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BackgroundLimited studies have reported the actual learning process of laparoscopic liver resection (LLR). This study aimed to chronologically evaluate our 15 years’ experience of LLR.MethodsAll consecutive LLRs between 2006 to 2020 were retrospectively analyzed. The time period was divided into three groups; first (2006–2010), second (2011–2015), and third (2016–2020) period. The primary endpoint of this study was a composite of overall (Clavien–Dindo grade ≥ II) or major (grade ≥ IIIa) postoperative complications within 30 days. Using the IWATE criteria (four difficulty levels based on six indices), LLR was categorized as basic (< 7 points) and advanced (≥ 7 points) one. All analyses were performed based on the intention-to-treat principles.ResultsDuring the study period, a total of 382 LLRs were gradually performed (first period, n = 54; second period, n = 114, and third period, n = 214). Low incidences of overall and major complications were maintained (9.3, 10.5, and 7.0%, p = 0.514, and 1.9, 2.6, and 2.3%, p = 1.000). Meanwhile, pure LLRs (i.e., LLRs without hand-assisted or hybrid approach) and advanced LLRs were increasingly performed in 25 (46.3%), 71 (62.3%), and 205 (95.8%) patients (p < 0.001) and 3 (5.6%), 18 (15.8%), and 58 (27.1%) patients (p < 0.001), respectively.ConclusionsThis study suggests that stepwise approach from basic to advanced procedures and use of hand-assisted or hybrid approach during the early phases for starting LLR practice may allow for maintaining low morbidity in specialized center.

BackgroundHepatopancreatoduodenectomy (HPD) is often indicated in the resection of cholangiocarcinoma but is associated with high mortality.1–3 From a risk–benefit perspective, HPD can be justified only when curative resection is achievable.4–6MethodsA liver transection-first approach is a surgical technique in which liver transection precedes pancreatoduodenectomy (PD) and skeletonization of the hepatoduodenal ligament in HPD. This approach enables an early assessment of resectability and curability.ResultsA 64-year-old with jaundice had a tumor located mainly in the proximal bile duct, spreading from the confluence of hepatic ducts (dominant in the left hepatic duct) to the intrapancreatic bile duct. The right hepatic artery and portal vein existed in close proximity to the tumor. HPD (left hemi-hepatectomy and subtotal stomach-preserving PD) with vascular resection was performed. After liver transection along the Cantlie line, the right Glissonean pedicle was collectively secured inside the liver. The right hepatic artery, right portal vein, and right hepatic duct (RHD) were isolated, and the feasibility of vascular reconstruction was confirmed. After the RHD was divided and the negative margin was confirmed, we proceeded to perform PD. The portal vein was reconstructed between the right portal vein and the portal vein trunk. The right hepatic artery was anastomosed to the second jejunal artery of the jejunal loop with the right gastroepiploic artery as an interposition graft.ConclusionThe liver transection-first technique in HPD facilitates early assessment of curability and resectability as well as a safe and secure manipulation and reconstruction of the hepatic artery and portal vein.

Backgrounds In the era of multidisciplinary treatment strategy, resectability for hepatocellular carcinoma (HCC) should be defined. This study aimed to propose and validate a resectability classification of HCC. Methods We proposed following the three groups; resectable-(R), borderline resectable-(BR), and unresectable (UR)-HCCs. Resectable two groups were sub-divided according to the value of indocyanine green clearance of remnant liver (ICG-Krem) and presence of macrovascular invasion (MVI); BR-HCC was defined as resectable HCCs with MVI and/or ICG-Krem≥0.03–<0.05, and R-HCC was the remaining. Consecutive patients with HCC who underwent liver resection (LR) and non-surgical treatment(s) (i.e., UR-HCC) between 2011 and 2017 were retrospectively analyzed to validate the proposed classification. Results A total of 361 patients were enrolled in the study. Of these, R-, BR- and UR-HCC were found in 251, 46, and 64 patients, respectively. In patients with resected HCC, ICG-Krem≥0.05 was associated with decreased risk of clinically relevant posthepatectomy liver failure ( p =0.013) and the presence of MVI was associated with worse overall survival (OS) ( p <0.001). The 3–5-years OS rates according to the proposed classification were 80.3, and 68.3% versus 51.4, and 35.6%, in the R and BR groups, respectively (both p <0.001). Multivariate analysis showed BR-HCC was independently associated with poorer OS ( p <0.001) after adjusting for known tumor prognostic factors. Meanwhile, BR-HCC was associated with benefit in terms of OS compared with UR-HCC ( p <0.001). Conclusion Our proposal of resectability for HCC allows for stratifying survival outcomes of HCC and may help to determine treatment strategy.

Background In laparoscopic anatomic liver resection, an increasingly common procedure, the hepatic vein-guided approach is widely used although the hepatic vein tributaries can be a major source of bleeding in the event of inadvertent injury. This report describes the anatomy of the middle hepatic vein (MHV) including its tributaries based on reconstructed three-dimensional computed tomography images and provides anatomic data to enable safe middle hepatic vein-guided liver resection. Methods Following simulation modeling of the hepatic vasculatures, reconstructed MHV data was pooled from 35 healthy liver donors. Yields of the MHV tributaries were analyzed to enable MHV-guided liver resection. Results A total of 252 tributaries were identified in the 35 donors. The MHV yielded fewer tributaries from its anterior and posterior aspects than from its right-side and left-side aspects (40 [15.9%], 13 [5.2%], 93 [36.9%], and 106 [42.1%], respectively). The MHV tributaries from the anterior and posterior aspects were smaller in diameter than those from the right-side and left-side aspects (median, 3.0, 2.0, 4.8, and 4.0 mm, respectively). Discussion Our simulation revealed that MHV dissection from the anterior or posterior aspect poses a lower risk of injury to the MHV tributaries compared to dissection from either lateral aspect. In addition, MHV dissection from the anterior or posterior aspect allows for safer identification and isolation of the thick MHV tributaries originating from the lateral aspects. Ideally, the anterior or posterior aspect of the MHV should be accessed and exposed before the lateral aspects are dissected to minimize the risk of MHV tributary injury.

Background This study aimed to assess an oncologic setting where patients with hepatocellular carcinoma (HCC) could benefit from liver resection (LR) compared to living donor liver transplantation (LDLT) using 18 F-fluorodeoxyglucose (FDG) positron emission tomography. Methods The consecutive data of patients with HCC who underwent 18 F-FDG PET before LR (LR group, n  = 314) and LDLT (LDLT group, n  = 65) between 2003 and 2015 were retrospectively analyzed. Tumor 18 F-FDG avidity was quantified as the tumor to liver standardized uptake value ratio (TLR, cut-off value was defined at 2). Multivariate analysis was performed to assess significant preoperative tumor factors in the LR group. Survival outcomes between the two groups were stratified by these factors. Results The 5-year overall survival (OS: 56.9% vs. 73.8%, LR vs. LDLT,  p  < 0.001) and recurrence-free survival rate (RFS: 27.4% vs. 70.7%,  p  < 0.001) were significantly better in the LDLT group compared to the LR group. In the LR study, multivariate analysis identified TLR and tumor multiplicity as significant preoperative tumor factors for OS. In patients with solitary and TLR < 2 HCC, the 5-year OS rate was not significantly different between the LR and LDLT groups (70.3% vs. 71.8%,  p  = 0.352); meanwhile, RFS rate was better in the LDLT group (34.3% vs. 71.8%,  p  = 0.001). Conclusions LDLT is associated with better long-term outcomes than LR in patients with HCC; however, selected patients with solitary and TLR < 2 HCC may benefit from LR.