Intraoperative blood loss (IBL) is the major concern in hepatectomy, which was closely relating to the central venous pressure (CVP). The controlled low central venous pressure (CLCVP) technique is moderately required for minimizing hemorrhage during hepatectomy nowadays. Nevertheless, an excessive reduction in CVP might give rise to the jeopardy of inadequate perfusion of vital organs. Sildenafil, being a first-line pharmaceutical for treating pulmonary hypertension, its mechanism of action lies in diminishing pulmonary vascular resistance (PVR) by dilating pulmonary arteries, and thereby alleviating the afterload of the right ventricle. We initially postulate that administration of sildenafil citrate in combination with intermittent Pringle's maneuver (IPM) can exert a notable impact in efficaciously reducing intraoperative blood loss (IBL), enhancing the surgical field of vision, and augmenting the safety of the operation.

This research constitutes a double-blind, randomized, controlled trial. All patients fulfilling the criteria for open or laparoscopic hepatectomy will be randomly allocated to the sildenafil (S) group and the placebo (C) group via the block randomization approach. All surgeons, anesthesiologists, and outcome assessors will remain oblivious to the patient's group details. The primary outcome is the intraoperative blood loss (IBL). Secondary outcomes include the classification of the surgical field, the cumulative consumption of nitroglycerine, hemodynamic parameters, blood gas analysis, coagulation function (comprising thromboelastogram (TEG), activated partial thromboplastin time (APTT), and prothrombin time (PT)), intraoperative urine output, adverse events in the recovery room (hypotension, hypoxemia and hematuria), biochemical markers (total bilirubin, total albumin, alanine aminotransferase, aspartate aminotransferase, creatinine, urea nitrogen), complete blood count (Hb, Plt, and Hct), cardiac function (brain natriuretic peptide, creatine kinase isoenzyme, troponin), postoperative hospital stay and indwelling time of drainage tube, and postoperative complications. These parameters will be comprehensively compared and analyzed in-depth through appropriate statistical means.

This trial evaluated the influence of administration of sildenafil citrate combined with IPM on IBL and surgical results during open or laparoscopic hepatectomy, as well as its safety and feasibility. It is expected to provide an innovative management optimization plan for reducing the bleeding in hepatectomy, and to provide empirical support for the potential value of sildenafil citrate or sildenafil-like drugs in improving the safety and quality of perioperative hepatectomy patients.

This trial was registered on June 25, 2024, in the US Clinical Trials Registry ( https://register.

gov ), with the ClinicalTrial.gov Identifier: NCT06237751. The protocol version is V1.0 (20,231,114).

Laparoscopic anatomical hepatectomy (LAH) of segments 5 and 8 (LAHSg5/Sg8) for hepatocellular carcinoma (HCC) remains one of the most challenging procedures due to the difficulty in exposing the main vascular structure. The aim of our study was to investigate the anatomical characteristics of inter-SVs based on the three-dimensional (3D) visualization technology exploring its safety and feasibility during LAHSg5/Sg8. A total of 110 patients who underwent LAHSg5/Sg8 in our center between January 2019 and August 2022 were enrolled and analyzed retrospectively. During the operation, the inter-SVs of the first 10 patients were observed. Subsequently, 100 patients were included based on the previous intraoperative understanding. The anatomical parameters of inter-SVs and the perioperative outcomes were recorded and evaluated. The safety and short-term efficacy of LAHSg5/Sg8 were assessed. All the patients underwent preoperative 3D processing software analysis. Of the included patients, 74.6% had inter-SVs in Sg5/Sg8, which could be classified into three types: trunk type, double branch type and multi branch type, accounting for 35.4%, 22.2% and 17.0%, respectively. The concordance between pre-operation and intra-operation in terms of portal vein territory of Sg5/Sg8 was 82 ± 31%. The inlet point diameter was 3.3 ± 1.0 mm. The distance between the inter-SVs in Sg5/Sg8 and P8, point "B" were 17.7 ± 6.2 mm, 6.1 ± 17 mm, respectively. The confluence of inter-SVs in Sg5/Sg8 at "point B" and below accounted for 10.2%. Preoperative 3D reconstruction and personalized surgical planning based on individual anatomical variations are crucial for successful LAHSg5/Sg8. Inter-SVs between Sg5/Sg8 as a landmark along the ISP during LAHS for HCC may be safe and feasible.

Hepatocellular carcinoma arises in the setting of cirrhosis in most cases, requiring multidisciplinary input to define resectability. In this regard, more precise surgical management considers patient factors and anatomical states, including resection margins, tumour biology, and perioperative therapy. Together with advances in surgical techniques, this integrated approach has resulted in considerable improvements in patient morbidity and oncological outcomes. Despite this, recurrence rates in hepatocellular carcinoma remain high. As the systemic treatment landscape in hepatocellular carcinoma continues to evolve and locoregional options are increasingly used, we review current and future opportunities to individualise the surgical management of patients with hepatocellular carcinoma.

The optimal strategy for patients with colorectal liver metastases (CRLM) is unclear. The Precision1 prospective, observational trial assessed whether pre-operative functional imaging and whole genome sequencing (WGS), could enhance individualized decision-making.

