal male to female ratio in the Asian population. Molecular classification is vital in the management of HCA. HCC and HCA are often difficult to differentiate; tumor biopsy is necessary for patients with atypical imaging findings and in younger patients without underlying liver disease. Since the effectiveness of radiation therapy on HCA has not been reported, surgery should be preferred.

Development of a novel educational tool to assess skills in laparoscopic liver surgery using the Delphi methodology: the laparoscopic liver skills scale (LLSS).

No specific performance assessment scales have been reported in laparoscopic liver resection. This study aimed at developing an objective scale specific for the assessment of technical skills for wedge resection in anterior segments (WRAS) and left lateral sectionectomy (LLS). A laparoscopic liver skills scale (LLSS) was developed using a hierarchical task analysis. A Delphi method obtained consensus among five international experts on relevant steps that should be included into the LLSS for assessment of operative performances. The consensus was predefined using Cronbach's alpha > 0.80. A semi-structured review extracted 15 essential subtasks for full laparoscopic WRAS and LLS for evaluation in the Delphi survey. Two rounds of the survey were conducted. Three over 15 subtasks did not reach the predefined level of consensus. Based on the expert's comments, 13 subtasks were reformulated, 4 subtasks were added, and a revised skills scale was developed. After the 2nd round survey (Cronbach's alpha 0.84), 19 subtasks were adopted. The LLSS was composed of three main parts: patient positioning and intraoperative preparation (task 1 to 8), the core part of the WRAS and LLS procedure (tasks 9 to 14), and completion of procedure (task 15 to 19). The LLSS was developed for measuring the skill set for the education of safe and secure laparoscopic WRAS and LLS procedures in a dedicated training program. After validation, this scale could be also used as an assessment tool in the operating room and extrapolated as an operative roadmap to other complex procedures.

Minimally invasive versus open right anterior sectionectomy and central hepatectomy for central liver malignancies: a propensity‐score‐matched analysis

The utility of minimally-invasive liver resection (MILR) for deep centrally located tumours (CLT) remains controversial. We aimed to review our institution's experience and outcomes with minimally invasive central hepatectomy (CH) and right anterior sectionectomy (RAS) for CLT in a propensity score-matched (PSM) analysis. Retrospective review of a prospectively maintained surgical database revealed 23 patients who underwent MILR (6 CH, 17 RAS) and 53 patients who underwent open liver resection (OLR; 24 CH, 29 RAS) for CLT. PSM in a 1:1 ratio identified two groups of patients with similar baseline clinicopathological characteristics. Peri-operative outcomes were then compared. There was one laparoscopic-assisted, one robot-assisted and two laparoscopic-converted-open procedures in the MILR cohort. Across the unmatched cohort, there was only one mortality (MILR) and five patients with major morbidity (all OLR). MILR was associated with a longer operating time (P < 0.001), but shorter post-operative hospital stay (P = 0.002) and decreased morbidity (P = 0.018) in the unmatched cohort. Examination of peri-operative outcomes after PSM revealed that MILR was similarly associated with a longer operating time (P = 0.001) and shortened post-operative hospital stay (P = 0.043). OLR was associated with a significantly reduced application of Pringle manoeuvre (P = 0.004). There were no significant differences between MILR and OLR with regards to blood loss, blood transfusions, morbidity and margin status in the PSM analysis. MILR for CLT is safe and feasible when performed by experienced surgeons. It is associated with shorter hospital stays but at the expense of longer operation times and more frequent application of Pringle manoeuver.

Central Hepatectomy Versus Major Hepatectomy for Centrally Located Hepatocellular Carcinoma: A Propensity Score Matching Study.

In terms of anatomical liver sectionectomy approaches, both a central hepatectomy (CH) and major hepatectomy (MH) are feasible options for a centrally located hepatocellular carcinoma (HCC). We retrospectively reviewed the surgical outcomes of central HCC patients who underwent CH or MH. MH includes hemihepatectomy or trisectionectomy, whereas CH involves a left medial sectionectomy, right anterior sectionectomy, or central bisectionectomy. The surgical outcomes were compared before and after propensity score matching (PSM). A total of 233 patients were enrolled, including 132 in the CH group and 101 in the MH group. The MH group cases were pathologically more advanced and had poorer overall survival rates than the CH group. After PSM, 68 patients were selected into each group, both of which showed similar overall and recurrence-free survival outcomes. The CH group showed a tendency for a longer operation time; however, other perioperative outcomes were similar between the two groups. Multivariate analyses of our matched HCC patients revealed that the type of surgery (CH or MH) was not an independent prognostic factor. More patients in the matched CH group experienced a repeat hepatectomy for recurrence and no patients in this group underwent a preoperative portal vein embolization. The short- and long-term surgical outcomes of CH and MH for a centrally located HCC are similar under a matched clinicopathological background. CH has the advantage of not requiring a preoperative portal vein embolization and increased chances of conducting a repeat hepatectomy for recurrence.

