• Laparoscopic
• Liver resection
• Minimally invasive

• Humans
• Laparoscopy/methods
• Hepatectomy/methods
• Patient Selection
• Liver Neoplasms/surgery
• Liver Diseases/surgery
• Treatment Outcome

• Abdominal procedures
• Future predictions
• Laparoscopy
• Minimally invasive surgery (MIS)
• Robotic surgery
• Trends

• Humans
• Laparoscopy/methods
• Laparoscopy/statistics & numerical data
• Robotic Surgical Procedures/statistics & numerical data
• Robotic Surgical Procedures/trends
• Retrospective Studies
• Male
• United States

• conversion therapy
• hepatocellular carcinoma
• laparoscopic hepatectomy
• open hepatectomy
• propensity score matching

• the National Natural Science Foundation of China

• laparoscopic liver resection
• learning curve
• modified two-surgeon technique
• on-the-job training
• surgeons-in-training

• Laparoscopic liver resection
• Liver fibrosis
• M2BPGi score
• Postoperative complications
• Surgical difficulty
• Surgical training

• elderly patients
• hepatocellular carcinoma
• laparoscopic hepatectomy
• meta-analysis
• open hepatectomy

While minimizing intraoperative blood loss during liver resection is one of the most important tasks, it is more difficult to control the refractory bleeding during laparoscopic liver resection than with an open approach. We herein provide a modification of the two-surgeon technique that enables laparoscopic liver parenchymal transection to be performed as quickly and securely as open liver resection. To achieve proper "role sharing," the "transection mode" and the "hemostatic mode" are independent sets in place in this procedure, and these modes are switched rigidly according to the surgical field condition. By thoroughly sharing the roles, rapid laparoscopic liver parenchymal transection comparable to open liver resection can be accomplished. The present modified approach achieves satisfactory transection and hemostasis of the liver parenchyma and is also advantageous for teaching young surgeons and the entire surgical team.

• Outcomes
• laparoscopic
• survival

• liver surgery
• laparoscopy
• fiducials
• cone beam computed tomography
• image guided surgery

The XXL trial has recently shown that biological downstaging is an effective strategy to also allow liver transplantation into patients with more advanced hepatocellular carcinoma without alternative curative options. Some potential limits of the XXL downstaging protocol are (a) the rather high downstaging failure rate (i.e., 32%), and (b) the additional prioritization of transplantation for patients with a potential good prognosis without transplant, i.e., those obtaining a complete response to downstaging. In this study, we showed that, using aggressive surgical downstaging, it is possible to considerably decrease the downstaging failure rate. Moreover, we showed that it is possible to avoid an immediate prioritization of transplantation for patients with a sustained complete response to downstaging by applying a “wait and see” policy. This policy seems to spare a relevant number of organs without worsening patient outcome.

The XXL trial represents the first prospective validation of “biological downstaging” in liver transplantation (LT) for hepatocellular carcinoma. The aim of this study was to compare the Padua downstaging protocol to the XXL protocol in terms of downstaging failure rates and patient outcome. A total of 191 patients undergoing aggressive surgical downstaging and potentially eligible for LT from 2012 to 2018 at our center were retrospectively selected according to XXL trial criteria. Unlike the XXL trial, patients with a complete response to downstaging did not receive any prioritization for LT. Downstaging failure was defined as stable progressive disease or post-treatment mortality. The statistical method of “matching-adjusted indirect comparison” was used to match the study group to the XXL population. Downstaging failure rate was considerably lower in the study group than in the XXL trial (12% vs. 32%, d value = |0.683|). The survival curves of our LT group (n = 68) overlapped with those of the LT-XXL group (p = 0.846). Survival curves of non-LT candidates with a sustained complete response (n = 64) were similar to those of transplanted patients (p = 0.281). Our study represents a validation of the current Padua and Italian policies of denying rapid prioritization to patients with complete response to downstaging. Such a policy seems to spare organs without worsening patient outcome.

• complete response
• downstaging
• hepatocellular carcinoma
• liver transplantation

The role of laparoscopic hepatectomy (LH) in hepatocellular carcinoma (HCC) with cirrhosis remains controversial and needs to be further assessed. The present meta-analysis aimed to compare the surgical and oncological outcomes of LH with those of open hepatectomy (OH) for HCC with cirrhosis.

