Pure Laparoscopic Liver Resection Research Articles

Impact of tumor proximity to vessel on conversion in laparoscopic liver resection: A retrospective cohort study.

Although various difficulty scoring systems have been proposed for laparoscopic liver resection (LLR), details remain uncertain regarding distance between the tumor and vessels as a factor of difficulty. We aimed to examine the risk factors for conversion to open hepatectomy in LLR, including distance between tumor and vessels. Between January 2012 and December 2022, 118 patients who underwent LLR were retrospectively enrolled and their perioperative characteristics were evaluated. A total of 10 cases (8.5%) were converted to open hepatectomy during LLR. The conversion group had lower platelet count, shorter distance between the tumor and a medium vessel (defined as diameter of 5-10 mm), and greater tumor depth compared with the pure LLR group. Receiver-operating characteristic curve analysis identified 10 mm as the optimal cutoff value of tumor proximity to a medium vessel (sensitivity, 80.0%, specificity, 78.7%, AUC 0.817) for predicting conversion. In multivariate analysis, lower platelet count (p = .028) and tumor proximity within 10 mm to a medium vessel (p = .001) were independent risk factors for conversion in LLR. Our study suggests tumor proximity within 10 mm to a medium vessel and lower platelet count as predictors of unfavorable intraoperative conversion in LLR.

The efficacy and safety of pure laparoscopic liver resection for hepatocellular carcinoma in super-elderly patients over 80 years: A multicenter propensity analysis.

Very few reports have evaluated the safety of laparoscopic liver resection in super-elderly patients. We assessed the short-term outcomes of laparoscopic liver resection in patients with hepatocellular carcinoma aged ≥80 years, using propensity score matching. We retrospectively analyzed the data of 287 patients (aged ≥80 years) who underwent liver resection for hepatocellular carcinoma at eight hospitals belonging to Hiroshima Surgical study group of Clinical Oncology, between January 2012 and December 2021. The perioperative outcomes were compared between laparoscopic and open liver resection, using propensity score matching. Of the 287 patients, 83 and 204 were included in the laparoscopic and open liver resection groups, respectively. Propensity score matching was performed, and 52 patients were included in each group. The operation (p = .68) and pringle maneuver (p = .11) time were not different between the groups. There were no significant differences in the incidences of bile leakage or organ failure. The laparoscopic liver resection group had significantly less intraoperative bleeding and a lower incidence of cardiopulmonary complications (both p < .01). Laparoscopic liver resection can be safely performed in elderly patients aged ≥80 years.

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.

Surgical outcomes of pure laparoscopic versus open liver resection for intrahepatic cholangiocarcinoma

Kyeong Deok KIM, Jong Man KIM*, Manuel LIM, Ji Eun KWON, Eun Sung JEONG, Jaehun YANG, Young Ju OH, Sunghae PARK, Sang Oh YUN, Jinsoo RHU, Gyu-Seong CHOI, Jae-Won JOH. Ann Hepatobiliary Pancreat Surg 2022;26:S180. https://doi.org/10.14701/ahbps.2022S1.LV-PP-1-5

Risk factors of unplanned intraoperative conversion to hand-assisted laparoscopic surgery or open surgery in laparoscopic liver resection.

