Published papers

Background: Data on the effect of body mass index on laparoscopic liver resections are conflicting. We performed this study to investigate the association between body mass index and postoperative outcomes after laparoscopic major hepatectomies. Methods: This is a retrospective review of 4,348 laparoscopic major hepatectomies at 58 centers between 2005 and 2021, of which 3,383 met the study inclusion criteria. Concomitant major operations, vascular resections, and previous liver resections were excluded. Associations between body mass index and perioperative outcomes were analyzed using restricted cubic splines. Modeled effect sizes were visually rendered and summarized. Results: A total of 1,810 patients (53.5%) had normal weight, whereas 1,057 (31.2%) were overweight and 392 (11.6%) were obese. One hundred and twenty-four patients (3.6%) were underweight. Most perioperative outcomes showed a linear worsening trend with increasing body mass index. There was a statistically significant increase in open conversion rate (16.3%, 10.8%, 9.2%, and 5.6%, P <.001), longer operation time (320 vs 305 vs 300 and 266 minutes, P <.001), increasing blood loss (300 vs 300 vs 295 vs 250 mL, P =.022), and higher postoperative morbidity (33.4% vs 26.3% vs 25.0% vs 25.0%, P =.009) in obese, overweight, normal weight, and underweight patients, respectively (P <.001). However, postoperative major morbidity demonstrated a “U”-shaped association with body mass index, whereby the highest major morbidity rates were observed in underweight and obese patients. Conclusion: Laparoscopic major hepatectomy was associated with poorer outcomes with increasing body mass index for most perioperative outcome measures.

Introduction: Currently, the impact of body mass index (BMI) on the outcomes of laparoscopic liver resections (LLR) is poorly defined. This study attempts to evaluate the impact of BMI on the peri-operative outcomes following laparoscopic left lateral sectionectomy (L-LLS). Methods: A retrospective analysis of 2183 patients who underwent pure L-LLS at 59 international centers between 2004 and 2021 was performed. Associations between BMI and selected peri-operative outcomes were analyzed using restricted cubic splines. Results: A BMI of >27kg/m2 was associated with increased in blood loss (Mean difference (MD) 21 mls, 95% CI 5–36), open conversions (Relative risk (RR) 1.13, 95% CI 1.03–1.25), operative time (MD 11 min, 95% CI 6–16), use of Pringles maneuver (RR 1.15, 95% CI 1.06–1.26) and reductions in length of stay (MD -0.2 days, 95% CI -0.3 to −0.1). The magnitude of these differences increased with each unit increase in BMI. However, there was a “U” shaped association between BMI and morbidity with the highest complication rates observed in underweight and obese patients. Conclusion: Increasing BMI resulted in increasing difficulty of L-LLS. Consideration should be given to its incorporation in future difficulty scoring systems in laparoscopic liver resections.

Introduction: To assess the impact of cirrhosis and portal hypertension (PHT) on technical difficulty and outcomes of minimally invasive liver resection (MILR) in the posterosuperior segments. Methods: This is a post-hoc analysis of patients with primary malignancy who underwent laparoscopic and robotic wedge resection and segmentectomy in the posterosuperior segments between 2004 and 2019 in 60 centers. Surrogates of difficulty (i.e, open conversion rate, operation time, blood loss, blood transfusion, and use of the Pringle maneuver) and outcomes were compared before and after propensity-score matching (PSM) and coarsened exact matching (CEM). Results: Of the 1954 patients studied, 1290 (66%) had cirrhosis. Among the cirrhotic patients, 310 (24%) had PHT. After PSM, patients with cirrhosis had higher intraoperative blood transfusion (14% vs. 9.3%; p = 0.027) and overall morbidity rates (20% vs. 14.5%; p = 0.023) than those without cirrhosis. After coarsened exact matching (CEM), patients with cirrhosis tended to have higher intraoperative blood transfusion rate (12.1% vs. 6.7%; p = 0.059) and have higher overall morbidity rate (22.8% vs. 12.5%; p = 0.007) than those without cirrhosis. After PSM, Pringle maneuver was more frequently applied in cirrhotic patients with PHT (62.2% vs. 52.4%; p = 0.045) than those without PHT. Conclusion: MILR in the posterosuperior segments in cirrhotic patients is associated with higher intraoperative blood transfusion and postoperative morbidity. This parameter should be utilized in the difficulty assessment of MILR.

