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Cancer Biol Med ; Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Laparoscopic excision of benign liver lesions. Obstet Gynecol ; Laparoscopic partial hepatectomy and left lateral segmentectomy: technique and results of a clinical series. Surgery ; Laparoscopic liver resection of hepatocellular carcinoma. Am J Surg ; World Consensus Conference on Laparoscopic Surgery. The international position on laparoscopic liver surgery: The Louisville Statement, Laparoscopic liver resection for subcapsular hepatocellular carcinoma complicating chronic liver disease.
Arch Surg ; Laparoscopic versus open liver resection for hepatocellular carcinoma in patients with histologically proven cirrhosis: short- and middle-term results. Surg Endosc ; Pure laparoscopic hepatectomy for hepatocellular carcinoma patients with severe liver cirrhosis.
Asian J Endosc Surg ; Impact of laparoscopic liver resection for hepatocellular carcinoma with F4-liver cirrhosis. Can we expand the indications for laparoscopic liver resection?
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A systematic review and meta-analysis of laparoscopic liver resection for patients with hepatocellular carcinoma and chronic liver disease. Neither multiple tumors nor portal hypertension are surgical contraindications for hepatocellular carcinoma. Gastroenterology ; Prognosis of hepatocellular carcinoma: the BCLC staging classification. Semin Liver Dis ; Management of hepatocellular carcinoma: an update. Hepatology ; Surgery for small liver cancers. Semin Surg Oncol ; Current management of hepatocellular carcinoma: an Eastern perspective.
Outcomes of hepatopancreatic robotic surgery: Update from the literature - Hepatic surgery.
World J Gastroenterol ; A prediction scoring system to select the surgical treatment of liver cancer. Further refinement based on 10 years of use. Radiofrequency ablation of hepatocellular cancer in patients with cirrhosis. Increased risk of tumor seeding after percutaneous radiofrequency ablation for single hepatocellular carcinoma. Radiofrequency ablation for hepatocellular carcinoma in socalled high-risk locations. Usefulness of ICG fluorescence imaging in laparoscopic liver resection. Tokyo: Springer Japan; A novel difficulty scoring system for laparoscopic liver resection.
Paraumbilical venous collateral circulations: color Doppler ultrasound features. J Clin Ultrasound ; Hepatic and portal vein blood flow during carbon dioxide pneumoperitoneum forlaparoscopic hepatectomy. Carbon dioxide and argon gas embolism during laparoscopic hepatic resection. Acta Anaesthesiol Scand ; Gas embolism in laparoscopic hepatectomy: what is the optimal pneumoperitoneal pressure for laparoscopic major hepatectomy? Hepatic resection using stapling devices. Laparoscopic hepatectomy for liver tumors: proposals for standardization. J Hepatobiliary Pancreat Surg ; Robotic versus laparoscopic hepatectomy: a matched comparison.
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Robotic versus laparoscopic resections of posterosuperior segments of the liver: a propensity score-matched comparison. Intention-to-treat analysis of surgical treatment for early hepatocellular carcinoma: resection versus transplantation. The adverse effect of indirectly diagnosed portal hypertension on the complications and prognosis after hepatic resection of hepatocellular carcinoma. Korean J Hepatol ; Predictive factors for long-term survival in patients with clinically significant portal hypertension following resection of hepatocellular carcinoma.
Liver Int ; Portal hypertension: contraindication to liver surgery? World J Surg ; Is portal hypertension a contraindication to hepatic resection? Laparoscopic versus open hepatic resections for benign and malignant neoplasms: a meta-analysis. Laparoscopic vs. Laparoscopic hepatectomy: a systematic review, meta-analysis, and power analysis.
Surg Today ; Meta-analysis of laparoscopic versus open resection for hepatocellular carcinoma. Dig Dis Sci ; Short- and long-term outcomes after laparoscopic and open hepatic resection: systematic review and meta-analysis. HPB Oxford ; Meta-analysis of trials comparing minimally-invasive and open liver resections for hepatocellular carcinoma. J Surg Res ;e Surgical and oncologic outcomes following laparoscopic versus open liver resection for hepatocellular carcinoma: a meta-analysis.