Laparoscopic liver resection (LLR) is possible in many patients, but pure LLR is sometimes difficult to complete, and unplanned intraoperative hand-assisted laparoscopic surgery (HALS) or open conversion is sometimes necessary. However, appropriate indications and timing for conversion are unclear. This study aimed to clarify the indications for HALS and open conversion from pure LLR. We collected data from 208 patients who underwent LLR from January 2010 to February 2021 in our department. We retrospectively examined these data between cases of unplanned intraoperative HALS conversion, open conversion, and pure LLR, and clarified risk factors and indications for HALS or open conversion. There were 191 pure LLRs, nine HALS conversions, and eight open conversions. In the HALS conversion group versus pure LLR group, body mass index (BMI) (27.0 vs. 23.7kg/m2, p = 0.047), proportions of patients with history of upper abdominal surgery (78% vs. 33%; p = 0.006), repeat hepatectomy (56% vs. 15%; p = 0.002), S7 or S8 tumor location (67% vs. 35%; p = 0.049), and difficulty score (DS) ≥ 7 (56% vs. 19%; p = 0.008) were significantly higher, and surgical time (339 vs. 239min; p = 0.031) was significantly longer. However, postoperative states were not significantly different between the two groups. The BMI cutoff value for risk of unplanned intraoperative conversion determined by receiver operating characteristic curve analysis was 25kg/m2, and the proportion of patients with BMI ≥ 25kg/m2 (89% vs. 31%, p < 0.001) was significantly higher in the HALS conversion versus pure LLR group. In the open conversion group, although there were no significant differences compared to the HALS group in clinicopathological factors except for sex, blood loss was greater (1425 vs. 367mL; p < 0.001). Risk factors for considering HALS during LLR were patients with a history of upper abdominal surgery including repeat hepatectomy, BMI ≥ 25kg/m2, S7 or S8 tumor location, DS ≥ 7, and prolonged surgical time. Furthermore, uncontrollable intraoperative bleeding was an indication for open conversion.

Pure laparoscopic major liver resection after yttrium90 radioembolization: a case-matched series analysis of feasibility and outcomes

BackgroundLiver surgery after radioembolization (RE) entails highly demanding and challenging procedures due to the frequent combination of large tumors, severe RE-related adhesions, and the necessity of conducting major hepatectomies. Laparoscopic liver resection (LLR) and its associated advantages could provide benefits, as yet unreported, to these patients. The current study evaluated feasibility, morbidity, mortality, and survival outcomes for major laparoscopic liver resection after radioembolization.Material and methodsIn this retrospective, single-center study patients diagnosed with hepatocellular carcinoma, intrahepatic cholangiocarcinoma or metastases from colorectal cancer undergoing major laparoscopic hepatectomy after RE were identified from institutional databases. They were matched (1:2) on several pre-operative characteristics to a group of patients that underwent major LLR for the same malignancies during the same period but without previous RE.ResultsFrom March 2011 to November 2020, 9 patients underwent a major LLR after RE. No differences were observed in intraoperative blood loss (50 vs. 150 ml; p = 0.621), operative time (478 vs. 407 min; p = 0.135) or pedicle clamping time (90.5 vs 74 min; p = 0.133) between the post-RE LLR and the matched group. Similarly, no differences were observed on hospital stay (median 3 vs. 4 days; p = 0.300), Clavien–Dindo ≥ III complications (2 vs. 1 cases; p = 0.250), specific liver morbidity (1 vs. 1 case p = 1.000), or 90 day mortality (0 vs. 0; p = 1.000).ConclusionThe laparoscopic approach for post radioembolization patients may be a feasible and safe procedure with excellent surgical and oncological outcomes and meets the current standards for laparoscopic liver resections. Further studies with larger series are needed to confirm the results herein presented.

Risk factors for and management of morbidity in pure laparoscopic resection of the right posterosuperior segments of the liver: A multicenter retrospective study.

This study aimed to determine the risk factors for severe postoperative complications in patients undergoing pure laparoscopic liver resection (LLR) for tumors in the right posterosuperior (PS) segments. The study included 289 patients who underwent parenchyma-sparing pure LLR for tumors in the right PS segments at eight treatment centers between January 2009 and December 2019. Multivariate analysis revealed tumor size ≥3cm (P=.016), segmentectomy (P=.044), and liver cirrhosis (P=.029) as independent risk factors for severe postoperative complications. The severe complication rates (2.7% vs 12.1%, P=.0025), median intraoperative blood loss (100 mL vs 150 mL, P=.001), and median operation time (248 minutes vs 299.5 minutes, P=.0013) were lower in the patients without all these three risk factors than those with at least one risk factor. The median length of postoperative hospital stay was shorter in patients with no risk factors than those with at least one risk factor (9 days vs. 10 days, P=.001). Tumor size ≥3cm, segmentectomy, and liver cirrhosis were the risk factors for severe postoperative complications after parenchyma-sparing pure LLR for tumors in the right PS segments. Patients without these three risk factors would be appropriate candidates for safely performing parenchyma-sparing pure LLR in the right PS segments at the outset.