Introduction: We performed this study in order to investigate the impact of liver cirrhosis (LC) on the difficulty of minimally invasive liver resection (MILR), focusing on minor resections in anterolateral (AL) segments for primary liver malignancies. Methods: This was an international multicenter retrospective study of 3675 patients who underwent MILR across 60 centers from 2004 to 2021. Results: 1312 (35.7%) patients had no cirrhosis, 2118 (57.9%) had Child A cirrhosis and 245 (6.7%) had Child B cirrhosis. After propensity score matching (PSM), patients in Child A cirrhosis group had higher rates of open conversion (p = 0.024), blood loss >500 mls (p = 0.001), blood transfusion (p < 0.001), postoperative morbidity (p = 0.004), and in-hospital mortality (p = 0.041). After coarsened exact matching (CEM), Child A cirrhotic patients had higher open conversion rate (p = 0.05), greater median blood loss (p = 0.014) and increased postoperative morbidity (p = 0.001). Compared to Child A cirrhosis, Child B cirrhosis group had longer postoperative stay (p = 0.001) and greater major morbidity (p = 0.012) after PSM, and higher blood transfusion rates (p = 0.002), longer postoperative stay (p < 0.001), and greater major morbidity (p = 0.006) after CEM. After PSM, patients with portal hypertension experienced higher rates of blood loss >500 mls (p = 0.003) and intraoperative blood transfusion (p = 0.025). Conclusion: The presence and severity of LC affect and compound the difficulty of MILR for minor resections in the AL segments. These factors should be considered for inclusion into future difficulty scoring systems for MILR.

Background: Minimally invasive liver resections (MILR) offer potential benefits such as reduced blood loss and morbidity compared with open liver resections. Several studies have suggested that the impact of cirrhosis differs according to the extent and complexity of resection. Our aim was to investigate the impact of cirrhosis on the difficulty and outcomes of MILR, focusing on major hepatectomies. Methods: A total of 2534 patients undergoing minimally invasive major hepatectomies (MIMH) for primary malignancies across 58 centers worldwide were retrospectively reviewed. Propensity score (PSM) and coarsened exact matching (CEM) were used to compare patients with and without cirrhosis. Results: A total of 1353 patients (53%) had no cirrhosis, 1065 (42%) had Child-Pugh A and 116 (4%) had Child-Pugh B cirrhosis. Matched comparison between non-cirrhotics vs Child-Pugh A cirrhosis demonstrated comparable blood loss. However, after PSM, postoperative morbidity and length of hospitalization was significantly greater in Child-Pugh A cirrhosis, but these were not statistically significant with CEM. Comparison between Child-Pugh A and Child-Pugh B cirrhosis demonstrated the latter had significantly higher transfusion rates and longer hospitalization after PSM, but not after CEM. Comparison of patients with cirrhosis of all grades with and without portal hypertension demonstrated no significant difference in all major perioperative outcomes after PSM and CEM. Conclusions: The presence and severity of cirrhosis affected the difficulty and impacted the outcomes of MIMH, resulting in higher blood transfusion rates, increased postoperative morbidity, and longer hospitalization in patients with more advanced cirrhosis. As such, future difficulty scoring systems for MIMH should incorporate liver cirrhosis and its severity as variables.

