Open Right Hepatectomy Research Articles

Comment on: Textbook Outcomes Following Open Live Donor Right Hepatectomy and Open Right Hepatic Lobectomy for Cancer in 686 Patients: Re-Defining the Benchmark.

We read the article by Dogeas et al1 with great interest. This study used a prospective database to compare textbook outcomes (TO) rates between right hepatectomy (RH) for live donor purposes and RH for malignancy. The author found that the TO rates of RH for live donor purposes (92.2%) were significantly higher than that for malignancy (53.7%) and considered that these indicators represented a new benchmark for “real world” TO after open RH. Despite inspiring and thought-provoking, we have the following comments. First, in our experience, in the real world, regardless of the type of hepatectomy, the most common cause is hepatocellular carcinoma. However, among cancer patients in this study, the most common pathology was colorectal cancer liver metastases, accounting for 58.4% (184 patients). This also means that cirrhosis has a very low proportion of cancer patients, only 5.4% (17 patients). In fact, there may be a higher incidence of cirrhosis in all cancer patients who underwent RH. Although cirrhosis was only confirmed as an independent risk factor associated with a lower TO rate of hepatocellular carcinoma hepatectomy in our previous study,2 we still believe that cirrhosis may strongly affect the TO rate in all cases of hepatectomy. Therefore, it is reasonable to wonder whether the TO rate in the tumor patients in this study can be viewed as a new benchmark for the “real world” and whether independent factors associated with not achieving TO can be applied to all RH cancer patients. Second, this study noted that the live donor RH people had higher TO rates, as they were younger, healthier, and thinner, but logistic regression analysis showed no significant association between body mass index (BMI) and TO rates. The study did not mention the grouping method of BMI in the methods section. If BMI is analyzed as a continuous variable, it is likely to obtain negative results that BMI is not related to TO rates. However, high BMI often means that body obesity, while low BMI means body malnutrition or cachexia. Consequently, appropriate BMI grouping may directly determine the results of the study. We wanted to know how the authors analyzed of the association between BMI and TO rates. Third, TO rates were compared between RH for live donor purposes and RH for malignancy in this study. However, direct comparisons between the 2 groups may not be statistically appropriate due to the large difference between the 2 groups. Therefore, we believe that some statistical methods, such as propensity score matching or inverse probability of treatment weighting, should be used first to balance the baseline data between the 2 groups, perhaps to make the 2 groups more comparable. Although balancing may not have changed the final results of this study, we still believe that balancing the baselines of the 2 groups and then comparing them can make the results of this study more solid. Finally, we are still very appreciative of Dogeas et al1 for the new benchmark for “real world” TO after RH. We hold the belief that these findings will contribute to the further improvement and development of liver surgery.

Textbook Outcomes following Open Live Donor Right Hepatectomy and Open Right Hepatic Lobectomy for Cancer in 686 patients: Re-defining the Benchmark.

To compare textbook outcomes (TO) of open live donor right hepatectomy (RH) versus open right hepatic lobectomy for cancer in a single Western center, and to identify clinical factors associated with failure to achieve a TO. TO, a composite quality measure that captures multiple aspects of peri-operative care, has not been thoroughly studied in open RH. We hypothesized that TO rates after RH for live donor transplant could represent the "best-achievable" results of this operation and could serve as the benchmark for RH performed for an oncologic indication. A prospective database was reviewed to compare TO rates after RH for live donor purposes versus RH for cancer at a single center from 2010-2020. A TO was defined as achieving 7 metrics: no peri-operative transfusion, no major postoperative complications, no significant bile leak, no unplanned transfer to the ICU, no 30-day mortality, no 30-day re-admission, and no R1 margins for cancer cases. Amongst 686 RH patients (371 live donor and 315 cancer cases), a TO was achieved in 92.2% of RH donors and 53.7% of RH cancer cases. Live donor patients tended to be younger, healthier, and thinner. Amongst donors, increased intra-operative blood loss, and in cancer cases, male gender, tumor size, and increased intra-operative blood loss were associated with TO failure. A TO can be achieved in over 90% of patients undergoing living donor RH and in approximately half of RH cancer cases. These metrics represent a new benchmark for "real-world" TO after open RH.

Pure laparoscopic vs open right hepatectomy in patients with hepatocellular carcinoma: A propensity score-matched analysis.

