Minimally Invasive Liver Resection Research Articles

Impact of liver cirrhosis, severity of cirrhosis and portal hypertension on the difficulty of laparoscopic and robotic minor liver resections for primary liver malignancies in the anterolateral segments

IntroductionWe performed this study in order to investigate the impact of liver cirrhosis (LC) on the difficulty of minimally invasive liver resection (MILR), focusing on minor resections in anterolateral (AL) segments for primary liver malignancies. MethodsThis was an international multicenter retrospective study of 3675 patients who underwent MILR across 60 centers from 2004 to 2021. Results1312 (35.7%) patients had no cirrhosis, 2118 (57.9%) had Child A cirrhosis and 245 (6.7%) had Child B cirrhosis. After propensity score matching (PSM), patients in Child A cirrhosis group had higher rates of open conversion (p = 0.024), blood loss >500 mls (p = 0.001), blood transfusion (p < 0.001), postoperative morbidity (p = 0.004), and in-hospital mortality (p = 0.041). After coarsened exact matching (CEM), Child A cirrhotic patients had higher open conversion rate (p = 0.05), greater median blood loss (p = 0.014) and increased postoperative morbidity (p = 0.001). Compared to Child A cirrhosis, Child B cirrhosis group had longer postoperative stay (p = 0.001) and greater major morbidity (p = 0.012) after PSM, and higher blood transfusion rates (p = 0.002), longer postoperative stay (p < 0.001), and greater major morbidity (p = 0.006) after CEM. After PSM, patients with portal hypertension experienced higher rates of blood loss >500 mls (p = 0.003) and intraoperative blood transfusion (p = 0.025). ConclusionThe presence and severity of LC affect and compound the difficulty of MILR for minor resections in the AL segments. These factors should be considered for inclusion into future difficulty scoring systems for MILR.

Impact of liver cirrhosis and portal hypertension on minimally invasive limited liver resection for primary liver malignancies in the posterosuperior segments: An international multicenter study

IntroductionTo assess the impact of cirrhosis and portal hypertension (PHT) on technical difficulty and outcomes of minimally invasive liver resection (MILR) in the posterosuperior segments. MethodsThis is a post-hoc analysis of patients with primary malignancy who underwent laparoscopic and robotic wedge resection and segmentectomy in the posterosuperior segments between 2004 and 2019 in 60 centers. Surrogates of difficulty (i.e, open conversion rate, operation time, blood loss, blood transfusion, and use of the Pringle maneuver) and outcomes were compared before and after propensity-score matching (PSM) and coarsened exact matching (CEM). ResultsOf the 1954 patients studied, 1290 (66%) had cirrhosis. Among the cirrhotic patients, 310 (24%) had PHT. After PSM, patients with cirrhosis had higher intraoperative blood transfusion (14% vs. 9.3%; p = 0.027) and overall morbidity rates (20% vs. 14.5%; p = 0.023) than those without cirrhosis. After coarsened exact matching (CEM), patients with cirrhosis tended to have higher intraoperative blood transfusion rate (12.1% vs. 6.7%; p = 0.059) and have higher overall morbidity rate (22.8% vs. 12.5%; p = 0.007) than those without cirrhosis. After PSM, Pringle maneuver was more frequently applied in cirrhotic patients with PHT (62.2% vs. 52.4%; p = 0.045) than those without PHT. ConclusionMILR in the posterosuperior segments in cirrhotic patients is associated with higher intraoperative blood transfusion and postoperative morbidity. This parameter should be utilized in the difficulty assessment of MILR.

