Posterosuperior Segments Research Articles

Experience-based transition to robotic surgery in an experienced program in minimally invasive hepatobiliary surgery.

The adoption of robotic techniques in liver surgery introduces significant challenges for their safe integration within hepatobiliary surgery units. This study is designed to investigate the complexities associated with establishing a robotic surgery program. Data on robotic hepatobiliary surgeries were prospectively collected from October 2021 to October 2023. Historical cohorts from the institutional experiences for comparison were hand-assisted (HALS) and purely laparoscopic procedures (PLS). Inverse probability of treatment weighting and propensity score matching were employed to compare outcomes between PLS and robotic resections. The learning curve for robotic surgeries was evaluated by the cumulative sum method. In this study, 454 patients were enrolled (113 robotic surgeries, 157 HALS, and 184 PLS). The posterosuperior segments resections were significantly higher in the robotic group (47.8%) compared to PLS (31.5%) and HALS (35.7%). There were no conversions in the robotic group, in PLS 2.7% and HALS 3.8%. The degree of difficulty according to the median of the IWATE score and IMM score was significantly higher in the robot group (p < 0.001 and p = 0.008, respectively). No significant differences in short-term outcomes were observed between robotic procedures and PLS in a matched subset of patients. Operative efficiency and blood loss improved significantly after the 75th robotic surgery patient, with high-difficulty cases (IWATE ≥ 10) incorporated from the beginning. This study suggests that robotic liver surgery in units with prior experience in minimally invasive liver surgery offers benefits, such as a lower conversion rate and a higher rate of successful difficult resections.

Caudate lobe and posterosuperior segment hepatectomy using the robotic approach. Outcome analysis of liver resection in difficult locations

BackgroundCaudate and posterosuperior hepatectomy are technically challenging resections, especially in a minimally invasive approach. We aimed to analyze the outcomes of isolated caudate resection (ICR), en-bloc caudate resection with right/left hepatic lobectomy (ECR), and posterosuperior segment resection (PSR) using our institutional database. MethodsFollowing IRB approval, we prospectively followed 500 consecutive patients between 2013 and 2023 who underwent robotic hepatectomy. Posterosuperior segments include segment 4 ​A, 7, and 8. The data are presented as median (mean ​± ​standard deviation). ResultsOf the 500 patients included in this study, 19 (4 ​%) underwent ICR, 65 (13 ​%) underwent ECR, and 131 (26 ​%) patients underwent PSR. ECR was associated with significantly longer operative time, increased EBL, and longer LOS when compared with those of ICR and PSR. The patients who underwent ICR had the shortest operation duration, lowest EBL, and shortest LOS compared to ECR and PSR. ConclusionsRobotic resection of liver tumors located in difficult segments is safe and feasible with excellent clinical and oncological outcomes. With appropriate expertise, a minimally invasive approach to those operations should not be avoided.

The differential benefit of laparoscopic over open minor liver resection for lesions situated in the anterolateral or posterosuperior segments.

It is well known that laparoscopic liver surgery can offer advantages over open liver surgery in selected patients. However, what type of procedures can benefit most from a laparoscopic approach has been investigated poorly thus far. The aim of this study is thus to define the extent of advantages of laparoscopic over open liver surgery for lesions in the anterolateral (AL) and posterosuperior (PS) segments. In this international multicentre retrospective cohort study, laparoscopic and open minor liver resections for lesions in the AL and PS segments were compared after propensity score matching. The differential benefit of laparoscopy over open liver surgery, calculated using bootstrap sampling, was compared between AL and PS resections and expressed as a Delta of the differences. After matching, 3,040 AL and 2,336 PS resections were compared, encompassing open and laparoscopic procedures in a 1:1 ratio. AL and PS laparoscopic liver resections were more advantageous in comparison to open in terms of blood loss, transfusion rate, complications, and length of stay. However, AL resections benefitted more from laparoscopy than PS in terms of overall and severe complications (D-difference were 4.8%, P=0.046 and 3%, P=0.046) and blood loss (D-difference was 195 mL, P<0.001). Similar results were observed in the subset for high-volume centres, while in recent years no significant differences were found in the differential benefit between AL and PS segments. The advantage of laparoscopic over open liver surgery is greater in the AL segments than in the PS segments.

