The efforts are worth the benefits for laparoscopic liver resection

Last year,Hepatobiliary Surgery and Nutrition published an interesting analysis performed by Ratti and colleagues(1).This study aimed to understand if the efforts associated with the laparoscopic approach in liver surgery are always worthwhile,specifically in high-complexity cases.Primary endpoint was to analyse the degree of benefit of laparoscopy over open liver surgery(OLS)in different levels of technical difficulty.Secondary endpoint was to confirm that advantages of minimally invasive techniques over open are detectable within all levels of complexity.

Role of laparoscopic and robotic liver resection compared to open surgery in elderly hepatocellular carcinoma patients: a systematic review and meta-analysis

Aim:This study aimed to compare mini-invasive liver resection(MILR)(laparoscopic/robotic approach)and open liver resection(OLR)for hepatocellular carcinoma(HCC)in elderly patients with regard to clinical and oncological outcomes through a comprehensive systematic review.Methods:The MEDLINE and Cochrane Library electronic databases were systematically searched from 2009 to December 2019 to identify relevant English written studies comparing MILR and OLR.The main endpoints were Child-Pugh score,serum total bilirubin level,comorbidity,presence/absence of cirrhosis,minor/major resection,challenge segment approach,operative time,estimated intraoperative blood loss,liver failure rate,morbidity according to the Clavien-Dindo classification,length of hospital stay(LOS),postoperative mortality,number of lesions,tumor size,readmission rate,recurrence rate and survival at 1,3 and 5 years after operation.Meta-analyses provided pooled relative risks and mean differences for these outcomes.Cut-off for"elderly age"was set at 65 years old.Results:Eight studies that evaluated 3051 patients who underwent liver resection for HCC,with 950 undergoing MILR and 2101 OLR,were included after the screening process.Blood loss,morbidity,and LOS showed statistical significance in favor of MILR.In particular,with respect to OLR,MILR decreased on average blood loss by 161.43 mL(95%CI:250.24-72.61),risk of morbidity by 42%(P<0.01),LOS by 4 days(95%CI:7-2),postoperative mortality risk by 47%(although not significantly,P=0.06).Major resections were significantly more common in the OLR group(P<0.0001).Recurrence,although not significant(P=0.06),must also be emphasized.The two surgical approaches were comparable with regard to the other outcomes investigated.Conclusion:Meta-analyses confirmed the advantages of MILR in terms of short perioperative outcomes,where it may promote the extension of liver resection to HCC patients with borderline liver function.MILR may be considered an important treatment option with significant benefits in the elderly and fragile patients.However,large well-designed prospective comparative studies or randomized controlled trials would be necessary to further confirm our conclusions.

Difficult procedures,better outcomes

Despite the initial skepticism and challenges,minimally invasive liver surgery especially laparoscopic liver resections(LLR),has become a first-choice surgical treatment for various liver tumors in many specialized centers worldwide(1-3).It is a safe alternative to open surgery thanks to advantages such as reduced blood loss and complication rates,shorter hospital stay,and better quality of life(4-7).However,laparoscopy requires relatively long learning,and complex procedures are limited to high-volume expert centers(8).