The PubMed, Embase, and Cochrane Library databases were searched for studies comparing LH and OH until Mar 2021. Weighted mean differences (WMDs), odds ratios (ORs), and hazard ratios (HRs) were calculated for continuous, dichotomous, and long-term variables, respectively, with 95% confidence intervals (CIs). Subgroup analysis was performed according to different resection types: major resection and minor resection. The meta-analysis was performed using the STATA 12.0.

A total of 16 case-matched studies (784 patients in the LH group and 1,191 patients in the OH group.) were included in this meta-analysis. In terms of primary outcomes, LH was associated with decreased overall complication rate (OR 0.57; 95% CI 0.46 to 0.71; P <0.01), major complication rate (OR 0.52; 95% CI 0.33 to 0.82; P < 0.01), postoperative mortality (OR 0.27; 95% CI 0.11 to 0.66; P  <0.01), 1-y overall survival (OS) rate (HR 0.48; 95% CI 0.31 to 0.73; P <0.01), 2-y OS (HR 0.61; 95% CI 0.45 to 0.83; P < 0.01), and 5-y OS (0.67; 95% CI 0.53 to 0.85; P < 0.01). With respect to secondary outcomes, blood loss (WMD −69.16; 95% CI −101.72 to −36.61; P < 0.01), length of hospitalization (LOH) (WMD −2.65; 95% CI −3.41 to −1.89; P < 0.01), minor complication rate (OR 0.70; 95% CI 0.53 to 0.94; P = 0.02), postoperative liver failure (OR 0.60; 95% CI 0.38 to 0.95; P = 0.03), and postoperative ascites (OR 0.44; 95% CI 0.28 to 0.72; P < 0.01) was lower in LH than in OH. No significant differences in operation time (P = 0.07), transfusion rate (P = 0.05), 1-, 2-, and 5-year DFS rate (1-year, P = 0.08; 2-year, P = 0.08; 5-year, P = 0.23) were noted between LH and OH. Subgroup analysis based on minor resection revealed that LH had similar favored outcomes in comparison with those in the overall pooled analysis. However, LH had a longer operation time than OH in the setting of major resection (P < 0.01).

LH is technically feasible and safe for selected HCC patients with cirrhosis. LH can achieve favored short-term and long-term oncological outcomes in minor liver resection. Laparoscopic major hepatectomy (LMH) seems to offer some advantages over the open approach; however concerns about surgical and oncological safety remain. More evidence on LMH is warranted before expanding its indication to patients with cirrhosis.

• cirrhosis
• hepatocellular carcinoma
• laparoscopic hepatectomy
• meta-analysis
• prognosis

The Pringle maneuver is generally performed to reduce the amount of blood loss during hepatic resection. During laparoscopic liver resection, the Pringle maneuver can be used in several ways. We have developed a new Pringle maneuver (PM) with Penrose drain tube to sufficiently control blood loss during laparoscopic liver resection. This study was performed to determine the safety and outcome during laparoscopic left-sided hepatectomy performed using this new method.

We describe the technique and results of the left-sided liver resection with totally intracorporeal PM with Penrose drain tube. We performed 37 laparoscopic left-sided hepatic resections with (PM group) or without the Penrose PM (No PM group). We retrospectively compared the short-term operative outcome between the No PM group (n=12) and the PM group (n=25) during laparoscopic left-sided liver resection.

Median PM duration was 34.3 min. The median duration of the surgery using the totally intracorporeal PM with Penrose drain tube was 174 min, while the surgical duration required for resection without the PM was 156 min. The median volume of operative blood loss was lower in the PM group than in the No PM group (No PM group (341 ml) vs. PM group (165 ml)). There was no postoperative mortality and no open conversion.

The totally intracorporeal PM with Penrose drain tube for laparoscopic hepatectomy is safe, reproducible, and can facilitate liver dissection during left-sided liver resection.