Background: The impact of cirrhosis and portal hypertension on perioperative outcomes of minimally invasive left lateral sectionectomies remains unclear. We aimed to compare the perioperative outcomes between patients with preserved and compromised liver function (noncirrhotics versus Child-Pugh A) when undergoing minimally invasive left lateral sectionectomies. In addition, we aimed to determine if the extent of cirrhosis (Child-Pugh A versus B) and the presence of portal hypertension had a significant impact on perioperative outcomes. Methods: This was an international multicenter retrospective analysis of 1,526 patients who underwent minimally invasive left lateral sectionectomies for primary liver malignancies at 60 centers worldwide between 2004 and 2021. In the study, 1,370 patients met the inclusion criteria and formed the final study group. Baseline clinicopathological characteristics and perioperative outcomes of these patients were compared. To minimize confounding factors, 1:1 propensity score matching and coarsened exact matching were performed. Results: The study group comprised 559, 753, and 58 patients who did not have cirrhosis, Child-Pugh A, and Child-Pugh B cirrhosis, respectively. Six-hundred and thirty patients with cirrhosis had portal hypertension, and 170 did not. After propensity score matching and coarsened exact matching, Child-Pugh A patients with cirrhosis undergoing minimally invasive left lateral sectionectomies had longer operative time, higher intraoperative blood loss, higher transfusion rate, and longer hospital stay than patients without cirrhosis. The extent of cirrhosis did not significantly impact perioperative outcomes except for a longer duration of hospital stay. Conclusion: Liver cirrhosis adversely affected the intraoperative technical difficulty and perioperative outcomes of minimally invasive left lateral sectionectomies.

Background: In the last three decades, minimally invasive liver resection has been replacing conventional open approach in liver surgery. More recently, developments in neoadjuvant chemotherapy have led to increased multidisciplinary management of colorectal liver metastases with both medical and surgical treatment modalities. However, the impact of neoadjuvant chemotherapy on the surgical outcomes of minimally invasive liver resections remains poorly understood. Methods: A multicenter, international, database of 4998 minimally invasive minor hepatectomy for colorectal liver metastases was used to compare surgical outcomes in patients who received neoadjuvant chemotherapy with surgery alone. To correct for baseline imbalance, propensity score matching, coarsened exact matching and inverse probability treatment weighting were performed. Results: 2546 patients met the inclusion criteria. After propensity score matching there were 759 patients in both groups and 383 patients in both groups after coarsened exact matching. Baseline characteristics were equal after both matching strategies. Neoadjuvant chemotherapy was not associated with statistically significant worse surgical outcomes of minimally invasive minor hepatectomy. Conclusion: Neoadjuvant chemotherapy had no statistically significant impact on short-term surgical outcomes after simple and complex minimally invasive minor hepatectomy for colorectal liver metastases.

Background: Minimal invasive liver resections are a safe alternative to open surgery. Different scoring systems considering different risks factors have been developed to predict the risks associated with these procedures, especially challenging major liver resections (MLR). However, the impact of neoadjuvant chemotherapy (NAT) on the difficulty of minimally invasive MLRs remains poorly investigated. Methods: Patients who underwent laparoscopic and robotic MLRs for colorectal liver metastases (CRLM) performed across 57 centers between January 2005 to December 2021 were included in this analysis. Patients who did or did not receive NAT were matched based on 1:1 coarsened exact and 1:2 propensity-score matching. Pre- and post-matching comparisons were performed. Results: In total, the data of 5189 patients were reviewed. Of these, 1411 procedures were performed for CRLM, and 1061 cases met the inclusion criteria. After excluding 27 cases with missing data on NAT, 1034 patients (NAT: n = 641; non-NAT: n = 393) were included. Before matching, baseline characteristics were vastly different. Before matching, the morbidity rate was significantly higher in the NAT-group (33.2% vs. 27.2%, p-value = 0.043). No significant differences were seen in perioperative outcomes after the coarsened exact matching. After the propensity-score matching, statistically significant higher blood loss (mean, 300 (SD 128–596) vs. 250 (SD 100–400) ml, p-value = 0.047) but shorter hospital stay (mean, 6 [4-8] vs. 6 [5-9] days, p-value = 0.043) were found in the NAT-group. Conclusion: The current study demonstrated that NAT had minimal impact on the difficulty and outcomes of minimally-invasive MLR for CRLM.