Patients with CRLM considered for hepatectomy were recruited. In addition to standard staging, patients underwent a quantitative multiparametric MRI (mpMRI) scan, to assess liver function. Use of mpMRI to aid surgical decision-making, was prospectively recorded, as were short-term clinical outcomes in patients who underwent hepatectomy. In the first 45 patients, WGS was performed on blood and liver tumour samples collected per-operatively.

95 mpMRI scans were performed in 84 patients, who underwent 87 resections. The mpMRI scan affected surgical decision-making in 41 % (39/95) of scans, with 11 undergoing dual-vein embolization, 16 undergoing more conservative parenchymal-sparing surgery, 11 having more extensive surgery, and one patient following a low calorie diet pre-operatively. There were significant (Clavien-Dindo grades 3/4) complications in 5 % of patients, no Grade C post-hepatectomy liver failure, and zero 90-day mortality. WGS suggested additional therapeutic options and prognostic factors for 22 of 35 (63 %) evaluable patients.

Precision1 shows mpMRI can aid surgical decision-making, and optimise clinical outcomes. WGS provides additional information, to further enhance personalised decision-making.

Robotic techniques can theoretically overcome the limitations of laparoscopic liver resection and are currently recognized as safe options; however, it is not known which approach is better. The purpose of this study was to compare the advantages of robotic hepatectomy and laparoscopic hepatectomy.

Electronic databases (the Cochrane Library, PubMed (MEDLINE), Embase and Web of Science) were systematically searched from January 2000 to August 2023 for eligible studies that compared robotic hepatectomy and laparoscopic hepatectomy. Studies that met the inclusion criteria were then reviewed systematically. The reported data were aggregated statistically using RevMan 5.4 software. The parameters of interest included intraoperative, postoperative, survival and financial outcomes. Subgroup analysis was performed according to the type and difficulty level of hepatectomy and the study setting.

A total of 26 propensity-score matching comparative trials met the inclusion criteria, which comprised 9355 participants (robotic hepatectomy versus laparoscopic hepatectomy: 3938 versus 5417) in the meta-analysis. For surgical outcomes, lower blood loss, lower open conversion rate and higher R0 resection rate were observed in the robotic hepatectomy group compared with the laparoscopic hepatectomy group (mean difference (MD) -86.22, 95% c.i. -116.49 to -55.95, I² = 87%, P < 0.001; OR 0.51, 95% c.i. 0.38 to 0.69, I² = 40%, P < 0.001; OR 1.31, 95% c.i. 1.03 to 1.67, I² = 0%, P = 0.030 respectively). The lower blood loss (major hepatectomy group: MD -56.88, 95% c.i. -109.09 to -4.28, I² = 76%, P = 0.030; IWATE score (advanced/expert more than 80%) group: MD -0.61, 95% c.i. -1.14 to -0.08, I² = 95%, P < 0.001) and lower open conversion rate (major hepatectomy group: OR 0.41, 95% c.i. 0.30 to 0.56, I² = 0%, P < 0.001; IWATE score (advanced/expert less than 80%) group: OR 0.52, 95% c.i. 0.36 to 0.75, I² = 0%, P = 0.659) advantage persisted across subgroup analyses.

The robotic approach had advantages to laparoscopic in terms of lower blood loss and reduced rates of open conversion, especially in difficult hepatectomies.

Minimally invasive liver surgery (MILS) is superior to open surgery when considering decreased blood loss, fewer complications, shorter hospital stay, and similar or improved oncologic outcomes. However, operative limitations in laparoscopic hepatectomy have curved its applicability and momentum of complex minimally invasive liver surgery. Transitioning to robotic hepatectomy may bridge this complexity gap.

Retrospective cohort study conducted on comparable hepatectomies (open, laparoscopic, robotic) for benign or malignant diseases at Weill Cornell by three surgeons from 2017 to 2023. Case volume and Iwate difficulty scoring were examined over time by surgical approach. Outcome associations (operative time, estimated blood loss, length of stay, 90-day complications, open conversion, and resection margin) were analyzed using generalized estimating equations to account for the hierarchical data structure of different surgeons and controlled for clinical covariates.

Among 353 hepatectomies, 112 were open (OH), 107 were laparoscopic (LH), and 134 were robotic (RH). OH patients were more likely to have malignant pathology (83% vs. LH 69%, RH 57%) and less likely to have cirrhosis (6% vs. LH 6%, RH 14%). OH and RH had similar case complexity (Median Iwate: OH 7 vs. RH 7). After adjustments, LH and RH had 39% and 43% shorter median lengths of stay, respectively, and 89% and 62% lower odds of complications compared to OH. RH had 87% lower odds of conversion to OH compared to LH. The odds of R0 resection were similar between LH, RH, and OH. These results remained consistent in high difficulty cases (Iwate 7-12). Over the study period, RH usage increased from 36 to 68%, while LH decreased from 39 to 9%. By 2023, RH was predominantly used over OH (74% vs.26%).

The transition from laparoscopic to all-robotic approach resulted in increased case volume and complexity in MILS, largely improving perioperative outcomes in hepatectomy.

The outcomes of minimally invasive liver surgery for posterosuperior segments (PS) are still debated. Since the results of ongoing trials focusing on the results of laparoscopic liver resection (LLR) and robotic liver resection (RLR) in this setting are still awaited, the best evidence currently comes from retrospective propensity-score matched (PSM) studies. The aim of this meta-analysis was to assess the outcomes of RLR for difficult located lesions and to provide evidence for its use in clinical practice.

