Laparoscopic liver resections for hepatocellular carcinoma:Current role and limitations

Liver resection for hepatocellular carcinoma(HCC)is currently known to be a safer procedure than it was before because of technical advances and improvement in postoperative patient management and remains the first-line treatment for HCC in compensated cirrhosis.The aim of this review is to assess current indications,advantages and limits of laparoscopic surgery for HCC resections.We also discussed the possible evolution of this surgical approach in parallel with new technologies.

Indications of pro-inflammatory cytokines in laparoscopic and open liver resection for early-stage hepatocellular carcinoma

Background:Our clinical practice of laparoscopic liver resection(LLR)had achieved better short-term and long-term benefits for patients with hepatocellular carcinoma(HCC)over open liver resection(OLR),but the underlying mechanisms are not clear.This study was to find out whether systemic inflammation plays an important role.Methods:A total of 103 patients with early-stage HCC under liver resection were enrolled(LLR group,n=53;OLR group,n=50).The expression of 9 inflammatory cytokines in patients at preoperation,postoperative day 1(POD1)and POD7 was quantified by Luminex Multiplex assay.The relationships of the cytokines and the postoperative outcomes were compared between LLR and OLR.Results:Seven of the circulating cytokines were found to be significantly upregulated on POD1 after LLR or OLR compared to their preoperative levels.Compared to OLR,the POD1 levels of granulocytemacrophage colony-stimulating factor(GM-CSF),interleukin-6(IL-6),IL-8,and monocyte chemoattractant protein-1(MCP-1)in the LLR group were significantly lower.Higher POD1 levels of these cytokines were significantly correlated with longer operative time and higher volume of blood loss during operation.The levels of these cytokines were positively associated with postoperative liver injury,and the length of hospital stay.Importantly,a high level of IL-6 at POD1 was a risk factor for HCC recurrence and poor disease-free survival after liver resection.Conclusions:Significantly lower level of GM-CSF,IL-6,IL-8,and MCP-1 after liver resection represented a milder systemic inflammation which might be an important mechanism to offer better short-term and long-term outcomes in LLR over OLR.

Development of a novel difficulty scoring system for laparoscopic liver resection procedure in patients with intrahepatic duct stones

BACKGROUND For intrahepatic duct(IHD)stones,laparoscopic liver resection(LLR)is currently a reliable treatment.However,the current LLR difficulty scoring system(DSS)is only available for patients with hepatocellular carcinoma.AIM To explore the development of a DSS for IHD stone patients with LLR and the validation of its reliability.METHODS We used clinical data from 80 patients who received LLR for IHD stones.Forty-six of these patients were used in multiple linear regression to construct a scoring system.Another 34 patients from different centers were used as external validation.The completeness of our DSS was then evaluated in patients with varying degrees of surgical difficulty based on documented surgical outcomes in the study group of patients.RESULTS The following five predictors were ultimately included and scored by calculating the weighted contribution of each factor to the prediction of operative time in the training cohort:Location of stones,number of stones≥3,stones located in the bile ducts of several grades,previous biliary surgery less than twice,distal bile duct atrophy.Subsequently,the data set was validated using a DSS developed from the variables.The following variables were identified as statistically significant in external validation:Operative time,blood loss,intraoperative transfusion,postoperative alanine aminotransferase,and Clavien-Dindo grading≥3.These variables demonstrated statistically significant differences in patients with three or more grades.CONCLUSION Patients with IHD stones have varying degrees of surgical difficulty,and the newly developed DSS can be validated with external data to effectively predict risks and complications after LLR surgery.

Laparoscopic liver resection for hepatocellular carcinoma complicated with significant portal hypertension:A propensity score-matched survival analysis

