Laparoscopic versus open parenchymal preserving liver resections in the posterosuperior segments: a case-matched study

Explainable artificial intelligence prediction-based model in laparoscopic liver surgery for segments 7 and 8: an international multicenter study

BACKGROUND

Artificial intelligence (AI) is becoming more useful as a decision-making and outcomes predictor tool. We have developed AI models to predict surgical complexity and the postoperative course in laparoscopic liver surgery for segments 7 and 8.

METHODS

We included patients with lesions located in segments 7 and 8 operated by minimally invasive liver surgery from an international multi-institutional database. We have employed AI models to predict surgical complexity and postoperative outcomes. Furthermore, we have applied SHapley Additive exPlanations (SHAP) to make the AI models interpretable. Finally, we analyzed the surgeries not converted to open versus those converted to open.

RESULTS

Overall, 585 patients and 22 variables were included. Multi-layer Perceptron (MLP) showed the highest performance for predicting surgery complexity and Random Forest (RF) for predicting postoperative outcomes. SHAP detected that MLP and RF gave the highest relevance to the variables "resection type" and "largest tumor size" for predicting surgery complexity and postoperative outcomes. In addition, we explored between surgeries converted to open and non-converted, finding statistically significant differences in the variables "tumor location," "blood loss," "complications," and "operation time."

CONCLUSION

We have observed how the application of SHAP allows us to understand the predictions of AI models in surgical complexity and the postoperative outcomes of laparoscopic liver surgery in segments 7 and 8.

What Is the Role of Minimally Invasive Liver Surgery in Treating Patients with Hepatocellular Carcinoma on Cirrhosis?

Minimally invasive liver surgery (MILS) has been slowly introduced in the past two decades and today represents a major weapon in the fight against HCC, for several reasons. This narrative review conveys the major emerging concepts in the field. The rise in metabolic-associated steatotic liver disease (MASLD)-related HCC means that patients with significant cardiovascular risk will benefit more profoundly from MILS. The advent of efficacious therapy is leading to conversion from non-resectable to resectable cases, and therefore more patients will be able to undergo MILS. In fact, resection outcomes with MILS are superior compared to open surgery both in the short and long term. Furthermore, indications to surgery may be further expanded by its use in Child B7 patients and by the use of laparoscopic ablation, a curative technique, instead of trans-arterial approaches in cases not amenable to radiofrequency. Therefore, in a promising new approach, multi-parametric treatment hierarchy, MILS is hierarchically superior to open surgery and comes second only to liver transplantation.

Propensity Score-Matching Analysis Comparing Robotic Versus Laparoscopic Limited Liver Resections of the Posterosuperior Segments: An International Multicenter Study

OBJECTIVE

The purpose of this study was to compare the outcomes of robotic limited liver resections (RLLR) versus laparoscopic limited liver resections (LLLR) of the posterosuperior segments.

BACKGROUND

Both laparoscopic and robotic liver resections have been used for tumors in the posterosuperior liver segments. However, the comparative performance and safety of both approaches have not been well examined in the existing literature.

METHODS

This is a post hoc analysis of a multicenter database of 5446 patients who underwent RLLR or LLLR of the posterosuperior segments (I, IVa, VII, and VIII) at 60 international centers between 2008 and 2021. Data on baseline demographics, center experience and volume, tumor features, and perioperative characteristics were collected and analyzed. Propensity score-matching (PSM) analysis (in both 1:1 and 1:2 ratios) was performed to minimize selection bias.

RESULTS

A total of 3510 cases met the study criteria, of whom 3049 underwent LLLR (87%), and 461 underwent RLLR (13%). After PSM (1:1: and 1:2), RLLR was associated with a lower open conversion rate [10 of 449 (2.2%) vs 54 of 898 (6.0%); P =0.002], less blood loss [100 mL [IQR: 50-200) days vs 150 mL (IQR: 50-350); P <0.001] and a shorter operative time (188 min (IQR: 140-270) vs 222 min (IQR: 158-300); P <0.001]. These improved perioperative outcomes associated with RLLR were similarly seen in a subset analysis of patients with cirrhosis-lower open conversion rate [1 of 136 (0.7%) vs 17 of 272 (6.2%); P =0.009], less blood loss [100 mL (IQR: 48-200) vs 160 mL (IQR: 50-400); P <0.001], and shorter operative time [190 min (IQR: 141-258) vs 230 min (IQR: 160-312); P =0.003]. Postoperative outcomes in terms of readmission, morbidity and mortality were similar between RLLR and LLLR in both the overall PSM cohort and cirrhosis patient subset.

CONCLUSIONS

RLLR for the posterosuperior segments was associated with superior perioperative outcomes in terms of decreased operative time, blood loss, and open conversion rate when compared with LLLR.

Combined Ablation and Resection for Colorectal Liver Metastases in the Minimally Invasive Surgical Era

BACKGROUND

Thermal ablation is an accepted treatment modality for small and central liver tumors. In extensive colorectal liver metastatic disease (CRLM), hepatectomy can be combined with ablation, resulting in a parenchymal-sparing strategy. This may increase salvageability rates in case of recurrence.

METHODS

All patients with advanced CRLM that underwent combined ablation and resection between April 2012 and April 2021, were retrospectively analyzed from a prospectively maintained database. Primary endpoints include postoperative 30-day morbidity and ablation-site recurrence (ASR). The surgical approaches were compared. Ablated lesions were screened for ASR on postoperative follow-up imaging.

RESULTS

Of 54 patients that underwent combined ablation and resection, 32 (59.3%) were performed through a minimally invasive approach. Eleven (20.4%) were minor resections, 32 (59.3%) were technically major and 11 (20.4%) were anatomically major resections. Twelve complications occurred (22.2%), among which 2 (3.8%) major complications (Clavien-Dindo ≥IIIa). Ninety-day mortality rate was 1.9%. Out of 82 ablated lesions, 6 ASRs (11.1%) occurred. Median blood loss was significantly lower in the minimally invasive group, compared with open [90 mL (32.5 to 200) vs. 200 mL (100 to 400), P =0.005]. Pringle maneuver was significantly performed less in the minimally invasive group [8 (25.0%) vs. 16 (72.7%), P =0.001], but took more time [36.1 min (±15.6) vs. 21.6 (±9.9); P =0.011]. Short-term (1 y) overall and disease-free survival were respectively 81.4% and 50.0%.

CONCLUSION

Combining microwave ablation and liver resection is a feasible and safe parenchymal-sparing technique, through both minimally invasive and open approach for treating extended CRLM disease. It has a low ablation-related complication rate and acceptable ablation-site recurrence rate.