Role of preoperative 3D rendering for minimally invasive parenchyma sparing liver resections

Background3D rendering (3DR) represents a promising approach to plan surgical strategies. The study aimed to compare the results of minimally invasive liver resections (MILS) in patients with 3DR versus conventional 2D CT-scan. MethodsWe performed 118 3DR for various indications; the patients underwent a preoperative tri-phasic CT-scan and rendered with Synapse3D® Software. Fifty-six patients undergoing MILS with pre-operative 3DR were compared to a similar cohort of 127 patients undergoing conventional pre-operative 2D CT-scan using the propensity score matching (PSM) analysis. ResultsThe 3DR mandated pre-operative surgical plan variations in 33.9% cases, contraindicated surgery in 12.7%, providing a new surgical indication in 5.9% previously excluded cases. PSM identified 39 patients in both groups with comparable results in terms of conversion rates, blood loss, blood transfusions, parenchymal R1-margins, grade ≥3 Clavien-Dindo complications, 90-days mortality, and hospital stay respectively in 3DR and conventional 2D. Operative time was significantly increased in the 3DR group (402 vs. 347 min, p = 0.020). Vascular R1 resections were 25.6% vs 7.7% (p = 0.068), while the conversion rate was 0% vs 10.2% (p = 0.058), respectively, for 3DR group vs conventional 2D. Conclusion3DR may help in surgical planning increasing resectability rate while reducing conversion rates, allowing the precise identification of anatomical landmarks in minimally invasive parenchyma-preserving liver resections.

Practice variation and outcomes of minimally invasive minor liver resections in patients with colorectal liver metastases: a population-based study

IntroductionIn 2017, the Southampton guideline stated that minimally invasive liver resections (MILR) should considered standard practice for minor liver resections. This study aimed to assess recent implementation rates of minor MILR, factors associated with performing MILR, hospital variation, and outcomes in patients with colorectal liver metastases (CRLM).MethodsThis population-based study included all patients who underwent minor liver resection for CRLM in the Netherlands between 2014 and 2021. Factors associated with MILR and nationwide hospital variation were assessed using multilevel multivariable logistic regression. Propensity-score matching (PSM) was applied to compare outcomes between minor MILR and minor open liver resections. Overall survival (OS) was assessed with Kaplan–Meier analysis on patients operated until 2018.ResultsOf 4,488 patients included, 1,695 (37.8%) underwent MILR. PSM resulted in 1,338 patients in each group. Implementation of MILR increased to 51.2% in 2021. Factors associated with not performing MILR included treatment with preoperative chemotherapy (aOR 0.61 CI:0.50–0.75, p < 0.001), treatment in a tertiary referral hospital (aOR 0.57 CI:0.50–0.67, p < 0.001), and larger diameter and number of CRLM. Significant hospital variation was observed in use of MILR (7.5% to 93.0%). After case-mix correction, six hospitals performed fewer, and six hospitals performed more MILRs than expected. In the PSM cohort, MILR was associated with a decrease in blood loss (aOR 0.99 CI:0.99–0.99, p < 0.01), cardiac complications (aOR 0.29, CI:0.10–0.70, p = 0.009), IC admissions (aOR 0.66, CI:0.50–0.89, p = 0.005), and shorter hospital stay (aOR CI:0.94–0.99, p < 0.01). Five-year OS rates for MILR and OLR were 53.7% versus 48.6%, p = 0.21.ConclusionAlthough uptake of MILR is increasing in the Netherlands, significant hospital variation remains. MILR benefits short-term outcomes, while overall survival is comparable to open liver surgery.Graphical abstract

Latest Findings on Minimally Invasive Anatomical Liver Resection

Minimally invasive liver resection (MILR) is being widely utilized owing to recent advancements in laparoscopic and robot-assisted surgery. There are two main types of liver resection: anatomical (minimally invasive anatomical liver resection (MIALR)) and nonanatomical. MIALR is defined as a minimally invasive liver resection along the respective portal territory. Optimization of the safety and precision of MIALR is the next challenge for hepatobiliary surgeons, and intraoperative indocyanine green (ICG) staining is considered to be of considerable importance in this field. In this article, we present the latest findings on MIALR and laparoscopic anatomical liver resection using ICG at our hospital.