• Hepatectomy
• Laparoscopy
• Pringle maneuver

• cirrhosis
• hepatectomy
• hepatocellular carcinoma
• laparoscopy
• liver surgery
• portal hypertension
• robotic

• Bariatric surgery
• Cirrhosis
• Fibroscan
• Liver biopsy
• NASH

We aimed to compare the operative outcomes of laparoscopic right posterior sectionectomy (RPS) and open RPS and evaluate the feasibility of laparoscopic RPS.

From January 2009 to December 2017, laparoscopic liver resections were performed in 235 patients at Chonnam National University Hwasun Hospital, South Korea. We retrospectively analyzed the clinical data of 16 patients who underwent laparoscopic RPS and compared the outcomes with those who underwent open RPS (n=17).

The laparoscopic group had a mean tumor size of 3.82±1.73 cm (open group [OG]; 4.18±2.07 cm, p=0.596), mean tumor-free margin of 10.44±9.69 mm (OG; 10.06±10.62 mm, p=0.657), mean operation time of 412.2±102.2 min (OG; 275.0±60.5, p<0.001), mean estimated blood loss of 339.4±248.3 ml (OG; 236.4±102.7 ml, p=0.631), mean postoperative hospital stay of 11.63±2.58 days (OG; 14.71±4.69 days, p=0.027), and mean postoperative peaks of aspartate aminotransferase, alanine aminotransferase, total bilirubin, and prothrombin time of 545 mg/dl, 538 mg/dl, 1.39 mg/dl, 1.41 international normalized ratio (OG; 237 (p<0.001), 216 (p<0.001), 1.52 (p=0.817), and 1.45 (p=0.468)), respectively. There were no deaths or major complications in ether group. There were no cases of open conversion. Laparoscopic RPS was associated with a shorter hospital stay, prolonged operation time and lower complication rate. With long-term prognosis, no difference was found in overall survival rate and disease-free survival rate between the two groups.

Laparoscopic RPS can be performed, but the problems of long operative time and decrease in liver function should be resolved.

• Hepatectomy
• Laparoscopic
• Open
• Robotic

• Hepatocellular carcinoma
• Minimally invasive surgery
• Survival

• Case report
• Hepatectomy
• Hepatocellular carcinoma
• Laparoscopy
• Rupture

Laparoscopic hepatectomy (LH) has been accepted widely owing to its advantages as a minimally invasive surgery; however, laparoscopic right hemihepatectomy (LRH) has rarely been reported. We aimed to compare the benefits and drawbacks of LRH and open approaches. Between January 2014 and October 2017, 85 patients with tumor and hepatolithiasis who underwent LRH (n = 30) and open right hemihepatectomy (ORH) (n = 55) were enrolled in this study. For tumors, LRH showed significantly better results with respect to blood loss (P = 0.024) and duration of hospital stay (P = 0.008) than ORH, while hospital expenses (P = 0.031) and bile leakage rate (P = 0.012) were higher with LRH. However, the operative time and rate of other complications were not significantly different between the two groups. However, for hepatolithiasis, there was less blood loss (P = 0.015) and longer operative time (P = 0.036) with LRH than with ORH. There were no significant difference between LRH and ORH in terms of hospital stay, hospital expenses, and complication rate (P > 0.05). Moreover, the postoperative white blood cell count, alanine aminotransferase level, aspartate aminotransferase level, and total bilirubin were not significantly different in both types of patients (P > 0.05). Our results suggest the safety and feasibility of laparoscopy technology for right hemihepatectomy in both tumor and hepatolithiasis patients.

• Cirrhosis
• Elderly
• Hepatectomy
• Outcomes

Repeat liver resection (RLR) and salvage liver transplantation (SLT) are viable treatment options for recurrent hepatocellular carcinoma (HCC). With possibly superior survival outcomes than RLR, SLT is however, limited by liver graft availability and poses increased perioperative morbidity. In this study, we seek to compare the outcomes of RLR and SLT for patients with recurrent HCC.

Between 1999 and 2018, 94 and 16 consecutive patients who underwent RLR and SLT respectively were identified. Further retrospective subgroup analysis was conducted, comparing 16 RLR with 16 SLT patients via propensity-score matching.