Since minimally invasive surgery has been incorporated in overall surgery, pure laparoscopic technology is involved in most hepatectomies, including right hepatectomy, in patients with hepatocellular carcinoma (HCC). However, its feasibility and safety in right hepatectomy are still controversial owing to the limited literature. This study aimed to compare the short- and long-term outcomes of pure laparoscopic right hepatectomy (PLRH) with those of open right hepatectomy (ORH) in patients with HCC. The prospectively collected medical records of 327 patients with HCC who underwent right hepatectomy between January 2010 and April 2020 at Seoul National University Hospital were retrospectively reviewed. We performed 1:1 propensity score matching between the PLRH and ORH groups. The primary end point was short-term outcomes, including hospital stay, blood loss, and morbidity; the secondary end point was long-term outcomes, including overall and recurrence-free survival. Forty-nine patients were included in each group. Patients who underwent PLRH had a shorter postoperative hospital stay than those who underwent ORH (12.2 vs 8.9 days; P < .001). The requirement for blood transfusion was significantly lower in the PLRH group than in the ORH group (10.2% vs 2.0%; P=.010). The operative time (P=.479) and proportion of major complications (P=.487) were comparable between the groups. There were no significant differences in overall survival (P=.524) and the recurrence-free survival rate (P=.576) between the groups. Postoperative outcomes, including oncological outcomes, were comparable between PLRH and ORH, showing that PLRH can be a safe and feasible option to replace ORH in patients with HCC.

Laparoscopic Right Hepatectomy is as Safe and Feasible as Open Procedure in the Treatment of Liver Tumors: Meta-analysis

The purpose of this study was to compare the clinical effect of laparoscopic right hepatectomy (LRH) and open right hepatectomy (ORH) in the treatment of liver tumor. Patients and Methods We systematically searched PubMed, web of science, EMBASE, clinicaltrials.gov , and Cochrane Central Register for studies (study published August 1947 to December 2019). In this study, the perioperative data of laparoscopic right hepatectomy and open right hepatectomy were analyzed. Our meta-analysis included 7 studies involving 633 patients who underwent two types of surgery, laparoscopic right hepatectomy and open right hepatectomy. This study showed that compared with open right hepatectomy, there was no significant difference in operative time (weighted mean difference (WMD): 35.28, 95% confidence interval (CI): − 9.04–79.60, P = 0.12), but the result of laparoscopic right hepatectomy’s R0 resections (odd ratio (OR): 2.34, 95% confidence interval (CI): 0.60–9.11, P = 0.22), transfusion (odd ratio (OR): 0.64, 95% confidence interval (CI): 0.34–1.20, P = 0.17), mortality (odd ratio (OR): 0.44, 95% confidence interval (CI): 0.14–1.45, P = 0.18) was similar to that of open right hepatectomy. Laparoscopic right hepatectomy resulted in shorter hospital stay (weighted mean difference (WMD): − 4.75, 95% confidence interval (CI): − 5.96–3.55, P<0.00001) and less estimated blood loss (EBL) (weighted mean difference (WMD): − 161.97, 95% confidence interval (CI): − 257.47–66.46, P = 0.0009). The clinical effect of laparoscopic right hepatectomy in the treatment of liver tumor was similar to that of open right hepatectomy, which was safe, feasible, and has a good prognosis.

Minimally invasive versus open right hepatectomy: comparative study with propensity score matching analysis

BackgroundMinimally invasive liver resections (MILRs) have been increasingly performed in recent years. However, the majority of MILRs are actually minor or limited resections of peripheral lesions. Due to the technical complexity major hepatectomies remain challenging for minimally invasive surgery. The aim of this study was to compare the short and long-term outcomes of patients undergoing minimally invasive right hepatectomies (MIRHs) with contemporary patients undergoing open right hepatectomies (ORHs)MethodsConsecutive patients submitted to anatomic right hepatectomies between January 2013 and December 2018 in two tertiary referral centers were studied. Study groups were compared on an intention-to-treat basis after propensity score matching (PSM). Overall survival (OS) analyses were performed for the entire cohort and specific etiologies subgroupsResultsDuring study period 178 right hepatectomies were performed. After matching, 37 patients were included in MIRH group and 60 in ORH group. The groups were homogenous for all baseline characteristics. MIRHs had significant lower blood loss (400 ml vs. 500 ml, P = 0.01), lower rate of minor complications (13.5% vs. 35%, P = 0.03) and larger resection margins (10 mm vs. 5 mm, P = 0.03) when compared to ORHs. Additionally, a non-significant decrease in hospital stay (ORH 9 days vs. MIRH 7 days, P = 0.09) was observed. No differences regarding the use of Pringle’s maneuver, operative time, overall morbidity or perioperative mortality were observed. OS was similar between the groups (P = 0.13). Similarly, no difference in OS was found in subgroups of patients with primary liver tumors (P = 0.09) and liver metastasis (P = 0.80).ConclusionsMIRHs are feasible and safe in experienced hands. Minimally invasive approach was associated with less blood loss, a significant reduction in minor perioperative complications, and did not negatively affect long-term outcomes.