Minimally invasive versus open liver resection for hepatocellular carcinoma: a propensity score matching analysis of 224 patients.

To compare the peri-operative and long-term survival outcomes of minimally invasive liver resection (MILR) (robotic or laparoscopic) with open liver resection (OLR) in patients with hepatocellular carcinoma (HCC). Data of patients who underwent liver resection for HCC were reviewed from a prospectively collected database. Outcomes of MILR were compared with those of OLR. A propensity score matching analysis with a ratio of 1:1 was performed to minimise the potential bias in clinical pathological factors. From January 2003 to December 2017, a total of 705 patients underwent liver resection for HCC. Amongst them, 112 patients received MILR and 593 patients received OLR. After propensity score matching, there were 112 patients in each of the MILR and OLR groups. Patients were matched by age, sex, hepatitis status, presence of cirrhosis, platelet count, albumin level, bilirubin level, alkaline phosphatase (ALP) level, alanine transferase (ALT) level, creatinine level, tumour differentiation, tumour size, tumour number, presence of tumour rupture, presence of vascular invasion, extent of liver resection (minor/major) and difficulty score. The 1-, 3- and 5-year overall survival rates were 94.4%, 90.4% and 82.3% in the MILR group vs 95.4%, 80.5% and 71.8% in the open group (p = 0.240). The 1-, 3- and 5-year disease-free survival rates were 81.0%, 63.1% and 55.8% in the MILR group vs 79.1%, 58.1% and 45.7 in the open group (p = 0.449). The MILR group demonstrated significantly less blood loss (p < 0.001), less blood transfusion (p = 0.004), lower post-operative complications (p < 0.001) and shorter hospital stay (p < 0.001) when compared with the OLR group. Our data shows MILR yielded superior post-operative outcomes to OLR, with comparable survival outcomes.

The Pringle maneuver in the modern era: A review of techniques for hepatic inflow occlusion in minimally invasive liver resection.

During minimally invasive liver resection (MILR), the Pringle maneuver aims to minimize blood loss and provide a clear operative field, thereby identifying intrahepatic structures and facilitating safe parenchymal transection. Several techniques for using the Pringle maneuver in MILR have been described. This review presents various methods which have been reported in the literature. A systematic literature search used the MEDLINE/PubMed database from its earliest records to August 2022 using appropriate search headings and keywords. The primary outcome was identifying techniques for performing hepatic inflow occlusion during laparoscopic/robotic hepatectomy. Inclusion criteria consisted of publications describing technical steps to obtain hepatic inflow occlusion during minimally invasive hepatectomy. A literature search identified 23 relevant publications, and the full texts were examined. The techniques described in the reports can be broadly categorized into three groups: (1) the Rummel-tourniquet technique, (2) vascular clamp use, and (3) the Huang Loop technique. Various techniques have been used in MILR to achieve inflow confinement successfully. The authors prefer the modified Huang Loop technique because it is inexpensive, reliable, and quick to apply or release. Hepatobiliary surgeons are advised to familiarize themselves with these MILR techniques, which have proven effective and safe inflow occlusion.

Conversion of Minimally Invasive Liver Resection for HCC in Advanced Cirrhosis: Clinical Impact and Role of Difficulty Scoring Systems