Background: Significant portal hypertension(SPH) is a relative contraindication for patients with resectable hepatocellular carcinoma(HCC). However, increasing evidence indicates that liver resection is feasible for HCC patients with SPH. Methods: HCC patients with cirrhosis who underwent laparoscopic liver resection(LLR) in two centers from January 2013 to April 2018 were included. Surgical and survival outcomes were analyzed to explore potential prognostic factors. Propensity score matching(PSM) analysis was performed to minimize bias. Results: A total of 165 patients were divided into two groups based on the presence(SPH, n = 76) or absence(non-SPH, n = 89) of SPH. Patients in the SPH group had longer operative time, more blood loss, and more advanced TNM stage than patients in the non-SPH group( P < 0.05). However, there were no significant differences in the postoperative 90-day mortality rate( n = 0), overall postoperative complications(47.4% vs. 41.6%, P = 0.455), Clavien-Dindo classification( P = 0.347), conversion to open surgery(9.2% vs. 6.7%, P = 0.557), or length of hospitalization(16 vs. 15 days, P = 0.203) between the SPH and non-SPH groups before PSM. Similar results were obtained after PSM. The 1-, 3-, and 5-year overall survival(OS) and recurrence-free survival rates in the SPH group were not significantly different from those in the non-SPH group both before and after PSM(log-rank P > 0.05). After PSM, alpha-fetoprotein(AFP) ≥ 400 μg/L [hazard ratio(HR) = 4.71, 95% confidence interval(CI): 2.69-8.25], ascites(HR = 2.18, 95% CI: 1.30-3.66), American Society of Anesthesiologists(ASA) classification(Ⅲ vs. Ⅱ)(HR = 2.13, 95% CI: 1.11-4.07) and tumor diameter > 5 cm(HR = 3.91, 95% CI: 2.02-7.56) independently predicted worse OS. Conclusions: LLR for patients with HCC complicated with SPH appears feasible at the price of increasing operative time and blood loss. AFP, ascites, ASA classification and tumor diameter may predict the prognosis of HCC complicated with SPH after LLR.

Single incision laparoscopic surgery for hepatocellular carcinoma

Single incision laparoscopic liver resection(SILLR)is the most recent develop-ment in the laparoscopic approach to the liver.SILLR for hepatocellular carci-noma(HCC)has developed much more slowly than multiport LLR.So far,195 patients completed SILLR for HCC.In this paper,we reviewed all published papers about SILLR for HCC and discussed the feasibility of the SILLR,peri and postoperative findings,tricks of patient selection and whether SILLR compromise the oncological principles.

Laparoscopic liver resection for malignancy:A review of the literature

AIM: To review the published literature about laparoscopic liver resection for malignancy.

Laparoscopic liver resection under hemihepatic vascular inflow occlusion using the lowering of hilar plate approach

BACKGROUND： With advances in technology, laparoscopic liver resection is widely accepted. Laparoscopic liver resection under hemihepatic vascular inflow occlusion has advantages over the conventional total hepatic inflow occlusion using the Pringle＇s maneuver, especially in patients with cirrhosis.METHOD： From November 2011 to August 2012, eight consecutive patients underwent laparoscopic liver resection under hemihepatic vascular inflow occlusion using the lowering of hilar plate approach with biliary bougie assistance.RESULTS： The types of liver resection included right hepatectomy（n1）, right posterior sectionectomy（n1）, left hepatectomy and common bile duct exploration（n1）, segment 4b resection（n1）, left lateral sectionectomy（n2）, and wedge resection（n2）. Four patients underwent right and 4 left hemihepatic vascular inflow occlusion. Four patients had cirrhosis. The mean operation time was 176.3 minutes. The mean time taken to achieve hemihepatic vascular inflow occlusion was 24.3minutes. The mean duration of vascular inflow occlusion was54.5 minutes. The mean intraoperative blood loss was 361 mL.No patient required blood transfusion. Postoperatively, one patient developed bile leak which healed with conservative treatment. No postoperative liver failure and mortality occurred. The mean hospital stay of the patients was 7 days.CONCLUSION： Our technique of hemihepatic vascular inflow vascular occlusion using the lowering of hilar plate approachwas safe, and it improved laparoscopic liver resection by minimizing blood loss during liver parenchymal transection.

Impact of laparoscopic liver resection on bleeding complications in patients receiving antithrombotics