Perioperative and long-term survival outcomes of laparoscopic versus open hepatectomy for BCLC stage A large hepatocellular carcinoma patients in difficult segments: A two-centre, propensity score matching analysis

Background

The differences in short- and long-term outcome between laparoscopic liver resection (LLR) and open liver resection (OLR) for BCLC stage A large hepatocellular carcinoma (HCC) in difficult segments (I, IVa, VII, VIII) remain unclear. This PSM two-centre study aimed to compare perioperative and long-term survival outcomes of LLR with OLR for this HCC.

Methods

HCC patients with BCLC stage A who underwent OLR or LLR in two medical centres were enrolled in the study. PSM analysis was performed to match patients between the LLR cohort and OLR cohort. Survival was analysed based on the Kaplan–Meier method. Independent risk factors were identified by Cox regression.

Results

After PSM, 35 patients remained in the LLR cohort, and 84 remained in the OLR cohort. Patients in the LLR cohort had more intraoperative blood loss (p=0.036) and shorter hospital stays after surgery (p&lt;0.001). The LLR cohort and OLR cohort had no difference in intraoperative blood transfusion, surgical margin or postoperative short-term outcomes. The OS and RFS were not significantly different between the two cohorts. The OS and RFS of these two cohorts were not different in the subgroup analysis. Surgical margin was identified as an independent risk factor for tumour recurrence.

Conclusion

For BCLC stage A large HCC patients with lesions in difficult segments, LLR was feasible and had shorter hospital stay than OLR. In addition, a surgical margin ≥1 cm could significantly decrease the recurrence probability for large HCC located in different segments without compromising short-term outcomes.

Pure robotic major hepatectomy with biliary reconstruction for hepatobiliary malignancies: first European results

BACKGROUND

Combined liver and bile duct resection with biliary reconstruction for hepatobiliary malignancies are defined as highly complex surgical procedures. The robotic platform may overcome some major limitations of conventional laparoscopic surgery for these complex cases but its precise role is however still to be defined.

METHODS

In our institution, patients requiring major hepatectomy with biliary reconstruction for malignancies were consecutively selected for minimally invasive robotic surgery from September 2020. All surgeries were undertaken using the da Vinci Xi Surgical System® (Intuitive Surgical, Sunnyvale, CA, USA). Intra-operative technique and postoperative outcome were analyzed.

RESULTS

A total number of 10 patients (3 males and 7 females, median age 72 years) underwent robotic major hepatectomy and bile duct resection for hepatobiliary malignancies between September 2020 and March 2022. The indication for surgery was perihilar cholangiocarcinoma in 5 of 10 patients. Median operative time was 338 min and median blood loss was 110 mL. Postoperative length of stay was between 3 and 16 days (median: 9 days). There was no postoperative 90-day mortality.

CONCLUSIONS

A robotic approach for hepatobiliary malignancies requiring combined major hepatectomy and bile duct resection seems feasible and safe in experienced hands.

Long-term outcomes of laparoscopic liver resection versus open liver resection for hepatocellular carcinoma: A single-center 10-year experience

Background

Laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) has increased. However, the long-term outcomes of LLR for HCCs should be validated further. Besides, the validity of laparoscopic minor liver resection in difficult segments (1, 4a, 7, 8) (LMLR-DS) and laparoscopic major hepatectomy (LMH) for HCCs need to be studied.

Methods

A total of 1773 HCC patients were collected: 683 received LLR and 1090 received OLR. Propensity score matching (PSM) with 1:1 ratio was used to eliminate the selection bias. Short-term and long-term outcomes were compared. In subgroup analyses, the validity of LMLR-DS or LMH for HCCs was studied.

Results

After PSM, 567 patients were in LLR or OLR group. LLR had lower intraoperative blood-loss and shorter postoperative hospital-stays than OLR. The postoperative complications were lower in LLR group (23.8% vs. 32.8%, P=0.001). The Overall survival (OS) and disease-free survival (DFS) had no significant difference between LLR and OLR groups (P=0.973, P=0.812). The cumulative 1-, 3-, and 5-year OR rates were 87.9%, 68.9%, and 57.7% for LLR group, and 85.9%, 68.8%, 58.8% for OLR group. The cumulative 1-, 3-, and 5-year DFS rates were 73.0%, 51.5%, 40.6% for LLR group, and 70.3%, 49.0%, 42.4% for OLR group. In subgroup analyses, 178 patients were in LMLR-DS or open surgery (OMLR-DS) group after PSM. LMLR-DS had lower intraoperative blood-loss and shorter postoperative hospital-stays than OMLR-DS. The postoperative complications were lower in LMLR-DS group. The OS and DFS had no difference between LMLR-DS and OMLR-DS groups. The cumulative 5-year OR and DFS rates were 61.6%, 43.9% for LMLR-DS group, and 66.5%, 47.7% for OMLR-DS group. In another subgroup analyses, 115 patients were in LMH or open major hepatectomy (OMH) group. LMH had lower blood-loss and shorter postoperative hospital-stays than OMH. The complications, OS and DFS had no significantly differences between two groups. The cumulative 5-year OR and DFS rates were 44.3%, 29.9% for LMH group, and 44.7%, 33.2% for OMH group.

Conclusions

LLR for HCCs showed better short-term outcomes and comparable long-term outcomes with OLR, even for patients who received LMLR-DS or LMH. LLR could be reliable and recommended for HCC treatment.

Limited liver resections in the posterosuperior segments: international multicentre propensity score-matched and coarsened exact-matched analysis comparing the laparoscopic and robotic approaches

Background

Limited liver resections (LLRs) for tumours located in the posterosuperior segments of the liver are technically demanding procedures. This study compared outcomes of robotic (R) and laparoscopic (L) LLR for tumours located in the posterosuperior liver segments (IV, VII, and VIII).

Methods

This was an international multicentre retrospective analysis of patients who underwent R-LLR or L-LLR at 24 centres between 2010 and 2019. Patient demographics, perioperative parameters, and postoperative outcomes were analysed; 1 : 3 propensity score matching (PSM) and 1 : 1 coarsened exact matching (CEM) were performed.

Results

Of 1566 patients undergoing R-LLR and L-LLR, 983 met the study inclusion criteria. Before matching, 159 R-LLRs and 824 L-LLRs were included. After 1 : 3 PSM of 127 R-LLRs and 381 L-LLRs, comparison of perioperative outcomes showed that median blood loss (100 (i.q.r. 40–200) versus 200 (100–500) ml; P = 0.003), blood loss of at least 500 ml (9 (7.4 per cent) versus 94 (27.6 per cent); P &lt; 0.001), intraoperative blood transfusion rate (4 (3.1 per cent) versus 38 (10.0 per cent); P = 0.025), rate of conversion to open surgery (1 (0.8 per cent) versus 30 (7.9 per cent); P = 0.022), median duration of Pringle manoeuvre when applied (30 (20–46) versus 40 (25–58) min; P = 0.012), and median duration of operation (175 (130–255) versus 224 (155–300); P &lt; 0.001) were lower in the R-LLR group compared with the L-LLR group. After 1 : 1 CEM of 104 R-LLRs with 104 L-LLRs, R-LLR was similarly associated with significantly reduced blood loss and a lower rate of conversion to open surgery.