Hepatol Res ; Short- and long-term outcomes after laparoscopic and open hepatectomy for hepatocellular carcinoma: a global systematic review and meta-analysis. A retrospective analysis has found a good agreement between the difficulty level assessed by the surgeon and a difficulty index based on tumor location, extent of liver resection, tumor size, proximity to major vessels, and liver function [ 25 ]. Appropriate patient selection, practicing and honing LLR skills is paramount for success [ 25 ].
LLR has been found to be significantly better compared to OLR for minor hepatectomies for short-term outcomes such as the operation time, blood loss, and post-operative hospital stay [ 27 ]. Although there are numerous case-reports and retrospective series of LLR, few well-designed randomized controlled trials RCTs and meta-analyses are currently available [ 27 - 35 ].
Meta-analyses show that LLR has clinical benefits over OLR with significant reduction in blood loss, blood transfusion, complications and hospital stay with comparable operative time and resection margin positivity. However potential biases due to low statistical power of many studies included in the meta-analyses cannot be undermined [ 28 - 35 ].
The results of these studies are summarized in Table 2. Current evidence suggests that local tumor recurrence, disease free survival and overall survival are similar between laparoscopic and open resections [ 39 - 42 ]. The results of these studies are summarized in Table 3.
Minimally Invasive Techniques and Outcomes in Hepatic Resection
Recently published meta-analysis on LLR for colorectal liver metastases CRLM concluded that LLR is a beneficial alternative to OLR in selected patients and does not compromise oncological outcomes including surgical margins, tumor recurrence, disease-free survival or 5-year overall survival, with even a possibility of better 3-year overall survival [ 40 ].
Even though this meta-analysis used propensity matching for compensating for selection bias, differences in proportions of major and minor resections and studies with low statistical power might be a potential source of bias [ 40 ]. The scope for LLR is increasing with improvements in LLR skills, availability of surgical gadgets and use of the robotic platform [ 41 ]. Robotic assistance is promising to aid difficult LLRs such as postero-superior resections, non-anatomical resections along angulated or curvilinear resection planes, those requiring complex vascular and biliary reconstructions, but these need further refinement in skills and prospective validation [ 41 ].
Even single incision laparoscopic liver resection has been reported in very suitable tumors [ 42 - 44 ]. Laparoscopic re-resection of liver tumors may be feasible even after previous OLR, up to two prior LLRs, after previous major hepatectomy, even in cirrhotic livers and postero-superiorly located tumors [ 47 ].
Recent advances in LLR also include laparoscopic living donor hepatectomy and laparoscopic associating liver partition and portal vein ligation amongst others [ 48 ].
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Laparoscopic left lateral sectionectomy and minor laparoscopic liver resection are now considered standard approaches. Major laparoscopic hepatectomy has been shown to be feasible and safe at few select experienced centers. Long-term oncologic and survival outcomes have been found to be similar to open liver resection in case-matched studies.
Although LLR has a steep learning curve, indications for it are expanding fast with advances in laparoscopic techniques and skills.
- Open, Laparoscopic and Robotic Hepatic Transection?
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LLR is a safe and effective approach to liver surgery for well selected patients in the hands of well trained surgeons with experience in hepatobilliary and laparoscopic surgery. The current scientific support in its favour is limited to case series, expert consensus recommendations, guidelines, meta-analyses with very few matched controlled studies and a single randomised controlled trial. Randomized trials and structured training will help benefit more patients with the advancement in this technique.
The international position on laparoscopic liver surgery: The Louisville Statement, Ann Surg ; Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. The Southampton consensus Guidelines for laparoscopic liver surgery. Ann surg ; Laparoscopic robot-assisted resection of tumors located in posterosuperior liver segments.