A systematic review with meta-analysis was conducted to evaluate the safety and efficacy of LLR and RLR for PS segments. The Medline, Embase and Web of Science Library electronic databases were searched to identify available research published up to June 2024.

Five studies with a total of 2907 patients (RLR: n = 1084; LLR: n = 1823) were included in the meta-analysis. The RLR group had less estimated blood loss (EBL) (MD: - 88.3, 95% CI - 144.2-- 32.3; p = 0.012), fewer blood transfusions (OR 0.70, 95% CI 0.39-0.80, p = 0.033), and a shorter operative time (MD - 27.3, 95% CI - 49.4-- 5.1; p = 0.027). No differences in postoperative morbidity, mortality and R1 resection rates were observed.

RLR for lesions in the PS segments are safe and effective, and may have superior surgical outcomes than LLR.

The objective of this study was to investigate the long-term outcomes between laparoscopic anatomical liver resection (LAR) and laparoscopic non-anatomical liver resection (LNAR) in patients with hepatocellular carcinoma (HCC).

In this single-center retrospective cohort study, 1773 patients, from January 2009 to December 2017, were assessed for inclusion. After exclusions, 661 patients were included: 304 patients received LAR and 357 patients received LNAR. Propensity score matching (PSM) with 1:1 ratio was used to eliminate the selection bias between LAR and LNAR groups. The Kaplan-Meier and Cox models were used for survival analysis.

After PSM, 250 patients were in LAR or LNAR group, respectively. The overall survival (OS) had no significant difference between LAR and LNAR by Kaplan-Meier analysis. While, LAR had better disease-free survival (DFS) compared with LNAR (Log-rank P=0.035). The cumulative 5-year DFS rates were 48% for LAR, and 38% for LNAR. By Cox analysis, LAR was an independent risk factor of DFS (HR=1.308, P=0.030). In subgroup analysis for tumor size ≤ 5 cm, 207 patients were in LAR or LNAR subgroup after PSM. LAR had better DFS compared with LNAR (Log-rank P=0.033). LAR was an independent risk factor of DFS (HR=1.333, P=0.036). The cumulative 5-year DFS rates were 50% for LAR, and 39% for LNAR. In another subgroup analysis for tumor size > 5 cm, 43 patients were in LAR or LNAR subgroup after PSM. The DFS had no significant difference between LAR and LNAR (Log-rank P=0.912).

LAR is preferred for HCC patients with tumor size ≤5cm compared with LNAR because of the better DFS. For patients with tumor size >5cm, LAR and LNAR might be alternative procedures with comparable long-term outcomes.

Intraoperative hemorrhage during laparoscopic hepatectomy (LH) is a risk factor for negative postoperative outcomes. Ensuring appropriate hemostasis enhances the safety of surgical procedures. An automatic bleeding recognition system based on deep learning can lead to safer surgeries; however, deep learning models that are useful for detecting and stopping bleeding in LH have not yet been reported. In this study, we aimed to develop a deep learning model to automatically recognize bleeding regions during liver transection in LH.

In this retrospective feasibility study, bleeding scenes were randomly selected from LH videos, and the videos were divided into frames at 30 frames per second. Bleeding regions within the images were annotated by pixels, and subsequently, all images were assigned to the training, validation, and test datasets to develop the deep learning model. A convolutional neural network algorithm was used to perform semantic segmentation. After training and validation, the model was evaluated using images from the test dataset. Precision, recall, and Dice coefficients served as the evaluation metrics for the model.

In total, 2203 annotated images from 44 LH videos were utilized and divided into 1500, 400, and 303 frames for the training, validation, and test datasets, respectively. The precision, recall, and Dice coefficient values of the model were 0.76, 0.79, and 0.77, respectively.

We developed an automatic bleeding recognition model based on semantic segmentation and verified its performance. The proposed model is potentially useful for intraoperative alerting or evaluating surgical skills in the future.

Postoperative complications are vital factors affecting the prognosis of patients with hepatocellular carcinoma (HCC), especially for complex hepatectomy. The present study aimed to compare perioperative complications between laparoscopic and robotic complex hepatectomy (LCH vs. RCH).

Patients with solitary HCC after complex hepatectomy were collected from a multicenter database. Propensity score-matched (PSM) analysis was adopted to control confounding bias. Multivariable analysis was performed to determine the prognostic factors.

436 patients were included. After PSM, 43 patients were included in both the LCH and RCH groups. The results showed that compared to LCH, RCH had lower rates of blood loss and transfusion, and lower postoperative 30-day and major morbidity, and post-hepatectomy liver failure (PHLF) (all P < 0.05). Additionally, the length of hospital stay was shorter in the RCH group (P = 0.026). Multivariable analysis showed RCH is an independent protective factor for reducing the 30-day morbidity, major morbidity and PHLF.

RCH has advantages over LCH in the minimally invasive treatment of complex HCC, as it can reduce the incidence of postoperative morbidity. Therefore, RCH should be considered for patients with HCC who require complex hepatectomy.

Our clinical practice of laparoscopic liver resection (LLR) had achieved better short-term and long-term benefits for patients with hepatocellular carcinoma (HCC) over open liver resection (OLR), but the underlying mechanisms are not clear. This study was to find out whether systemic inflammation plays an important role.