Laparoscopic anatomical portal territory hepatectomy using Glissonean pedicle approach (Takasaki approach) with indocyanine green fluorescence negative staining: how I do it

BackgroundLaparoscopic anatomical resection (LAR) is a highly challenging procedure. This study aimed to describe our experience of the LAR with an indocyanine green fluorescence negative staining (ICGNS) by the Glissonean pedicle transection (Takasaki) approach. MethodsFrom April 2017 to December 2019, 43 consecutive patients underwent LAR with ICGNS strategy in our medical team. The details of the ICGNS strategy were described. The demographic and clinicopathological data of the included patients were retrospectively analyzed. ResultsThe extent of resections included right hemihepatectomy (n = 12), left hemihepatectom (n = 4), left lateral sectionectomy (n = 3), Right anterior sectionectomy (n = 3), Right posterior sectionectomy (n = 6), central hepatectomy (n = 2), single anterolateral segmentectomy (n = 5), single posterosuperior segmentectomy (n = 6), and bisegmentectomy (n = 2). The mean operation time was 212 ± 53 min, and the median estimated blood loss was 200 (100–300) ml. The overall complication rate was 30.2% (grade I, 14%; grade II, 14%; grade III, 2.3%). The median duration of postoperative hospital stay was 6 (4–7) days. ConclusionICGNS is a safe and feasible LAR strategy that greatly facilitates selecting the liver transection plane, although its benefits need to be verified by large-sample comparative studies.

Tailored Strategy for Dissecting the Glissonean Pedicle in Laparoscopic Right Anterior Sectionectomy: The Extrahepatic, Intrahepatic, and Transfissural Glissonean Approaches (with Video).

The Glissonean approach is a widely used anatomic liver resection technique, which can be divided into three types: the extrahepatic, intrahepatic, and transfissural approaches. This report describes the technical details and surgical outcomes of these laparoscopic right anterior sectionectomy (lap-RAS) approaches. Using the extrahepatic Glissonean approach, the posterior extremity of the cystic plate is dissected and divided. The hilar plate is detached from Laennec's capsule covering the liver parenchyma. The gap between the plate system and Laennec's capsule is entered. Without liver parenchymal transection, the right anterior Glissonean pedicle (RAGP) is dissected extrahepatically. Using the intrahepatic Glissonean approach, the posterior extremity of the cystic plate is divided, and the hilar plate is detached, which may decrease the visibility of the RAGP. The RAGP then is dissected intrahepatically through the minor parenchymal transection around the cystic plate. When the extra- or intrahepatic Glissonean approach fails, the transfissural Glissonean approach can be used, with the RAGP dissected through the major parenchymal transection along the main portal fissure. Three patients underwent lap-RAS using the Glissonean approach. The median operation time was 330min (range, 300-380min), and the median estimated blood loss was 160mL (range, 80-180mL). No cases of postoperative morbidity or mortality were observed. The feasibility of the Glissonean approach in lap-RAS could be increased by appropriate selection of the extrahepatic, intrahepatic, and transfissural Glissonean approaches.

Surgical outcomes of 118 complex laparoscopic liver resections: a single- center experience.

Indications for laparoscopic liver resection (LLR) are continuously expanding. The Japanese Society of Hepato-Biliary-Pancreatic Surgery defines highly difficult hepatectomy as a procedure involving one or more sections (except for left lateral sectionectomy) or anatomical segmentectomy. This study aimed to assess the outcomes of complex LLR procedures and compare their technical difficulties, about which only a little is known to date. We performed a retrospective review of the operative outcomes of 118 consecutive patients who underwent pure laparoscopic complex hepatectomy. The surgical outcomes, including operative times, blood loss amounts, and postoperative morbidity rates, were compared among complex LLR procedures. The overall median operative time was 280minutes, and the median intraoperative blood loss was 86mL. Two patients required conversion to open laparotomy (1.7%). The postoperative major morbidity rate was 11.0% Posterosuperior segmentectomy, right hemihepatectomy, and anterior sectionectomy required the longest operative times. Anterior and posterior sectionectomy resulted in the highest blood loss, and right hemihepatectomy and anterior sectionectomy resulted in the most complications. The surgical difficulties associated with complex LLR procedures vary. It is critical to recognize the specific risks and cautionary points to ensure patient safety and provide proper systemic training to surgeons.

