Minimally Invasive Hepatectomy Research Articles

Laparoscopic versus open hepatic resection in patients ≥75 years old: A NSQIP analysis evaluating 2674 patients.

Previous studies report promising outcomes with minimally invasive (MIS) hepatectomy in elderly patients but remain limited by small size. This study aims to comparatively evaluate the demographics and outcomes of geriatric patients undergoing MIS and open hepatectomy. The 2016-2021 NSQIP database was evaluated comparing patients ≥75 undergoing MIS versus open hepatectomy. Patient selection and outcomes were compared using bivariate analysis with multivariable modeling (MVR) evaluating factors associated with serious complications and mortality. Propensity score matched (PSM) analysis further evaluated serious complications, mortality, length of stay (LOS), Clavien Dindo Classification (CDC), and Comprehensive Complication Index (CCI) for cohorts. We evaluated 2674 patients with 681 (25.5%) receiving MIS hepatectomy. MIS approaches were used more for partial lobectomy (85.9% vs. 61.7%; p < 0.001), and required fewer biliary reconstructions (1.6% vs. 10.6%; p < 0.001). Patients were similar with regards to sex, body mass index, and other comorbidities. Unadjusted analysis demonstrated that MIS approaches had fewer serious complications (8.8% vs. 18.7%; p < 0.001). However, after controlling for cohort differences the MIS approach was not associated with reduced likelihood of serious complications (odds ratio [OR]: 0.77; p = 0.219) or mortality (OR: 1.19; p = 0.623). PSM analysis further supported no difference in serious complications (p = 0.403) or mortality (p = 0.446). However, following PSM a significant reduction in LOS (-1.99 days; p < 0.001), CDC (-0.26 points; p = 0.016) and CCI (-2.79 points; p = 0.022) was demonstrated with MIS approaches. This is the largest study comparing MIS and open hepatectomy in elderly patients. Results temper previously reported outcomes but support reduced LOS and complications with MIS approaches.

The First Prospective Study Investigating the Safety and Feasibility of a Spray-Type Adhesion Barrier (AdSpray™) in Minimally Invasive Hepatectomy: An Analysis of 124 Cases at Our Institution.

(1) Background: With the increasing demand for repeat hepatectomy, preventing perihepatic adhesion formation following initial hepatectomy is crucial. Adhesion-preventative barriers, like the new spray-type AdSprayTM (Terumo Corporation, Tokyo, Japan), have been proposed to reduce adhesion risk. However, data on their safety in minimally invasive hepatectomy (MIH) remain scarce. This is the first prospective study to evaluate the safety and feasibility of AdSprayTM in MIH. (2) Methods: A total of 124 patients who underwent MIH with AdSprayTM and 20 controls were analyzed. Subgroup analysis according to the AdSpray™ application area was conducted. Major complications were assessed using the Clavien-Dindo classification. Moreover, intraperitoneal pressure during AdSpray™ application was monitored in 20 cases. (3) Results: Major complications occurred in 6.4% of the patients, which was comparable to that in open hepatectomy. Intraperitoneal pressure remained stable below 12 mmHg during AdSpray™ application without any complications. No significant difference in complication rates was observed among subgroups. However, a potential increase in intra-abdominal abscess formation was suspected with AdSpray™ application to the resected liver surfaces. (4) Conclusions: AdSpray™ can be safely used in MIH; however, further research is needed to confirm the appropriacy of using AdSpray™, particularly over resected liver surfaces. Overall, AdSpray™ is a promising tool for enhancing the safety of MIH.