Conclusion

Based on a matched analysis of well selected patients, both robotic and laparoscopic access could be undertaken safely with good outcomes for tumours in the posterosuperior liver segments.

Pure laparoscopic vs. hand-assisted liver surgery for segments 7 and 8: propensity score matching analysis

BACKGROUND

Laparoscopic liver resection of tumors located in segments 7 and 8 are considered a complex resection. The aim of this study was to compare the intraoperative and early postoperative outcomes of patients operated by pure laparoscopic (PLS) vs hand-assisted laparoscopic surgery (HALS).

METHODS

From January 2003 to January 2021, we included patients with minimally invasive surgery for lesions located in segments 7 and 8. To overcome selection bias, we performed 1:1 propensity score matching (PSM) between HALS and PLS cohorts, including 30 patients in each of the groups. Of the 60 patients who underwent PSM, we compared the first 30 patients with the following 30 patients.

RESULTS

A total of 79 LLRs were performed, 46 by HALS and 33 by PLS. After PSM, in the PLS cohort, cirrhosis was more frequent (33.3% vs. 13.3%, p = 0.02). The surgical time, blood loss, Pringle maneuver, clamping time, and morbidity were similar between both groups, but with a lower hospital stay in the PLS group (3 days vs. 4 days, p < 0.01). In the first 30 patients who underwent LLR, the use of PLS was lower than the use of HALS, increasing due to the learning curve (16.7% in the first period vs. 83.3% in the second period; p < 0.01). The hospital stay was lower in the second period due to the more frequent use of PLS (3 vs. 4 days, p < 0.01).

CONCLUSION

PLS presents similar intraoperative and early postoperative results with lower hospital stay for lesions located in segments 7 and 8 compared to HALS. In centers with experience in LLRs, PLS could be performed safely in these segments.

Laparoscopic versus open resections in the posterosuperior liver segments within an enhanced recovery programme (ORANGE Segments): study protocol for a multicentre randomised controlled trial

BACKGROUND

A shift towards parenchymal-sparing liver resections in open and laparoscopic surgery emerged in the last few years. Laparoscopic liver resection is technically feasible and safe, and consensus guidelines acknowledge the laparoscopic approach in the posterosuperior segments. Lesions situated in these segments are considered the most challenging for the laparoscopic approach. The aim of this trial is to compare the postoperative time to functional recovery, complications, oncological safety, quality of life, survival and costs after laparoscopic versus open parenchymal-sparing liver resections in the posterosuperior liver segments within an enhanced recovery setting.

METHODS

The ORANGE Segments trial is an international multicentre randomised controlled superiority trial conducted in centres experienced in laparoscopic liver resection. Eligible patients for minor resections in the posterosuperior segments will be randomised in a 1:1 ratio to undergo laparoscopic or open resections in an enhanced recovery setting. Patients and ward personnel are blinded to the treatment allocation until postoperative day 4 using a large abdominal dressing. The primary endpoint is time to functional recovery. Secondary endpoints include intraoperative outcomes, length of stay, resection margin, postoperative complications, 90-day mortality, time to adjuvant chemotherapy initiation, quality of life and overall survival. Laparoscopic liver surgery of the posterosuperior segments is hypothesised to reduce time to functional recovery by 2 days in comparison with open surgery. With a power of 80% and alpha of 0.04 to adjust for interim analysis halfway the trial, a total of 250 patients are required to be randomised.

DISCUSSION

The ORANGE Segments trial is the first multicentre international randomised controlled study to compare short- and long-term surgical and oncological outcomes of laparoscopic and open resections in the posterosuperior segments within an enhanced recovery programme.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03270917 . Registered on September 1, 2017. Before start of inclusion.

PROTOCOL VERSION

version 12, May 9, 2017.

Hand-Assisted Laparoscopic Surgery Is Superior to Open Liver Resection for Colorectal Liver Metastases in the Posterosuperior Segments

Introduction: Laparoscopic liver resections (LLR) of colorectal metastasis located in posterosuperior segments (1, 4A, 7 and 8) are challenging and highly demanding. The aim of our study is to determine the safety and feasibility of hand-assisted laparoscopic surgery (HALS) in the resections of the posterosuperior lesions and to compare the peri-operative, short-term and long-term outcomes with the open liver resection (OLR) approach.

Methods and Results: A retrospective study of patients who underwent either HALS or OLR for metastatic colorectal cancer (mCRC) located in the posterosuperior segments of the liver between 2008 and 2018 in two university affiliated medical centers.

Results: A total of 187 patients were identified, of whom 78 underwent HALS and 109 underwent OLR. There was no difference between the HALS and OLR with regard to preoperative factors (age, primary CRC tumor location, number and anatomical distribution of liver metastasis, pre-operative neo-adjuvant treatment, operative time, blood transfusion rate, and resection margins positivity). On the other hand, HALS compared to OLR had a significantly shorter mean hospital stay (4 vs. 6 days; P = 0.003), and a lower total complications rate (25 vs. 47% P = 0.006). Both groups had no 30-day mortality. Also, patients who underwent HALS vs. OLR had similar liver metastases recurrence (55 vs. 51%. P = 0.65) and 5-year survival (47 vs. 45%. P = 0.72).

Conclusions: HALS for mCRC located in posterosuperior liver segments is safe and feasible and it is a preferable approach due to its lower complication rate and shorter hospital stay while not compromising survival and disease recurrence.

Impact of laparoscopic parenchyma-sparing resection of lesions in the right posterosuperior liver segments on surgical outcomes: A multicenter study based on propensity score analysis

BACKGROUND

Laparoscopic liver resection for hepatic lesions is increasingly performed worldwide. However, parenchyma-sparing laparoscopic liver resection for hepatic lesions in the right posterosuperior segments is very technically demanding. This study aimed to compare postoperative outcomes between patients undergoing laparoscopic liver resection and open liver resection for hepatic lesions in the right posterosuperior segments.

METHODS

In total, 617 patients who underwent liver resection of hepatic lesions in the right posterosuperior segments (segment Ⅶ or Ⅷ) at 8 centers were included in this study. We lessened the impact of confounders through propensity score matching, inverse probability weighting, and double/debiased machine learning estimations.