Risk factors for bile leakage: Latest analysis of 10102 hepatectomies for hepatocellular carcinoma from the Japanese national clinical database.

The aim of this study was to identify risk factors for bile leakage in hepatic resections without biliary reconstructions using the large Japanese national clinical database (NCD). A total of 10102 patients who had undergone hepatic resection involving more than one segment without biliary reconstructions for hepatocellular carcinoma during 2015-2017 were enrolled. Risk factors for bile leakage, with special reference to the type of hepatic resection, were identified by multivariable logistic regression analysis. Bile leakage occurred in 726 patients (7.2%). Risk factors for bile leakage were as follows: male sex (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.04-1.58), diabetes mellitus (+) (OR 1.19, 95% CI 1.01-1.39), hemoglobin <10g/dL (OR 1.4, 95% CI 1.02-1.93), albumin <3.5g/dL (OR 1.3, 95% CI 1.03-1.63), central bisectionectomy (OR 3.8, 95% CI 2.81-5.13), left trisectionectomy (OR 3.6, 95% CI 2.10-6.15), right anterior sectionectomy (OR 2.07, 95% CI 1.58-2.72), and S5 or S8 segmentectomy (OR 1.33, 95% CI 1.00-1.77). Central bisectionectomy, left trisectionectomy, and right anterior sectionectomy are high-risk types of hepatic resection for bile leakage.

Safety and feasibility of robotic major hepatectomy for novice surgeons in robotic liver surgery: A prospective multicenter pilot study

BackgroundRobotic liver resection has not yet been widely implemented. We aimed to evaluate the feasibility and safety of robotic major liver resection by performing a prospective multicenter study. MethodsFrom July 2017 to December 2018, five surgeons from five tertiary hospitals who were novices in robotic liver resection but experienced in open and laparoscopic liver resection performed 46 cases of robotic major anatomical liver resections. Perioperative clinical data and surgical data, including detailed procedure times were prospectively collected. All operations were performed according to a protocol for unify surgical techniques and instruments. ResultsTwenty-two cases of left hemihepatectomy, one case of extended left hemihepatectomy, 14 cases of right hemihepatectomy, two cases of right anterior sectionectomy, six cases of right posterior sectionectomy, and one case of central bisectionectomy were performed. The most common indications were hepatocellular carcinoma (21 cases) followed by intrahepatic duct stones (10 cases), intrahepatic cholangiocellular carcinoma (7 cases), liver metastases (3 cases), intraductal papillary neoplasms (2 cases), sarcoma (1 case), mucinous cystic neoplasm (1 case), and hemangioma (1 case). Surgical resection margins for all tumor cases were negative. The mean operation time was 378.58 ± 124.31 (190–696) minutes and the estimated intraoperative blood loss was 276.67 ± 397.41 mL (range, 10–2600 mL). Overall complications developed in 16 cases (34.8%). There were three cases of severe surgical complications (Clavien-Dindo classification of III or more). Only one of 46 cases was converted to conventional open left hemihepatectomy because of bleeding. The mean hospital stay was 7.3 ± 2.5 (4–18) days. ConclusionsThe results of this study indicate that robotic anatomic major liver resection can be safely performed by robotic beginners who are advanced open and laparoscopic liver surgeons.

Intermittent regional hepatic vascular inflow occlusion for laparoscopic right anterior sectionectomy

Objective To compare the efficacy and safety of intermittent regional hepatic vascular inflow occlusion with Pringle’s maneuvre for laparoscopic anterior sectionectomy. Methods From January 2014 to December 2018, 54 patients who underwent laparoscopic right anterior sectionectomy at the Department of Hepatopancreatobiliary Surgery, the Third Affiliated Hospital, Soochow University were recruited into this study. The patients were 40 to 60 years old, and 27 were males and 27 females. Intermittent regional hepatic vascular inflow occlusion was carried out in 24 patients (the intermittent occlusion group). The remaining patients underwent Pringle’s maneuvre (the Pringle group). Postoperative liver function, intraoperative blood loss, intraoperative blood transfusion, operation time and postoperative complications between the two groups were compared. Results Intraoperative hemorrhage and blood transfusion of the Pringle group (534±42)ml, (2.88±0.54)U were significantly higher than the intermittent occlusion group (374±21)ml, (1.86±0.29)U (all P 0.05). Conclusion Intermittent regional hepatic vascular inflow occlusion reduced intra-operative hemorrage and hepatic impairment, and shortened hospital stay. However, it required higher operation skills and it should gradually be promoted. Key words: Hepatectomy; Laparoscopes; Inflow occlusion; Liver function

Feasibility of purely laparoscopic right anterior sectionectomy.