To assess the impact of laparoscopic liver resection (LLR) on surgical blood loss (SBL), especially in patients with antithrombotics for thromboembolic risks. METHODSConsecutive 258 patients receiving liver resection at our institution between 2010 and 2016 were retrospectively reviewed. Preoperative antithrombotic therapy (ATT; antiplatelets and/or anticoagulation) was regularly used in 100 patients (ATT group, 38.8%) whereas not used in 158 (non-ATT group, 61.2%). Our perioperative management of high thromboembolic risk patients included maintenance of preoperative aspirin monotherapy for patients with antiplatelet therapy and bridging heparin for patients with anticoagulation. In both ATT and non-ATT groups, outcome variables of patients undergoing LLR were compared with those of patients receiving open liver resection (OLR), and the independent risk factors for increased SBL were determined by multivariate analysis. RESULTSThis series included 77 LLR and 181 OLR. There were 3 thromboembolic events (1.2%) in a whole cohort, whereas increased SBL (≥ 500 mL) and postoperative bleeding complications (BCs) occurred in 66 patients (25.6%) and 8 (3.1%), respectively. Both in the ATT and non-ATT groups, LLR was significantly related to reduced SBL and low incidence of BCs, although LLR was less performed as anatomical resection. Multivariate analysis showed that anatomical liver resection was the most significant risk factor for increased SBL [risk ratio (RR) = 6.54, P < 0.001] in the whole cohort, and LLR also had the significant negative impact (RR = 1/10.0, P < 0.001). The same effects of anatomical resection (RR = 15.77, P < 0.001) and LLR (RR = 1/5.88, P = 0.019) were observed when analyzing the patients in the ATT group. CONCLUSIONLLR using the two-surgeon technique is feasible and safely performed even in the ATT-burdened patients with thromboembolic risks. Independent from the extent of liver resection, LLR is significantly associated with reduced SBL, both in the ATT and non-ATT groups.

Laparoscopic left liver lobectomy for hepatocellular carcinoma in a cirrhotic patient： a video report

We present a video case of a 51-year-old man admitted to our surgical and liver transplantation unit for hepatocellular cancer（HCC）. Patient has a HCV cirrhosis with portal hypertension and esophageal varices F1. Child Pugh score was B7 and model of end staged liver disease（MELD） was 11. Body mass index（BMI） was 26.7 and ASA score was 2. No previous abdominal surgery. According with our multidisciplinary group we suggest a laparoscopic left lobectomy for the patient. Pringle manoeuvre was not performed. Operation time was 193 min and blood loss estimation was 100 cc. No transfusion was required. Postoperative course was uneventful, grade I of Clavien-Dindo Classification. Patient was discharged in day 8. In our experience laparoscopic resection in cirrhotic liver should be performed in selected patients and in an experienced team.

Laparoscopic liver resection for colorectal liver metastases—shortand long-term outcomes:A systematic review

BACKGROUND For well-selected patients and procedures,laparoscopic liver resection(LLR)has become the gold standard for the treatment of colorectal liver metastases(CRLM)when performed in specialized centers.However,little is currently known concerning patient-related and peri-operative factors that could play a role in survival outcomes associated with LLR for CRLM.AIM To provide an extensive summary of reported outcomes and prognostic factors associated with LLR for CRLM.METHODS A systematic search was performed in PubMed,EMBASE,Web of Science and the Cochrane Library using the keywords“colorectal liver metastases”,“laparoscopy”,“liver resection”,“prognostic factors”,“outcomes”and“survival”.Only publications written in English and published until December 2019 were included.Furthermore,abstracts of which no accompanying full text was published,reviews,case reports,letters,protocols,comments,surveys and animal studies were excluded.All search results were saved to Endnote Online and imported in Rayyan for systematic selection.Data of interest were extracted from the included publications and tabulated for qualitative analysis.RESULTS Out of 1064 articles retrieved by means of a systematic and grey literature search,77 were included for qualitative analysis.Seventy-two research papers provided data concerning outcomes of LLR for CRLM.Fourteen papers were eligible for extraction of data concerning prognostic factors affecting survival outcomes.Qualitative analysis of the collected data showed that LLR for CRLM is safe,feasible and provides oncological efficiency.Multiple research groups have reported on the short-term advantages of LLR compared to open procedures.The obtained results accounted for minor LLR,as well as major LLR,simultaneous laparoscopic colorectal and liver resection,LLR of posterosuperior segments,twostage hepatectomy and repeat LLR for CRLM.Few research groups so far have studied prognostic factors affecting long-term outcomes of LLR for CRLM.CONCLUSION In experienced hands,LLR for CRLM provides good short-and long-term outcomes,independent of the complexity of the procedure.

International experts consensus guidelines on robotic liver resection in 2023

The robotic liver resection(RLR)has been increasingly applied in recent years and its benefits shown in some aspects owing to the technical advancement of robotic surgical system,however,controversies still exist.Based on the foundation of the previous consensus statement,this new consensus document aimed to update clinical recommendations and provide guidance to improve the outcomes of RLR clinical practice.The guideline steering group and guideline expert group were formed by 29 international experts of liver surgery and evidence-based medicine(EBM).Relevant literature was reviewed and analyzed by the evidence evaluation group.According to the WHO Handbook for Guideline Development,the Guidance Principles of Development and Amendment of the Guidelines for Clinical Diagnosis and Treatment in China 2022,a total of 14 recommendations were generated.Among them were 8 recommendations formulated by the GRADE method,and the remaining 6 recommendations were formulated based on literature review and experts’opinion due to insufficient EBM results.This international experts consensus guideline offered guidance for the safe and effective clinical practice and the research direction of RLR in future.