Background: Tumor size (TS) represents a critical parameter in the risk assessment of laparoscopic liver resections (LLR). Moreover, TS has been rarely related to the extent of liver resection. The aim of this study was to study the relationship between tumor size and difficulty of laparoscopic left lateral sectionectomy (L-LLS). Methods: The impact of TS cutoffs was investigated by stratifying tumor size at each 10 mm-interval. The optimal cutoffs were chosen taking into consideration the number of endpoints which show a statistically significant split around the cut-points of interest and the magnitude of relative risk after correction for multiple risk factors. Results: A total of 1910 L-LLS were included. Overall, open conversion and intraoperative blood transfusion were 3.1 and 3.3%, respectively. The major morbidity rate was 2.7% and 90-days mortality 0.6%. Three optimal TS cutoffs were identified: 40-, 70-, and 100-mm. All the selected cutoffs showed a significant discriminative power for the prediction of open conversion, operative time, blood transfusion and need of Pringle maneuver. Moreover, 70- and 100-mm cutoffs were both discriminative for estimated blood loss and major complications. A stepwise increase in rates of open conversion rate (Z = 3.90, P <.001), operative time (Z = 3.84, P <.001), blood loss (Z = 6.50, P <.001), intraoperative blood transfusion rate (Z = 5.15, P <.001), Pringle maneuver use (Z = 6.48, P <.001), major morbidity(Z = 2.17, P =.030) and 30-days readmission (Z = 1.99, P =.047) was registered as the size increased. Conclusion: L-LLS for tumors of increasing size was associated with poorer intraoperative and early postoperative outcomes suggesting increasing difficulty of the procedure. We determined three optimal TS cutoffs (40-, 70- and 100-mm) to accurately stratify surgical difficulty after L-LLS.

Introduction: Although tumor size (TS) is known to affect surgical outcomes in laparoscopic liver resection (LLR), its impact on laparoscopic major hepatectomy (L-MH) is not well studied. The objectives of this study were to investigate the impact of TS on the perioperative outcomes of L-MH and to elucidate the optimal TS cutoff for stratifying the difficulty of L-MH. Methods: This was a post-hoc analysis of 3008 patients who underwent L-MH at 48 international centers. A total 1396 patients met study criteria and were included. The impact of TS cutoffs was investigated by stratifying TS at each 10-mm interval. The optimal cutoffs were determined taking into consideration the number of endpoints which showed a statistically significant split around the cut-points of interest and the magnitude of relative risk after correction for multiple risk factors. Results: We identified 2 optimal TS cutoffs, 50 mm and 100 mm, which segregated L-MH into 3 groups. An increasing TS across these 3 groups (≤ 50 mm, 51–100 mm, > 100 mm), was significantly associated with a higher open conversion rate (11.2%, 14.7%, 23.0%, P < 0.001), longer operating time (median, 340 min, 346 min, 365 min, P = 0.025), increased blood loss (median, 300 ml, ml, 400 ml, P = 0.002) and higher rate of intraoperative blood transfusion (13.1%, 15.9%, 27.6%, P < 0.001). Postoperative outcomes such as overall morbidity, major morbidity, and length of stay were comparable across the three groups. Conclusion: Increasing TS was associated with poorer intraoperative but not postoperative outcomes after L-MH. We determined 2 TS cutoffs (50 mm and 10 mm) which could optimally stratify the surgical difficulty of L-MH.

Background: There has been a progressive increase in the use of percutaneous cholecystostomy (PC) in acute cholecystitis (AC) over the last decades due to population aging, and the support of guidelines (Tokyo Guidelines (TG), World Society of Emergency Surgery (WSES) Guidelines) as a valid therapeutical option. However, there are many unanswered questions about the management of PCs. An international consensus on indications and PC management using Delphi methodology with contributions from experts from three surgical societies (EAHPBA, ANS, WSES) have been performed. Methods: A two-round Delphi consensus, which included 27 questions, was sent to key opinion leaders in AC. Participants were asked to indicate their ‘agreement/disagreement’ using a 5-point Likert scale. Survey items with less than 70% consensus were excluded from the second round. For inclusion in the final recommendations, each survey item had to have reached a group consensus (≥ 70% agreement) by the end of the two survey rounds. Results: 54 completed both rounds (82% of invitees). Six questions got > 70% and are included in consensus recommendations: In patients with acute cholecystitis, when there is a clear indication of PC, it is not necessary to wait 48 h to be carried out; Surgery is the first therapeutic option for the TG grade II acute cholecystitis in a patient suitable for surgery; Before PC removal a cholangiography should be done; There is no indication for PC in Tokyo Guidelines (TG) grade I patients; Transhepatic approach is the route of choice for PC; and after PC, laparoscopic cholecystectomy is the preferred approach (93.1%). Conclusions: Only six statements about PC management after AC got an international consensus. An international guideline about the management of PCs are necessary.