Comparing Outcomes of Minimally Invasive and Open Hepatectomy for Primary Liver Malignancies in Patients with Low-MELD Cirrhosis

IntroductionCirrhotic patients with primary liver cancer may undergo curative-intent resection when selected appropriately. Patients with T1 tumors and low-MELD are generally referred for resection. We aim to evaluate whether minimally invasive hepatectomy (MIH) is associated with improved outcomes versus open hepatectomy (OH). MethodsNSQIP hepatectomy database 2014–2021 was used to select patients with T1 Hepatocellular Carcinoma (HCC) or Intra-hepatic Cholangiocarcionoma (IHCC) and low-MELD cirrhosis (MELD ≤ 10) who underwent partial hepatectomy. Propensity score matching was applied between OH and MIH patients, and 30-day postoperative outcomes were compared. Multivariable regression was used to identify predictors of post-hepatectomy liver failure (PHLF) in the selected population. ResultsThere were 922 patients: 494 (53.6%) OH, 372 (40.3%) MIH, and 56 (6.1%) began MIH converted to OH (analyzed with the OH cohort). We matched 354 pairs of patients with an adequate balance between the groups. MIH was associated with lower rates of bile leak (HR 0.37 [0.19–0.72)], PHLF (HR 0.36 [0.15–0.86]), collections requiring drainage (HR 0.30 [0.15–0.63]), postoperative transfusion (HR 0.36 [0.21–0.61]), major (HR 0.45 [0.27–0.77]), and overall morbidity (HR 0.44 [0.31–0.63]), and a two-day shorter median hospitalization (3 vs. 5 days; HR 0.61 [0.45–0.82]). No difference was noted in operative time, wound, respiratory, and septic complications, or mortality. Regression analysis identified ascites, prior portal vein embolization (PVE), additional hepatectomies, Pringle’s maneuver, and OH (vs. MIH) as independent predictors of PHLF. ConclusionMIH for early-stage HCC/IHCC in low-MELD cirrhotic patients was associated with improved postoperative outcomes over OH. These findings suggest that MIH should be considered an acceptable approach in this population of patients.

Hospital Volume and Textbook Outcomes in Minimally Invasive Hepatectomy for Hepatocellular Carcinoma

BackgroundHospital volume affects outcomes of patients who underwent resection for hepatocellular carcinoma (HCC). We sought to assess the impact of minimally invasive hepatectomy (MIH) volume on short- and long-term outcomes among patients with HCC. MethodsPatients who underwent MIH for HCC from 2010 to 2018 were identified from the National Cancer Database. Multivariable modeling with restricted cubic splines (RCS) was utilized to identify the MIH hospital volume threshold. Textbook outcome (TO) was defined as no conversion to open resection, negative margins after resection (R0), no extended length-of-stay, no readmission, and no 90-day mortality. ResultsAmong 3268 patients who underwent MIH for HCC, median age was 65.0 (IQR 59.0–72.0) and the majority was male (n = 2308, 70.6%). MIH hospital volume ranged from 1 to 87 cases, with a median of 13 (IQR 7–23). Overall, 2151 (60.9%) patients achieved TO after resection. While particularly high rates of achievement were found for no 90-day mortality (n = 3106, 95.0%), no readmission (n = 3153, 96.5%), and R0 resection (n = 3,017, 92.3%), other TO components including no conversion to open (n = 2778, 85.0%) and no prolonged LOS (n = 2584, 79.1%) were achieved less frequently. Patients treated at high-volume centers (≥50 MIH cases) were more likely to experience TO (high volume centers, n = 334, 68.7% vs. low volume centers, n = 1656, 59.5%, p < 0.001) and better long-term survival (5-year OS; high volume centers, 64.7% vs. low volume centers, 54.6%, p < 0.001). ConclusionsMIH hospital volume was associated with a higher likelihood of achieving TO and improved long-term survival among patients undergoing resection of HCC.

The impact of hospital volume on the outcomes of minimally invasive hepatectomy for HCC

Background: Volume-outcome effects in healthcare have been previously reported, including in hepato-pancreato-biliary surgery. However, the definition of high-volume care for minimally invasive hepatectomy (MIH) for hepatocellular carcinoma (HCC) remains unclear. We sought to define the impact of MIH hospital volume associated with better short- and long-term survival outcomes among patients with HCC.