Pure Laparoscopic Liver Resection versus Percutaneous Radiofrequency Ablation for Small Hepatocellular Carcinoma: A Propensity Score and Multivariate Analysis

Introduction: In treatment of hepatocellular carcinoma (HCC), both laparoscopic liver resection (LLR) and radiofrequency ablation (RFA) provided similar short-term advantages. However, there was no robust clinical trial comparing the efficacy of LLR and RFA especially for small HCC. This study aimed to compare the short-term and long-term outcomes of LLR and RFA for patients with small HCC. Methods: All patients underwent RFA or LLR for small HCC from April 2005 to August 2020 were included. Propensity score matching was conducted to match patients in the LLR group and RFA group. The demographic data, tumor characteristics, operative data, post-operative outcomes and survival data of the two groups were compared. A multivariate analysis based on Cox regression was used to identify factors associated with survival. Results: LLR and RFA had similar overall survival (91.8% vs. 79.2% at 5-year, p=0.060); while the LLR had a significantly better disease-free survival (49.0% vs. 30.3% at 5-year, p=0.002) and local recurrence-free survival (96.0% vs. 63.7% at 5-year, p<0.001) when compared with the RFA. Multivariate analysis showed that treatment received by patient, prothrombin time and platelet counts were significantly associated with disease-free survival. On the other hand, the only factor associated with local recurrence-free survival was the treatment received by patient. Conclusion: Both RFA and LLR are safe and feasible treatment options for patients with small HCC. LLR should be considered for patients with preserved liver function with a better disease-free survival; while RFA offered a comparable overall survival with less surgical trauma and shorter hospital stay.

Pure laparoscopic liver resection versus percutaneous radiofrequency ablation for small hepatocellular carcinoma: a propensity score and multivariate analysis

BackgroundIn treatment of hepatocellular carcinoma (HCC), both laparoscopic liver resection (LLR) and radiofrequency ablation (RFA) provided similar short-term advantages. However, there was no robust clinical trial comparing the efficacy of LLR and RFA especially for small HCC. This study aimed to compare the short-term and long-term outcomes of LLR and RFA for patients with small HCC using a propensity score matching analysis to minimize potential selection bias. Factors affecting survival were then identified with multivariate analysis.MethodsAll patients underwent RFA or LLR for small HCC [defined as Barcelona Clinic Liver Cancer (BCLC) stage 0 or A, size ≤3 cm, ≤3 nodules on contrast CT scan or MRI with no evidence of macrovascular invasion] from April 2005 to August 2020 were included. Propensity score matching was conducted to match patients in the LLR group and RFA group. Prognostic indicators, i.e., age, gender, tumor size, tumor number, Child’s grading, albumin, bilirubin, platelet count, international normalized ratio, alpha-fetoprotein level and presence of cirrhosis on imaging were chosen for propensity score calculation. The demographic data, tumor characteristics, operative data, post-operative outcomes and survival data of the two groups were compared. A multivariate analysis based on Cox regression was used to identify factors associated with survival.ResultsMedian follow-up was 34 months. LLR and RFA had similar overall survival (91.8% vs. 79.2% at 5-year, P=0.060); while the LLR had a significantly better disease-free survival (49.0% vs. 30.3% at 5-year, P=0.002) and local recurrence-free survival (96.0% vs. 63.7% at 5-year, P<0.001) when compared with the RFA. Multivariate analysis showed that treatment received by patient (LLR vs. RFA), prothrombin time and platelet counts were significantly associated with disease-free survival. On the other hand, the only factor associated with local recurrence-free survival was the treatment received by patient.ConclusionsBoth RFA and LLR are safe and feasible treatment options for patients with small HCC. LLR should be considered for patients with preserved liver function with a better disease-free survival; while RFA offered a comparable overall survival with less surgical trauma and shorter hospital stay.