Background Laparoscopic liver resection has been associated with less morbidity than, and similar global outcomes to, open liver resection. There is no robust evidence that these outcomes lead to similar clinical outcomes in patients aged over 80 years. The aim of this study was to analyse the short-term outcomes between open and laparoscopic liver resection in patients over 80 years old. Methods A retrospective analysis was undertaken. The study population comprised patients aged ≥ 80 years who underwent laparoscopic or open liver resection between January 2014 and December 2019, and who presented with resectable malignant tumours. The primary outcome was postoperative morbidity, according to Dindo-Clavien grading. Cox regression models were used to compute hazard ratios and 95% confidence intervals. Propensity score matching (1: 1) was performed to balance the two groups according to independent prognostic factors for morbidity. Results A total of 988 patients were analysed from 34 centres (16 from Asia, 14 from Europe and 4 from America): 487 in the open group and 501 in the laparoscopic group. Independent risk factors associated with severe morbidity were the open approach (hazard ratio 1.59, 95% confidence interval 1.19 to 2.11; P < 0.001), Charlson Co-morbidity Index score > 7 (HR 1.69, 1.26 to 2.27; P < 0.001), more than one resected tumour (hazard ratio 1.55, 1.13 to 2.11; P = 0.006), major hepatectomy (hazard ratio 1.86, 1.22 to 2.83; P = 0.003), and Iwate score ≥ 7 (hazard ratio 1.43, 1.02 to 2.01; P = 0.03). Before propensity score matching, severe morbidity, length of intensive care unit stay, 90-day mortality, length of hospital stay, and readmission were better in the laparoscopic group (P < 0.050). These observations were confirmed after propensity score matching. Conclusion The laparoscopic approach is a safe procedure for elderly patients, with better morbidity and mortality outcomes than the open approach, and should be considered as a default option.

Background: Limited anatomic resections (LARs), such as segmentectomies, performed using a fully laparoscopic approach, have gained popularity for liver malignancies. However, the oncologic efficacy of laparoscopic LARs (Lap-LARs) needs further investigation. This cohort study evaluated the oncologic outcomes of Lap-LAR for hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM). Methods: At a Japanese referral center, 112 patients underwent Lap-LAR using the Glissonean approach and indocyanine green (ICG) fluorescence navigation. Recurrence-free survival (RFS), overall survival (OS), time to interventional failure (TIF), and time to surgical failure (TSF) were assessed. Results: Among the 112 patients (median age, 74 years [range, 66–80 years]; 80 men [71.4 %]), Lap-LAR showed promising results. The median operative time was 348 min (range, 280–460 min), and the median blood loss was 190 mL (range, 95.5–452.0 mL). The median error between the estimated and actual liver volumes was 2 % (1.2–4.8 %). Complications greater than Clavien–Dindo 3a were observed in 11.6 % of the patients. The 5-year RFS, OS, and TIF rates for HCC were 45.1 % ± 7.9 %, 73.1 % ± 6.7 %, and 74.2 % ± 6.6 %, respectively. The 5-year RFS, OS, and TSF rates for CRLM were 36.8 % ± 8.7 %, 60.1 % ± 13.3 %, and 63.6 % ± 10.4 %, respectively. Conclusions: Lap-LAR showed favorable oncologic outcomes for HCC and CRLM. Its precise technique makes it a promising therapeutic option for liver malignancies. Further comparisons with conventional approaches are warranted.

Minimally invasive liver resection (MILR) is being widely utilized owing to recent advancements in laparoscopic and robot-assisted surgery. There are two main types of liver resection: anatomical (minimally invasive anatomical liver resection (MIALR)) and nonanatomical. MIALR is defined as a minimally invasive liver resection along the respective portal territory. Optimization of the safety and precision of MIALR is the next challenge for hepatobiliary surgeons, and intraoperative indocyanine green (ICG) staining is considered to be of considerable importance in this field. In this article, we present the latest findings on MIALR and laparoscopic anatomical liver resection using ICG at our hospital.