Black patients experience severe complications and reduced access to minimally invasive hepatectomy

Background: Hepatocellular carcinoma and hepatic metastasis are two important cause of liver resection. Literature has shown that Minimally invasive Hepatectomies (MIH) have shorter length of stay and fewer complications. However, limited literature exists about the association between race and access to MIH. This study aims to identify the racial disparities in the different approaches to hepatectomy. We further evaluate the relationship between the race and postoperative complications.

Purely laparoscopic living donor right posterior sectionectomy: expanding living donors in America

Background: Minimally-invasive hepatectomy in living donor transplantation remains an infrequent practice in American institutions, limited to few centers with expertise. The practice of living donation is further restricted by anatomical variants in certain donors where a standard right or left hepatectomy does not provide adequate donor remnant volume or sufficient graft weight for the recipient. Whenever feasible, the use of right posterior sector grafts can provide a suitable alternative. This video aims to showcase our approach to a purely laparoscopic right posterior sectionectomy for living donation.

Comparison of Clinical Outcome between Minimally Invasive and Open Hepatectomy at High Difficulty Score for Hepatocellular Carcinoma

Introduction: Minimally invasive (MIS) hepatectomy at high difficulty score for hepatocellular carcinoma (HCC) is controversial. Method: From 2004 to 2019, there were 338 patients (MIS group n = 35, open group n = 303) undergone hepatectomy at high difficulty score (score 7 – 10) for HCC. Propensity score (PS) matching was performed between two groups. Short-term and long-term outcomes were compared. Univariate and multivariate analyses was performed to identify prognostic factors affecting overall and disease-free survival. Results: After PS matching, there were 35 patients in MIS group and 70 patients in open group. Compared with open group, MIS group had less blood loss (150 mL vs. 360 mL), longer operative time (375 min vs. 250 min) and shorter hospital stay (6 days vs. 7 days). The R0 resection rate, hospital mortality, severe complication rate and hospital stay were similar between two groups. With a median follow-up of 24 months, there was no difference in tumor recurrence rate (MIS group: 25.7%; open group: 47.1%). There was no significant difference in 5-year overall survival rate between MIS and open groups (85.9% vs. 71.6%) (P = 0.083). The 5-year disease-free survival rate was also comparable between two groups (66.2% vs. 45.2%) (P = 0.199). Serum albumin, cirrhosis, intraoperative blood loss and postoperative complication, but not surgical approach (MIS vs. open), were associated with poor disease-free survival. Conclusions: MIS hepatectomy at high difficulty score for HCC can achieve similar clinical outcomes in selected patients as those with open approach.

Long-term Outcomes of Open versus Minimally Invasive Hepatectomy for Hepatocellular Carcinoma: A Single-Center Experience in the USA

Introduction: Surgical resection is the treatment of choice for hepatocellular carcinoma (HCC). With advances in technology, minimally invasive surgery has become the standard of care in most fields of general surgery, including hepatectomy. We compared the clinicopathologic features and long-term prognosis of HCC between open hepatectomy (OH) and minimally invasive hepatectomy (MIH).

Donor Outcomes after a Split Policy Implementation at a Dual Pediatric-Adult Transplant Center

Introduction: Minimally-invasive hepatectomy has been associated with reduced length of stay (LOS) and recovery time compared to open hepatectomy. Minimally-assisted living donor hepatectomy (MLDH, laparoscopic or robotic) is performed in a small number of centers in the US. Herein, we reviewed our experience of MLDH.

Parenchymal-sparing hepatectomy for colorectal liver metastases reduces postoperative morbidity while maintaining equivalent oncologic outcomes compared to non-parenchymal-sparing resection