RESULTS

After matching and weighting, the imbalance between the 2 groups significantly decreased. Compared with open liver resection, laparoscopic liver resection was associated with a lower volume of intraoperative blood loss and incidence of postoperative complications in the matched and weighted cohorts. After surgery, the incidence of pulmonary complication and cardiac disease was lower in the laparoscopic liver resection group than in the open liver resection group in both the matched and weighted cohorts. The odds ratios of laparoscopic liver resection for postoperative complications in the matched and weighted cohorts were 0.49 (95% confidence interval, 0.29-0.83) and 0.40 (95% confidence interval, 0.25%-0.64%), respectively. The double/debiased machine learning risk difference estimator for postoperative complications of laparoscopic liver resection was -19.8% (95% confidence interval, -26.8% to -13.4%).

CONCLUSION

Parenchyma-sparing laparoscopic liver resection for hepatic lesions in the right posterosuperior segments had clinical benefits, including lower volume of intraoperative blood loss and incidence of postoperative complications.

Laparoscopic Versus Open Liver Resection for Tumors in the Posterosuperior Segments: A Systematic Review and Meta-analysis

OBJECTIVE

The objective of this study was to compare the outcomes of laparoscopic and open liver resection for tumors in the posterosuperior segments.

METHODS

We performed a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. We conducted a search of electronic information sources to identify all studies comparing outcomes of laparoscopic and open liver resection for tumors in the posterosuperior segments. We used the Risk Of Bias In Nonrandomized Studies-of Interventions (ROBINS-I) tool to assess the risk of bias of the included studies. Fixed-effect or random-effects models were applied to calculate pooled outcome data.

RESULTS

We identified 11 observational studies, enrolling a total of 1023 patients. The included population in both groups were comparable in terms of baseline characteristics. Laparoscopic approach was associated with lower risks of total complications [odds ratio (OR): 0.45; 95% confidence interval (CI): 0.33, 0.61; P<0.00001], major complications (Dindo-Clavien III or more) (OR: 0.52; 95% CI: 0.36, 0.73; P=0.0002), and intraoperative blood loss [mean difference (MD): -114.71; 95% CI: -165.64, -63.79; P<0.0001]. Laparoscopic approach was associated with longer operative time (MD: 50.28; 95% CI: 22.29, 78.27; P=0.0004) and shorter length of hospital stay (MD: -2.01; 95% CI: -2.09, -1.92; P<0.00001) compared with open approach. There was no difference between the 2 groups in terms of need for blood transfusion (OR: 1.23; 95% CI: 0.75, 2.02; P=0.41), R0 resection (OR: 1.09; 95% CI: 0.66, 1.81; P=0.72), postoperative mortality (risk difference: -0.00; 95% CI: -0.02, 0.02; P=0.68), and need for readmission (OR: 0.70; 95% CI: 0.19, 2.60; P=0.60). In terms of oncological outcomes, there was no difference between the groups in terms disease recurrence (OR: 1.58; 95% CI: 0.95, 2.63; P=0.08), overall survival (OS) at maximum follow-up (OR: 1.09; 95% CI: 0.66, 1.81; P=0.73), 1-year OS (OR: 1.53; 95% CI: 0.48, 4.92; P=0.47), 3-year OS (OR: 1.26; 95% CI: 0.67, 2.37; P=0.48), 5-year OS (OR: 0.91; 95% CI: 0.41, 1.99; P=0.80), disease-free survival (DFS) at maximum follow-up (OR: 0.91; 95% CI: 0.65, 1.27; P=0.56), 1-year DFS (OR: 1.04; 95% CI: 0.60, 1.81; P=0.88), 3-year DFS (OR: 1.13; 95% CI: 0.75, 1.69; P=0.57), and 5-year DFS (OR: 0.73; 95% CI: 0.44, 1.24; P=0.25).

CONCLUSIONS

Compared with the open approach in liver resection for tumors in the posterosuperior segments, the laparoscopic approach seems to be associated with a lower risk of postoperative morbidity, less intraoperative blood loss, and shorter length of hospital stay with comparable survival and oncological outcomes. The best available evidence is derived from observational studies with moderate quality; therefore, high-quality randomized controlled trials with adequate statistical power are required to provide a more robust basis for definite conclusions.

The role of the laparoscopic approach in two-stage hepatectomy for colorectal liver metastases: a single-center experience

BACKGROUND

In selected patients, laparoscopic liver surgery for the treatment of colorectal liver metastases (CRLM) leads to better short-term outcomes and comparable oncologic outcomes in comparison with an open approach. However, its role in two-stage hepatectomy (TSH) remains poorly explored.

METHODS

A single-center retrospective study was performed to evaluate the role of laparoscopic liver resection (LLR) in the first and second stage of TSH. Demographic data, comorbid factors, perioperative outcomes, and short-term outcomes were evaluated.

RESULTS

Between September 2011 and May 2020, 23 patients were planned to undergo a TSH. The first stage hepatectomy (FSH) was performed laparoscopically in 22 patients (96%) without need for conversion. The median blood loss was 50 cc (IQR 30-100 cc) and postoperative length of hospital stay was 4 days (IQR 2.5-5 days). R0 resections were obtained in 18 FSHs (78%), while all others were R1 vascular (22%). Fourteen patients (61%) underwent a second stage hepatectomy (SSH). All SSHs were anatomically major hepatectomies. SSH was performed laparoscopically in 7 patients (50%), with need for conversion in 1 case (14%). The median blood loss was slightly lower in the open liver resection (OLR) group compared to the LLR group (200 cc (IQR 110-375 cc) vs. 240 cc (IQR 150-400 cc), respectively. The median postoperative length of hospital stay was 3 days shorter in the LLR group compared to the OLR group (4 days (IQR 3.5-4 days) vs. 7 days (IQR 4.5-8.5 days), respectively).

CONCLUSIONS

The already proven advantages of LLR in the treatment of CRLM favor the role of a laparoscopic approach in TSH for CRLM. In first stage minor or technically major hepatectomy, LLR is progressively becoming the gold standard. Laparoscopic second stage anatomically major hepatectomy is feasible in experienced hands, but should be limited to selected cases and should be performed in expert centers.

Frequency and risk factors for major complications after stereotactic radiofrequency ablation of liver tumors in 1235 ablation sessions: a 15-year experience

Objectives

To assess the frequency of major complications after multi-probe stereotactic radiofrequency ablation (SRFA) in a large cohort of patients over 15 years and to elucidate risk factors for adverse events.

Materials and methods

A retrospective study was carried out between July 2003 and December 2018. Seven hundred ninety-three consecutive patients (median 65.0 years (0.3–88), 241 women and 552 men, were treated in 1235 SRFA sessions for 2475 primary and metastatic liver tumors with a median tumor size of 3.0 cm (0.5–18 cm). The frequency of major complications was evaluated according to SIR guidelines and putative predictors of adverse events analyzed using simple and multivariable logistic regression.