Here we present the first case of both laparoscopic and robot-assisted repeat liver resections in a patient with Situs Inversus Totalis (SIT). The patient is a 69-year-old male who had been diagnosed in 2020, at the age of 65, with a 44 mm hepatocellular carcinoma (HCC) located at segment 4, treated through a laparoscopic left hepatectomy. After a disease-free period of 18 months, he underwent a laparoscopic segment 5 segmentectomy for recurrence. 21 months later, due to new recurrences located at segment 6 and segment 8, he underwent a segment 6 and segment 8 partial resection with robot-assisted approach. Both the laparoscopic liver resections were performed with selective extrahepatic Glissonean approach and ICG negative staining, after accurate 3D preoperative planning. 3D navigation proved crucial as well during the third surgery, which was performed with robot-assisted approach. To our knowledge, this is the first case of laparoscopic and robot-assisted repeat liver surgery in a patient affected by SIT, proving the feasibility of minimally invasive surgery even in extremely complex contexts, especially with the help of innovative tools such as ICG guidance and 3D navigation.

Background: Neoadjuvant chemotherapy (NAC) may improve outcomes in perihilar cholangiocarcinoma (PHC); however, its efficacy compared with upfront surgery (US) for resectable PHC remains unclear. We compared survival and clinicopathological characteristics between NAC and US in patients with technically resectable PHC, using propensity score matching (PSM). Methods: We retrospectively analyzed 261 patients with resectable PHC who underwent surgical treatment (2016–2024) across multiple institutions. Among them, 50 received NAC and 199 underwent US. The 38 patients receiving NAC were matched 1:1 with patients undergoing US using PSM. Overall survival (OS) and progression-free survival (PFS) were compared between groups. Pathological response to NAC and its association with chemotherapy doses were also evaluated. Results: Before PSM, OS and PFS did not differ significantly between the US and NAC groups. After PSM, OS did not differ significantly between groups, but PFS was significantly longer in the NAC group, where patients with a therapeutic-effect grade ≥1b had better PFS than those with US. Grade ≥1b response was associated with receiving ≥7 NAC doses. Discussion: NAC may improve PFS in selected patients with resectable PHC, especially those showing major pathological responses. Prospective studies should validate these findings and define optimal selection criteria and regimens.

Background: As the elderly population increases, cases of elderly advanced gastric cancer (AGC) also increase. This study aims to investigate the safety and utility of curative gastrectomy, as well as the efficacy of laparoscopic gastrectomy, for these elderly patients. Methods: We retrospectively analyzed the surgical outcomes of patients with cStage IB-III AGC who underwent distal gastrectomy (DG) with D2 lymph node dissection in our institution. We compared the results between elderly patients (.75 years) and non-elderly patients (,75 years). We further divided the elderly patients into 2 groups: Those who underwent laparoscopic DG (LDG) and those who underwent open DG (ODG). Further, we compared the results of the 2 groups. Results: From January 2014 to March 2019, 84 patients underwent DG with D2 lymph node dissection for cStage IB-III AGC (52 elderly patients and 32 non-elderly patients). ASA was significantly higher in elderly patients; however, there was no significant difference in surgical outcomes nor in overall survival (OS) and recurrence-free survival (RFS) between the 2 groups. Among 52 elderly patients, 19 had LDG, whereas 33 had ODG. The LDG group had a significantly shorter length of hospital stay and a significantly less amount of blood loss. There was no significant difference in RFS and OS between these 2 groups. Conclusions: Safety and oncologic curability may be achieved in elderly patients with AGC. LDG may be safely performed as ODG in elderly patients with AGC and it is expected to benefit them by achieving minimally invasive surgery.

