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Background The incidence of hepatocellular carcinoma (HCC) is increasing in the western world over the past decades. As liver resection (LR) represents one of the most efficient treatment options, advantages of anatomic (ALR) versus non‐anatomic liver resection (NALR) show a lack of consistent evidence. Therefore, the aim of this study was to investigate complications and survival rates after both resection types. Methods This is a multicentre cohort study using retrospectively and prospectively collected data. We included all patients undergoing LR for HCC between 2009 and 2020 from three specialised centres in Switzerland and Germany. Complication and survival rates after ALR versus NALR were analysed using uni‐ and multivariate Cox regression models. Results Two hundred and ninety‐eight patients were included. Median follow‐up time was 52.76 months. 164/298 patients (55%) underwent ALR. Significantly more patients with cirrhosis received NALR (n = 94/134; p < 0.001). Complications according to the Clavien Dindo classification were significantly more frequent in the NALR group (p < 0.001). Liver failure occurred in 13% after ALR versus 8% after NALR (p < 0.215). Uni‐ and multivariate cox regression models showed no significant differences between the groups for recurrence free survival (RFS) and overall survival (OS). Furthermore, cirrhosis had no significant impact on OS and RFS. Conclusion No significant differences on RFS and OS rates could be observed. Post‐operative complications were significantly less frequent in the ALR group while liver specific complications were comparable between both groups. Subgroup analysis showed no significant influence of cirrhosis on the post‐operative outcome of these patients. Investigation of Anatomic (ALR) versus non‐anatomic liver resection for hepatocellular carcinoma showed no significant differences on recurrence free survival and overall survival rates. Post‐operative complications were significantly less frequent in the ALR group while liver specific complications were comparable between both groups. Subgroup analysis showed no significant influence of cirrhosis on the post‐operative outcome of these patients.

Laparoscopic ventral and dorsal segmentectomies 8 are an option for parenchymal-sparing liver resection. However, laparoscopic anatomic posterosuperior liver segment resection is technically demanding because of its deep location and the many variations in the segment 8 Glissonean pedicle (G8). In this study, we describe a hepatic vein-guided approach (HVGA) to overcome these limitations. For ventral segmentectomy 8, liver parenchymal transection was initiated at the ventral side of the middle hepatic vein (MHV) and continued exposing it toward the periphery. The G8 ventral branch (G8vent) was identified on the right side of the MHV. Following G8vent dissection, liver parenchymal transection was completed by connecting the demarcation line and G8vent stump. For dorsal segmentectomy 8, the anterior fissure vein (AFV) was exposed peripherally. The G8 dorsal branch (G8dor) was identified on the right side of the AFV. Following G8dor dissection, the right hepatic vein (RHV) was exposed from the root. Liver parenchymal transection was completed by connecting the demarcation line and RHV. Between April 2016 and December 2022, we performed laparoscopic ventral and dorsal segmentectomy 8 in fourteen patients. No complications (Clavien–Dindo classification, Grade ≥ IIIa) were observed. An HVGA is feasible and useful for standardizing safe laparoscopic ventral and dorsal segmentectomies 8.

Background: Inflow control is one of the most important procedures during anatomical liver resection (ALR), and Glissonean pedicle isolation (GPI) is one of the most efficacious methods used in laparoscopic anatomical liver resection (LALR). Recognition of the Laennec’s capsule covering the liver parenchyma is essential for safe and precise GPI. The purpose of this study was to verify identification of the Laennec’s capsule, to confirm the validity of GPI in minimally invasive surgery, and to demonstrate the value of GPI focusing on the Laennec’s capsule using a robotic system that has been developed in recent years. Methods: We used a cadaveric model to simulate the Glissonean pedicle and the surrounding liver parenchyma for pathologic verification of the layers. We performed 60 LALRs and 39 robotic anatomical liver resections (RALRs) using an extrahepatic Glissonean approach, from April 2020 to April 2023, and verified the layers of the specimens removed during LALR and RALR based on pathologic examination. In addition, the surgical outcomes of LALR and RALR were compared. Results: Histologic examination facilitated by Elastica van Gieson staining revealed the presence of Laennec’s capsule covering the liver parenchyma in a cadaveric model. Similar findings were obtained following LALR and RALR, thus confirming that the gap between the Glissonean pedicle and the Laennec’s capsule can be dissected without injury to the parenchyma. The mean GPI time was 32.9 and 27.2 min in LALR and RALR, respectively. The mean blood loss was 289.7 and 131.6 mL in LALR and RALR, respectively. There was no significant difference in the incidence of Clavien–Dindo grade ≥III complications between the two groups. Conclusions: Laennec’s capsule is the most important anatomical landmark in performing a safe and successful extrahepatic GPI. Based on this concept, it is possible for LALR and RALR to develop GPI focusing on the Laennec’s capsule. Furthermore, a robotic system has the potential to increase the safety and decrease the difficulty of this challenging procedure.