Minimally invasive liver resections (MILRs) in cirrhosis are at risk of conversion since cirrhosis and complexity, which can be estimated by scoring systems, are both independent factors for. We aimed to investigate the consequence of conversion of MILR for hepatocellular carcinoma in advanced cirrhosis. After retrospective review, MILRs for HCC were divided into preserved liver function (Cohort-A) and advanced cirrhosis cohorts (Cohort-B). Completed and converted MILRs were compared (Compl-A vs. Conv-A and Compl-B vs. Conv-B); then, converted patients were compared (Conv-A vs. Conv-B) as whole cohorts and after stratification for MILR difficulty using Iwate criteria. 637 MILRs were studied (474 Cohort-A, 163 Cohort-B). Conv-A MILRs had worse outcomes than Compl-A: more blood loss; higher incidence of transfusions, morbidity, grade 2 complications, ascites, liver failure and longer hospitalization. Conv-B MILRs exhibited the same worse perioperative outcomes than Compl-B and also higher incidence of grade 1 complications. Conv-A and Conv-B outcomes of low difficulty MILRs resulted in similar perioperative outcomes, whereas the comparison of more difficult converted MILRs (intermediate/advanced/expert) resulted in several worse perioperative outcomes for patients with advanced cirrhosis. However, Conv-A and Conv-B outcomes were not significantly different in the whole cohort where "advanced/expert" MILRs were 33.1% and 5.5% in Cohort A and B. Conversion in the setting of advanced cirrhosis can be associated with non-inferior outcomes compared to compensated cirrhosis, provided careful patient selection is applied (patients elected to low difficulty MILRs). Difficulty scoring systems may help in identifying the most appropriate candidates.

Can minimally invasive liver resections be performed on an outpatient basis?

Background: Minimally invasive liver resections (MILR) are being widely performed, reducing post-operative morbidities and length of stay. Studies on MILRs as outpatient surgeries are limited.

Surgery for hepatocellular carcinoma and intrahepatic cholangiocarcinoma: milestone changes in the last two decades potentially affecting current guidelines

The aim of this review is to describe the relevance of minimally invasive liver resection (MILR) for the treatment of most common primary liver tumors. The uptake has been slow but steady, and thus MILR has become a well-established field of hepatobiliary surgery and is considered a landmark change of the past 30 years. There is evidence that the advantage of MILR regarding specific complications of liver surgery for HCC (reduced incidence of postoperative hepatic decompensation and ascites) can be a tool to potentially expand the indications to surgical treatment. Evidence for intrahepatic cholangiocarcinoma is early and exploratory; however, it is beginning to be documented that the fundamental principles of surgical oncology for this tumor can be respected while offering patients the advantages of minimal invasiveness.

HPB O04 Venous thromboembolism after hepatectomy: comparison between open and minimally invasive liver resection. Results of a systematic review with meta-analysis

Abstract Background Even though the risk of postoperative venous thromboembolism (VTE) after liver resection is well recognized, the association between surgical approach and VTE risk is unknown. This study aims to compare VTE rates following open liver resection (OLR) and minimally invasive liver resection (MILR). Methods MEDLINE, Web Of Sciences and EMBASE databases were analyzed to identify eligible studies. The studies that we included in the meta-analysis were published between February 2016 and May 2021. The last database search was performed on May 22nd, 2022. Studies were considered suitable if they reported a comparison between OLR and MILR (including laparoscopic liver resection [LLR] or robotic liver resection, [RLR]), or if postoperative VTE was the main focus of the study. Extracted data were pooled and subsequently used in a meta-analysis. Results 14 studies including 11356 patients met inclusion criteria and were considered for meta-analysis, with a total of 5622 patients who underwent OLR and 5734 patients who underwent MILR. Overall, our findings showed that VTE rate was higher among patients who underwent OLR compared to MILR (2.8% vs 1.4%, p=&amp;lt;00001). Similarly, the subgroup analysis showed a higher rate of deep venous thrombosis (DVT) (1.4% vs 0.7%, p=0.02) and pulmonary embolism (PE) (1.3% vs 0.7%, p=0.002) in patients who underwent OLR compared to MILR. Conclusions Patients who undergo OLR have a higher incidence of postoperative VTE when compared to MILR. This finding is consistent for both DVT and PE.

Systematic review and meta-analysis of difficulty scoring systems for laparoscopic and robotic liver resections.

