Laparoscopic liver resection: Toward a truly minimally invasive approach

In the surgical treatment of hepatocellular carcinoma and colorectal liver metastasis, it is important to preserve sufficient liver volume after resection in order to avoid post-hepatectomy liver sufficiency and to increase the feasibility of repeated hepatectomyin case of intrahepatic recurrence. Parenchymasparing approach, which minimizes the extent of resection while obtaining sufficient surgical margins, has been developed in open hepatectomy. Although this approach can possibly have positive impacts on morbidity and mortality, it is not popular in laparoscopic approach because parenchyma-sparing resection is technically demanding especially by laparoscopy due to its intricate curved transection planes. "Small incision, big resection" is the words to caution laparoscopic surgeons against an easygoing trend to seek for a superficial minimal-invasiveness rather than substantial patient-benefits. Minimal parenchyma excision is often more important than minimal incision. Recently, several reports have shown that technical evolution and accumulation of experience allow surgeons to overcome the hurdle in laparoscopic parenchymasparing resection of difficult-to-access liver lesions in posterosuperior segments, paracaval portion, and central liver. Laparoscopic surgeons should now seek for the possibility of laparoscopic parenchyma-sparing hepatectomy as open approach can, which we believe is beneficial for patients rather than just a small incision and lead laparoscopic hepatectomy toward a truly minimally-invasive approach.

Current status of laparoscopic repeat liver resection for recurrent hepatocellular carcinoma

Repeat liver resection(RLR)is an effective treatment approach for recurrent hepatocellular carcinoma(HCC)and can provide acceptable long-term outcomes in select patients.Recent randomized controlled trials comparing RLR with radiofrequency ablation revealed that the latter approach was associated with a higher rate of early recurrence compared with RLR.With recent advances in laparoscopic liver resection(LLR),RLR has been increasingly performed using laparoscopy.Several propensity score-matched studies reported that laparoscopic RLR achieved lower blood loss and shorter hospital stays compared to open RLR.However,laparoscopic RLR requires more advanced techniques because of adhesions formed after the previous liver resection,changes in anatomical landmarks,and deformity of the remnant liver.The recently described difficulty classification of laparoscopic RLR is based on five factors including type of previous liver resection(open or laparoscopic),number of previous liver resections,surgical procedure used in previous liver resections,tumor location in previous liver resections,and difficulty score of LLR for recurrent HCC.We reviewed the available literature to summarize available evidence suggesting that laparoscopic RLR might be considered a more minimally invasive surgical treatment approach for recurrent HCC as long as the indication for laparoscopic RLR is carefully determined.