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.

Background： Laparoscopic liver resection （LLR） has been considered to be safe and feasible. However, few studies focused on the comparison between the anatomic and nonanatomic LLR. Therefore, the purpose of this study was to compare the perioperative factors and outcomes of the anatomic and nonanatomic LLR, especially the area of liver parenchymal transection and blood loss per unit area. Methods： In this study, surgical and oncological data of patients underwent pure LLR procedures for malignant liver tumor were prospectively collected. Blood loss per unit area of liver parenchymal transection was measured and considered as an important parameter. All procedures were conducted by a single surgeon. Results： During nearly 5 years, 84 patients with malignant liver tumor received a pure LLR procedure were included. Among them, 34 patients received anatomic LLR and 50 received nonanatomic LLR, respectively. Patients of the two groups were similar in terms of demographic features and tumor characteristics, despite the tumor size was significantly larger in the anatomic LLR group than that in the nonanatomic LLR group （4.77 ± 2.57 vs. 2.87 ± 2.10 cm, P = 0.001）. Patients who underwent anatomic resection had longer operation time （364.09 ± 131.22 vs. 252.00±135.21 min, P 〈 0.001） but less blood loss per unit area （7.85 ± 7.17 vs. 14.17 ± 10.43 ml/cm2, P = 0.018）. Nonanatomic LLR was associated with more blood loss when the area of parenchymal transection was equal to the anatomic LLR. No mortality occurred during the hospital stay and 30 days alter the operation. Moreover, there was no difference in the incidence of postoperative complications. The disease-free and overall survival rates showed no significant differences between the anatomic LLR and nonanatomic LLR groups. Conclusions： Both anatomic and nonanatomic pure LLR are safe and feasible. Measuring the area of parenchymal transection is a simple and effective method to estimate the outcomes of the liver resection surgery＇. Blood loss per unit area is an important parameter which is comparable between the anatomic LLR and nonanatomic LLR groups.

Surgical techniques and outcomes of minimally invasive anatomic liver resection (AR) using the extrahepatic Glissonian approach for hepatocellular carcinoma (HCC) are undefined. In 327 HCC cases undergoing 185 open (OAR) and 142 minimally invasive (MIAR; 102 laparoscopic and 40 robotic) ARs, perioperative and long-term outcomes were compared between the approaches, using propensity score matching. After matching (91:91), compared to OAR, MIAR was significantly associated with longer operative time (643 vs. 579 min, p = 0.028); less blood loss (274 vs. 955 g, p < 0.0001); a lower transfusion rate (17.6% vs. 47.3%, p < 0.0001); lower rates of major 90-day morbidity (4.4% vs. 20.9%, p = 0.0008), bile leak or collection (1.1% vs. 11.0%, p = 0.005), and 90-day mortality (0% vs. 4.4%, p = 0.043); and shorter hospital stay (15 vs. 29 days, p < 0.0001). On the other hand, laparoscopic and robotic AR cohorts after matching (31:31) had comparable perioperative outcomes. Overall and recurrence-free survivals after AR for newly developed HCC were comparable between OAR and MIAR, with potentially improved survivals in MIAR. The survivals were comparable between laparoscopic and robotic AR. MIAR was technically standardized using the extrahepatic Glissonian approach. MIAR was safe, feasible, and oncologically acceptable and would be the first choice of AR in selected HCC patients.

BackgroundAnatomic liver resection (ALR) has been established to eliminate the tumor-bearing hepatic region with preservation of the remnant liver volume for liver malignancies. Recently, laparoscopic ALR has been widely applied; however, there are few reports on laparoscopic segmentectomy 2. This study aimed to present the standardization of laparoscopic segmentectomy 2 with surgical outcomes.MethodsThis study included seven patients who underwent pure laparoscopic segmentectomy 2 by the Glissonean approach from January 2020 to December 2021. Four of them had hepatocellular carcinoma, two had colorectal liver metastasis, and one had hepatic angiomyolipoma, which was preoperatively diagnosed with hepatocellular carcinoma. In all patients, preoperative three-dimensional (3D) simulation images from dynamic CT were reconstructed using a 3D workstation. The layer between the hepatic parenchyma and the Glissonean pedicle of segment 2 (G2) was dissected to encircle the root of G2. After clamping or ligation of the G2, 2.5 mg of indocyanine green was injected intravenously to identify the boundaries between segments 2 and 3 with a negative staining method under near-infrared light. Parenchymal transection was performed from the caudal side to the cranial side according to the demarcation on the liver surface, and the left hepatic vein was exposed on the cut surface if possible.ResultsThe mean operative time for all patients was 281 min. The mean blood loss was 37 mL, and no transfusion was necessary. Estimated liver resection volumes significantly correlated with actual liver resection volumes (r = 0.61, P = 0.035). After the operation, one patient presented with asymptomatic deep venous and pulmonary thrombosis, which was treated with anticoagulant therapy. The mean length of hospital stay was 8.9 days.ConclusionLaparoscopic segmentectomy 2 by the Glissonean approach is a feasible and safe procedure with the preservation of the nontumor-bearing segment 3 for liver tumors in segment 2.