Four-year experience with more than 1000 cases of total laparoscopic liver resection in a single center

BACKGROUND Laparoscopic liver resection(LLR)has become a safe surgical procedure that needs additional summarization.AIM To review 4 years of total LLR surgeries,exceeding 1000 cases,which were performed at a single center.METHODS Patients who underwent LLR at West China Hospital of Sichuan University between January 2015 and December 2018 were identified.Surgical details,including the interventional year,category of liver disease,and malignant liver tumors prognosis,were evaluated.The learning curve for LLR was evaluated using the cumulative sum method.The Kaplan-Meier method was used to perform survival analysis.RESULTS Ultimately,1098 patients were identified.Hepatocellular carcinoma(HCC)was the most common disease that led to the need for LLR at the center(n=462,42.08%).The average operation time was 216.94±98.51 min.The conversion rate was 1.82%(20/1098).The complication rate was 9.20%(from grade II to V).The 1-year and 3-year overall survival rates of HCC patients were 89.7%and 81.9%,respectively.The learning curve was grouped into two phases for local resection(cases 1-106 and 107-373),three phases for anatomical segmentectomy(cases 1-44,45-74 and 75-120),and three phases for hemihepatectomy(cases 1-17,18-48 and CONCLUSION LLR may be considered a first-line surgical intervention for liver resection that can be performed safely for a variety of primary,secondary,and recurrent liver tumors and for benign diseases once technical competence is proficiently attained.

The differential benefit of laparoscopic over open minor liver resection for lesions situated in the anterolateral or posterosuperior segments

Background:It is well known that laparoscopic liver surgery can offer advantages over open liver surgery in selected patients.However,what type of procedures can benefit most from a laparoscopic approach has been investigated poorly thus far.The aim of this study is thus to define the extent of advantages of laparoscopic over open liver surgery for lesions in the anterolateral(AL)and posterosuperior(PS)segments.Methods:In this international multicentre retrospective cohort study,laparoscopic and open minor liver resections for lesions in the AL and PS segments were compared after propensity score matching.The differential benefit of laparoscopy over open liver surgery,calculated using bootstrap sampling,was compared between AL and PS resections and expressed as a Delta of the differences.Results:After matching,3,040 AL and 2,336 PS resections were compared,encompassing open and laparoscopic procedures in a 1:1 ratio.AL and PS laparoscopic liver resections were more advantageous in comparison to open in terms of blood loss,transfusion rate,complications,and length of stay.However,AL resections benefitted more from laparoscopy than PS in terms of overall and severe complications(D-difference were 4.8%,P=0.046 and 3%,P=0.046)and blood loss(D-difference was 195 mL,P<0.001).Similar results were observed in the subset for high-volume centres,while in recent years no significant differences were found in the differential benefit between AL and PS segments.Conclusions:The advantage of laparoscopic over open liver surgery is greater in the AL segments than in the PS segments.

Research of goal-directed fluid therapy on laparoscopic liver resection

Objective To explore the application effect of goal-directed fluid therapy(GDFT)on laparoscopic liver resection.Methods From July 2023 to December 2023,48 patients who underwent laparoscopic liver resection were randomly divided into the GDFT group and the CLCVP(controlled low central venous pressure)group.The patients in the GDFT group were guided by stroke volume variability(SVV)during surgery,while those in the CLCVP group were guided by a controlled low central venous pressure technique during fluid replacement surgery.Intraoperative bleeding volume,fluid replacement volume,urine output,liver blood flow obstruction time,postoperative exhaust time,length of hospital stays,and incidence of complications were recorded and compared between the two groups of patients.Results There was a difference between the two groups in terms of crystal fluid,colloid fluid,total fluid volume,and urine volume(P>0.05).However,the bleeding volume in the GDFT group(515.61±246.71)mL was lower than that in the CLCVP group(389.37±187.35)mL(P<0.05);and the blockade time of liver blood flow in the GDFT group(46.33±7.26)min was shorter than that of the CLCVP group(41.84±6.24)min(P<0.05);the postoperative exhaust time of patients in the GDFT group(4.86±1.24)d was shorter than that of patients in the CLCVP group(6.42±1.05)d(P<0.05);the hospitalization days of patients in the GDFT group(9.21±2.15)d were fewer than those in the CLCVP group(11.04±4.29)d(P<0.05).There were no statistically significant differences in the incidence of postoperative complications between the two groups of patients(P>0.05).Conclusion GDFT guided by SVV can stabilize intraoperative hemodynamics in patients undergoing laparoscopic liver resection,reduce intraoperative bleeding,and reduce liver blood flow blockage time.It is safer and more reliable than traditional fluid therapy.