Abstract Objective Modern chemotherapy and repeat hepatectomy allow to tailor the surgical strategies for the treatment of colorectal liver metastases (CRLM). This study addresses the hypothesis that parenchymal-sparing hepatectomy reduces postoperative complications while ensuring similar oncologic outcomes compared to the standardized non-parenchymal-sparing procedures. Methods Clinicopathological data of patients who underwent liver resection for CRLM between 2012 and 2019 at a major hepatobiliary center in Switzerland were assessed. Patients were stratified according to the tumor burden score [TBS2 = (maximum tumor diameter in cm)2 + (number of lesions)2)] and were dichotomized in a lower and a higher tumor burden cohort according to the median TBS. Postoperative outcomes, overall survival (OS) and disease-free survival (DFS) of patients following parenchymal-sparing resection (PSR) for CRLM were compared with those of patients undergoing non-PSR. Results During the study period, 153 patients underwent liver resection for CRLM with curative intent. PSR was performed in 79 patients with TBS &amp;lt; 4.5, and in 42 patients with TBS ≥ 4.5. In patients with lower tumor burden (TBS &amp;lt; 4.5), PSR was associated with lower complication rate (15.2% vs. 46.2%, p = 0.009), and shorter length of hospital stay (5 vs. 9 days, p = 0.006) in comparison to non-PSR. For TBS &amp;lt; 4.5, PSR resulted in equivalent 5-year OS (48% vs. 39%, p = 0.479) and equivalent 5-year DFS rates (DFS, 44% vs. 29%, p = 0.184) compared to non-PSR. For TBS ≥ 4.5, PSR resulted in lower postoperative complication rate (33.3% vs. 63.2%, p = 0.031), lower length of hospital stay (6 vs. 9 days, p = 0.005), equivalent 5-year OS (29% vs. 22%, p = 0.314), and equivalent 5-year DFS rates (29% vs. 22%, p = 0.896) compared to non-PSR. Among all patients treated with PSR, patients undergoing minimal-invasive hepatectomy had equivalent 5-year OS (42% vs. 37%, p = 0.261) and equivalent 5-year DFS (34% vs. 34%, p = 0.613) rates compared to patients undergoing open hepatectomy. Conclusion PSR for CRLM is associated with lower postoperative morbidity, shorter length of hospital stay, and equivalent oncologic outcomes compared to non-PSR independently from tumor burden. Our findings suggest that minimal-invasive PSR should be considered as the preferred method for the treatment of curatively resectable CRLM if allowed by tumor size and location.

Risk Factors for Postoperative Bile Leak and Outcomes in Patients Undergoing Minimally Invasive Hepatectomy: A Contemporary ACS NSQIP Analysis

Introduction: Despite advances in surgical technique, bile leak remains a common complication associated with morbidity following hepatectomy. We sought to identify risk factors of biliary leak and outcomes in patients undergoing minimally-invasive hepatectomy. Methods: An ASC-NSQIP multi-institutional retrospective cohort study from 2014-2017. Distribution of bile leak by surgical approach was identified. Univariate and multivariate factors associated with bile leak and outcomes were evaluated using chi-square and logistic regression. Results: Of 13,955 patients who underwent hepatectomy, 10,190(73%) were open, 3438(24.6%) were laparoscopic and 323(2.3%) were robotic. A laparoscopic approach was associated with decreased bile leak for all hepatectomies (5.4% vs 8.4%; p=0.028) compared to robotic. Multivariate operative risk factors for bile leak in minimally-invasive hepatectomies included laparoscopic (vs robotic) approach (OR=0.51 [95% CI 0.33-5.06]; p=0.003), conversion (OR=2.28 [95% CI 1.62-3.10]; p< 0.001), biliary reconstruction (OR=4.11 [95% CI 2.14-7.90]; p< 0.001) and transfusion (OR=1.88 [95% CI 1.28-2.75]; p=0.001). Bile leak was associated with increased reoperation (0.8% vs 8.9%; p< 0.001), 30-day readmission (5.4% vs 27.2%; p< 0.001), 30-day mortality (0.6% vs 1.9%; p=0.042), increased median length of stay (3 days vs 6 days; p< 0.001), and any (15.2% vs 65.3%; p< 0.001), surgical (9.7% vs 59.6%; p< 0.001) and medical (6.9% vs 28.6%; p< 0.001) complications for patients who underwent minimally-invasive hepatectomy (Table 1). Conclusion: Risk factors for developing bile leak in patients undergoing minimally-invasive hepatectomy were identified. Bile leaks were associated with multiple additional complications, and the robotic approach was a greater risk for bile leak than laparoscopic approach.Table 1

