Gradual expansion of the indications for minimally invasive liver resection to include highly complex procedures may improve postoperative outcomes

Abstract

Aim: Liver resection is performed in patients with benign and malignant liver tumors. Advancements in surgical instruments and improved perioperative management have enabled safe laparoscopic and robotic liver resections. Herein, we aimed to evaluate the patients who underwent minimally invasive liver resection (MISLR) and compare their short-term outcomes with those of patients who underwent open liver resection (OLR), according to surgical complexity.

Methods: Data of patients who underwent liver resection at our institution from January 2011 to August 2023 were obtained from a prospectively maintained database. We gradually expanded the indications for MISLR from technically less demanding procedures to intermediate- and high-complexity MISLRs. The procedures were categorized into three grades (low, intermediate, and high) according to the liver resection complexity classification.

Results: Of the 1,866 patients who underwent liver resection, 953 were included in the analysis. Of the 953 patients, 781 underwent OLR and 172 underwent MISLR. The operative time and estimated blood loss increased with the increase in surgical complexity in the MISLR group, which was similar to finding in the OLR group. The complication rate also increased with the increase in surgical complexity in the OLR group (low complexity vs. high complexity, 34.8% vs. 50.1%). However, the complication rate was steadily low and approximately 10% across all complexity grades in the MISLR group.

Conclusion: Careful selection and gradual expansion of the indications of MISLR may facilitate improved postoperative outcomes in patients undergoing highly complex MISLRs.

Keywords

Liver resection / laparoscopic liver resection / robot liver resection / the liver resection complexity classification

References

[1] Lurje I,Bednarsch J.Treatment strategies for hepatocellular carcinoma - a multidisciplinary approach.Int J Mol Sci2019;20:1465 PMCID:PMC6470895

[2] Orcutt ST.Liver resection and surgical strategies for management of primary liver cancer.Cancer Control2018;25:1073274817744621 PMCID:PMC5933574

[3] Mazzaferro V,Roayaie S,Sapisochin G.Liver resection and transplantation for intrahepatic cholangiocarcinoma.J Hepatol2020;72:364-77

[4] Lu Q,Gao WM,Zhang XF.Intraoperative blood transfusion and postoperative morbidity following liver resection.Med Sci Monit2018;24:8469-80 PMCID:PMC6270889

[5] Jin S,Wuyun G.Management of post-hepatectomy complications.World J Gastroenterol2013;19:7983-91 PMCID:PMC3848145

[6] Maki H.Advances in the surgical treatment of liver cancer.Biosci Trends2022;16:178-88

[7] Ayabe RI,Tran Cao HS.Robot-assisted liver resection: the real benefit so far.Langenbecks Arch Surg2022;407:1779-87

[8] Dogeas E,Geller DA.Laparoscopic liver resection: global diffusion and learning curve.Ann Acad Med Singap2021;50:736-8

[9] Kawaguchi Y,Kokudo N.Difficulty of laparoscopic liver resection: proposal for a new classification.Ann Surg2018;267:13-7

[10] Kawaguchi Y,Fuks D.Validation and performance of three-level procedure-based classification for laparoscopic liver resection.Surg Endosc2020;34:2056-66

[11] Kawaguchi Y,Tzeng CWD.Performance of a modified three-level classification in stratifying open liver resection procedures in terms of complexity and postoperative morbidity.Br J Surg2020;107:258-67

[12] Kawaguchi Y,Vauthey JN.Surgical resection: old dog, any new tricks?.Clin Liver Dis2020;24:637-55

[13] Kawaguchi Y,Hayakawa T.A data-informed timeline for hospital discharge with a reasonably low risk of unplanned readmission after open and minimally invasive liver resections.J Hepatobiliary Pancreat Sci2024;31:243-50

[14] Kawaguchi Y,Fuks D,Kokudo N.Hemorrhage control for laparoscopic hepatectomy: technical details and predictive factors for intraoperative blood loss.Surg Endosc2016;30:2543-51

[15] Dindo D,Clavien PA.Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.Ann Surg2004;240:205-13 PMCID:PMC1360123

[16] Berardi G,Fretland ÅA.Evolution of laparoscopic liver surgery from innovation to implementation to mastery: perioperative and oncologic outcomes of 2,238 patients from 4 European Specialized Centers.J Am Coll Surg2017;225:639-49

[17] Ban D,Ito H.A novel difficulty scoring system for laparoscopic liver resection.J Hepatobiliary Pancreat Sci2014;21:745-53

[18] Halls MC,Cipriani F.Development and validation of a difficulty score to predict intraoperative complications during laparoscopic liver resection.Br J Surg2018;105:1182-91

[19] Hasegawa Y,Nitta H.A novel model for prediction of pure laparoscopic liver resection surgical difficulty.Surg Endosc2017;31:5356-63

[20] Wakabayashi G.What has changed after the Morioka consensus conference 2014 on laparoscopic liver resection?.Hepatobiliary Surg Nutr2016;5:281-9 PMCID:PMC4960417

[21] Sucandy I,Adorno J.Validity of the Institut Mutualiste Montsouris classification system for robotic liver resection.HPB2023;25:1022-9

[22] Russolillo N,Fleres F,Lo Tesoriere R.Comparison and validation of three difficulty scoring systems in laparoscopic liver surgery: a retrospective analysis on 300 cases.Surg Endosc2020;34:5484-94

[23] Goh BKP,Syn N.Validation and comparison of the Iwate, IMM, Southampton and Hasegawa difficulty scoring systems for primary laparoscopic hepatectomies.HPB2021;23:770-6

[24] Russolillo N, Aldrighetti L, Cillo U, et al; I Go MILS Group. Risk-adjusted benchmarks in laparoscopic liver surgery in a national cohort. Br J Surg 2020;107:845-53.

[25] Dubray Q,Tribillon E.Analysis of economic impact of laparoscopic liver resection according to surgical difficulty.Surg Endosc2021;35:1006-13

[26] Watanabe G,Ichida A.Understanding conditional cumulative incidence of complications following liver resection to optimize hospital stay.HPB2022;24:226-33

[27] Kobayashi K,Schneider M.Probability of postoperative complication after liver resection: stratification of patient factors,operative complexity, and use of enhanced recovery after surgery.J Am Coll Surg2021;233:357-68.e2

[28] Hobeika C,Barbier L.Influence of surgical approach and quality of resection on the probability of cure for early-stage HCC occurring in cirrhosis.JHEP Rep2020;2:100153 PMCID:PMC7502347

[29] Mazzotta AD,Ito K.Graduated autonomy of laparoscopic liver resection based on liver resection complexity: a western and eastern bi-institution study for learning curve. J Am Coll Surg 2024.