Results

Thirty-day mortality after SRFA was 0.5% (6/1235) with an overall major complication rate of 7.4% (91/1235). The major complication rate decreased from 11.5% (36/314) (before January 2011) to 6.0% (55/921) (p = 0.001). 50.5% (46/91) of major complications were successfully treated in the same anesthetic session by angiographic coiling for hemorrhage and chest tube insertion for pneumothorax. History of bile duct surgery/intervention, number of coaxial needles, and location of tumors in segment IVa or VIII were independent prognostic factors for major complications following multivariable logistic regression analysis. Simple logistic regression revealed the number of tumors, tumor size, location close to the diaphragm, tumor conglomerate, and segment VII as other significant predictors.

Conclusion

SRFA of liver tumors is safe and can extend the treatment spectrum of conventional RFA. Adaptations over time combined with increasing experience resulted in a significant decrease in complications.

Key Points

• In 1235 ablation sessions in 793 patients over 15 years, we found a mortality rate of 0.5% (6/1235) and an overall major complication rate of 7.4%, which fell from 11.5 (36/314) to 6.0% (55/921, p = 0.001) after January 2011, likely due to procedural adaptations.

• History of bile duct surgery/intervention (p = 0.013, OR = 3.290), number of coaxial needles (p = 0.026, OR = 1.052), and location of tumors in segment IVa (p = 0.016, OR = 1.989) or VIII (p = 0.038, OR = 1.635) were found to be independent prognostic factors.

• Simple logistic regression revealed that number of tumors, tumor size, location close to the diaphragm, tumor conglomerates, and segment VII were other significant predictors of major complications.

Laparoscopic versus open liver resections of posterolateral liver segments - a systematic review and meta-analysis

INTRODUCTION

Laparoscopic resection has become an accepted approach to liver tumour surgery. However, it is considered difficult, especially in unfavourably located lesions.

AIM

To compare the outcomes of laparoscopic (LLR) and open liver resection (OLR) of posterolateral segments.

MATERIAL AND METHODS

We searched the PubMed, EMBASE, and Scopus databases from inception to 30 September 2019. Full text articles and conference abstracts were included for further analysis. This review follows the PRISMA guidelines.

RESULTS

From 643 articles, 15 studies (N = 1196 patients) were included in the meta-analysis. All of them were non-randomised. Our findings showed that LLR had significantly lowered overall morbidity compared to OLR (MD = 0.66; 95% CI: 0.51-0.86; p = 0.002). Length of hospital stay (MD = 2.48; 95% CI: -3.87, -1.08; p < 0.001) was also shorter in the LLR group. Operative time (MD = 55.65; 95% CI: 24.14-87.16; p < 0.001) was significantly shorter in the OLR group. In terms of blood loss, major complications, R0 resection rates, and resection margin, there were no significant differences.

CONCLUSIONS

Our meta-analysis showed that the laparoscopic approach to resections of posterolateral liver segments is beneficial. However, the results are based on non-randomised trials, and further research is needed to fully establish their clinical application.

Is minimally invasive surgery of lesions in the right superior segments of the liver justified? A multi-institutional study of 245 patients

BACKGROUND

Controversy exists regarding the safety and feasibility of minimally invasive resection for lesions in segments 7 or 8. We compare outcomes of minimally invasive surgery (MIS) and Open parenchymal sparing liver resections at two high-volume centers.

METHODS

From 2003 to 2016 we identified patients who underwent MIS or Open resections for lesions in segments 7 or 8 at two institutions (MSKCC and SGH). Outcomes were compared using univariate and multivariate analyses.

RESULTS

Two-hundred and forty-five patients underwent resection of lesions in segments 7 or 8 (MIS 30% and Open 70%). Compared to the Open group, the MIS group had longer operative time (223 ± 88 vs 188 ± 72 minutes, P = .003), lower blood loss (297 ± 287 vs 448 ± 670 mL, P = .03), and shorter mean length of stay (5.2 ± 7.4 vs 8.3 ± 11.7 days, P < .001), which remained significant on multivariate analysis. No differences in Pringle time, rate of postoperative complications, or R0 resections were detected.

CONCLUSIONS

With appropriately selected patients treated by experienced MIS hepatopancreatobiliary surgeons, MIS resection of segments 7 or 8 is safe with similar rates of complications and R0 resections, with significantly less blood loss and shorter length of stay.

Laparoscopic Liver Resections for Tumors in the Posterosuperior Segments: A Single-center Experience of 174 Consecutive Cases

BACKGROUND

Laparoscopic posterosuperior liver resection is a technically difficult and complex surgery. These patients are seen as poor candidates for laparoscopic surgery. This study aimed to show the safe and effective applicability of the posterosuperior segment resections by experienced surgeons in advanced centers.

MATERIALS AND METHODS

Patients who underwent laparoscopic posterosuperior liver resection between October 2011 and October 2019 at the Groeninge Hospital were evaluated retrospectively. Demographic and perioperative data were obtained from the prospectively maintained database. Resection of at least 3 consecutive Couinaud segments was accepted as a major surgery (trisegmentectomy). Postoperative complications were registered according to the Clavien-Dindo classification.

RESULTS

The median age of the 174 patients was 68 years [interquartile range (IQR): 60 to 75]. The semiprone position was used in the majority of operations (82.2%). Nonanatomic resection was performed in more than half of the operations (55.1%). A total of 5 patients underwent major hepatic resection. The median time of surgery was 150 (IQR: 120 to 190) minutes. Median blood loss was determined to be 150 (IQR: 50 to 300) mL. Malignancy was detected in 95% of the cases. The surgical margin was reported to be R0 in 93.3% of the specimens. The median hospitalization time was 4 (IQR: 3 to 6) days. The major complication rate was 1.7%, and only 1 patient died. Overall survival rates for patients who underwent a resection for colorectal liver metastases in the first and fifth years were 97.5% and 62.2%, and disease-free survival rates were 69.8% and 35.5%, respectively.

CONCLUSION

Laparoscopic resections in the posterosuperior segments can be performed safely in experienced hands with good short and long term (oncologial) outcomes.