Laparoscopic resection vs laparoscopic radiofrequency ablation for the treatment of small hepatocellular carcinomas: A single-center analysis

AIMTo compare survival and recurrence after laparoscopic liver resection (LLR) and laparoscopic radiofrequency ablation (LRFA) for the treatment of small hepatocellular carcinoma (HCC).METHODSBetween June 1, 2005 and November 30, 2010, 46 patients (62.26 &#x000b1; 8.55 years old; female/male: 12/34) treated for small HCC were enrolled following strict criteria. Patients with better liver function and larger tumors were referred for LLR (n = 24), while those with poorer liver function and multiple tumors were referred for LRFA (n = 22), and they were then followed for similar durations (44.74 &#x000b1; 21.3 mo for LLR vs 40.27 &#x000b1; 30.8 mo for LRFA).RESULTSThe LLR and LRFA groups were homogeneous with regard to age, sex, etiology of liver cirrhosis, and AFP levels. The overall survival (OS) and disease-free survival (DFS) probability was 0.354 and 0.260, respectively. A significantly higher OS was observed in the LLR group (LLR: 0.442; LRFA: 0.261; P = 0.048), whereas no statistical difference was found for DFS (LLR: 0.206; LRFA: 0.286; P = 0.205). In the LRFA group was treated a greater number of nodules (LLR: 1.41 &#x000b1; 0.77; LRFA: 2.72 &#x000b1; 1.54; P &#x0003c; 0.001). Cox regression analysis found the number of intraoperative HCC nodules as the unique variable statistically significant for OS (hazard ratio: 2.225; P &#x0003c; 0.001). The rank-hazard plot showed a steeper increase of relative hazard for intraoperative nodules &#x0003e; 2.CONCLUSIONOur preliminary results confirm the superiority of hepatic resection on thermoablation in the treatment of small HCC in selected patients, when both approaches are made laparoscopically. LLR showed better results compared to LRFA in terms of OS. These data need to be confirmed by further studies on a larger number of patients.

Advances and challenges in laparoscopic surgery in the management of hepatocellular carcinoma

Hepatocellular carcinoma is the fifth most common malignancy and the third most common cause of cancer-related mortality worldwide. From the wide variety of treatment options, surgical resection and liver transplantation are the only therapeutic ones. However, due to shortage of liver grafts, surgical resection is the most common therapeutic modality implemented. Owing to rapid technological development, minimally invasive approaches have been incorporated in liver surgery. Liver laparoscopic resection has been evaluated in comparison to the open technique and has been shown to be superior because of the reported decrease in surgical incision length and trauma, blood loss, operating theatre time, postsurgical pain and complications, R0 resection, length of stay, time to recovery and oral intake. It has been reported that laparoscopic excision is a safe and feasible approach with near zero mortality and oncologic outcomes similar to open resection. Nevertheless, current indications include solid tumors in the periphery < 5 cm, especially in segments Ⅱ through Ⅵ, while according to the consensus laparoscopic major hepatectomy should only be performed by surgeons with high expertise in laparoscopic and hepatobiliary surgery in tertiary centers. It is necessary for a surgeon to surpass the 60-cases learning curve observed in order to accomplish the desirable outcomes and preserve patient safety. In this review, our aim is to thoroughly describe the general principles and current status of laparoscopic liver resection for hepatocellular carcinoma, as well as future prospects.