Predictors of Conversion and Outcomes for Patients Undergoing Minimally Invasive Hepatectomy: A Contemporary ASC NSQIP Analysis

Introduction: Minimally-invasive techniques are growing for liver resections. Laparoscopic and robotic liver resections may differ in unplanned conversions. We sought to identify risk factors for conversion and if conversion was associated with increased morbidity and mortality. Methods: This is an ACS-NSQIP multi-institutional retrospective study from 2014-2017. Patients were grouped into open, robotic and laparoscopic hepatectomy. Univariate and multivariate analysis (MVA) of factors associated with conversion and outcomes were investigated. Results: Of 14,055 patients who underwent hepatectomy, 10,279(73.1%) were open, 3,452(24.6%) were laparoscopic and 324(2.3%) were robotic. The rate of unplanned conversions was significantly lower in robotic vs laparoscopic (5.6% vs 15.4%; p< 0.001). Robotic hepatectomy was associated with decreased conversion for minor (5.5% vs 13.7%; p< 0.001), major (5.9% vs 23.8%; p=0.003) and right (3.2% vs 24.4%; p=0.007) hepatectomy compared to laparoscopic. Operative factors associated with conversion on MVA included concurrent intraoperative ablation (OR=1.49 [95% CI 1.13-1.96]; p=0.005), Pringle (OR=2.15 [95% CI 1.70-2.73]; p< 0.001), and laparoscopy (OR=3.00 [95% CI 1.85-4.86]; p< 0.001). Patients who underwent minimally-invasive hepatectomy with conversion were associated with increased bile leak (13% vs 4.5%; p< 0.001), 30-day readmission (11.7% vs 5.9%; p< 0.001), 30-day mortality (1.6% vs 0.5%; p=0.008), length of stay (5 days vs 3 days; p< 0.001), and increased surgical (29.7% vs 9.7%; p< 0.001), wound (9.1% vs 3.6%; p< 0.001) and medical (17% vs 6.6%; p< 0.001) complications (Table 1). Conclusion: Minimally-invasive hepatectomies with conversion are associated with increased complications. More conversions are associated with the laparoscopic approach compared to robotic.

Minimal-Invasive Versus Open Hepatectomy for Colorectal Liver Metastases: Bicentric Analysis of Postoperative Outcomes and Long-Term Survival Using Propensity Score Matching Analysis.

Minimal-invasive hepatectomy (MIH) has been increasingly performed for benign and malignant liver lesions with most promising short-term results. However, the oncological role of MIH in the treatment of patients with colorectal liver metastases (CRLM) needs further investigation. Clinicopathological data of patients who underwent liver resection for CRLM between 2012 and 2017 at the Department of Surgery, Charité-Universitätsmedizin Berlin, and the Inselspital Bern were assessed. Postoperative outcomes und long-term survivals of patients following MIH were compared with those after conventional open hepatectomy (OH) after 1:1 propensity score matching. During the study period, 229 and 91 patients underwent liver resection for CRLM at the Charité Berlin and the Inselspital Bern, respectively. Patients who underwent MIH in one of the two centers (n = 69) were compared with a matched cohort of patients who underwent OH. MIH was associated with lower complication rates (23% vs. 44%, p = 0.011), shorter length of intensive care unit stay (ICU, 1 vs. 2 days, p = 0.043), shorter length of hospital stay (7 vs. 11 days, p < 0.0001), and a reduced need for intraoperative transfusions (12% vs. 25%, p = 0.047) compared to OH. R0 status was achieved in 93% and 75% of patients after MIH and OH, respectively (p = 0.005). After a median follow-up of 31 months, MIH resulted in similar five-year overall survival (OS) rate (56% vs. 48%, p = 0.116) in comparison to OH. MIH for CRLM is associated with lower postoperative morbidity, shorter length of ICU and hospital stay, reduced need for transfusions, and comparable oncologic outcomes compared to the established OH. Our findings suggest that MIH should be considered as the preferred method for the treatment of curatively resectable CRLM.