Laparoscopic Liver Resection of Segments 7 and 8: from the Initial Restrictions to the Current Indications

Since the beginning of laparoscopic liver surgery, resection of the posterosuperior segments has been considered one of the most challenging procedure due to its difficult access. The main drawbacks of the laparoscopic approach to dome lesions are poor visualization, the difficulty of instrumentation and the greater complexity in the control of bleeding. In the evolution of minimally invasive techniques from hybrid techniques to the current purely laparoscopic approaches, the different authors have established gradually the currents indications and surgical techniques to operate these segments with a similar feasibility and safety than open approach. The standardization in the patient position, the use of intercostal trocars, the learning curve in laparoscopic liver surgery, the management of the hepatic blood flow and the refinement of the technique in the extrahepatic and intrahepatic Glissonean pedicle approaches, has allowed to leave behind the initial contraindications about the laparoscopic approach in these segments. In the present review of the literature, the accumulated experience of the different groups in minimally invasive liver surgery together with the technological advances in the different laparoscopic devices have facilitated the resection of tumors in segments 7 and 8 with similar and even better results than open surgery.

Laparoscopic or open approaches for posterosuperior and anterolateral liver resections? A propensity score based analysis of the degree of advantage

BACKGROUND

Benefits over the open technique are demonstrated for laparoscopic liver resections. Whether the degree of advantage is different for anterolateral and posterosuperior resections is investigated in this retrospective study.

METHODS

Laparoscopic anterolateral and posterosuperior resections (Lap-AL/Lap-PS) were compared with open (Open-AL/Open-PS) after propensity score matching. Mean/median differences of relevant parameters were calculated after bootstrap sampling. The degree of advantage was compared between anterolateral and posterosuperior resections and expressed as delta of differences (Δ-difference).

RESULTS

239 Lap-AL were compared with 239 matched Open-AL, and 176 Lap-PS with 176 matched Open-PS. Lap-AL showed reduced blood loss, morbidity, time to orally-controlled pain, mobilization and total stay; Lap-PS showed reduced blood loss, transfusions, morbidity, time to orally-controlled pain, mobilization, functional recovery and total stay. The degree of advantage of Lap-PS resulted significantly greater than Lap-AL blood loss (Δ-difference: 101 mL, p 0.017), transfusions (Δ-difference: 6.3%, p 0.008), morbidity (Δ-difference: 7.6%, p 0.034), time to orally-controlled pain (Δ-difference: 1 day, p 0.020) and functional recovery (Δ-difference: 1 day, p 0.042).

CONCLUSIONS

While both resulting in benefit, the advantage of laparoscopy is greater for posterosuperior than anterolateral resections. Despite their technical difficulty, these should be considered among the most worthwhile laparoscopic liver resections.

Stepwise implementation of laparoscopic pancreatic surgery. Case series of a single centre's experience

BACKGROUND

Laparoscopic pancreatic surgery still represents a challenge for surgeons. However, in recent decades the experience is expanding. Recent systematic reviews and meta-analyses confirm that laparoscopic pancreatic resection (LPR) is safe, feasible and worthwhile. This study analyses the first 100 consecutive LPRs in our centre.

METHODS

A retrospective analysis was conducted of the first 100 LPRs in a single supra-regional Belgian centre, performed between January 2012 and January 2019. Pre-, peri- and postoperative data were retrieved from a prospectively maintained database. All procedures were performed laparoscopically by two attending surgeons, specialized in minimally invasive and hepatopancreatobiliary surgery.

RESULTS

Of 100 procedures, 62 laparoscopic pancreatoduodenectomies (LPD) and 36 laparoscopic distal pancreatectomies (LDP) were performed, along with 1 enucleation and 1 central pancreatectomy. Indication was malignancy in 70%. Conversion rate was 24,2% in LPD and 11% in LDP. Median operative time was 330 min (IQR 300-360) in LPD and 150 min (IQR 142.5-210) in LDP. Median blood loss was 200 mL (IQR 100-487.5) in LPD and 150 mL (IQR 50-500) in LDP, transfusion rate was 22.6% and 8.3% respectively. Median length of stay (LOS) was 13 days (IQR 10-19.25) in LPD and 9 days (IQR 9-14) in LDP. R0 resection rate was 88.6% (62/70). Major complication rate (Clavien-Dindo grade III-IV) was 12%. Thirty-day mortality was 0%, 90-day mortality was 2%.

CONCLUSION

Our results confirm that LPR is a feasible and safe alternative to open pancreatic surgery. Safe implementation with a clear strategy is fundamental to gain experience and overcome the learning curve of this technically demanding procedures.

Laparoscopic liver resection for liver tumours in proximity to major vasculature: A single-center comparative study

BACKGROUND

With growing popularity and experience in laparoscopic liver surgery, the options for more difficult procedures increase. Only small case series have been published regarding laparoscopic liver resection (LLR) for tumours in proximity to major vessels (MVs). The aim was to compare outcomes of LLR for tumours located less or more than 15 mm from MVs.

METHODS

This was a retrospective analysis of a prospectively collected database of consecutive LLR (October 2011-August 2017). Proximity to MVs (PMV) was defined as lesions located within 15 mm to the caval vein, hepatic veins and portal vein (main trunk and first branches). The control group were all lesions located more than 15 mm from MVs.

RESULTS

Some 60/235 LLR were performed for lesions in proximity to major vasculature (24%). In the PMV group, median IWATE Difficulty Score was higher (8.5 (IQR: 6.0-9.0) VS 5.0 (IQR: 3.0-6.0), p < 0.001) as was the use of CUSA® (45.0% VS 8.6%, p < 0.001) and Pringle manoeuvre (8.3% VS 1.7%; p = 0.028). Operative time was longer (180min (IQR: 140-210) VS 120min (IQR: 75-150), p < 0.001) and blood loss was higher (190 ml (IQR: 100-325) VS 75 ml (IQR: 50-220), p < 0.001) in the PMV group. There was no difference in perioperative blood transfusion (3.3% VS 1.7%, p = 0.60) or postoperative morbidity (15.0% VS 14.3%, p = 0.89). There was no mortality in both groups. On mean follow-up of 21 months, no significant differences could be found in disease free (p = 0.77) and overall survival (p = 0.12).

CONCLUSION

In experienced hands, LLR of lesions in proximity to MVs is safe and feasible with acceptable short and long-term results.

Laparoscopic versus open liver resection in the posterosuperior segments: a sub-group analysis from the OSLO-COMET randomized controlled trial

BACKGROUND

Laparoscopic liver resection in the posterosuperior segments is technically challenging. This study aimed to compare the perioperative outcomes for laparoscopic and open resection of colorectal liver metastases located in the posterosuperior segments.

METHODS

This was a subgroup analysis of the OSLO-COMET randomized controlled trial, where 280 patients were randomly assigned to open or laparoscopic parenchyma-sparing liver resections of colorectal metastases. Patients with tumors in the posterosuperior segments were identified, and perioperative outcomes and health related quality of life (HRQoL) were compared.