The Learning Curve of Laparoscopic Liver Resection Utilising the Southampton Difficulty Score

Background: This study aimed to quantitatively evaluate the learning curve of laparoscopic liver resection (LLR) of a single surgeon. Methods: A retrospective review of a prospectively maintained database of liver resections was conducted. 171 patients undergoing pure LLRs between April 2008 and April 2021 were analysed. The Southampton difficulty score (SDS) for theoretical predictions of intraoperative complications (IOC) during LLR was applied. IOC was defined as blood loss over 775 mL, unintentional damage to the surrounding structures, and conversion to an open approach. Theoretical association between SDS and the predicted probability of IOC was utilised to objectify the shape of the learning curve. Results: The obtained learning curve (Figure 1) has resulted from thirteen years of surgical effort of a single surgeon. It consists of an absolute and a relative part in the mathematical description of the additive function described by the logarithmic function (absolute complexity) and fifth-degree regression curve (relative complexity). The obtained learning curve determines the functional dependency of the learning outcome versus time and indicates several local extreme values (peaks and valleys) in the learning process until proficiency is achieved. Conclusion: This learning curve indicates an ongoing learning process for LLR. The proposed mathematical model can be applied for any surgical procedure with an existing difficulty score and a known theoretically predicted association between the difficulty score and given outcome (for example, IOC).

The learning curve of laparoscopic liver resection utilising a difficulty score.

BackgroundThis study aimed to quantitatively evaluate the learning curve of laparoscopic liver resection (LLR) of a single surgeon.Patients and methodsA retrospective review of a prospectively maintained database of liver resections was conducted. 171 patients undergoing pure LLRs between April 2008 and April 2021 were analysed. The Halls difficulty score (HDS) for theoretical predictions of intraoperative complications (IOC) during LLR was applied. IOC was defined as blood loss over 775 mL, unintentional damage to the surrounding structures, and conversion to an open approach. Theoretical association between HDS and the predicted probability of IOC was utilised to objectify the shape of the learning curve.ResultsThe obtained learning curve has resulted from thirteen years of surgical effort of a single surgeon. It consists of an absolute and a relative part in the mathematical description of the additive function described by the logarithmic function (absolute complexity) and fifth-degree regression curve (relative complexity). The obtained learning curve determines the functional dependency of the learning outcome versus time and indicates several local extreme values (peaks and valleys) in the learning process until proficiency is achieved.ConclusionsThis learning curve indicates an ongoing learning process for LLR. The proposed mathematical model can be applied for any surgical procedure with an existing difficulty score and a known theoretically predicted association between the difficulty score and given outcome (for example, IOC).

Learning process of laparoscopic liver resection and postoperative outcomes: chronological analysis of single-center 15-years' experience.

Limited studies have reported the actual learning process of laparoscopic liver resection (LLR). This study aimed to chronologically evaluate our 15years' experience of LLR. All consecutive LLRs between 2006 to 2020 were retrospectively analyzed. The time period was divided into three groups; first (2006-2010), second (2011-2015), and third (2016-2020) period. The primary endpoint of this study was a composite of overall (Clavien-Dindo grade ≥ II) or major (grade ≥ IIIa) postoperative complications within 30days. Using the IWATE criteria (four difficulty levels based on six indices), LLR was categorized as basic (< 7 points) and advanced (≥ 7 points) one. All analyses were performed based on the intention-to-treat principles. During the study period, a total of 382 LLRs were gradually performed (first period, n = 54; second period, n = 114, and third period, n = 214). Low incidences of overall and major complications were maintained (9.3, 10.5, and 7.0%, p = 0.514, and 1.9, 2.6, and 2.3%, p = 1.000). Meanwhile, pure LLRs (i.e., LLRs without hand-assisted or hybrid approach) and advanced LLRs were increasingly performed in 25 (46.3%), 71 (62.3%), and 205 (95.8%) patients (p < 0.001) and 3 (5.6%), 18 (15.8%), and 58 (27.1%) patients (p < 0.001), respectively. This study suggests that stepwise approach from basic to advanced procedures and use of hand-assisted or hybrid approach during the early phases for starting LLR practice may allow for maintaining low morbidity in specialized center.

