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Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Jan 27, 2016; 8(1): 5-26
Published online Jan 27, 2016. doi: 10.4240/wjgs.v8.i1.5
Laparoscopic liver resection: Experience based guidelines
Fabricio Ferreira Coelho, Jaime Arthur Pirola Kruger, Gilton Marques Fonseca, Raphael Leonardo Cunha Araújo, Vagner Birk Jeismann, Marcos Vinícius Perini, Renato Micelli Lupinacci, Ivan Cecconello, Paulo Herman
Fabricio Ferreira Coelho, Jaime Arthur Pirola Kruger, Gilton Marques Fonseca, Raphael Leonardo Cunha Araújo, Vagner Birk Jeismann, Ivan Cecconello, Paulo Herman, Liver Surgery Unit, Department of Gastroenterology, University of São Paulo Medical School, São Paulo, CEP 05403-900, Brazil
Marcos Vinícius Perini, Austin Health, Department of Surgery, University of Melbourne, Heidelberg, VIC 3084, Australia
Renato Micelli Lupinacci, Service de Chirurgie Digestive, Viscérale et Endocrinienne Groupe Hospitalier Diaconesses-Croix Saint Simon, 75020 Paris, France
Author contributions: Coelho FF, Kruger JAP and Herman P designed the study, reviewed the literature, collected data, wrote the manuscript and approved the final version of the manuscript; Fonseca GM, Araújo RLC and Jeismann VB reviewed the literature, collected data and wrote the manuscript; Perini MV, Lupinacci RM and Ceconello I completed final revision of the manuscript.
Conflict-of-interest statement: All authors have no conflict of interest related to the manuscript.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Fabricio Ferreira Coelho, MD, PhD, Liver Surgery Unit, Department of Gastroenterology, University of Sao Paulo Medical School, Rua Dr. Enéas de Carvalho Aguiar, 255 - 9º andar - sala 9025, São Paulo, CEP 05403-900, Brazil.
Telephone: +55-11-26617561 Fax: +55-11-26619008
Received: April 28, 2015
Peer-review started: May 7, 2015
First decision: August 4, 2015
Revised: September 7, 2015
Accepted: November 24, 2015
Article in press: November 25, 2015
Published online: January 27, 2016

Laparoscopic liver resection (LLR) has been progressively developed along the past two decades. Despite initial skepticism, improved operative results made laparoscopic approach incorporated to surgical practice and operations increased in frequency and complexity. Evidence supporting LLR comes from case-series, comparative studies and meta-analysis. Despite lack of level 1 evidence, the body of literature is stronger and existing data confirms the safety, feasibility and benefits of laparoscopic approach when compared to open resection. Indications for LLR do not differ from those for open surgery. They include benign and malignant (both primary and metastatic) tumors and living donor liver harvesting. Currently, resection of lesions located on anterolateral segments and left lateral sectionectomy are performed systematically by laparoscopy in hepatobiliary specialized centers. Resection of lesions located on posterosuperior segments (1, 4a, 7, 8) and major liver resections were shown to be feasible but remain technically demanding procedures, which should be reserved to experienced surgeons. Hand-assisted and laparoscopy-assisted procedures appeared to increase the indications of minimally invasive liver surgery and are useful strategies applied to difficult and major resections. LLR proved to be safe for malignant lesions and offers some short-term advantages over open resection. Oncological results including resection margin status and long-term survival were not inferior to open resection. At present, surgical community expects high quality studies to base the already perceived better outcomes achieved by laparoscopy in major centers’ practice. Continuous surgical training, as well as new technologies should augment the application of laparoscopic liver surgery. Future applicability of new technologies such as robot assistance and image-guided surgery is still under investigation.

Keywords: Minimally invasive surgery, Laparoscopic surgery, Hand-assisted laparoscopy, Liver neoplasm, Liver cirrhosis, Living donor, Liver, Hepatectomy, Liver transplantation

Core tip: Liver surgery was one of the last frontiers reached by minimally invasive surgery. Surgical technique and specialized equipment evolved to overcome technical limitations, making laparoscopic liver resections (LLR) safe and feasible. Surgeons developed skills in a stepwise approach, beginning with low complexity operations for benign diseases and reaching high-complexity surgeries for malignant cases and living donor organ harvesting. Despite a cautious slow start laparoscopic liver surgery has been incorporated to practice. On the following pages the successful history of LLR is depicted, along with an updated panel of it’s current role and expected achievements.