Transitioning From Open to Robotic Liver Resection. Results of 46 Consecutive Procedures Including a Majority of Major Hepatectomies

Aims. Minimally invasive liver resection is a complex and challenging operation. Although authors have reported robotic liver resection shows improved safety and efficacy compared with open liver resection, robotic major liver resections for malignant liver lesions treatment remain inadequately evaluated. The aims of the present study were to evaluate the feasibility and safety of transitioning from open to robotic liver resection in a nonuniversity hospital. Patients and Methods. From December 2015 to March 2020, 46 patients underwent totally robotic-assisted liver resections out of 446 robotic procedures. Also, we retrospectively reviewed the last 27 open right hepatectomies (ORHs) and compared then with the first 25 anatomic robotic-assisted right hepatectomies (RRHs). Results. Mean operative time, mean blood lost, rate of complications, and mean hospital stay were associated with the complexity of the procedure. The comparison between ORH and RRH showed that intraoperative complications were less frequently observed during ORH whereas RRH showed a trend in favor of less blood loss. ORH had a trend toward smaller surgical margins and higher rate of R1 resections. Recurrence occurred in 31 (59%) patients and was more frequently observed after ORH. However, the mean follow-up was significantly shorter after RRH. Conclusion. Our study demonstrated the technical feasibility and safety of transitioning from open to robotic liver resection (including major hepatectomies) in a nonuniversity setting. Higher costs remain an important drawback for robotic surgery.

Laparoscopic right hepatectomy using the caudal approach is superior to open right hepatectomy with anterior approach and liver hanging maneuver: a comparison of short-term outcomes.

A standardized laparoscopic right hepatectomy (LRH) approach named the "caudal approach" was recently reported. Yet, the value of this approach compared with state-of-the-art open right hepatectomy (ORH) remains unknown. The purpose of this study was therefore to compare the short-term outcomes of LRH using the caudal approach and ORH with anterior approach and liver hanging maneuver. One-hundred eleven consecutive patients who underwent LRH with caudal approach were prospectively collected; 346 patients who underwent ORH with anterior approach and liver hanging maneuver were enrolled as a control group. Propensity score matching (PSM) of patients in a ratio of 1: 1 was conducted and the perioperative outcomes were compared. After PSM, two well-balanced groups of 72 patients each were analyzed and compared. The conversion rate in the LRH group was 18.1%. Perioperative blood loss and transfusion rates were significantly lower in the LRH group as compared to the ORH group (median, 200ml vs. 500ml, p < 0.001 and 9.9% vs. 26.8%, p = 0.009, respectively), while operation time was significantly longer (median, 348min vs. 290min, p < 0.001). Overall (26.4% vs. 48.6%, p = 0.006) and symptomatic pulmonary (6.9% vs. 19.4%, p = 0.027) complication rates were significantly lower in the LRH group. Hospital stay was significantly shorter in the LRH group (median, 8days vs. 9days, p = 0.013). LRH using the caudal approach is associated with improved short-term outcomes compared to state-of-the-art ORH in patients qualifying for both approaches, and can be proposed as standard practice.