A total of 103 patients with early-stage HCC under liver resection were enrolled (LLR group, n = 53; OLR group, n = 50). The expression of 9 inflammatory cytokines in patients at preoperation, postoperative day 1 (POD1) and POD7 was quantified by Luminex Multiplex assay. The relationships of the cytokines and the postoperative outcomes were compared between LLR and OLR.

Seven of the circulating cytokines were found to be significantly upregulated on POD1 after LLR or OLR compared to their preoperative levels. Compared to OLR, the POD1 levels of granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin-6 (IL-6), IL-8, and monocyte chemoattractant protein-1 (MCP-1) in the LLR group were significantly lower. Higher POD1 levels of these cytokines were significantly correlated with longer operative time and higher volume of blood loss during operation. The levels of these cytokines were positively associated with postoperative liver injury, and the length of hospital stay. Importantly, a high level of IL-6 at POD1 was a risk factor for HCC recurrence and poor disease-free survival after liver resection.

Significantly lower level of GM-CSF, IL-6, IL-8, and MCP-1 after liver resection represented a milder systemic inflammation which might be an important mechanism to offer better short-term and long-term outcomes in LLR over OLR.

Laparoscopic anatomical hepatectomy (LAH) for patients with hepatocellular carcinoma (HCC) has been advocated by many surgeons in the hope of producing better oncological outcomes. Two recent techniques, 3D laparoscopic system and 2D real-time indocyanine green fluorescence imaging (r-ICG) guidance, are benefit for improving the operative precision of LAH in different aspects. However, these two techniques cannot be applied concomitantly because of the technical limitation. Although a new modern laparoscopic system with both 3D and indocyanine green (ICG) imaging mode has been designed, it has not been listed in many countries including China. Thus, we design a new procedure to perform the 3D LAH with 2D r-ICG guidance for HCCs with conventional laparoscopic systems. In this procedure, both 3D and 2D laparoscopic systems were used. A total of 11 patients with HCC received 3D laparoscopic right posterior sectionectomy (LRPS) with 2D r-ICG guidance. The right posterior Glissonian pedicle was clamped under the 3D vision. Then ICG solution was then intravenously administrated. The liver parenchyma was transected under the 3D vision and guided by 2D ICG vision simultaneously. There was no severe complications (Clavien-Dindo ≥III) and operation related death. The 90-day mortality was also nil. By using this procedure, the advantages of two techniques, 3D laparoscopic system and 2D r-ICG guidance, were combined so that LAH could be performed with more precision. However, it should be validated in more studies.

This study aimed at analyzing and comparing the perioperative results and long-term oncological outcomes of hepatocellular carcinoma (HCC) patients with type 2 diabetes mellitus (T2DM) treated with laparoscopic (LLR) versus open liver resection (OLR).

Clinicopathological data of HCC patients with T2DM who underwent LLR or OLR as initial treatment from four medical centers were retrospectively reviewed. The survival outcomes of patients who underwent laparoscopic liver resection (LLR) were compared with those of patients who underwent open liver resection (OLR). Using the Kaplan-Meier method, survival curves for the two groups of patients were generated, and the log-rank test was used to compare survival differences. Propensity score matching (PSM) analysis was used to match patients of the LLR and OLR groups in a 1:1 ratio.

230 HCC patients with T2DM were enrolled, including 101 patients in the LLR group and 129 patients in the OLR group. After PSM, 90 patients were matched in each of the study group. Compared with the OLR group, the LLR group had less blood loss, a shorter hospitalization and fewer postoperative complications. The LLR group had a significantly better overall survival (OS) and recurrence-free survival (RFS) than the OLR group before and after PSM. Subgroup analysis demonstrated that HCC patients with T2DM had survival benefits from LLR regardless of the course of T2DM.

Laparoscopic liver resection for HCC patients with T2DM can be safely performed with favorable perioperative and long-term oncological outcomes at high-volume liver cancer centers, regardless of the course of T2DM.

Despite the advances in minimally invasive (MI) liver surgery, most major hepatectomies (MHs) continue to be performed by open surgery. This study aimed to evaluate the risk factors and outcomes of open conversion during MI MH, including the impact of the type of approach (laparoscopic vs. robotic) on the occurrence and outcomes of conversions.

Data on 3880 MI conventional and technical (right anterior and posterior sectionectomies) MHs were retrospectively collected. Risk factors and perioperative outcomes of open conversion were analyzed. Multivariate analysis, propensity score matching, and inverse probability treatment weighting analysis were performed to control for confounding factors.

Overall, 3211 laparoscopic MHs (LMHs) and 669 robotic MHs (RMHs) were included, of which 399 (10.28%) had an open conversion. Multivariate analyses demonstrated that male sex, laparoscopic approach, cirrhosis, previous abdominal surgery, concomitant other surgery, American Society of Anesthesiologists (ASA) score 3/4, larger tumor size, conventional MH, and Institut Mutualiste Montsouris classification III procedures were associated with an increased risk of conversion. After matching, patients requiring open conversion had poorer outcomes compared with non-converted cases, as evidenced by the increased operation time, blood transfusion rate, blood loss, hospital stay, postoperative morbidity/major morbidity and 30/90-day mortality. Although RMH showed a decreased risk of conversion compared with LMH, converted RMH showed increased blood loss, blood transfusion rate, postoperative major morbidity and 30/90-day mortality compared with converted LMH.