The ability to stratify the difficulty of minimally invasive liver resection (MILR) allows surgeons at different phases of the learning curve to tackle cases of appropriate difficulty safely. Several difficulty scoring systems (DSS) have been formulated which attempt to accurately stratify this difficulty. The present study aims to review the literature pertaining to the existing DSS for MILR. We performed a systematic review and metanalysis of the literature reporting on the formulation, supporting data, and comparison of DSS for MILR. A total of 11 studies were identified which reported on the formulation of unique DSS for MILR. Five of these (Ban, Iwate, Hasegawa, Institut Mutaliste Montsouris [IMM], and Southampton DSS) were externally validated and shown to predict difficulty of MILR via a range of outcome measures. The Ban DSS was supported by pooled data from 10 studies (9 LLR, 1 RLR), Iwate by 10 studies (8 LLR, 2 RLR), Hasegawa by four studies (all LLR), IMM by eight studies (all LLR), and Southampton by five studies (all LLR). There was no clear superior DSS. The existing DSS were all effective in predicting difficulty of MILR. Present studies comparing between DSS have not established a clear superior system, and the five main DSS have been found to be predictive of difficulty in LLR and two of these in RLR.

Association of standardized liver volume and body mass index with outcomes of minimally invasive liver resections.

While minimally invasive liver resections (MILR) have demonstrated advantages in improved post-operative recovery, widespread adoption is hampered by inherent technical difficulties. Our study attempts to analyze the role of anthropometric measures in MILR-related outcomes. Between 2012 and 2020, 676 consecutive patients underwent MILR at the Singapore General Hospital of which 565 met study criteria and were included. Patients were stratified based on Body Mass Index (BMI) as well as Standardized Liver Volumes (SLV). Associations between BMI and SLV to selected peri-operative outcomes were analyzed using restricted cubic splines. A BMI of ≥ 29 was associated with increase in blood loss [Mean difference (MD) 69 mls, 95% CI 2 to 137] as well as operative conversions [Relative Risk (RR) 1.63, 95% CI 1.02 to 2.62] among patients undergoing MILR while a SLV of 1600cc or higher was associated with an increase in blood loss (MD 30 mls, 95% CI 10 to 49). In addition, a BMI of ≤ 20 was associated with an increased risk of major complications (RR 2.25, 95% 1.16 to 4.35). The magnitude of differences observed in these findings increased with each unit change in BMI and SLV. Both BMI and SLV were useful anthropometric measures in predicting peri-operative outcomes in MILR and may be considered for incorporation in future difficulty scoring systems for MILR.

A chronological review of 500 minimally invasive liver resections in a North American institution: overcoming stagnation and toward consolidation.

Although interest in expanding the application of minimally invasive liver resection (MILR) is high the world over, most of the extensive experience in MILR has been reported from Far East Asia and Europe and its adoption in North America is limited. The aim of this study was to review the experience of MILR in a single North American institute over a 15-year period, highlighting both the obstacles encountered and strategies adopted to overcome the stagnation in its uptake. This study included 500 MILR cases between 2006 and 2020. Patient demographics, disease characteristics, surgical technique, and perioperative outcomes are summarized. The major hepatectomy rate and conversion rate were assessed according to case numbers (first 100, 101-300, and 301-500 cases) to assess chronological trends. Of 500, 402 MILRs were done by pure laparoscopic (80.4%), 67 were hand assisted (13.4%), and 31 were robotic (6.2%). The majority (64%) of cases were performed for malignancy (n = 320; 100 Hepatocellular carcinoma, 153 Colorectal metastases, 27 Intrahepatic cholangiocarcinoma, and others, 40, 64%). A total of 71 cases were converted to open (14.2%). The annual case number gradually increased over the first few years; however, case numbers stayed around 30 between 2009 and 2017. In this period, despite accumulating MILR experience, open conversion rates increased despite no change in major hepatectomy rate. After this period of long-term stagnation, we introduced crucial changes in team composition and laparoscopic instrumentation. Our MILR case number and major hepatectomy rate thereafter increased significantly without increasing conversion or complication rates. Our recovery from long-term stagnation by instituting key changes as detailed in this study could be used as a guidepost for programs that are contemplating transitioning their MILR program from minor to advanced resections. Establishing a formal MILR training model through proper mentorship/proctorship and building a dedicated MILR team would be imperative to this strategy.