Robot-assisted fenestration of giant hepatic cysts in posterosuperior segments

Robot-assisted fenestration of giant hepatic cysts in posterosuperior segments

A safe and effective endoscopic treatment method for simple hepatic cysts (with video).

Background and study aims Symptomatic simple hepatic cysts require treatment, with several guidelines recommending laparoscopic deroofing. However, cysts located in the posterosuperior segments are considered poor candidates for this procedure. Gastrointestinal endoscopes are more flexible and able to reach less accessible areas than laparoscopes. This study aimed to evaluate the utility of endoscopic transgastric hepatic cyst deroofing (ETGHCD) for treatment of simple hepatic cysts. Patients and methods Seven patients with simple hepatic cysts were evaluated between June 2021 and October 2023. The success rate, procedure time, post-procedure length of hospital stays, complications, pathologic diagnosis, and efficacy were recorded. Results Eleven cysts in seven patients (5 men; mean age 65.5 (standard deviation [SD] 8.5) years) were successfully treated without any complications. The mean procedure time was 65.6 minutes (SD 17.2). Mean post-procedure hospitalization was 4.4 days (SD 1.0). The pathologic diagnosis of 11 cysts showed simple hepatic cysts. The size of the cysts was significantly decreased from 337.0 cm 3 (SD 528.8) to 5.2 cm 3 (SD 6.3) 1 month after ETGHCD. During the median 12.7-month follow-up in seven patients, the cysts showed a 99.6% reduction with no recurrence. Conclusions ETGHCD provided a feasible, safe, effective, and minimal invasive alternative approach for the treatment of simple hepatic cysts.

Evaluation of the economic impact of the robotic approach in major and postero-superior segment liver resections: a multicenter retrospective analysis.

Economic impact of robotic liver surgery (RLS) is still a debated issue due to the heterogeneity of liver resections considered and the lack of a rigorous methodology. Therefore, the aim of this study is to perform a time-driven activity-based costing (TD-ABC) comparing the costs of RLS, laparoscopic liver surgery (LLS) and open liver surgery (OLS) in the context of complex liver resections and to compare short term perioperative outcomes. The institutional databases of two Italian high volume hepatobiliary centres were retrospectively reviewed from February 2021 to April 2022. Patients submitted to major hepatectomies or postero-superior liver resections were selected and divided into three groups according to the approach scheduled (RLS, LLS and OLS) and compared. Major contributors of perioperative expenses were calculated using the TD-ABC model and accurately quantifying each unit resource consumed per patient and the time spent performing each activity. A primary intention-to-treat analysis (ITT-A) including conversions in the RLS and LLS groups was performed. Forty-seven RLS, 101 LLS and 124 OLS were collected. LLS and RLS showed reduced blood loss, morbidity, mortality and hospital stay compared with open. A trend towards reduced conversion rate in RLS compared to LLS was registered. Total costs associated with RLS were estimated at €10,637 vs. €9,543 for LLS and vs. €13,960 for OLS. The higher intraoperative costs associated with RLS (+153.3% vs. OLS and +148.2% vs. LLS, P<0.001), primarily related to surgical equipment expenses, were slightly offset by the postoperative savings (-56.0% vs. OLS and -29.4% vs. LLS, P<0.001) resulting from significantly reduced hospital stays. RLS offers economic advantages over OLS, as initial higher costs are offset by better perioperative outcomes. The evolving robotic marketplace is expected to drive down RLS costs, promoting widespread adoption in minimally invasive procedures. Despite its higher costs than LLS, RLS's ability to enhance minimally invasive feasibility makes it a preferred choice for complex cases, reducing the need for conversions.

Robotic Versus Laparoscopic Liver Resection in Various Settings: An International Multicenter Propensity Score Matched Study of 10.075 Patients.