Multiple risk factors are associated with conversion. Converted cases, especially those due to intraoperative bleeding, have unfavorable outcomes. Robotic assistance seemed to increase the feasibility of the MI approach, but converted robotic procedures showed inferior outcomes compared with converted laparoscopic procedures.

Minimally invasive liver resection (MILR) is widely recognized as a safe and beneficial procedure in the treatment of both malignant and benign liver diseases. Hepatolithiasis has traditionally been reported to be endemic only in East Asia, but has seen a worldwide uptrend in recent decades with increasingly frequent and invasive endoscopic instrumentation of the biliary tract for a myriad of conditions. To date, there has been a woeful lack of high-quality evidence comparing the laparoscopic (LLR) and robotic (RLR) approaches to treatment hepatolithiasis.

This is an international multicenter retrospective analysis of 273 patients who underwent RLR or LRR for hepatolithiasis at 33 centers in 2003-2020. The baseline clinicopathological characteristics and perioperative outcomes of these patients were assessed. To minimize selection bias, 1:1 (48 and 48 cases of RLR and LLR, respectively) and 1:2 (37 and 74 cases of RLR and LLR, respectively) propensity score matching (PSM) was performed.

In the unmatched cohort, 63 (23.1%) patients underwent RLR, and 210 (76.9%) patients underwent LLR. Patient clinicopathological characteristics were comparable between the groups after PSM. After 1:1 and 1:2 PSM, RLR was associated with less blood loss (p = 0.003 in 1:2 PSM; p = 0.005 in 1:1 PSM), less patients with blood loss greater than 300 ml (p = 0.024 in 1:2 PSM; p = 0.027 in 1:1 PSM), and lower conversion rate to open surgery (p = 0.003 in 1:2 PSM; p < 0.001 in 1:1 PSM). There was no significant difference between RLR and LLR in use of the Pringle maneuver, median Pringle maneuver duration, 30-day readmission rate, postoperative morbidity, major morbidity, reoperation, and mortality.

Both RLR and LLR were safe and feasible for hepatolithiasis. RLR was associated with significantly less blood loss and lower open conversion rate.

This meta-analysis was dedicated to evaluating the safety and effectiveness of indocyanine green (ICG) -mediated fluorescence molecular imaging (FMI) technology in liver tumors resection.

A literature search of PubMed, Embase databases, Cochrane Library, and Web of Science was performed to identify all clinical controlled studies exploring the effects of fluorescence imaging on liver tumors resection. Quality assessment and data extraction of studies were conducted independently by 3 reviewers. Mean difference (MD) and odds ratio (OR) with 95% confidence interval (CI) were calculated using a fixed-effects or random-effects model. The meta-analysis was performed with RevMan 5.3 software.

14 retrospective cohort studies (RCSs) involving a total of 1227 patients were finally included. The results showed that Fluorescence-assisted liver tumors resection could improve the R0 resection rate (OR = 2.63; 95% CI: 1.46~4.73, p = 0.001), reduce overall complications (OR = 0.66; 95% CI: 0.44~0.97, p = 0.04), biliary fistula (OR = 0.20; 95% CI: 0.05~0.77, p = 0.02), intraoperative blood loss (MD = -70.76, 95% CI: -106.11 to -35.41; p < 0.0001), and shortens hospital stay (MD = -1.41, 95% CI: -1.90 to -0.92; p < 0.00001). There were no significant differences in the incidences of operative time (MD = -8.68, 95% CI: -18.59 to -1.22; p = 0.09), complications of grade III or above (OR = 0.73; 95% CI: 0.43~1.25, p = 0.26), liver failure (OR = 0.86; 95% CI: 0.39~1.89, p = 0.71), and blood transfusion (OR = 0.66; 95% CI: 0.42~1.03, p = 0.07).

Current evidence suggests that ICG-mediated FMI technology could enhance the clinical effectiveness of patients with liver tumors resection and is clinically worthy of promotion.

PROSPERO, identifier CRD42022368387.

This study aims to investigate whether indocyanine green (ICG) tumor imaging helps determine the safe surgical margin in laparoscopic hepatectomy.

Eighty-six patients with hepatic malignancies [including hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM)] were included in this study. ICG-R15 testing was performed 5-7 days before surgery. Fluorescence staining of the tumor was detected by a fluorescent laparoscope, and the width of fluorescence band surrounding tumor was measured by an electronic vernier caliper.

The positive rate of hepatic malignant lesions successfully stained by ICG fluorescence was 96.0% (95/99). HCC with better differentiation demonstrated non-rim fluorescence patterns, while cases with poor differentiation demonstrated rim patterns. CRLM uniformly demonstrated rim pattern. The width of fluorescence surrounding tumors was 0 in HCC with non-rim patterns. The minimum width of fluorescence surrounding tumors in poor differentiated HCC and CRLM were 2.4 ± 1.9 mm and 2.8 ± 2.5 mm, respectively, with no significant difference (P > 0.05). ICG fluorescence imaging revealed eight small lesions, which were not detected preoperatively in seven patients, of which five lesions were confirmed as malignancies by pathology.

Resection along the ICG fluorescence edge can supply a safe surgical margin only for CRLM, but not for HCC. Otherwise, ICG fluorescence tumor imaging can preliminarily determine the pathological type of hepatic malignancies and histological differentiation of HCC and help detect small lesions that cannot be detected preoperatively.