Early experience of pure minimally invasive donor hepatectomy by junior surgeon

Although the pure minimally invasive donor hepatectomy (PMIDH) has been increasingly performed, it is still reported by experienced surgeons. Here we reported the early experience of PMIDM by junior surgeon. From April 2019 to November 2020, PMIDHs were performed for 19 patients by single novice surgeon (H.D.H) at Yonsei University College of Medicine. Clinical characteristics, perioperative outcomes of donors and clinical features of recipients were analyzed. Eighteen of 19 donors had pure laparoscopic liver resection. Right, left hemihepatectomies and left lateral sectionectomies were performed for 15, 1 and 3 donors, respectively. Mean total operation time was 460.63 ± 70.89 minutes and median operative bleeding was 200 mL (50-1,600 mL). Median hospital stay was 8 (7-11) days. In terms of laparoscopic donor right hemihepatectomy, mean total operation time was 464.21 ± 43.52 minutes. Median amount of bleeding during operation was 225 mL (50-1,600 mL). Mean estimated total liver volume was 1,228.26 ± 217.01 (935.80-1,584.90) and mean real graft weight was 764.86 ± 153.46 (529.00-1,077.00). The robotic donor right hemihepatectomy was performed for one donor. Total operation time was 663 minutes with 550 mL of operative bleeding. There was no conversion to open surgery. Only the first donor had transfusion during operation. There was no severe perioperative complication more than grade III according to classification of Clavien-Dindo surgical complication. Although the PMIDH may need high level of surgical skill, it appears to be a safe and feasible procedure by junior surgeon in properly selected donors.

Safety and efficacy of laparoscopic repeat liver resection and re-operation for liver tumor

Laparoscopic liver resection (LLR) has been reported as a safe, minimally invasive, and effective surgery for the management of liver tumor. However, the efficacy and safety of laparoscopic repeat liver resection (LRLR) for recurrent liver tumor are unclear. Here, we analyzed the surgical results of LRLR. From June 2010 to May 2019, we performed 575 LLR surgeries in our department, and 454 of them underwent pure LLR for the single tumor. We classified the patients who received pure LLR for the single tumor into three groups: LRLR (n = 80), laparoscopic re-operation after previous abdominal surgery (LReOp; n = 136), and laparoscopic primary liver resection (LPLR; n = 238). We compared patient characteristics and surgical results between patients undergoing LRLR, LReOp and LPLR. We found no significant differences between LRLR and LPLR in the conversion rate to laparotomy (p = 0.8033), intraoperative bleeding (63.0 vs. 152.4 ml; p = 0.0911), or postoperative bile leakage rate (2.50 vs. 3.78%; p = 0.7367). We also found no significant difference in the surgical results between LReOp and LPLR. However, the number of patients undergoing the Pringle maneuver was lower in the LRLR group than the LPLR group (61.3 vs. 81.5%; p = 0.0004). This finding was more pronounced after open liver resection than laparoscopic liver resection (38.9 vs. 67.7%; p = 0.0270). The operative time was significantly longer in patients with proximity to previous cut surface than patients with no proximity to previous cut surface (307.4 vs. 235.7 min; p = 0.0201). LRLR can safely be performed with useful surgical results compared to LPLR.

Laparoscopic Liver Resection in Patients with Previous Upper Abdominal Laparotomy

Introduction: Laparoscopic Liver Resection (LLR) is now performed worldwide. However, LLR is sometimes difficult in patients with previous upper abdominal laparotomy. Methods: We did 78 LLRs in our institution from January 2012 to December 2019. In our cases, 7 patients were performed upper abdominal laparotomy previously. We did pure LLR and partial hepatetomy in the patients. We report the surgical outcomes of LLR in the patients. Results: The history of the upper abdominal surgery was as follows: gastrectomy in 2 cases, cholecystectomy in 1, and hepatectomy in 4. LLRs were performed for hepatocellular carcinoma in 5 cases and metastasis of gastro intestinal stromal tumor in 2. Their Child-Pugh Score was as follows: A in 5 cases and B in 2. There were no cases of conversion to open hepatectomy. Median intraoperative blood loss was 75ml and operative time was 151 minutes. Blood transfusion was performed in only one case. No postoperative complication was seen. Average duration postoperative hospital stay was 8 days. Conclusion: We investigated surgical outcome of LLR in patients with previous upper abdominal laparotomy. While our outcomes seems favorable and safety, further number of cases would be required to determine whether LLR is superior to open hepatectomy in patients with previous upper abdominal laparotomy.