To compare the perioperative outcomes of robotic liver surgery (RLS) and laparoscopic liver surgery (LLS) in various settings. Clear advantages of RLS over LLS have rarely been demonstrated, and the associated costs of robotic surgery are generally higher than those of laparoscopic surgery. Therefore, the exact role of the robotic approach in minimally invasive liver surgery remains to be defined. In this international retrospective cohort study, the outcomes of patients who underwent RLS and LLS for all indications between 2009 and 2021 in 34 hepatobiliary referral centers were compared. Subgroup analyses were performed to compare both approaches across several types of procedures: (1) minor resections in the anterolateral (2, 3, 4b, 5, and 6) or (2) posterosuperior segments (1, 4a, 7, 8), and (3) major resections (≥3 contiguous segments). Propensity score matching was used to mitigate the influence of selection bias. The primary outcome was textbook outcome in liver surgery (TOLS), previously defined as the absence of intraoperative incidents ≥grade 2, postoperative bile leak ≥grade B, severe morbidity, readmission, and 90-day or in-hospital mortality with the presence of an R0 resection margin in case of malignancy. The absence of a prolonged length of stay was added to define TOLS+. Among the 10.075 included patients, 1.507 underwent RLS and 8.568 LLS. After propensity score matching, both groups constituted 1.505 patients. RLS was associated with higher rates of TOLS (78.3% vs 71.8%, P < 0.001) and TOLS+ (55% vs 50.4%, P = 0.026), less Pringle usage (39.1% vs 47.1%, P < 0.001), blood loss (100 vs 200 milliliters, P < 0.001), transfusions (4.9% vs 7.9%, P = 0.003), conversions (2.7% vs 8.8%, P < 0.001), overall morbidity (19.3% vs 25.7%, P < 0.001), and microscopically irradical resection margins (10.1% vs. 13.8%, P = 0.015), and shorter operative times (190 vs 210 minutes, P = 0.015). In the subgroups, RLS tended to have higher TOLS rates, compared with LLS, for minor resections in the posterosuperior segments (n = 431 per group, 75.9% vs 71.2%, P = 0.184) and major resections (n = 321 per group, 72.9% vs 67.5%, P = 0.086), although these differences did not reach statistical significance. While both produce excellent outcomes, RLS might facilitate slightly higher TOLS rates than LLS.

Advantages of laparoscopic segmentectomy of the liver using ICG fluorescent navigation by the negative staining method: A comparison with open procedure.

Laparoscopic segmentectomy (LS) using indocyanine green (ICG) fluorescence navigation with negative staining method has potential for performing accurate and safe anatomical excision. This study aimed to evaluate the significance of LS using ICG fluorescence navigation compared with open segmentectomy (OS). Eighty-seven patients who underwent anatomical segmentectomies were evaluated for OS (n = 44) and LS (n = 43). The Glissonean pedicle approach was performed using either extra- or intrahepatic method, depending on the location of segment in LS. After clamping pedicle, negative staining method was performed. Liver transection was done along intersegmental plane visualizing by overlay mode of ICG camera. Surgical outcomes were compared between two groups. Correlation between predicted resecting liver volume (PRLV) calculated using volumetry and actual resected liver volume (ARLV) was assessed in two groups. Patients who underwent LS showed better outcomes in operative time, blood loss, and length of hospital stay. There were significantly fewer Grade II and Grade III or higher postoperative complications in LS group. Both values of AST (p < 0.001) and ALT (p < 0.001) on postoperative day 1 were significantly lower in LS group than in OS group. PRLV and ARLV were more strongly correlated in LS (r = 0.896) than in OS (r = 0.773). The difference between PRLV and ARLV was significantly lower in LS group than in OS group (p = 0.022), and this trend was particularly noticeable in posterosuperior segment (p = 0.008) than in anterolateral segment (p = 0.811). LS using ICG navigation allows precise resection and may contribute to safer short-term outcomes than OS, particularly in posterosuperior segment.

Achieving Textbook Outcomes after Laparoscopic Resection in Posterosuperior Segments of the Liver: The Impact of the Learning Curve.

Achieving textbook outcomes (TOs) improves the short-term and long-term performance of a hospital. Our objective was to assess TOs in the laparoscopic liver resection (LLR) of tumors in the PS (posterosuperior) section of the liver and identify the impact of the learning curve. We conducted a retrospective cohort study analyzing patients who underwent LLR for lesions located in the PS segments. Patients were divided into a TO and no-TO group. TOs were defined as negative margins, no transfusion, no readmission, no major complications, no 30-day mortality, and a length of stay ≤ 50th percentile. Patients' outcomes were assessed in two study periods before and after 2015. TOs were achieved in 47.6% (n = 117). In multivariable analysis, obesity (p = 0.001), shorter operation time (p < 0.001), less blood loss (p < 0.001), normal albumin (p = 0.003), and minor resection (p = 0.046) were significantly associated with achieving TOs. Although the 5-year recurrence-free survival rate (p = 0.096) was not significantly different, the 5-year overall survival rate was significantly greater in the TO group (p = 0.001). Body mass index > 25 kg/m2 (p = 0.020), age > 65 years (p = 0.049), and achievement of TOs (p = 0.024) were independently associated with survival. The proportion of patients who achieved a TO was higher after 2015 than before 2015 (52.3% vs. 36.1%; p = 0.022). TOs are important markers not only for assessing hospital and surgeon performance but also as predictors of overall survival. As the number of surgeons who achieve the learning curve increases, the number of patients with TOs will gradually increase with a subsequent improvement in overall survival.