The initiation, standardization and proficiency (ISP) phases of the learning curve for minimally invasive liver resection: comparison of a fellowship-trained surgeon with the pioneers and early adopters.

Using the Ideal Development Exploration Assessment and Long-term study (IDEAL) paradigm, Halls et al. created risk-adjusted cumulative sum (RA-CUSUM) curves concluding that Pioneers (P) and Early Adopters (EA) of minimally invasive (MI) liver resection obtained similar results after fewer cases. In this study, we applied this framework to a MI Hepatic-Pancreatic and Biliary fellowship-trained surgeon (FT) in order to assess where along the curves this generation fell. The term FT was used to designate surgeons without previous independent operative experience who went from surgical residency directly into fellowship. Three phases of the learning curve were defined using published data on EAs and Ps of MI Hepatectomy, including phase 1 (initiation) (i.e., the first 17 or 50), phase 2 (standardization) (i.e., cases 18-46 or 1-50) and phase 3 (proficiency) (i.e., cases after 46, 50 or 135). Data analysis was performed using the Social Science Statistics software ( www.socscistatistics.com ). Statistical significance was defined as p < .05. From November 2007 until April 2018, 95 MI hepatectomies were performed by a FT. During phase 1, the FT approached larger tumors than the EA group (p = 0.002), that were more often malignant (94.1%) when compared to the P group (52.5%) (p < 0.001). During phase 2, the FT operated on larger tumors and more malignancies (93.1%) when compared to the Ps (p = 0.004 and p = 0.017, respectively). However, there was no difference when compared to the EA. In the phase 3, the EAs tended to perform more major hepatectomies (58.7) when compared to either the FT (30.6%) (p = 0.002) or the P's cases 51-135 and after 135 (35.3% and 44.3%, respectively) (both p values < 0.001). When compared to the Ps cases from 51-135, the FT operated on more malignancies (p = 0.012), but this was no longer the case after 135 cases by the Ps (p = 0.164). There were no statistically significant differences when conversions; major complications or 30- and 90-day mortality were compared among these 3 groups. Using the IDEAL framework and RA-CUSUM curves, a FT surgeon was found to have curves similar to EAs despite having no previous independent experience operating on the liver. As in our study, FTs may tend to approach larger and more malignant tumors and do more concomitant procedures in patients with higher ASA classifications than either of their predecessors, without statistically significant increases in major morbidity or mortality. It is possible that the ISP (i.e., initiation, standardization, proficiency) model could apply to other innovative surgical procedures, creating different learning curves depending on where along the IDEAL paradigm surgeons fall.

Minimally Invasive Hepatectomy in North America: Laparoscopic Versus Robotic

BackgroundMinimally invasive hepatectomy has been shown to be associated with improved outcomes when compared with open surgery. However, data comparing laparoscopic and robotic hepatectomy is lacking and limited to single-center studies. MethodsPatients undergoing major (≥ 3 segments) or partial (≤ 2 segments) hepatectomy were identified in the 2014–2017 ACS-NSQIP hepatectomy targeted database. Patients undergoing laparoscopic and robotic approaches were compared, and propensity score matching was utilized to adjust for bias. ResultsOf 3152 minimally invasive hepatectomies (MIHs), 86% (N = 2706) were partial and 14% (N = 446) were major. The laparoscopic approach was utilized in 92% of patients (N = 2905) and 8% were performed robotically (N = 247). The percentage of MIHs increased over time (p < 0.01). After matching, 240 were identified in each cohort. Compared with the robotic approach, patients undergoing laparoscopic hepatectomy had a significantly higher conversion rate (23% vs. 7.4%) but had shorter operative time (159 vs. 204 min) (p < 0.001). Laparoscopic cases undergoing an unplanned conversion to open were associated with increased morbidity (p < 0.001), but this difference was not observed in robotic cases. Both MIH approaches had low mortality (1.0%, p = 1.00), overall morbidity (17%, p = 0.47), and very short length of stay (3 days, p = 0.80). ConclusionMinimally invasive hepatectomy is performed primarily for partial hepatectomies. Laparoscopic hepatectomy is associated with a significantly higher conversion rate, and converted cases have worse outcomes. Both minimally invasive approaches are safe with similar mortality, morbidity, and a very short length of stay. [Display omitted]

Critical appraisal of the learning curve of minimally invasive hepatectomy: experience with the first 200 cases of a Southeast Asian early adopter.