Laparoscopic liver resection (LLR) is now widely performed in treating primary liver cancer (PLC) and yields equal long-term and superior short-term outcomes to those of open liver resection (OLR). The optimal surgical approach for resectable PLC (rPLC) remains controversial. Herein, we aimed to develop a nomogram to determine the most appropriate resection approach for the individual patient.

Patients with rPLC who underwent hepatectomy from January 2013 to December 2018 were reviewed. Prediction model for risky surgery during LLR was constructed.

A total of 900 patients in the LLR cohort and 423 patients in the OLR cohort were included. A history of previous antitumor treatment, tumor diameter, tumor location and resection extent were independently associated with risky surgery of LLR. The nomogram which was constructed based on these risk factors demonstrated good accuracy in predicting risky surgery with a C index of 0.83 in the development cohort and of 0.76 in the validation cohort. Patients were stratified into high-, medium- or low-risk levels for receiving LLR if the calculated score was more than 0.8, between 0.2 and 0.8 or less than 0.2, respectively. High-risk patients who underwent LLR had more blood loss (441 ml to 417 ml) and a longer surgery time (183 min to 150 min) than those who received OLR.

Patients classified into the high-risk level for LLR instead undergo OLR to reduce surgical risks and complications and patients classified into the low-risk level undergo LLR to maximize the advantages of minimally invasive surgery.

This study was registered in the Chinese Clinical Trial Registry (registration number: ChiCTR2100049446).

Liver fibrosis or cirrhosis frequently makes parenchymal transection more difficult, but the difficulty score of laparoscopic liver resection (LLR), including the IWATE criteria, does not include a factor related to liver fibrosis. Therefore, this study aimed to evaluate M2BPGi as a predictor of the difficulty of parenchymal transection and the incidence of postoperative complications in LLR.

Data from 54 patients who underwent laparoscopic partial liver resection (LLR-P) and 24 patients who underwent laparoscopic anatomical liver resection between 2017 and 2019 in our institution were retrospectively analyzed. All cases were classified according to M2BPGi scores, and reserve liver function, intraoperative blood loss, and postoperative complications were compared among these groups.

Sixteen cases (29.6%) were M2BPGi negative (cut-off index < 1.0), 25 cases (46.3%) were 1+ (1.0 ≤ cut-off index < 3.0), and 13 cases (24.1%) were 2+ (cut-off index ≥ 3.0). M2BPGi-positive cases had significantly worse hepatic reserve function (K-ICG: 0.16 vs 0.14 vs 0.08, p < 0.0001). Intraoperative bleeding was significantly greater in M2BPGi-positive cases [50 ml vs 150 ml vs 200 ml, M2BPGi (-) or (1+) vs M2BPGi (2+), p = 0.045]. Postoperative complications (Clavien-Dindo ≥ II) were significantly more frequent in M2BPGi-positive cases [0% vs 4% vs 33%, M2BPGi (-) or (1+) vs M2BPGi (2+), p = 0.001].

M2BPGi could predict surgical difficulty and complications in LLR-P. In particular, it might be better not to select M2BPGi (2+) cases as teaching cases because of the massive bleeding during parenchymal transection.

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.

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.

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.

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.

Laparoscopic liver resection (LLR) is widely accepted in the surgical treatment of hepatocellular carcinoma (HCC) through international consensus conferences and the development of difficulty classifications. LLR has been reported to result in earlier postoperative recovery and fewer postoperative complications than open liver resection (OLR) for HCC. However, the prevalence of liver cirrhosis, obesity, the elderly, HCC recurrence (repeat liver resection), and major resection must be considered for LLR for HCC. Some systematic reviews, meta-analysis studies, and large cohort studies indicated that LLR is technically feasible for selected patients with HCC with these factors that led to less intraoperative blood loss, fewer transfusions and postoperative complication incidences, and shorter hospital stays than OLR. Furthermore, some reported LLR prevents postoperative loss of independence. No difference was reported in long-term outcomes among patients with HCC who underwent LLR and OLR; however, some recent reports indicated better long-term outcomes with LLR. In recent years, robot-assisted liver resection (RALR) has gradually become popular, and its short- and long-term results for HCC are not different from those of LLR. Additionally, RALR is expected to become the mainstay of minimally invasive surgery in the future.

While minimally invasive liver resections (MILR) have demonstrated advantages in improved post-operative recovery, widespread adoption is hampered by inherent technical difficulties. Our study attempts to analyze the role of anthropometric measures in MILR-related outcomes.

Between 2012 and 2020, 676 consecutive patients underwent MILR at the Singapore General Hospital of which 565 met study criteria and were included. Patients were stratified based on Body Mass Index (BMI) as well as Standardized Liver Volumes (SLV). Associations between BMI and SLV to selected peri-operative outcomes were analyzed using restricted cubic splines.

A BMI of ≥ 29 was associated with increase in blood loss [Mean difference (MD) 69 mls, 95% CI 2 to 137] as well as operative conversions [Relative Risk (RR) 1.63, 95% CI 1.02 to 2.62] among patients undergoing MILR while a SLV of 1600 cc or higher was associated with an increase in blood loss (MD 30 mls, 95% CI 10 to 49). In addition, a BMI of ≤ 20 was associated with an increased risk of major complications (RR 2.25, 95% 1.16 to 4.35). The magnitude of differences observed in these findings increased with each unit change in BMI and SLV.