Current status of minimally invasive liver surgery for cancers

Hepatocellular carcinoma(HCC)patients have chronic liver disease with functional deterioration and multicentric oncogenicity.Liver surgeries for the patients should be planned on both oncological effects and sparing liver function.In colorectal patients with post-chemotherapy liver injury and multiple bilateral tumors,handling multiple tumors in a fragile/easy-to-bleed liver is an important issue.Liver surgery for biliary tract cancers is often performed as a resection of large-volume functioning liver with extensive lymphadenectomy and bile duct resection/reconstruction.Minimally invasive liver surgery(MILS)for HCC is applied with the advantages of laparoscopic for cases of cirrhosis or repeat resections.Small anatomical resections using the Glissonian,indocyanine greenguided,and hepatic vein-guided approaches are under discussion.In many cases of colorectal liver metastases,MILS is applied combined with chemotherapy owing to its advantage of better hemostasis.Two-stage hepatectomy and indocyanine green-guided tumor identification for multiple bilateral tumors are under discussion.In the case of biliary tract cancers,MILS with extensive lymphadenectomy and bile duct resection/reconstruction are developing.A robotassisted procedure for dissection of major vessels and handling fragile livers may have advantages,and well-simulated robot-assisted procedure may decrease the difficulty for biliary tract cancers.

Robotic versus laparoscopic liver resection for huge (≥10 cm) liver tumors: an international multicenter propensity-score matched cohort study of 799 cases

Background:The use of laparoscopic(LLR)and robotic liver resections(RLR)has been safely performed in many institutions for liver tumours.A large scale international multicenter study would provide stronger evidence and insight into application of these techniques for huge liver tumours≥10 cm.Methods:This was a retrospective review of 971 patients who underwent LLR and RLR for huge(≥10 cm)tumors at 42 international centers between 2002-2020.Results:One hundred RLR and 699 LLR which met study criteria were included.The comparison between the 2 approaches for patients with huge tumors were performed using 1:3 propensity-score matching(PSM)(73 vs.219).Before PSM,LLR was associated with significantly increased frequency of previous abdominal surgery,malignant pathology,liver cirrhosis and increased median blood.After PSM,RLR and LLR was associated with no significant difference in key perioperative outcomes including media operation time(242 vs.290 min,P=0.286),transfusion rate rate(19.2%vs.16.9%,P=0.652),median blood loss(200 vs.300 mL,P=0.694),open conversion rate(8.2%vs.11.0%,P=0.519),morbidity(28.8%vs.21.9%,P=0.221),major morbidity(4.1%vs.9.6%,P=0.152),mortality and postoperative length of stay(6 vs.6 days,P=0.435).Conclusions:RLR and LLR can be performed safely for selected patients with huge liver tumours with excellent outcomes.There was no significant difference in perioperative outcomes after RLR or LLR.

Using the win ratio to compare laparoscopic versus open liver resection for colorectal cancer liver metastases

Background:We sought to assess the overall benefit of laparoscopic versus open hepatectomy for treatment of colorectal liver metastases(CRLMs)using the win ratio,a novel methodological approach.Methods:CRLM patients undergoing curative-intent resection in 2001-2018 were identified from an international multi-institutional database.Patients were paired and matched based on age,number and size of lesions,lymph node status and receipt of preoperative chemotherapy.The win ratio was calculated based on margin status,severity of postoperative complications,90-day mortality,time to recurrence,and time to death.Results:Among 962 patients,the majority underwent open hepatectomy(n=832,86.5%),while a minority underwent laparoscopic hepatectomy(n=130,13.5%).Among matched patient-to-patient pairs,the odds of the patient undergoing laparoscopic resection“winning”were 1.77[WR:1.77,95%confidence interval(CI):1.42-2.34].The win ratio favored laparoscopic hepatectomy independent of low(WR:2.94,95%CI:1.20-6.39),medium(WR:1.56,95%CI:1.16-2.10)or high(WR:7.25,95%CI:1.13-32.0)tumor burden,as well as unilobar(WR:1.71,95%CI:1.25-2.31)or bilobar(WR:4.57,95%CI:2.36-8.64)disease.The odds of“winning”were particularly pronounced relative to short-term outcomes(i.e.,90-day mortality and severity of postoperative complications)(WR:4.06,95%CI:2.33-7.78).Conclusions:Patients undergoing laparoscopic hepatectomy had 77%increased odds of“winning”.Laparoscopic liver resection should be strongly considered as a preferred approach to resection in CRLM patients.

Single incision laparoscopic liver resection： a case report

Laparoscopic procedure as a minimally invasive surgery has been introduced into many abdominal surgeries. Smaller incisions of the abdominal wall reduce postoperative pain and the risk of wound complications, and provide an excellent cosmetic result compared with open surgery. Natural orifice transluminal endoscopic surgery （NOTES）, a no-scar surgery, is a hot spot of modern surgery. However,