After propensity-score adjusted analyses, SLT demonstrated inferior short-term perioperative outcomes than RLR, with increased major morbidity (57.8% vs 5.4 %, p=0.0001), reoperations (39.1% vs 0, p<0.0001), renal insufficiency (30.1% vs 3%, p=0.0071), bleeding (19.8% vs 2.2%, p=0.0289), prolonged intensive care unit stay (median=4 vs 0 days, p<0.0001) and hospital stay (median=19.8 vs 7.1days, p<0.001). However, SLT showed significantly lower recurrence rate (15.4% versus 70.3%, p=0.0005) and 5-year cumulative incidence of recurrences (19.4% versus 68.4%, p=0.005). Propensity-matched subgroup analysis showed concordant findings.

While SLT offers potentially reduced risks of recurrence and trended towards improved long-term survival outcomes relative to RLR, it has poorer short-term perioperative outcomes. Patient selection is prudent amidst organ shortages to maximise allocated resources and optimise patient outcomes.

• Hepatocellular carcinoma
• Propensity score
• Repeat liver resection
• Salvage liver transplantation
• Survival analysis
• Tumour recurrence

In view of the increasing life expectancy in different parts of the world, a larger proportion of elderly patients with hepatocellular carcinoma (HCC) requiring oncological treatment is expected. The clinicopathological characteristics of HCC in elderly patients and in younger patients are different. Elderly patients, in general, also have more comorbidities. Evaluation of the efficacy of different HCC treatment options in elderly patients is necessary to optimize treatment outcomes for them. Treatment modalities for HCC include hepatectomy, liver transplantation, radiofrequency ablation, transarterial chemoembolization, and molecular-targeted therapy with sorafenib. In this review, current evidence on the risks and outcomes of the different HCC treatments for elderly patients are discussed. According to data in the literature, elderly patients and younger patients benefited similarly from HCC treatments. More clinical data are needed for the determination of selecting criteria on elderly HCC patients to maximize their chance of getting the most appropriate and effective treatments. As such, further studies evaluating the outcomes of different HCC treatment modalities in elderly patients are warranted.

• Hepatocellular carcinoma
• Aged
• Clinical outcome
• Surgery
• Hepatectomy

• Age Factors
• Aged
• Aged, 80 and over
• Antineoplastic Agents/therapeutic use
• Carcinoma, Hepatocellular/mortality
• Carcinoma, Hepatocellular/therapy
• Chemoembolization, Therapeutic/methods
• Comorbidity
• Disease-Free Survival
• Hepatectomy
• Humans
• Liver Neoplasms/mortality
• Liver Neoplasms/therapy
• Liver Transplantation
• Middle Aged
• Molecular Targeted Therapy/methods
• Patient Selection
• Radiofrequency Ablation
• Sorafenib/therapeutic use
• Survival Rate
• Treatment Outcome

• Laparoscopic surgery
• Minimally invasive surgery
• Posterosuperior liver lesions

• Hepatocellular carcinoma
• Primary liver transplantation
• Salvage liver transplantation
• Survival

• ALBI‐TNM score
• albumin‐bilirubin grade
• hepatectomy
• hepatocellular carcinoma

• Hepatocellular carcinoma
• Laparoscopic liver surgery
• Liver cirrhosis

The advantages of laparoscopy are widely known. Nevertheless, its legitimacy in liver surgery is often questioned because of the uncertain value associated with minimally invasive methods. Our main goal was to compare the outcomes of pure laparoscopic (LLR) and open liver resection (OLR) in patients with hepatocellular carcinoma.

We searched EMBASE, MEDLINE, Web of Science, and The Cochrane Library databases to find eligible studies. The most recent search was performed on December 1, 2017. Studies were regarded as suitable if they reported morbidity in patients undergoing LLR versus OLR. Extracted data were pooled and subsequently used in a meta-analysis with a random-effects model. Clinical applicability of results was evaluated using predictive intervals. Review was reported following the PRISMA guidelines.

From 2085 articles, forty-three studies (N = 5100 patients) were included in the meta-analysis. Our findings showed that LLR had lower overall morbidity than OLR (15.59% vs. 29.88%, p < 0.001). Moreover, major morbidity was reduced in the LLR group (3.78% vs. 8.69%, p < 0.001). There were no differences between groups in terms of mortality (1.58% vs. 2.96%, p = 0.05) and both 3- and 5-year overall survival (68.97% vs. 68.12%, p = 0.41) and disease-free survival (46.57% vs. 44.84%, p = 0.46).