Both BMI and SLV were useful anthropometric measures in predicting peri-operative outcomes in MILR and may be considered for incorporation in future difficulty scoring systems for MILR.

To compare the short- and long-term outcomes of robot-assisted (RALR), laparoscopic (LLR), or open liver resection (OLR) in the treatment of Barcelona Clinic Liver Cancer (BCLC) stage 0-A hepatocellular carcinoma (HCC).

Following the Balliol IDEAL classification, long-term oncological outcomes can be used to evaluate the value of minimally invasive techniques in the treatment of HCC, and to assess whether they should become a standard practice.

Data from prospective cohorts of patients with BCLC stage 0-A HCC who underwent curative liver resection using OLR, LLR, or RALR at Tongji Hospital were reviewed. The short-term and long-term oncological outcomes of these 3 different surgical approaches after adequate follow-up were compared using propensity score matching to reduce selection bias.

Of 369 patients included in this study (71, RALR; 141, LLR; and 157, OLR), 56 patients in each of the 3 groups were chosen for further comparison, after propensity score matching. In the minimally invasive group (RALR+LLR), both the operative time and duration of Pringle's maneuver were significantly longer than those in the OLR group; however, the length of hospital stay was significantly shorter. There were no significant differences in the other intraoperative parameters and the incidence of postoperative complications among the 3 groups. HCC recurrence in the minimally invasive group when compared with the OLR group was characterized by a significantly higher proportion of single lesion or early-stage HCC. However, there were no significant differences in the 5-year disease-free survival (63.8%, 54.4%, and 50.6%) or overall survival rates (80.8%, 78.6%, and 75.7%, respectively) among the 3 groups. Clinically significant portal hypertension was the only risk factor that negatively affected the 5-year disease-free survival rate. Multivariate Cox regression analysis showed that clinically significant portal hypertension, serum alpha-fetoprotein level (≥400 ng/mL), and Edmondson-Steiner grading (III+IV) were independent risk factors for poor long-term survival.

Both robotic and laparoscopic hepatectomies were safe and effective for patients with BCLC stage 0-A HCC when compared with open hepatectomy.

This study is aimed to compare the occurrence of postoperative infections between patients with hepatocellular carcinoma (HCC) undergoing laparoscopic liver resection (LLR) and those undergoing open liver resection (OLR).

This study included 446 patients who underwent initial curative liver resection for HCC 5 cm or less in size without macroscopic vascular invasion. To adjust for confounding factors between the LLR and OLR groups, propensity score matching and inverse probability weighting (IPW) analysis were performed. The incidence rates of postoperative infection, including incisional surgical site infection (SSI), organ/space SSI, and remote infection (RI), were compared between the two groups.

An imbalance in several confounding variables, including period of surgery, extent of liver resection, difficult location, proximity to a major vessel, tumor size ≥ 3 cm, and multiple tumors, was observed between the two groups in the original cohort. After matching and weighting, the imbalance between the two groups significantly decreased. Compared with OLR, LLR was associated with a lower volume of intraoperative blood loss (140 vs. 350 mL, P < 0.001 in the matched cohort; 120 vs. 320 mL, P < 0.001 in the weighted cohort) and reduced risk of postoperative infection (2.0% vs. 12%, P = 0.015 in the matched cohort; 2.9% vs. 14%, P = 0.005 in the weighted cohort). Of the types of postoperative infections, organ/space SSI and RI were less frequently observed in the LLR group than in the OLR group in the matched cohort (1.0% vs. 6.0%, P = 0.091 for organ/space SSI; 0% vs. 6.0%, P < 0.001 for RI) and in the weighted cohort (1.2% vs. 7.8%, P < 0.001 for organ/space SSI; 0.3% vs. 5.1%, P = 0.009 for RI).

Compared with OLR, LLR for HCC might reduce postoperative infections, including organ/space SSI and RI.

Left hemihepatectomy requires exposure of the middle hepatic vein (MHV) at the cutting-surface. Two procedures are used to approach the MHV: a conventional ventral approach and a laparoscopy-specific dorsal approach. This multicenter retrospective observational study aimed to evaluate the perioperative outcomes of these two procedures.

Clinical records of 38 consecutive patients that underwent laparoscopic left hemihepatectomy in four university hospitals between 2016 and 2021 were retrospectively reviewed. Outcome measurements were operative blood loss, operating time, trend of postoperative laboratory data within 7 days after hepatectomy, and postoperative complications. Quality of MHV exposure was also evaluated and compared by three-grade evaluation (excellent/good/poor) using recorded still images of the cut-surface of the remnant liver (n = 35).

Dorsal and ventral approaches were performed in 9 and 29 patients, respectively. Median operating time was 316 min (dorsal) and 314 min (ventral) (P = 0.71). Median operative blood loss was 45 ml (dorsal) and 105 ml (ventral) (P = 0.10). Two patients in the ventral approach group had bleeding in excess of 500 ml, which was not seen in the dorsal approach group. Excellent/good/poor MHV appearance on the cutting-surface was observed in 5/3/1 patients in the dorsal approach group, respectively, and in 7/8/11 patients in the ventral approach group, respectively (P = 0.03). In the ventral approach group, significant increases of aspartate aminotransferase (on postoperative day 1 and day 4/5) and of alanine aminotransferase (on postoperative day 2/3 and 4/5) were observed (P < 0.05). Postoperative complications were observed only in the ventral approach group (n = 3).