A recent study analysing the experience of fellowship-trained early adopting surgeons during stage 3 of the IDEAL paradigm demonstrated that the learning curve (LC) of minimally invasive hepatectomy (MIH) can be shortened compared to the long steep LC of pioneering surgeons. In this study, we aimed to critically appraise the contemporary learning experience with MIH of a 'self-taught' early adopter during stage 3 of the IDEAL paradigm. A review of the first 200 patients who underwent MIH over an 88-month period since 2011 by a single surgeon who had no prior training in MIH was conducted. The cohort was divided into four groups of 50 patients. Risk-adjusted cumulative sum analysis of the LC was performed. Two hundred patients underwent MIH and there were 13 (6.5%) open conversions. There were 55 (27.5%) major resections and 94 (47.0%) were graded as high/expert difficulty according to the Iwate criteria. Fifty-one (25.5%) patients had cirrhosis and 98 (49%) had previous abdominal surgery including 28 (14%) with previous liver resections. There were five (2.5%) major (Grade 3b-5) morbidities, zero 30-day mortality and one (0.5%) 90-day mortality. Comparison across the four groups demonstrated a significant trend towards increased adoption of total MIH, increased multifocal tumours, increased performance of major hepatectomies and decreased blood loss. Risk-adjusted cumulative sum analysis demonstrated that the LC in terms of blood loss, blood transfusion rate, open conversion rate, operation time and post-operative length of stay to be 65 cases. The LC for MIH of Iwate low/intermediate difficulty and of Iwate high/expert difficulty were 35 and 30 cases, respectively. MIH of all difficulty levels is feasible and can be safely adopted today even by surgeons with no prior formal training. The LC of the 'self-taught' early adopter is about 65 cases.

Minimally invasive hepatectomy is associated with decreased morbidity and resource utilization in the elderly.

The aim of this study was to evaluate whether elderly patients undergoing elective hepatectomy experience increased morbidity/mortality and whether these outcomes could be mitigated by minimally invasive hepatectomy (MIH). 15,612 patients from 2014 to 2017 were identified in the Hepatectomy Targeted Procedure Participant Use File of the American College of Surgeons National Surgical Quality Improvement Program. Multivariable logistic regression models were constructed to examine the effect of elderly status (age ≥ 75years, N = 1769) on outcomes with a subgroup analysis of elderly only patients by open (OH) versus MIH (robotic, laparoscopic, and hybrid, N = 4044). Propensity score matching was conducted comparing the effect of MIH to OH in elderly patients to ensure that results are not the artifact of imbalance in baseline characteristics. Overall, elderly patients had increased risk for 30-day mortality, major morbidity, prolonged length of hospital stay, and discharge to destination other than home. In the elderly subgroup, MIH was associated with decreased major morbidity (OR 0.71, P = 0.031), invasive intervention (OR 0.61, P = 0.032), liver failure (OR 0.15, P = 0.011), bleeding (OR 0.46, P < 0.001), and prolonged length of stay (OR 0.46, P < 0.001). Propensity score-matched analyses successfully matched 4021 pairs of patients treated by MIH vs. OH, and logistic regression analyses on this matched sample found that MIH was associated with decreased major complications (OR 0.69, P = 0.023), liver failure (OR 0.14, P = 0.010), bile leak (OR 0.46, P = 0.009), bleeding requiring transfusion (OR 0.46, P < 0.001), prolonged length of stay (OR 0.46, P < 0.001), and discharge to destination other than home (OR 0.691, P = 0.035) compared to OH. MIH is associated with decreased risk of major morbidity, liver failure, bile leak, bleeding, prolonged length of stay, and discharge to destination other than home among elderly patients in this retrospective study. However, MIH in elderly patients does not protect against postoperative mortality.