Laparoscopic Right Hepatectomy for Hepatocellular Carcinoma: A Propensity Score Matching Analysis of Outcomes Compared with Conventional Open Surgery

The application of laparoscopic hepatectomy is gaining momentum. However, the safety and efficacy of laparoscopic right hepatectomy (LRH) on hepatocellular carcinoma (HCC) are yet to be adequately evaluated. We aimed to assess the surgical and oncological outcomes of LRH for HCC by comparing it with open right hepatectomy (ORH). Data of patients who underwent hepatectomy for HCC from May 2007 to January 2018 in our hospital were obtained. Baseline characteristics, postoperative recovery, and survival outcomes were compared. One-to-one propensity score matching (PSM) was used to minimize selection biases by balancing factors, including age, sex, preoperative therapy, tumor size, and pattern. The original cohort included 109 patients (LRH, 41 patients; ORH, 68 patients). Of the 41 patients who underwent LRH, 8 patients (19.5%) required conversion to laparotomy. The overall morbidity was 19.5%, and no mortality in LRH was noted. After PSM, LRH was associated with a tendency of prolonged operative time (255.5 ± 93.4 minutes versus 225.9 ± 39.8 minutes, P = .08) and less intraoperative blood loss [300 (100-1200) versus 500 (200-2000) mL, P < .01]. LRH showed up a trend of less overall morbidity without statistical significance (18.4% versus 26.3%, P = .41). Moreover, the 3-year overall and disease-free survival did not differ significantly between the groups during a median follow-up of 19 (3-58) months for the LRH group and 23 (3-97) months for the ORH group. LRH can be performed as safe and effective as ORH for HCC in regard to both surgical and oncological outcomes. LRH holds the benefit in less intraoperative blood loss and appears to achieve less postoperative morbidity, which could serve as a promising alternative to ORH in selected individuals.

Pure laparoscopic versus open right hepatectomy for hepatocellular carcinoma in patients with cirrhosis: A propensity-score matched analysis

Introduction: We aimed to describe our experience with pure laparoscopic right hepatectomy (LRH) and to compare it with open right hepatectomy (ORH) among hepatocellular carcinoma (HCC) patients with liver cirrhosis. Method: We retrospectively reviewed the medical records of 152 patients who underwent pure LRH (n=37) or ORH (n=115) between June 2008 and July 2015 at Asan Medical Center. We performed 1:1 propensity score (PS) matching between the 2 groups. Subsequently, 33 patients were included in each group. Result: There were no statistically significant differences in intraoperative blood loss (p = 0.612) between both groups. The operative time was longer (median, 297 vs. 176 min; p < 0.0001) and the length of postoperative hospital stay was shorter (median, 9.97 vs. 13.94 days; p ≤ 0.0001) in the laparoscopic group. There were no significant differences in the complications rate, 2-year disease-free survival rate, or 2-year overall survival rate between both groups (p = 0.05, p = 0.645, and p = 0.873, respectively). Conclusion: Even in patients with cirrhosis, complication rate was comparable and the length of hospital stay was shorter with pure LRH than with the traditional open approach. The oncological outcomes of HCC were comparable in both groups. Pure LRH for HCC performed in selected patients appears to represent a viable alternative to ORH.

Standardization of operative technique in minimally invasive right hepatectomy: improving cost-value relationship through value stream mapping in hepatobiliary surgery

BackgroundWith current emphasis on improving cost-quality relationship in medicine, it is imperative to evaluate cost-value relationships for surgical procedures. Previously the authors demonstrated comparable clinical outcomes for minimally invasive right hepatectomy (MIRH) and open right hepatectomy (ORH). MIRH had significantly higher intraoperative cost, though overall costs were similar. MethodsMIRH was decoded into its component critical steps using value stream mapping, analyzing each associated cost. MIRH technique was prospectively modified, targeting high cost steps and outcomes were re-examined. Records were reviewed for elective MIRH before (pre-MIRH n = 50), after (post MIRH n = 25) intervention and ORH (n = 98), between January 1, 2008 and November 30, 2016. ResultsAverage overall cost was significantly lower for post-standardization MIRH (post-MIRH $21 768, pre-MIRH $28 066, ORH $33 020; p < 0.001). Average intraoperative blood loss was reduced with MIRH (167, 292 and 509 mL p < 0.001). Operative times were shorter (147, 190 and 229 min p < 0.001) and LOS was reduced for MIRH (3, 4, 7 days p < 0.002). ConclusionsUsing a common quality improvement tool, the authors established a model for cost effective clinical care. These tools allow surgeons to overcome personal or traditional biases such as stapler choices, but most importantly eliminate non-value added interventions for patients.