Achieving textbook outcomes after laparoscopic resection in posterosuperior segments of the liver: the impact of the learning curve

Achieving textbook outcomes after laparoscopic resection in posterosuperior segments of the liver: the impact of the learning curve

Achieving textbook outcomes after laparoscopic resection in postero-superior segments of the liver: the impact of the learning curve

Achieving textbook outcomes after laparoscopic resection in postero-superior segments of the liver: the impact of the learning curve

Laparoscopic anatomical versus non-anatomical liver resection for hepatocellular carcinoma in the posterosuperior segments: a propensity score matched analysis.

Since laparoscopic anatomical resection (LAR) for tumors, especially located in the posterosuperior (PS) segments of the liver remains difficult, laparoscopic non-anatomical resection (LNAR) are generally preferred. To compare the clinical outcomes between LAR and LNAR for hepatocellular carcinoma (HCC) located in the PS segments. We retrospectively reviewed the data for 1,029 patients who underwent hepatectomy for HCC between 2004 and 2019. Of 167 patients who underwent laparoscopic hepatectomy for HCC in PS segments, 64 underwent LNAR and 103 underwent LAR. Patients were matched one-to-one using propensity score matching (46:46). LNAR was associated with significantly shorter operation time (P=0.001), lower estimated blood loss (P=0.001), lower transfusion rate (P=0.006) and shorter hospital stay (P=0.012) than LAR. The respective 1- ,3-, and 5-year overall survival rates (LAR: 95.3%, 87.1%, and 77.8%; LNAR: 96.7%, 91.6%, and 85.0%; P=0.262) and recurrence-free survival rates (LAR: 75.7%, 70.3%, and 68.9%; LNAR: 81.8%, 58.3%, and 55.3%; P=0.879) were similar. The intrahepatic recurrence rate was significantly higher in LNAR group than in LAR group (78.6% vs. 57.1%, P=0.023), but the post-recurrence treatments differed significantly between the two groups (P=0.016); the re-resection rate was much greater in the LNAR group (45.0% vs. 0%) group. The respective 1-, 3-, and 5-year post-recurrence survival rates were similar in the LAR and LNAR groups (P=0.212). After recurrence, survival in re-resection group was significantly greater than not (P=0.026). LNAR is safe and feasible for HCC located in PS segments, and provided acceptable oncologic outcomes that are comparable to those of LAR. LNAR can be considered for patient with tumor located in PS segment when LAR is not feasible.

Posterosuperior Segments of the Liver: Comparison of Short-Term Outcomes between Open and Minimally Invasive Surgery Performed by a Single Surgeon

Laparoscopic posterosuperior liver segment resection is considered technically challenging. This is a retrospective single-center single-surgeon study. The aim of the present study is to investigate the short-term outcomes in a single institution between laparoscopic (LLR) and open (OLR) posterosuperior liver segments (PSSs) resections performed by a single surgeon at Parma University Hospital. The patients were divided into Group 1 (OLR) and Group 2 (LLR) and stratified in two different time settings according to the experience of the surgeon (2010–2015 and 2016–2021). A total 112 patients were included in the study. The 75.3% of OLR were performed in the first period, while 70.2% of LLR were carried out during the second period (2016–2021). The Iwate score was significantly (p &lt; 0.001) higher in OLR group compared to the LLR group. Most of the advanced (77%) and expert (100%) LLRs were performed during the second period. LOS was shorter in LLR group comparing to OLR group (p &lt; 0.001). The postoperative morbidity rate was similar in both groups (p &gt; 0.05). The presence of liver cirrhosis and multiple lesions were identified as risk factors for severe postoperative complications. PSS-LLR has become much safer and more effective due to increasing surgeon’s expertise along with the implementation of cutting-edge technology and innovative surgical techniques.

Subsegmental approaches to S7: anatomic laparoscopic transdiaphragmatic and nonanatomic robotic transthoracic.