Evaluation of Iwate Criteria Model to Predict Difficulty of Laparoscopic Liver Resection

Background: Iwate criteria is a recently proposed classification system for assessing the surgical difficulty of laparoscopic liver resection (LLR). The aim of the present study was to externally validate this scoring system. Methods: All consecutive patients who underwent pure LLR between April 2008 and October 2019 at a single tertiary referral center were included. Iwate criteria was calculated according to original proposition which includes four difficulty levels based on six risk factors. Both intra- and postoperative complications were compared according to the difficulty scores. Results: The difficulty of 142 LLR were scored as low, intermediate, advanced and expert level in 41 (28.9%), 53 (37.3%), 32 (22.5%) and 16 (11.3%) patients, respectively. Intraoperative complication was detected in 26 (18.3%) patients. The rates of intraoperative complications (2.4, 7.5, 34.3, and 62.5%) increased gradually with statistically significant values among difficulty levels (P ˂ 0.001). 90-day major postoperative complications occurred in 19 (13.4%) patients where rates were also statistically significant among difficulty levels (P ˂ 0.001). We analysed our results and proposed mean risk curves/assessments for intraoperative complications and postoperative complications, based on the original proposal and the improved proposal with the new tumor size threshold (n = 3,8 cm) to validate the Iwate criteria and its practical application. Conclusion: We observed associations between the Iwate criteria and intraoperative and postoperative outcomes on our database. Additionally we proposed different tumor size threshold, which gives better results especially for intraoperative complications.

Evaluation of the Iwate Model for Predicting the Difficulty of Laparoscopic Liver Resection: Does Tumor Size Matter?

BackgroundThis study aimed to externally validate the Iwate scoring model and its prognostic value for predicting the risks of intra- and postoperative complications of laparoscopic liver resection. MethodsConsecutive patients who underwent pure laparoscopic liver resection between 2008 and 2019 at a single tertiary center were included. The Iwate scores were calculated according to the original proposition (four difficulty levels based on six indices). Intra- and postoperative complications were compared across difficulty levels. Fitting the obtained data to the cumulative density function of the Weibull distribution and a linear function provided the mean risk curves for intra- and postoperative complications, respectively. ResultsThe difficulty levels of 142 laparoscopic liver resections were scored as low, intermediate, advanced, and expert level in 41 (28.9%), 53 (37.3%), 32 (22.5%), and 16 (11.3%) patients, respectively. Intraoperative complications were detected in 26 (18.3%) patients and its rates (2.4%, 7.5%, 34.3%, and 62.5%) increased gradually with statistically significant values among difficulty levels (P ˂ 0.001). Major postoperative complications occurred in 21 (14.8%) patients and its rates (4.8%, 5.6%, 28.1%, 43.7%; P ˂ 0.001) showed the same trend as for intraoperative complications. Then, the mean risk curves of both complications were obtained. Due to outliers, a new threshold for a tumor size index was proposed at 38 mm. The repeated analysis showed improved results. ConclusionsThe Iwate scoring model predicts the probability of complications across difficulty levels. Our proposed tumor size threshold (38 mm) improves the quality of the prediction. The model is upgraded by a probability of complications for every difficulty score.

The external validation of a difficulty scoring system for predicting the risk of intraoperative complications during laparoscopic liver resection