RESULTS

We identified a total of 136 patients, 62 in the laparoscopic and 74 in the open group. The postoperative complication rate was 26% in the laparoscopic and 31% in the open group. The blood loss was less in the open group (500 vs. 250 ml, P = 0.006), but the perioperative transfusion rate was similar. The operative time was similar, while postoperative hospital stay was shorter in the laparoscopic group (2 vs. 4 days, P < 0.001). HRQoL was significantly better after laparoscopy at 1 month.

CONCLUSION

In patients undergoing laparoscopic or open liver resection of colorectal liver metastases in the posterosuperior segments, laparoscopic surgery was associated with shorter hospital stay and comparable perioperative outcomes.

Feasibility, safety, and long-term efficacy of stereotactic radiofrequency ablation for tumors adjacent to the diaphragm in the hepatic dome: a case-control study

Objectives

Achievement of adequate treatment margins may be challenging when the target is either difficult to visualize, awkward to access, or situated adjacent to vulnerable structures. Treatment of tumors located close to the diaphragm in the hepatic dome is challenging for percutaneous radiofrequency (RF) ablation for these reasons. The purpose was to assess the feasibility, safety, and clinical outcome of multi-probe stereotactic RF ablation (SRFA) of liver tumors in the subdiaphragmatic area.

Methods

Between 2006 and 2018, 177 patients (82 HCCs, 6 ICCs, and 89 metastatic tumors) underwent SRFA of 238 tumors abutting the diaphragm in the hepatic dome. For comparison, 177 patients were randomly selected from our database by the R package “MatchIt” for propensity score matching to compare treatment safety and efficacy in this retrospective, single-center study.

Results

Median treated tumor size was 2.2 cm (range 0.5 to 10 cm). SRFA was primarily successful for 232/238 (97.5%) tumors. Five tumors were successfully retreated, resulting in a secondary technical efficacy rate of 99.6%. Local tumor recurrence developed in 21 of 238 tumors (8.8%). The major ablation complication rate was 10.7% (22 of 204). Twelve (55%) of 22 major complications could be successfully treated by the interventional radiologist in the same anesthesia session. There was no significant difference in adverse events or disease control rates between the subdiaphragmatic tumors and matched controls.

Conclusions

SRFA is a safe and feasible option in the management of difficult-to-treat tumors abutting the diaphragm in the hepatic dome, with similar safety profile compared with matched controls.

Key Points

• RFA was primarily successful for 232/238 (97.5%) subdiaphragmatic dome tumors. Local tumor recurrence developed in 21 of 238 tumors (8.8%).

• The major complication rate directly related to ablation of the hepatic dome tumors was 10.7% (22 of 204). 12/22 (55%) of major complications could be successfully treated in the same anesthesia session.

• There was no significant difference in adverse events or disease control rates between the subdiaphragmatic tumors and matched controls.

Comparison of laparoscopic versus open liver resection for lesions located in posterosuperior segments: a meta-analysis of short-term and oncological outcomes

BACKGROUND

The role of laparoscopic liver resection (LLR) for lesions located in posterosuperior (PS) segments remains a matter of development to be further assessed. This systematic review aims to compare the short-term and oncological outcomes between laparoscopic and open liver resection (OLR) in PS lesions.

METHODS

EMBASE, MEDLINE and Cochrane Library were searched from date of inception to June 2019. This meta-analysis was performed using the STATA 12.0 statistical software. Standardized mean differences (SMDs), odds ratios (ORs) and hazard ratios (HRs) were calculated for continuous variables, dichotomous variables and long-term variables, respectively, with 95% confidence intervals (CIs).

RESULTS

A total of 788 patients from eight studies were identified for the final analysis, with 371 patients in the LLR group and 417 in the OLR group. Although the operation time (SMD 0.22; 95% CI 0.08-0.36; P = 0.003) was longer whereas overall complication rate (OR 0.50; 95% CI 0.36-0.70; P < 0.001) and postoperative hospital stay (SMD - 0.45; 95% CI - 0.59 to - 0.30; P = 0.003) were lower in the LLR group than in the OLR group, no significant differences in blood loss (SMD - 0.14; 95% CI - 0.28 to 0.00; P = 0.054), transfusion rate (OR 0.92; 95% CI 0.56-1.54; P = 0.764), major complication rate (OR 0.63; 95% CI 0.38-1.05; P = 0.079), R0 resection rate (OR 1.04; 95% CI 0.55-1.96; P = 0.902), and disease-free survival (DFS) for hepatocellular carcinoma (HCC) (HR 1.43; 95% CI 0.95-2.17), DFS for colorectal liver metastases (HR 1.05; 95% CI 0.61-1.81), overall survival for HCC (HR 1.00; 95% CI 0.43-2.30) were noted between the groups.

CONCLUSION

LLR is technically feasible and safe without compromising long-term oncological outcomes for selected patients with lesions in the PS segments of the liver.

Theory of Relativity for Posterosuperior Segments of the Liver

BACKGROUND

The accessibility to posterosuperior segments of the liver has traditionally constituted a restrain to adopt the laparoscopic approach in this setting. To overcome this challenge, multiple approaches have been reported in literature. Total transabdominal approach has been previously described for this purpose, even though the rationale to standardly adopt it and a technical depiction of how to achieve an optimal mobilization has never been specifically addressed.

METHODS

Total transabdominal purely laparoscopic approach to posterosuperior segments of the liver is presented, with detailed emphasis to the rotational motions targeted in laparoscopy. A literature review is presented to summarize all other possible accesses to posterosuperior area of the liver. The institutional series for the laparoscopic approach to Sg 7, Sg 6+7, and Sg8 is retrospectively described.

RESULTS

Three rotational motions of the liver are specifically addressed in a video presentation and described for the laparoscopic total-transabdominal approach; the local institutional series using this approach is presented. Other miscellaneous approaches identified from literature encompassing variations in operative position, transabdominal, transthoracic, and combined approaches are described.

CONCLUSIONS

Complete mobilization of the ligaments of the liver leads to a rotation of the transection line in front of the operator's view, allowing to achieve a safe total trans-abdominal laparoscopic approach to the posterosuperior ligaments of the liver, without compromising the vascular inflow control, the possibility to convert to open approach, nor requiring potentially harmful decubitus.

Laparoscopic liver surgery in cirrhosis - Addressing lesions in posterosuperior segments

BACKGROUND

Minimal-invasive liver resection has gained considerable attention in recent years, assuming a weighty position in the field of HPB surgery. Even lesions in posterosuperior segments, the technically most challenging localization, have been resected while achieving comparable outcomes to laparotomy. The objective of this study is to evaluate whether the similar beneficial results can be conveyed through minimal-invasive techniques for patients with liver cirrhosis.

MATERIALS AND METHODS

We retrospectively analyzed all consecutive patients undergoing laparoscopic liver resection with at least one lesion in the posterosuperior liver segments (IVa, VII, VIII) at our center between January 2012 and July 2018. Patients were separated in two groups based on the presence (n = 43) or absence (n = 115) of liver cirrhosis.