Minimally invasive liver surgery of postero-superior segments (S4a, S7, S8) remains a challenge. The caudal view, an increased distance between trocars and the operative field, and the liver fulcrum limiting the view, contribute to the difficulty [1, 2]. We and other groups have previously reported the use of intercostal trocars to access subdiaphragmatic tumors (transdiaphragmatic approach) [3-5], only few reports on a laparoscopic total transthoracic approach, none (to our knowledge) dynamic manuscripts of a total transthoracic robotic approach, and none (to our knowledge) that use preoperative port site and anatomic modelling exist. Further, we developed a total transthoracic (thoracoscopic) approach to avoid a hostile abdomen, while bringing viewing axis and instruments close to the target [6-10]. In this context, this report details the advantages of a laparoscopic vs. robotic transthoracic approach. According to institutional protocol, reports of individual cases in print or video format do not require institutional review board approval. A 68-year-old male on peritoneal dialysis with left colon adenocarcinoma and a single synchronous liver metastasis in S6-7 close to the root of the right hepatic vein underwent a laparoscopic transdiaphragmatic metastasectomy. Two years later, the patient developed a recurrent 1.5cm liver metastasis in S7, which lend itself to a robotic transthoracic approach. Following 3-D modelling and virtual port placement planning, the first metastasectomy was performed laparoscopically using a transdiaphragmatic approach. The recurrence was managed transthoracically due to more apical, subdiaphragmatic location. For this operation, a robotic approach was optimal as robotic wrist articulation facilitates manipulation via the limited intercostal space. This was particularly helpful during the diaphragmatic reconstruction. Total transthoracic liver surgery is certainly an advanced procedure requiring superior MIS liver skills. Recommendations for starting with a total transthoracic approach are not unlike from starting a standard, none-transthoracic liver surgery. Early on in the experience we recommend advanced liver MIS skills, and single, small, subdiaphragmatic tumors away from major vessels. Nonetheless, when these recommendations are followed a total transthoracic approach may be safer and result in less access trauma, than traversing a hostile abdomen to reach the posterior-superior liver. Both laparoscopic and robotic transthoracic approaches can facilitate the resection of subdiaphragmatic tumors, especially in patients with hostile abdomens. While the laparoscopic approach has advantages due to a broader spectrum of available surgical tools (flexible tip camera, parenchymal dissection, and energy devices), the robotic wrist articulation facilitates manipulation via the restricted intercostal space.

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.

Standardization of robotic right liver mobilization.

Since its introduction 2decades ago, robotics has been increasingly used for resection of benign and malignant liver lesions. The robotic platform seems to preserve minimally invasive approach benefits, overcoming laparoscopy limitations. Robotic right liver mobilisation represents a key step for many robotic resections from non-anatomical resections of posterosuperior segments to right hepatectomy. We present here a standardized technique of right hepatic lobe mobilisation including technical steps and videos. Robotic resection provide all benefits of minimally invasive approaches in terms of preserving abdominal wall, early alimentation, reduced respiratory stress, associated with more ergonomic conditions for surgeon. We present our standardized and feasible right liver lobe mobilisation needed for posterosuperior resections to the right hepatectomy. The standardisation of right liver lobe represented our aim to provide a safe and reproducible initial step for many procedures to reduce the conversion rate and to improve the learning curve in young surgeons.

Efficacy of laparoscopic liver resection for small hepatocellular carcinoma located in the posterosuperior segments: A multi-institutional study using propensity score matching by the Kyushu Study Group of Liver Surgery.

Laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) located in the posterosuperior segments (PS) have generally been considered more difficult than those for HCC in anterolateral segments (AL), but may be safe and feasible for selected patients with accumulated experience. In the present study, we investigated the effectiveness of LLR for single nodular HCCs ≤3cm located in PS. In total, 473 patients who underwent partial liver resection for single nodular HCCs ≤3cm at the 18 institutions belonging to the Kyusyu Study Group of Liver Surgery from January 2010 to December 2018 were enrolled. The short-term outcomes of laparoscopic partial liver resection and open liver resection (OLR) for HCCs ≤3cm, with subgroup analysis of PS and AL, were compared using propensity score-matching analysis. Furthermore, results were also compared between LLR-PS and LLR-AL. The original cohort of patients with HCC ≤3cm included 328 patients with LLR and 145 with OLR. After matching, 140 patients with LLR and 140 with OLR were analyzed. Significant differences were found between groups in terms of volume of blood loss (median, 55 vs. 287ml, p<0.001), postoperative complications (0.71 vs. 8.57%, p=0.003), and postoperative hospital stay (median, 9 vs. 14days, p<0.001). The results of subgroup analysis of PS were similar. Short-term outcomes did not differ significantly between LLR-PS and LLR-AL after matching. Laparoscopic partial resection could be the preferred option for single nodular HCCs ≤3cm located in PS.