Laparoscopic Hepatectomy (with or without Robotic Assistance) versus Radiofrequency Ablation as a Minimally Invasive Treatment for Very Early-Stage or Early-Stage Hepatocellular Carcinoma

Background: The advantages of radiofrequency ablation (RFA) over hepatectomy as a treatment for early-stage hepatocellular carcinoma (HCC) include reduced morbidity and more rapid recovery. Although minimally invasive surgery provides similar benefits, few studies have compared the long-term oncological outcomes of these techniques. This study aimed to compare the outcomes of minimally invasive hepatectomy (MIH) and RFA. Methods: Patients who underwent MIH or RFA for HCC between January 2005 and January 2015 were included in a propensity score matching analysis. Only patients who underwent minimally invasive procedures for small HCC were included. Baseline clinical and laboratory parameters were retrieved from the hospital database and analyzed. Results: Two hundred and twenty-five patients underwent MIH or RFA for HCC during the study period. Propensity score matching yielded 59 patient-pairs. The complication rates did not differ statistically between the 2 groups (p = 0.309). However, MIH provided significantly better overall (p = 0.005) and disease-free survival outcomes (p < 0.001) than RFA. Conclusions: Compared with RFA, MIH provided better long-term survival outcomes in patients with early-stage HCC, with no increase in the incidence of complications. When feasible, MIH should be considered a first-line treatment for this patient population.

Minimally invasive hepatectomy reduces major morbidity and hospital resource utilization in the elderly

Background: Elderly patients undergoing liver resection are at increased risk for surgical morbidity and mortality. Previous studies suggest minimally invasive hepatectomy (MIH) is associated with some improved peri-operative outcomes compared to open hepatectomy (OH), such as decreased length of stay (LOS) and blood loss. We aimed to determine whether MIH (laparoscopic, robotic, both, or assisted) compared to OH may mitigate increased peri-operative risks in elderly patients undergoing liver resection for all indications. Methods: 13,775 patients undergoing elective liver resections (sub-segmentectomy excluded) from 2014-2016 were identified in the participant use file from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) with hepatectomy targeted procedure variables. Elderly (Age ≥ 75 years) were compared to non-elderly patients with respect to risk-adjusted surgical mortality, major morbidity, and hospital resource utilization. Major morbidity was defined as any reoperation, invasive intervention, or end organ failure. Major hepatectomy was defined as any trisectionectomy or hemihepatectomy compared to partial hepatectomy. Multivariable logistic regression models were constructed to evaluate outcomes between MIH and OH in the elderly subgroup, controlling for variables identified on baseline demographic analysis to be significant confounders of the intervention-outcome association. Effect modification by extent of hepatectomy was also evaluated. Results: On multivariable analysis, elderly patients had increased risk of 30-day mortality (OR = 2.8, P < 0.001), major morbidity (OR = 1.2, P = 0.021), post-hepatectomy liver failure (OR = 1.5, P = 0.015), prolonged LOS (OR = 1.5, P < 0.001), and discharge to destination other than home (OR = 4.2, P < 0.001). When examining the effect of MIH on outcomes in the elderly subgroup on multivariable analysis, MIH compared to OH was associated with decreased risk of major morbidity (OR = 0.66, P = 0.038), postoperative invasive interventions (OR = 0.47, P = 0.018), bleeding requiring transfusion (OR = 0.37, P < 0.001), and prolonged LOS (OR = 0.49, P < 0.001), but no effect on mortality and other relevant outcomes was seen [Table]. These results were not modified by the extent of hepatectomy performed. Conclusion: In a prospective, multi-center, and nationally representative sample, MIH compared to OH improves perioperative major morbidity, need for invasive interventions, bleeding requiring transfusion, and prolonged LOS in the elderly. There were no significant differences between MIH and OH in the elderly with respect to mortality, reoperation, post hepatectomy liver failure, bile leak, discharge disposition other than home, and readmission. Elderly patients may benefit from MIH for both major and minor hepatectomy.