Aim Minimally invasive anatomic liver resection (AR) is technically demanding, and the efficacy of robotic surgery in AR remains unestablished. This systematic review aims through a meta‐analysis to compare surgical outcomes between robotic (RAR) and conventional laparoscopic (LAR) AR. Methods A systematic literature search of relevant studies published between 2001 and 2024 in PubMed/MEDLINE, Embase and Cochrane Library was carried out, and 15 studies were selected. Meta‐analysis was performed to compare perioperative outcomes between RAR and LAR. Results A total of 4171 patients comprising 2042 RAR and 2129 LAR patients who underwent major hepatectomy or liver parenchyma‐sparing AR (PSAR) were included. All included studies were retrospective comparative studies, including eight using propensity score‐matched analysis. Meta‐analysis demonstrated that as primary outcomes, the 30‐day and 90‐day mortalities and postoperative overall morbidity were comparable between RAR and LAR, while RAR had significantly less morbidity≥Clavien‐Dindo grade II and a lower rate of open conversion. As secondary outcomes, compared to LAR, RAR showed significantly less blood loss and shorter postoperative hospital stay, while RAR had a higher rate of postoperative 30‐day readmission. Operative time, blood transfusion, Pringle maneuver, R0 resection, and reoperation were comparable. Subgroup meta‐analyses showed a lower rate of blood transfusion in robotic PSAR and a lower rate of open conversion in RAR in the right cranial regions. Conclusion This large‐scale meta‐analysis of minimally invasive AR suggests that RAR can confer comparable or partly better perioperative outcomes as compared to LAR, indicating potential advantages of the robotic approach to AR. Minimally invasive anatomic liver resection (AR) including major hepatectomy and liver parenchyma‐sparing AR is technically complex and demanding. This systematic review with meta‐analysis including 15 studies comparing 2042 robotic AR and 2129 laparoscopic AR patients demonstrated largely comparable perioperative outcomes and partly better outcomes including significantly less major postoperative morbidity, a lower rate of open conversion, less blood loss, and shorter postoperative hospital stay in robotic AR. These results suggest potential perioperative advantages conferred by robotic surgery over laparoscopic surgery for this type of complex liver resection.

PurposeAnatomic isolated liver segmentectomy 8 (ILSeg8) for malignancies remains technically challenging. The feasibility, safety, and oncologic validity of laparoscopic ILSeg8 are undefined, and thus were evaluated in comparison with the open approach.MethodsThis study enrolled 35 open and 29 laparoscopic ILSeg8 cases of hepatocellular carcinoma (n = 47), metastatic liver tumors (n = 16), and intrahepatic cholangiocarcinoma (n = 1) at our institution. The surgical techniques were based on the pre-hepatectomy extrahepatic Glissonian pedicle control, followed by cranial-to-caudal parenchymal dissection from the hepatic vein root side. The short- and long-term outcomes after ILSeg8 were retrospectively evaluated and compared between the open and laparoscopic approaches using 1:1 propensity score matching (PSM).ResultsBoth before and after PSM, the laparoscopic ILSeg8 group had significantly less blood loss, lower postoperative serum bilirubin level, and a shorter postoperative hospital stay than the open group. The overall survival rates were comparable between the laparoscopic and open groups before (P = 0.017) and after (P = 0.043) PSM, with the similar recurrence-free survival rates between the groups. In a multivariable analysis of the cohort before PSM (n = 64), the laparoscopic approach was identified to be an independent factor for favorable overall survival (hazard ratio = 0.20, P = 0.039).ConclusionLaparoscopic ILSeg8 using the extrahepatic Glissonian approach and hepatic vein root at first parenchymal dissection was feasible, safe, and oncologically acceptable. In ILSeg8 for malignancy, the laparoscopic approach potentially confers short-term advantages over the open approach with comparable long-term outcomes in select patients.