BackgroundThis study aimed to externally validate and upgrade the recent difficulty scoring system (DSS) proposed by Halls et al. to predict intraoperative complications (IOC) during laparoscopic liver resection (LLR).MethodsThe DSS was validated in a cohort of 128 consecutive patients undergoing pure LLRs between 2008 and 2019 at a single tertiary referral center. The validated DSS includes four difficulty levels based on five risk factors (neoadjuvant chemotherapy, previous open liver resection, lesion type, lesion size and classification of resection). As established by the validated DSS, IOC was defined as excessive blood loss (> 775 mL), conversion to an open approach and unintentional damage to surrounding structures. Additionally, intra- and postoperative outcomes were compared according to the difficulty levels with usual statistic methods. The same five risk factors were used for validation done by linear and advanced nonlinear (artificial neural network) models. The study was supported by mathematical computations to obtain a mean risk curve predicting the probability of IOC for every difficulty score.ResultsThe difficulty level of LLR was rated as low, moderate, high and extremely high in 36 (28.1%), 63 (49.2%), 27 (21.1%) and 2 (1.6%) patients, respectively. IOC was present in 23 (17.9%) patients. Blood loss of >775 mL occurred in 8 (6.2%) patients. Conversion to open approach was required in 18 (14.0%) patients. No patients suffered from unintentional damage to surrounding structures. Rates of IOC (0, 9.5, 55.5 and 100%) increased gradually with statistically significant value among difficulty levels (P < 0.001). The relations between the difficulty level, need for transfusion, operative time, hepatic pedicle clamping, and major postoperative morbidity were statistically significant (P < 0.05). Linear and nonlinear validation models showed a strong correlation (correlation coefficients 0.914 and 0.948, respectively) with the validated DSS. The Weibull cumulative distribution function was used for predicting the mean risk probability curve of IOC.ConclusionThis external validation proved this DSS based on patient’s, tumor and surgical factors enables us to estimate the risk of intra- and postoperative complications. A surgeon should be aware of an increased risk of complications before starting with more complex procedures.

Long-term perioperative outcomes of pure laparoscopic liver resection versus open liver resection for hepatocellular carcinoma: a retrospective study.

Laparoscopic treatment for hepatocellular carcinoma (HCC) has increased. We retrospectively compared the perioperative and long-term oncological outcomes of laparoscopic liver resection (LLR) with those of open liver resection (OLR) for hepatocellular carcinoma (HCC) in well-matched patient groups using propensity score matching (PSM). We reviewed medical records of patients with HCC who underwent liver resection between July 2007 and April 2016 at our center. In total, 2335 patients were included in this study and divided into LLR (n = 264) and OLR (n = 2071) groups. For group comparisons, 1:2 PSM was used with covariates of baseline characteristics, including tumor characteristics and surgical liver resection procedures. After PSM, there were 217 and 434 patients in the LLR and OLR groups, respectively. The LLR group had shorter hospital stays (8.9 vs. 14.8days; P < 0.001) and lower postoperative morbidity (6.5% vs. 12.0%; P = 0.022). The 1-, 3-, and 5-year overall survival rates were 98.1%, 87.0%, and 78.6%, respectively, for the LLR group, and 98.3%, 90.8%, and 84.3%, respectively, for the OLR group (P = 0.570). The 1-, 3-, and 5-year disease-free survival rates were 81.0%, 62.0%, and 49.1%, respectively, for the LLR group, and 85.3%, 64.7%, and 56.2%, respectively, for the OLR group (P = 0.563). Long-term oncological outcomes were comparable between LLR and OLR for selected patients. LLR was associated with multiple benefits, even for selected patients with cirrhosis who underwent major hepatectomy. LLR for HCC performed by an experienced surgeon could be considered a safe and feasible alternative to OLR for selected patients.

Pure laparoscopic liver resection for giant liver hemangioma with extrahepatic growth based on preoperative 3-dimensional simulation: A case report

BackgroundPerforming laparoscopic liver resection for giant hemangiomas is challenging, and careful preoperative planning is essential. Controlling intraoperative bleeding and handling surgical instruments within a limited workspace is necessary.Case presentationIn the present case, the patient was a 38-year-old woman diagnosed with a 16-cm giant liver hemangioma in segment 5/6, with extrahepatic growth. Preoperative three-dimensional simulations for port placement and the laparoscopic view from the left upper abdomen were performed to complete the pure laparoscopic liver resection. The laparoscopic resection was then safely performed on the same way.ConclusionsPure laparoscopic resection could be applied to giant hemangiomas with extrahepatic growth, and the preoperative three-dimensional simulation of port placement and the laparoscopic view might be helpful when the intraabdominal workplace is restricted.