Right anterior sectionectomy is complex in comparison to other liver resections. Thus, the operation has not been widely performed via a laparoscopic approach. We herein present a purely laparoscopic method for right anterior sectionectomy using the standardized techniques. Between May 2017 and December 2018, ten pure laparoscopic right anterior sectionectomies were performed for hepatic malignancy. To perform laparoscopic anatomical liver resection safely and securely, we developed an original surgical procedure based on the isolation of the targeted Glissonean pedicle at the hilum, with appropriate transection planes built sequentially according to anatomical landmarks. The extrahepatic right anterior Glissonean pedicle was isolated without parenchymal destruction by utilizing a unique view in the laparoscopic approach. The selective right anterior segment inflow was temporary occluded, consequently liver parenchymal transection consisted of four planes according to the demarcation line, middle hepatic vein (MHV), right anterior Glissonean pedicle, and right hepatic vein (RHV), which were used as anatomical landmarks. Transection was started between the demarcation line and ventral of the MHV (plane 1). Transection of the parenchyma was then performed from dorsal of the MHV to the right anterior Glissonean pedicle (plane 2). Parenchyma was then transected from dorsal of the RHV to the right anterior Glissonean pedicle (plane 3). We subsequently divide the right anterior Glissonean pedicle with a linear stapler. Finally, the resection plane was completed by performing parenchymal transection between the demarcation line and ventral of the RHV (plane 4). The mean operation time was 446min with 334ml of estimated blood loss. No cases required conversion to open surgery. Bile leakage occurred as a postoperative complication in one patient. There was no mortality. Isolating the extrahepatic Glissonean pedicle at the hilum and transection along four planes determined according to anatomical landmarks made purely laparoscopic right anterior sectionectomy feasible.

Laparoscopic treatment of Caroli’s disease

Caroli’s disease is a rare hepatobiliary disorder characterized by malformations of the intrahepatic medium and large bile ducts, resulting in non-obstructive ductal dilatation, with focal or multifocal segmental involvement of the liver. It is often associated with hepatolithiasis and acute cholangitis. The curative treatment of the localized form is surgical liver resection involving any pathologic bile duct tissue, in order to avoid the development of recurrent disease and life-threatening complications. We have reviewed the literature during the period 2005–2018 concerning the surgical treatment of Caroli’s disease (including 243 liver resections), in order to evaluate the impact of laparoscopic surgery, its technical aspects, feasibility, safety, short- and long-term outcomes. Only 6 reports describing 16 cases available in the most recent literature (years 2009–2018) reported laparoscopic liver resections (7 left lateral hepatic sectionectomies, 7 left hepatectomies, 1 segmentectomy, 1 right anterior sectionectomy). Only 1 conversion to open surgery and 1 complication (a fluid collection) treated conservatively were described. Few data have been reported about the long-term post-operative follow-up. Caroli’s disease is a rare condition with variable clinical complexity, due to the extension of the disease, the localization of pathological bile ducts and the presence of complications. Radical surgery is the treatment of choice for localized disease and in these cases minimally invasive liver resection can have an important therapeutic role, particularly for left located Caroli’s disease. Minimally invasive approach to Caroli’s disease requires high expertise in liver surgery and in complex biliary procedures. Data of the literature are still lacking in long term results and more studies are necessary to confirm the short and long-term results.

Minor hepatectomies: focusing a blurred picture. Analysis of the outcome of 4471 open resections in non-cirrhotic patients