Standardization of operative technique in laparoscopic right hepatectomy: improving cost-value relationship through value stream mapping

Background: With the current emphasis on improving quality and cost reduction in medicine, it is imperative to critically evaluate cost-value relationships for surgical procedures. Previously our group had demonstrated comparable clinical outcomes, reduced length of stay (LOS) and reduced operative time for Laparoscopic Right Hepatectomy (LRH) compared to open right hepatectomy (ORH). Though the two groups had similar overall costs, intraoperative cost in the LRH group was higher. Methods: We decoded LRH into its component critical steps using value stream mapping (VSM), and analyzed the associated costs. We prospectively modified our surgical technique to target those steps that had high intraoperative costs (parenchymal transection, hemostasis) and measured the changes in outcomes. We reviewed medical records at our institution for patients who underwent elective LRH before (pre-LRH n = 22) and after (post-LRH n = 22) the intervention and those who had ORH (n = 65), between January 1, 2008 and November 30, 2016. Results: Average overall cost for the procedure was significantly lower for the post- standardization LRH group (post-LRH $21,768, pre-LRH $28,066, ORH $33,020; p < 0.0001). Average intraoperative blood loss was significantly reduced with LRH (post-LRH 167 mL, pre-LRH 292 mL, ORH 509 mL; p < 0.001). Operative times were significantly shorter for LRH (post-LRH 147 mins, pre- LRH 190 mins, ORH 229 mins; p < 0.001). LOS was significantly reduced for LRH (post-LRH 3 days, pre- LRH 4 days, ORH 7 days; p < 0.002). Conclusion: Using a common quality improvement tool (VSM), we have established a model for cost effective clinical care in hepatobiliary surgery. These tools allow surgeons to overcome personal and traditional biases such as stapler choices, but most importantly eliminate nonvalue added interventions for patients.

Laparoscopy-Specific Surgical Concepts for Hepatectomy Based on the Laparoscopic Caudal View: A Key to Reboot Surgeons' Minds.

Despite diffusion of laparoscopic hepatectomy, the acquisition of necessary skills is not easy for open liver surgeons. Concepts and techniques have totally changed in laparoscopic hepatectomy compared with open hepatectomy, which is an underlying cause of a technical hurdle in laparoscopic hepatectomy. This study aimed to illustrate laparoscopy-specific concepts and techniques for hepatectomy. Video footages of laparoscopic and open hepatectomies stored in the Institut Mutualiste Montsouris and Kyoto University were reviewed to define the differences in surgical view, surgical concept, and technical details, using left lateral sectionectomy (LLS) and right hepatectomy (RH) as representative examples. By comparison with open LLS and RH, laparoscopy-specific procedures were identified with regard to surgical view, parenchymal transection, available landmarks, and vascular dissection. By laparoscopy, the surgical field was constantly viewed and accessed from the caudal side to the cranial side. Similarly, the parenchyma was divided, and intrahepatic vessels were dissected in the same direction. Laparoscopy-specific landmarks were identified for both LLS and RH, behind the liver. The concepts and techniques in laparoscopic hepatectomy are totally different from those of open hepatectomy because of the different surgical views. Understanding the laparoscopy-specific concepts and techniques would facilitate safe and efficient execution of laparoscopic hepatectomy.

Laparoscopic vs Open Right Hepatectomy: A Value-Based Analysis

Current literature lacks sufficient data on outcomes after extensive laparoscopic liver resections. We hypothesized that laparoscopic right hepatectomy (LRH) is associated with better clinical outcomes and less overall hospital costs than open right hepatectomy (ORH), supporting the notion that major laparoscopic hepatic resections carry increased value when compared with the open approach. We reviewed medical records of all patients at our institution who underwent elective LRH (n = 48) or ORH (n = 57) from May 16, 2008 to March 1, 2012. Patient demographics, preoperative comorbidities, operative details, and postoperative outcomes were compared between the 2 groups. Hospital billing data were collected for each case to determine the average hospital costs per case. Average operative duration, estimated blood loss, intravenous fluid resuscitation requirements, high-grade postoperative complications, the need for postoperative admission to the ICU, and hospital length of stay were significantly less within the LRH cohort. Thirty-day mortality and readmission rates were equivalent between the 2 groups. Despite higher operative costs for LRH ($16,605 vs $10,411, p < 0.001), total postoperative costs were significantly less ($9,075 for LRH vs $16,341 for ORH, p < 0.001), resulting in equivalent overall costs ($25,679 for LRH vs $26,751 for ORH, p = 0.65). Although overall costs between LRH and ORH are equivalent, clinical outcomes after LRH are comparable to those after ORH, supporting the value of laparoscopy in extensive right hepatic resections. Efforts to reduce operative costs of LRH, while maintaining optimal patient outcomes, should be the focus of surgeons and hospitals moving forward.