Objective:The aim of this study was to describe laparoscopic anatomical parenchymal sparing liver resections for hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) and report the short-term outcomes.Background:Anatomical resections (ARs) have better oncological outcomes compared to partial resections in patients with HCC, and some suggest should be performed also for CRLM as micrometastasis occurs through the intrahepatic structures. Furthermore, remnant liver ischemia after partial resections has been associated with worse oncological outcomes. Few experiences on laparoscopic anatomical resections have been reported and no data on limited AR exist.Methods:We performed a retrospective analysis of 86 patients undergoing full laparoscopic anatomical parenchymal sparing resections with preoperative surgical simulation and standardized procedures.Results:A total of 55 patients had HCC, whereas 31 had CRLM with a median of 1 lesion and a size of 30mm. During preoperative three-dimensional (3D) simulation, a median resection volume of 120 mL was planned. Sixteen anatomical subsegmentectomies, 56 segmentectomies, and 14 sectionectomies were performed. Concordance between preoperative 3D simulation and intraoperative resection was 98.7%. Two patients were converted, and 7 patients experienced complications. Subsegmentectomies had comparable blood loss (166mL, P = 0.59), but longer operative time (426min, P = 0.01) than segmentectomies (blood loss 222 mL; operative time 355min) and sectionectomies (blood loss 120 mL; operative time 295min). R0 resection and margin width remained comparable among groups.Conclusions:A precise preoperative planning and a standardized surgical technique allow to pursue the oncological quality of AR enhancing the safety of the parenchyma sparing principle, reducing surgical stress through a laparoscopic approach.

Introduction. The changes occurring in the liver in cases of outflow deprivation have rarely been investigated, and no measurements of this phenomenon are available. This investigation explored outflow occlusion in a pig model using a hyperspectral camera. Methods. Six pigs were enrolled. The right hepatic vein was clamped for 30 min. The oxygen saturation (StO2%), deoxygenated hemoglobin level (de-Hb), near-infrared perfusion (NIR), and total hemoglobin index (THI) were investigated at different time points in four perfused lobes using a hyperspectral camera measuring light absorbance between 500 nm and 995 nm. Differences among lobes at different time points were estimated by mixed-effect linear regression. Results. StO2% decreased over time in the right lateral lobe (RLL, totally occluded) when compared to the left lateral (LLL, outflow preserved) and the right medial (RML, partially occluded) lobes (p < 0.05). De-Hb significantly increased after clamping in RLL when compared to RML and LLL (p < 0.05). RML was further analyzed considering the right portion (totally occluded) and the left portion of the lobe (with an autonomous draining vein). StO2% decreased and de-Hb increased more smoothly when compared to the totally occluded RLL (p < 0.05). Conclusions. The variations of StO2% and deoxy-Hb could be considered good markers of venous liver congestion.

Background: Laparoscopic liver resection has been increasingly utilized due to its less invasiveness approach compared with open surgery,1–3 but often creates challenges. Hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT) portends a poorer prognosis and often precludes patients from potential liver resection.4–6 We herein report a case of laparoscopic hepatectomy and thrombectomy in a patient with HCC and BDTT. Methods: CT, ERCP, and POCS showed a 40-mm tumor located in the right lobe with BDTT. A five 12-mm trocar was inserted at the umbilicus for laparoscope, the epigastrium, both sides of the hypochondrium, and right lateral region. Moreover, a 5-mm trocar was inserted at left hypochondrium. After cholecystectomy, hepatoduodenal ligament was encircled using the tourniquet through 5-mm trocar site. The right portal vein was transected by stapler following transection of the right hepatic artery. After ICG staining (0.5 mg/body i.v.),7 hepatic parenchymal transection was performed using clamp-crashing technique. Moreover, CUSA also was used near Glissonian sheath. BDTT was removed from the right BD. Moreover, the cholangioscopy confirmed no BDTT remnants. The resection stump was then sutured. Finally, the right hepatic vein was divided with a stapler. A drainage tube was placed in the right subphrenic space. Operation time was 496 min, and blood loss was 91 ml. The patient was discharged without complications on postoperative day 11. Pathological diagnosis showed moderately differentiated HCC, tumor size 40 × 45 mm with negative surgical margins. Conclusions: Pure laparoscopic resection for HCC with BDTT is a radical, yet feasible procedure.