Minimally Invasive vs Open Major Hepatectomies for Liver Malignancies: a Propensity Score–Matched Analysis

BackgroundThe majority of evidence with regards to minimally invasive liver resection (MILR) favors its application in minor hepatectomies. We conducted a propensity score–matched (PSM) analysis to determine its feasibility and safety in major hepatectomies (MIMH) for liver malignancies. MethodsRetrospective review of 130 patients who underwent MIMH and 490 patients who underwent open major hepatectomy (OMH) for malignant pathologies was performed. PSM in a 1:1 ratio identified two groups of patients with similar baseline clinicopathological characteristics. Perioperative outcomes were then compared. Major hepatectomies included traditional major (>3 segments) and technical major hepatectomies (right anterior and right posterior sectionectomies). ResultsBoth cohorts were well-matched for baseline characteristics after PSM. Of 130 MIMH cases, there were 12 conversions to open. Comparison of perioperative outcomes demonstrated a significant association of MIMH with longer operation time and more frequent application of Pringle’s maneuver (PM), but decreased postoperative stay. These results were consistent on a subgroup analysis that only included patients undergoing traditional major hepatectomies. A second subgroup analysis restricted to cirrhotic patients demonstrated that while perioperative outcomes were equivalent, MIMH was similarly associated with a longer operative time. Subset analyses of resections performed after 2015 demonstrated that MIMH was additionally associated with a lower postoperative morbidity compared to OMH. ConclusionComparison of perioperative and short-term oncological outcomes between MIMH and OMH for malignancies demonstrated that MIMH is feasible and safe. It is associated with a shorter hospital stay at the expense of a longer operation time compared to OMH.

The role of minimally invasive surgery in the treatment of HCC

Liver surgery is the first-line treatment for hepatocellular carcinoma (HCC). Minimally invasive liver resection (MILS) has become an attractive option thanks to reduced intraoperative blood losses, shortened length of hospital stay, and similar oncological outcomes when compared to open liver resection. Nonetheless, the safety of MILS is still debated in challenging situations, such as in cirrhotic patients, difficult tumor locations, multiple or large tumors, and repeat resection. The aim of this review is to discuss current indications of laparoscopic liver resection for HCC treatment in the light of its outcomes, focusing on technical aspects of minimally invasive anatomic liver resection and state of the art of MILS in challenging situations.

The Tri-level Transection Method of Laparoscopic Hemihepatectomy: Simplicity, Safety, Satisfaction

Introduction: While segmental resection is widely employed in minimally-invasive hepatic resection, hemihepatectomy continues to be performed in limited numbers due to complexity and the rigors of parenchymal transection. Over the span of greater that 500 laparoscopic hemihepatectomies we have honed a technique of transection of Cantlie's line that results in simplification, safety, and thus broader inclusion of candidate patients in minimally-invasive liver resection.

The Japanese Difficulty Scoring System Correlates with Postoperative Outcome Assessed by the Comprehensive Complication Index in Patients Undergoing Minimally Invasive Liver Resection