RESULTS

Preoperative patient characteristics showed that patients with cirrhosis were older (p < 0.001), had more frequently diabetes (p < 0.005) and a history of alcohol consumption (p < 0.0005). Preoperative liver function, as assessed by LiMAx score was markedly decreased in patients with liver cirrhosis (p < 0.005). While a similar percentage in both groups had anatomical resection, significantly more major resections were performed in patients without cirrhosis (cirrhosis: 23.3% vs. no cirrhosis 55.7%; p < 0.0005). Consequently, surgeries were markedly longer in the no cirrhosis group (p < 0.0005). There was no difference with regard to the need for perioperative transfusion or conversion to laparotomy. There was no differences found between both groups with regard to the postoperative course showing similar ICU- and hospital stays. Complication rate, both with regard to minor and major complications, as well as rate of clear resection margins were similar between the two groups as well.

CONCLUSION

Patients with liver cirrhosis and a lesion in the posterosuperior liver segments are amenable to the minimal-invasive approaches as no significant differences can be observed with regard to safety and oncologic sufficiency. As these procedures are from a technical perspective challenging, they should be performed in specialized centers.

Safety and Efficacy of Laparoscopic Liver Resection for Lesions Located on Posterosuperior Segments: A Meta-Analysis of Short-term Outcomes

INTRODUCTION

Laparoscopic liver resections (LLR) are currently acknowledged as safe and efficient procedures. LLR in posterosuperior (PS) segments are considered highly challenging procedures. The aim of our meta-analysis was to evaluate the effect of LLR versus open liver resection on short-term outcomes for PS segment lesions.

MATERIALS AND METHODS

A systematic search of Medline, Scopus, Google Scholar, Cochrane CENTRAL Register of Controlled Trials and Clinicaltrials.gov databases for articles was performed.

RESULTS

Five studies involving 531 patients who underwent resection for PS liver segments lesions were included. LLR were associated with reduced blood loss and overall complications. Operative time, blood transfusion, R0 resection, resection margin, hospital stay, and mortality were not found different among the 2 groups.

CONCLUSIONS

Notwithstanding their highly demanding nature, LLR in PS segments are safe and efficient procedures in the hands of experienced surgeons. Further studies are mandatory to evaluate their effect in these challenging liver resections.

Laparoscopic hepatectomy versus open hepatectomy in the management of posterosuperior segments of the Liver: A systematic review and meta-analysis

BACKGROUND

Previous guidance and consensus have well-addressed the advantages of laparoscopic procedures in the anterolateral segments of II, III, IVb and V of the liver, as for lesions located in the posterosuperior segments of I, IVa, VII and VIII is challenging but has become more practical recently due to progress in operative techniques.

METHODS

A systematic review and meta-analysis was conducted to evaluate the safety and efficacy of LH and OH patients with tumors located in posterosuperior segments. The primary sources of the reviewed studies through April 2018, with restriction on the language of English, were Pubmed and Embase.

RESULTS

A total of 5 studies qualified for inclusion in this quantified meta-analysis with a total of 647 patients. LH was associated with significantly less overall complication (OR = 0.43, 95%CI: 0.28-0.65; P < 0.0001, I² = 0%) and non-significantly less severe complication significantly (P = 0.06) compared with OH. Shorter length of hospital stay of 2.08day (95%CI: -3.68day to -0.49day; P = 0.01, I² = 81%) was observed in LH. As for mortality, transfusion, R0 resection, tumor-free margin and operative time the pooled outcomes were comparable. Long-term survivals were similar between LH and OH for the posterosuperior segments.

CONCLUSION

Laparoscopic hepatectomy could be the preferred option for posterosuperior segments for selected patients. Future well designed and large studies should focus on the impacts of underlined liver chronic diseases such as cirrhosis on patient prognosis.

Robotic Surgery of the Liver and Biliary Tract

BACKGROUND

The laparoscopic methods for major abdominal surgery are gaining increasing acceptance worldwide. Despite its relatively recent introduction in clinical practice, robotics has been accepted as an effective option to perform high-demanding procedures such as those required in hepatobiliary surgery. Some potential advantages over conventional laparoscopy have been suggested, but its actual role in clinical practice is still to be defined.

METHODS

The objective of this work is to critically review the available evidence on the application of robotic surgery to the liver and biliary tract. PubMed, Embase, and the Cochrane Library electronic databases were systematically searched for studies reporting on robotic hepatobiliary surgery with or without comparison with open surgery or conventional laparoscopy.

RESULTS

This review provides a comprehensive snapshot of the current application of the robot to the surgery of the liver and biliary tract. The overall available data show the noninferiority of the robotic system to conventional open and laparoscopic surgery. A number of studies suggest some potential advantages in performing high-demanding procedures in a minimally invasive fashion.

CONCLUSIONS

The robot can be used to perform various types of liver surgeries quite safely and competently, although the lack of randomized control trials, comparing it with open and laparoscopic surgery, precludes the possibility to reach definitive conclusions.

Laparoscopic Versus Open Liver Resection for Difficult Lesions: A Meta-Analysis

Background: The value of laparoscopic liver resection (LLR) for difficult lesions (located in segments I, IVa, VII, and VIII) is still controversial nowadays. The aim of this study was to summarize quantitatively the evidence related to this issue. Materials and Methods: Two investigators independently searched the Medline, Embase, Science Citation Index Expanded, and Cochrane Library databases for eligible studies published before December 2017. The RevMan 5.3 software was utilized for statistical meta-analysis. Weighted mean differences (WMDs) and odds ratios (ORs) were calculated for continuous and dichotomous variables, respectively. Results: Five studies with a total number of 638 patients were included in the present meta-analysis, with 274 patients in the LLR group and 364 in the open liver resection (OLR) group. The LLR did not increase the operative time (WMD 12.42 minutes; 95% confidence interval [CI] -8.54 to 33.38 minutes; P = .25) or blood transfusion requirement (OR 0.81; 95% CI 0.40-1.64; P = .57) compared with OLR. Conversely, LLR was associated with significantly lower intraoperative blood loss (WMD -140.57 mL; 95% CI -203.39 to -77.76 mL; P < .001), shorter hospital stay (WMD -2.88 days; 95% CI -4.84 to -0.92 days; P = .004), and lower overall morbidity (OR 0.43; 95% CI 0.28-0.65; P < .001). The oncologic outcomes of R0 resection rate, surgical margin, and tumor recurrence were comparable in the two groups. Conclusion: LLR for difficult lesions in selected patients is safe, technically feasible, and advantageous when performed by experienced surgeons.