Background: Liver surgery is moving toward a parenchyma-sparing approach, favoring minor hepatectomies (MiH) instead of major resections. MiH encompasse a wide range of procedures at different complexity, whose outcomes have not been fully elucidated. Methods: Consecutive patients undergoing a first liver resection in 17 highly-experienced centers were considered. Cirrhosis, associated digestive/biliary resection and mini-invasive surgery were exclusion criteria. We distinguished limited resections (LR), (mono)segmentectomies (S), left lateral sectionectomies (LLS), right anterior sectionectomies (RAS), right posterior sectionectomies (RPS), and other bisegmentectomies (BS). In addition: LR with exposure of intrahepatic vessels were defined 'complex LR' (CLR); mono/bisegmentectomies Sg7/Sg8 were defined 'postero-superior segmentectomies' (PSS); segmentectomies Sg1 and combined resections of Sg4s+Sg8+Sg1 were defined 'complex core hepatectomies' (CCH). Outcome of LLS and right hepatectomies (RH) were used as reference standards. Outcome of MiH were adjusted for covariates (liver function, diagnosis, chemotherapy, and center). Results: 4471 MiH were analyzed. In comparison with RH, MiH had lower 90-day mortality (0.5%/2.2%, p<0.001), severe morbidity (8.6%/14.4%, p<0.001), and liver failure rates (2.4%/11.6%, p<0.001), but similar bile leak rate. Non-complex LR had outcome similar to LLS. CLR and S/BS of anterolateral segments (Sg2-6) had higher bile leak rates than LLS (odds ratio (OR)=2.2 and OR=2.7), but similar severe morbidity rates. CCH had the highest bile leak rate (OR=5.5), even higher than RH (OR=1.9), and had severe morbidity rate approaching RH (vs. LLS OR=2.4). PSS and RAS had severe morbidity rates similar to RH (OR=1), while RPS had slightly lower rates. The three procedures had bile leak rates similar to RH. MiH had low liver failure rates (<5%) except for RAS (9.7% vs. 11.6% after RH). Conclusion: MiH include resections having heterogeneous outcome. Mortality rate is low, but MiH can be stratified according to severe morbidity, liver failure and bile leak rates, most complex resections having outcome similar to RH. Bile leak and severe morbidity rates of different MiH in comparison with LLS and RH

Unplanned conversion during minimally invasive liver resection for hepatocellular carcinoma: risk factors and surgical outcomes.

PurposeUnplanned conversion is sometimes necessary during minimally invasive liver resection (MILR) of hepatocellular carcinoma (HCC). The aims of this study were to compare surgical outcomes of planned MILR and unplanned conversion and to investigate the risk factors after unplanned conversion.MethodsWe retrospectively analyzed 286 patients who underwent MILR with HCC from January 2006 to December 2017. All patients were divided into a MILR group and an unplanned conversion group. The clinicopathologic characteristics and outcomes were compared between the 2 groups. In addition, surgical outcomes in the conversion group were compared with the planned open surgery group (n = 505). Risk factors for unplanned conversion were analyzed.ResultsOf the 286 patients who underwent MILR, 18 patients (6.7%) had unplanned conversion during surgery. The unplanned conversion group showed statistically more blood loss, higher transfusion rate and postoperative complication rate, and longer hospital stay compared to the MILR group, whereas no such difference was observed in comparison with the planned open surgery group. There were no significant differences in overall and disease-free survival among 3 groups. The right-sided sectionectomy (right anterior and posterior sectionectomy), central bisectionectomy and tumor size were risk factors of unplanned conversion.ConclusionUnplanned conversion during MILR for HCC was associated with poor perioperative outcomes, but it did not affect long-term oncologic outcomes in our study. In addition, when planning right-sided sectionectomy or central bisectionectomy for a large tumor (more than 5 cm), we should recommend open surgery or MILR with an informed consent for unplanned open conversions.

Minimally invasive major hepatectomies: a Southeast Asian single institution contemporary experience with its first 120 consecutive cases.

The role of minimally invasive major hepatectomy (MIMH) remains controversial and questions remain about its safety and reproducibility outside expert centres. This study examines the changing trends, safety and outcomes associated with the adoption of MIMH based on a contemporary single institution experience. This study is a review of 120 consecutive patients who underwent MIMH between 2011 and 2018. To determine the evolution of MIMH, the study population was stratified into four equal groups of patients. Both conventional major hepatectomies (CMHs) (≥3 segments) and technical major hepatectomies (right anterior and posterior sectionectomies) were included. There were 70 CMHs and 50 technical major hepatectomies. Seven MIMHs were laparoscopic-assisted and 113 (94.2%) were totally laparoscopic/robotic. There were 10 (8.3%) open conversions. Comparison across the four groups demonstrated that with increasing experience, there was a significant trend in a higher proportion of higher American Society of Anesthesiologists score patients, increasing frequency of CMH performed, increasing frequency of multifocal tumours resected, decreasing use of laparoscopic-assisted approach and decrease in blood loss. MIMH can be adopted safely today with a low open conversion rate. Over time with increasing experience, we performed MIMH with increasing frequency in higher risk patients and in patients with multifocal tumours but with a decrease in median estimated blood loss.