The meta-analysis showed that LLR is beneficial in terms of overall morbidity and non-procedure-specific complications. That being said, these results are based on non-randomized trials. For these reasons, we are calling for randomization in upcoming studies. Systematic review registration: PROSPERO registration number CRD42018084576.

The online version of this article (10.1007/s00464-018-6431-6) contains supplementary material, which is available to authorized users.

• Hepatocellular carcinoma
• Laparoscopic liver resection
• Meta-analysis
• Systematic review

• 3D laparoscopy
• Cirrhosis
• Evidence
• Hepatectomy
• Hepatocellular carcinoma
• International consensus conference
• International consensus guidelines
• Liver resection

• Hepatocellular carcinoma
• Laparoscopic hepatectomy
• Laparoscopic liver resection
• Liver malignant disease
• Minimally invasive surgery
• Surgical excision

• HCC
• laparoscopic hepatectomy
• laparoscopic versus open
• open liver resection

• anesthesia
• colloid
• crystalloid
• fluid therapy
• goal-directed therapy
• hepatic resection
• liver resection

To assess the impact of laparoscopic liver resection (LLR) on surgical blood loss (SBL), especially in patients with antithrombotics for thromboembolic risks.

Consecutive 258 patients receiving liver resection at our institution between 2010 and 2016 were retrospectively reviewed. Preoperative antithrombotic therapy (ATT; antiplatelets and/or anticoagulation) was regularly used in 100 patients (ATT group, 38.8%) whereas not used in 158 (non-ATT group, 61.2%). Our perioperative management of high thromboembolic risk patients included maintenance of preoperative aspirin monotherapy for patients with antiplatelet therapy and bridging heparin for patients with anticoagulation. In both ATT and non-ATT groups, outcome variables of patients undergoing LLR were compared with those of patients receiving open liver resection (OLR), and the independent risk factors for increased SBL were determined by multivariate analysis.

This series included 77 LLR and 181 OLR. There were 3 thromboembolic events (1.2%) in a whole cohort, whereas increased SBL (≥ 500 mL) and postoperative bleeding complications (BCs) occurred in 66 patients (25.6%) and 8 (3.1%), respectively. Both in the ATT and non-ATT groups, LLR was significantly related to reduced SBL and low incidence of BCs, although LLR was less performed as anatomical resection. Multivariate analysis showed that anatomical liver resection was the most significant risk factor for increased SBL [risk ratio (RR) = 6.54, P < 0.001] in the whole cohort, and LLR also had the significant negative impact (RR = 1/10.0, P < 0.001). The same effects of anatomical resection (RR = 15.77, P < 0.001) and LLR (RR = 1/5.88, P = 0.019) were observed when analyzing the patients in the ATT group.

LLR using the two-surgeon technique is feasible and safely performed even in the ATT-burdened patients with thromboembolic risks. Independent from the extent of liver resection, LLR is significantly associated with reduced SBL, both in the ATT and non-ATT groups.

• Laparoscopic liver resection
• Two-surgeon technique
• Antithrombotic therapy
• Increased surgical blood loss
• Bleeding complication

• laparoscopy
• hepatectomy
• liver neoplasms/surgery
• neoplastic metastasis

• Adult
• Aged
• Female
• Hepatectomy/methods
• Humans
• Laparoscopy
• Liver Neoplasms/mortality
• Liver Neoplasms/surgery
• Male
• Middle Aged
• Survival Rate
• Time Factors
• Treatment Outcome

• Hepatocellular carcinoma
• Laparoscopy
• Minimally invasive liver resection
• Open
• Resection

• hepatectomy
• hepatocellular carcinoma
• laparoscopy

• future liver remnant
• hepatectomy
• hepatocellular carcinoma
• transarterial chemoembolization (TACE)
• transarterial radioembolization (TARE)

• Cholecystectomy
• Revo
• Robot surgery
• Robotic surgical system
• da Vinci