Safety and Feasibility of Laparoscopic Parenchymal-Sparing Hepatectomy for Lesions with Proximity to Major Vessels in Posterosuperior Liver Segments 7 and 8

Laparoscopic parenchymal-sparing hepatectomy (PSH) for lesions with proximity to major vessels (PMV) in posterosuperior segments (PSS) has not yet been sufficiently examined. The aim of this study is to examine the safety and feasibility of laparoscopic PSH for lesions with PMV in PSS 7 and 8. We retrospectively reviewed the outcomes of laparoscopic liver resection (LLR) and open liver resection (OLR) for PSS lesions and focused on patients who underwent laparoscopic PSH for lesions with PMV in PSS. Blood loss was lower in the LLR group (n = 110) than the OLR group (n = 16) (p = 0.009), and no other short-term outcomes were significantly different. Compared to the pure LLR group (n = 93), there were no positive surgical margins or complications in hand-assisted laparoscopic surgery (HALS) (n = 17), despite more tumors with PMV (p = 0.009). Regarding pure LLR for one tumor lesion, any short-term outcomes in addition to the operative time were not significantly different between the PMV (n = 23) and no-PMV (n = 48) groups. The present findings indicate that laparoscopic PSH for lesions with PMV in PSS is safe and feasible in a matured team, and the HALS technique still plays an important role.

Open Parenchymal Sparing Posterosuperior Liver Tumor Resection for Colorectal Liver Metastasis With Proximity to Hepatic Veins.

Liver resection for stage 4 colorectal cancer with liver metastasis is the standard of care, in combination with systemic chemotherapy. R-0 complete resection for colorectal liver metastasis is a curative-intent operation, which is considered the only chance for cure in this disease. The location and proximity of the tumor to major intrahepatic vessels such as hepatic and portal vein determine technical difficulty. Tumors located in the posterosuperior segments of the liver (segments 7 and 8) are technically challenging to resect using a minimally invasive fashion; therefore, conventional open resection is still the technique of choice today. In this video, we demonstrated our approach of an open parenchymal-sparing posterosuperior liver resection for a colorectal liver metastasis.

Challenging Scenarios and Debated Indications for Laparoscopic Liver Resections for Hepatocellular Carcinoma.

Laparoscopic liver resections (LLRs) have been increasingly adopted for the treatment of hepatocellular carcinoma (HCC), with safe short- and long-term outcomes reported worldwide. Despite this, lesions in the posterosuperior segments, large and recurrent tumors, portal hypertension, and advanced cirrhosis currently represent challenging scenarios in which the safety and efficacy of the laparoscopic approach are still controversial. In this systematic review, we pooled the available evidence on the short-term outcomes of LLRs for HCC in challenging clinical scenarios. All randomized and non-randomized studies reporting LLRs for HCC in the above-mentioned settings were included. The literature search was run in the Scopus, WoS, and Pubmed databases. Case reports, reviews, meta-analyses, studies including fewer than 10 patients, non-English language studies, and studies analyzing histology other than HCC were excluded. From 566 articles, 36 studies dated between 2006 and 2022 fulfilled the selection criteria and were included in the analysis. A total of 1859 patients were included, of whom 156 had advanced cirrhosis, 194 had portal hypertension, 436 had large HCCs, 477 had lesions located in the posterosuperior segments, and 596 had recurrent HCCs. Overall, the conversion rate ranged between 4.6% and 15.5%. Mortality and morbidity ranged between 0.0% and 5.1%, and 18.6% and 34.6%, respectively. Full results according to subgroups are described in the study. Advanced cirrhosis and portal hypertension, large and recurrent tumors, and lesions located in the posterosuperior segments are challenging clinical scenarios that should be carefully approached by laparoscopy. Safe short-term outcomes can be achieved provided experienced surgeons and high-volume centers.