Assessment of the financial implications for laparoscopic liver surgery: a single-centre UK cost analysis for minor and major hepatectomy

Laparoscopic hepatectomy is progressively gaining popularity. However, it is still unclear whether the laparoscopic approach offers cost advantages compared with the open approach, especially when major hepatectomies are required. Data providing useful insights into the costs of the laparoscopic approach for clinicians and hospitals are needed. The aim of this study is to assess the financial implications of the laparoscopic approach for two standardized minor and major hepatectomies: left lateral sectionectomy and right hepatectomy. A cost comparison analysis of patients undergoing laparoscopic right hepatectomy (LRH) and laparoscopic left lateral sectionectomy (LLLS) versus the open counterparts was performed. Data considered for the comparison analysis were operative costs (theatre cost, consumables and surgeon/anaesthetic labour cost), postoperative costs (hospital stay, complication management and readmissions) and overall costs. A total of 149 patients were included: 38 patients underwent LRH and 46 open right hepatectomy (ORH); 46 patients underwent LLLS and 19 open left lateral sectionectomy (OLLS). For LRH the mean operative, postoperative and overall costs were £10,181, £4,037 and £14,218; for ORH the mean operative, postoperative and overall costs were £6,483 (p < 0.0001), £10,304 (p < 0.0001) and £16,787 (p = 0.886). Regarding LLLS, the mean operative, postoperative and overall costs were £5,460, £2,599 and £8,059; for OLLS the mean operative, postoperative and overall costs were £5,841 (p = 0.874), £5,796 (p < 0.0001) and £11,637 (p = 0.0001). Our data support the cost advantage of the laparoscopic approach for left lateral sectionectomy and the cost neutrality for right hepatectomy.

Single-Centre Comparative Study of Laparoscopic Versus Open Right Hepatectomy

BackgroundExpansion of laparoscopic major hepatectomy is still limited mainly due to the well-recognised technical difficulties compared to open surgery, and doubts regarding the oncological efficiency when major resections are required. MethodsPatients undergoing open right hepatectomy (ORH) were matched with patients undergoing laparoscopic right hepatectomy (LRH) and compared for perioperative outcomes. ResultsSeventy patients were included: 36 patients underwent LRH and 34 ORH. Operative time was significantly longer for LRH (median, 300 min vs. 180 min for ORH; p < 0.0001). Intensive care unit (median, 2 days for LRH vs. 4 days for ORH; p < 0.0001) and postoperative length of stay (5 days for LRH vs. 9 days for ORH; p < 0.0001) were significantly shorter for LRH. Four laparoscopic cases were converted to open surgery. No significant difference in postoperative complications and mortality was observed between LRH and ORH. Among patients with colorectal carcinoma liver metastases, R0 resection was obtained in 20/21 (95%) cases after LRH, and in 20/25 (80%) after ORH (p = 0.198). Mid-term overall survival did not significantly differ between the laparoscopic and the open group. ConclusionsLRH can be a safe, effective, and oncologically efficient alternative to open resection in selected cases. Extensive experience in hepatic and laparoscopic surgery is required.

Laparoscopic versus open right hepatectomy: a comparative study

Background The safety of laparoscopic major liver resections is still uncertain. The aim of this study was to compare our results for laparoscopic right hepatectomy (LRH) with those for open right hepatectomy (ORH). Methods Patients undergoing LRH were compared with retrospectively selected patients from our ORH database. The 2 groups were well matched for sex, age, American Society of Anesthesiologists score, body mass index, liver disease, and tumor size. Surgical and postsurgical outcomes were compared. Results Seventy-two patients were analyzed: 22 in the LRH group and 50 in the ORH group. Operating time was similar. Blood loss was significantly less in laparoscopic resections ( P = .038). Specific morbidity rates were not different, general morbidity was lower after laparoscopy ( P = .04), and the severity of postsurgical complications was not different. Mean hospital stay was significantly shorter after laparoscopy ( P = .009). Comments Laparoscopy improved surgical and postsurgical outcomes for ORH in selected patients. This is the first comparative study to demonstrate an advantage of laparoscopy for a major liver resection. Prospective randomized studies with a greater number of cases are needed to confirm the role of laparoscopy in major liver resections.