Introduction: The Japanese difficulty score (JDS) was developed to standardize the difficulty grading of laparoscopic hepatectomy. The JDS has not consistently correlated well with postoperative outcomes such as Clavien-Dindo complications. This study aims to determine if the JDS correlates with complications as classified by the more inclusive comprehensive complication index (CCI). Methods: A single institutional database was retrospectively queried for all purely minimally-invasive (MIS) hepatectomies performed between January 2008 and December 2019Patient charts were reviewed and data was collected. Patients were grouped into “Low” (<4), “Intermediate” (4-6), and “High” (7+) difficulty based on JDS. Complications were graded using CCI. Statistical comparisons were made using ANOVA or χ2 test, as appropriate. IRB approval was obtained. Results: 413 pure MIS resections were performed. There were 75 (18.2%) Low, 207 (50.1%) Intermediate, and 131 (31.7%) High difficulty MIS hepatectomies. There were no demographic differences. High difficulty was associated with longer operative time (p<0.001), higher mean EBL (p<0.001), and were more likely to require blood transfusion (p<0.001). Mean length of stay (LOS) was longer for more difficult resections (p<0.001). There was no difference between groups in Clavien-Dindo complications or 30-day readmissions. The CCI was significantly higher (Low 7.0, Intermediate 9.5, High 15.8; p=0.006) for more difficult resections. Post-hepatectomy liver failure (PHLF) occurred more frequently with higher JDS (p=0.0023). Conclusions: MIS liver resections with higher JDS were associated with increased operative times, EBL, blood transfusions, LOS, PHLF and overall complications as indicated by the CCI, despite no difference between groups in Clavien-Dindo complications.

Minimally invasive anatomic liver resection: Results of a survey of world experts

Although the number of minimally invasive liver resections (MILRs) has been steadily increasing in many institutions, minimally invasive anatomic liver resection (MIALR) remains a complicated procedure that has not been standardized. We present the results of a survey among expert liver surgeons as a benchmark for standardizing MIALR. We administered this survey to 34 expert liver surgeons who routinely perform MIALR. The survey contained questions on personal experience with liver resection, inflow/outflow control methods, and identification techniques of intersegmental/sectional planes (IPs). All 34 participants completed the survey; 24 experts (70%) had more than 11years of experience with MILR, and over 80% of experts had performed over 100 open resections and MILRs each. Regarding the methods used for laparoscopic or robotic anatomic resection, the Glissonean approach (GA) was a more frequent procedure than the hilar approach (HA). Although hepatic veins were considered essential landmarks, the exposure methods varied. The top three techniques that the experts recommended for identifying IPs were creating a demarcation line, indocyanine green negative staining method, and intraoperative ultrasound. Minimally invasive anatomic liver resection remains a challenging procedure; however, a certain degree of consensus exists among expert liver surgeons.

Selection criteria for minimally invasive resection of intrahepatic cholangiocarcinoma-a word of caution: a propensity score matched analysis using the national cancer database.

While minimally invasive liver resection (MILR) vs. open approach (OLR) has been shown to be safe, the perioperative and oncologic safety for intrahepatic cholangiocarcinoma (ICC) specifically, necessitating often complex hepatectomy and extended lymphadenectomy, remains ill-defined. The National Cancer Database was queried for patients with ICC undergoing liver resection from 2010 to 2016. After 1:1 Propensity Score Matching (PSM), Kruskal-Wallis and χ2 tests were applied to compare short-term outcomes. Kaplan-Meier survival analyses and Cox multivariable regression were performed. 988 patients met inclusion criteria: 140 (14.2%) MILR and 848 (85.8%) OLR resulting in 115 patients MILR and OLR after 1:1 PSM with c-index of 0.733. MILR had lower unplanned 30-day readmission [OR 0.075, P = 0.014] and positive margin rates [OR 0.361, P = 0.011] and shorter hospital length of stay (LOS) [OR 0.941, P = 0.026], but worse lymph node yield [1.52 vs 2.07, P = 0.001]. No difference was found for 30/90-day mortality. Moreover, multivariate analysis revealed that MILR was associated with poorer overall survival compared to OLR [HR 2.454, P = 0.001]. Subgroup analysis revealed that survival differences from approach were dependent on major hepatectomy, tumor size > 4cm, or negative margins. MILR vs. OLR is associated with worse lymphadenectomy and survival in patients with ICC greater than 4cm requiring major hepatectomy. Hence, MILR major hepatectomy for ICC should only be approached selectively and if surgeons are able to perform an appropriate lymphadenectomy.