The dorsal approach could achieve safe and precise anatomical left hemihepatectomy with operation time and operative blood loss comparable to the conventional ventral approach.

Laparoscopic and robotic techniques have both been well adopted as safe options in selected patients undergoing hepatectomy. However, it is unknown whether either approach is superior, especially for major hepatectomy such as right hepatectomy or extended right hepatectomy (RH/ERH).

To compare the outcomes of robotic vs laparoscopic RH/ERH.

In this case-control study, propensity score matching analysis was performed to minimize selection bias. Patients undergoing robotic or laparoscopic RH/EHR at 29 international centers from 2008 to 2020 were included.

Robotic vs laparoscopic RH/ERH.

Data on patient demographics, tumor characteristics, and short-term perioperative outcomes were collected and analyzed.

Of 989 individuals who met study criteria, 220 underwent robotic and 769 underwent laparoscopic surgery. The median (IQR) age in the robotic RH/ERH group was 61.00 (51.86-69.00) years and in the laparoscopic RH/ERH group was 62.00 (52.03-70.00) years. Propensity score matching resulted in 220 matched pairs for further analysis. Patients' demographics and tumor characteristics were comparable in the matched cohorts. Robotic RH/ERH was associated with a lower open conversion rate (19 of 220 [8.6%] vs 39 of 220 [17.1%]; P = .01) and a shorter postoperative hospital stay (median [IQR], 7.0 [5.0-10.0] days; mean [SD], 9.11 [7.52] days vs median [IQR], 7.0 [5.75-10.0] days; mean [SD], 9.94 [8.99] days; P = .048). On subset analysis of cases performed between 2015 and 2020 after a center's learning curve (50 cases), robotic RH/ERH was associated with a shorter postoperative hospital stay (median [IQR], 6.0 [5.0-9.0] days vs 7.0 [6.0-9.75] days; P = .04) with a similar conversion rate (12 of 220 [7.6%] vs 17 of 220 [10.8%]; P = .46).

Robotic RH/ERH was associated with a lower open conversion rate and shorter postoperative hospital stay compared with laparoscopic RH/ERH. The difference in open conversion rate was associated with a significant decrease for laparoscopic but not robotic RH/ERH after a center had mounted the learning curve. Use of robotic platform may help to overcome the initial challenges of minimally invasive RH/ERH.

With the development and application of laparoscopic hepatectomy in major medical centers, domestic and foreign guidelines have summarized the indications, surgical techniques and operational procedures of the surgery. But in primary care facilities, where the surgical equipment are available, laparoscopic hepatectomy is performed only in a small number of cases and the progress of its application remains slow. The reasons possibly lie in the failure of a full understanding of the surgery, the lack of anatomical knowledge of laparoscopic hepatectomy, the lack of close multidisciplinary cooperation in the perioperative period and insufficient training of laparoscopic technology. In this review, we elaborate on three aspects of laparoscopic hepatectomy: preoperative planning, surgical techniques and postoperative management. Before the operation, the surgeons should fully understand the anatomical structure of the liver and select appropriate cases considering both the difficulty of operation and the surgical experience of the surgeons. During the operation, the position of the patient and the layout of the stamping card should be appropriate, and the central venous pressure needs to be well controlled in close cooperation with the anesthesiologist. The surgeons should be proficient at the techniques of liver suspension and pulling and at the use of ultrasonic knife, and select correct techniques for management of bleeding and the control of blood flow in and out of the liver. The patient should receive postoperative management with standard enhanced recovery after surgery (ERAS) protocols. These experiences may help to improve the practice of laparoscopic hepatectomy in local hospitals or primary care facilities.

The impact of conversion on perioperative and long-term oncologic outcomes is controversial. Thus, we compared these outcomes between laparoscopic (Lap), unplanned conversion (Conversion), and planned open (Open) liver resection for hepatocellular carcinoma (HCC) located in anterolateral (AL) liver segments and aimed to identify risk factors for unplanned conversion.

We retrospectively studied 374 patients (Lap, 299; Open, 62; Conversion, 13) who underwent liver resection for HCC located in AL segments between 2004 and 2018.

Compared to the Lap group, the Conversion group showed greater values for operation time (p < 0.001), blood loss (p = 0.021), transfusion rate (p = 0.009), postoperative complication rate (p = 0.008), and hospital stay (p = 0.040), with a lower R0 resection rate (p < 0.001) and disease-free survival (p = 0.001). Compared with the Open group, the Conversion group had a longer operation time (p = 0.012) and greater blood loss (p = 0.024). Risk factors for unplanned conversion were large tumor size (odds ratio [OR], 1.35; 95% confidence interval [CI], 1.05-1.74; p = 0.020), multiple tumors (OR, 5.95; 95% CI, 1.45-24.39; p = 0.013), and other organ invasion (OR, 15.32; 95% CI, 1.80-130.59; p = 0.013).

In conclusion, patients who experienced unplanned conversion during LLR for HCC located in AL segments showed poor perioperative and long-term outcomes compared to those who underwent planned laparoscopic and open liver resection. Therefore, open liver resection should be considered in patients with risk factors for unplanned conversion.