Clinical feasibility of laparoscopic left lateral segment liver resection with magnetic anchor technique:The first clinical study from China

BACKGROUND Magnetic anchor technique(MAT)has been applied in laparoscopic cholecystectomy and laparoscopic appendectomy,but has not been reported in laparoscopic partial hepatectomy.AIM To evaluate the feasibility of the MAT in laparoscopic left lateral segment liver resection.METHODS Retrospective analysis was conducted on the clinical data of eight patients who underwent laparoscopic left lateral segment liver resection assisted by MAT in our department from July 2020 to November 2021.The Y-Z magnetic anchor devices(Y-Z MADs)was independently designed and developed by the author of this paper,which consists of the anchor magnet and magnetic grasping apparatus.Surgical time,intraoperative blood loss,intraoperative accidents,operator experience,postoperative incision pain score,postoperative complications,and other indicators were evaluated and analyzed.RESULTS All eight patients underwent a MAT-assisted laparoscopic left lateral segment liver resection,including three patients undertaking conventional 5-port and five patients having a transumbilical single-port operation.The mean operation time was 138±34.32 min(range 95-185 min)and the mean intraoperative blood loss was 123±88.60 mL(range 20-300 mL).No adverse events occurred during the operation.The Y-Z MADs showed good workability and maneuverability in both tissue and organ exposure.In particular,the operators did not experience either a“chopstick”or“sword-fight”effect in the single-port laparoscopic operation.CONCLUSION The results show that the MAT is safe and feasible for laparoscopic left lateral segment liver resection,especially,exhibits its unique abettance for transumbilical single-port laparoscopic left lateral segment liver resection.

Wedge gastrectomy:Robot-assisted with a hand-sewn repair versus a laparoscopic linear stapler technique for gastric subepithelial tumors

Objective:Minimally invasive surgery has become common in surgical resections of gastric subepithelial tumors.An endostapler technique is simple and easy to perform when cutting the stomach.Gastrotomy using a hand-sewn repair is a new approach for identifying and removing gastric subepithelial tumors,but few studies have evaluated its efficacy.In this study,we demonstrated the safety and effectiveness of this novel technique using a robot-assisted approach.Materials and methods:A retrospective cohorts of all patients who presented with gastric subepithelial tumors and underwent robotic or laparoscopic resection at Ramathibodi Hospital from 2012 to 2018 was reviewed.Surgical outcomes and complications of the robot-assisted approach with a hand-sewn repair were analyzed and compared to those of the laparoscopic linear stapler technique.Results:In total,25 patients were included in this study.Most of the subepithelial tumors were gastrointestinal stromal tumors(17 patients,68%).Ten patients(40%)underwent a robot-assisted procedure with a hand-sewing technique,and 15 patients underwent a laparoscopic linear stapler procedure.Mean tumor size was 3.79±1.35 cm in the robot-assisted procedure with a hand-sewing technique group and 3.52±1.88 cm in the laparoscopic linear stapler procedure group.The former experienced a longer operative time(261±54 vs 144±64 minutes,p<0.001)and a longer time to return to a normal diet(5.7±2.0 vs 4.0±1.4 days,p=0.028).Neither group experienced perioperative complications or mortality.Conclusion:Although the time to return to a normal diet and operative time were significantly longer compared to a laparoscopic procedure using a linear stapler,the robot-assisted approach using a handsewn repair for gastric subepithelial tumors is feasible,effective,and safe.This can be an alternative for the surgical treatment of gastric subepithelial lesions.

Combined laparoscopic and endoscopic method for foreign body removal from descending colon: A case report

BACKGROUND The majority of published reports on foreign bodies(FBs)involve the rectum and applied a transanal retrieval.Usually,patients with FB above the rectum are subjected to laparotomy for removal.Here,we illustrate the case of a man with an FB that had migrated into the descending colon,and its successful removal via a laparoscopic approach.CASE SUMMARY A 43-year-old man,who had the habit of FB insertion into his anus to aid defe-cation,presented upon experience of such an FB slipping through and migrating upward to the distal colon.Plain abdominal radiograph revealed a bottle-shaped FB,positioned in the left iliac fossa region.The FB was successfully removed via a laparoscopic-assisted procedure in which we combined diagnostic laparoscopic and endoscopic techniques during surgery.The patient was monitored for 2 d postoperatively and subsequently discharged home.CONCLUSION A minimally invasive approach should be adopted to aid extraction of colorectal FB as it is effective and safe.

Effectiveness and safety of a laparoscopic training system combined with modified reconstruction techniques for total laparoscopic distal gastrectomy

BACKGROUND Total laparoscopic distal gastrectomy(TLDG)is increasing due to some advantages over open surgery,which has generated interest in gastrointestinal surgeons.However,TLDG is technically demanding especially for lymphadenectomy and gastrointestinal reconstruction.During the course of training,trainee surgeons have less chances to perform open gastrectomy compared with that of senior surgeons.AIM To evaluate an appropriate,efficient and safe laparoscopic training procedures suitable for trainee surgeons.METHODS Ninety-two consecutive patients with gastric cancer who underwent TLDG plus Billroth I reconstruction using an augmented rectangle technique and involving trainees were reviewed.The trainees were taught a laparoscopic view of surgical anatomy,standard operative procedures and practiced essential laparoscopic skills.The TLDG procedure was divided into regional lymph node dissections and gastrointestinal reconstruction for analyzing trainee skills.Early surgical outcomes were compared between trainees and trainers to clarify the feasibility and safety of TLDG performed by trainees.Learning curves were used to assess the utility of our training system.RESULTS Five trainees performed a total of 52 TLDGs(56.5%),while 40 TLDGs were conducted by two trainers(43.5%).Except for depth of invasion and pathologic stage,there were no differences in clinicopathological characteristics.Trainers performed more D2 gastrectomies than trainees.The total operation time was significantly longer in the trainee group.The time spent during the lesser curvature lymph node dissection and the Billroth I reconstruction were similar between the two groups.No difference was found in postoperative complications between the two groups.The learning curve of the trainees plateaued after five TLDG cases.CONCLUSION Preparing trainees with a laparoscopic view of surgical anatomy,standard operative procedures and practice in essential laparoscopic skills enabled trainees to perform TLDG safely and feasibly.

Usefulness of Detailed Analysis with Operative Procedure of Total Laparoscopic Hysterectomy (TLH) Done a Single Surgeon, to Master the Surgical Technique of TLH and Gain Higher Proficiency

Objective: To analyze the relationship between the numbers of cases experienced and the operation time for a single surgeon aiming to master the TLH surgical technique. Material and Methods: Retrospective data analysis of women who underwent TLH for benign diseases between April, 2014 and March, 2016 was conducted by a single surgeon in a single hospital (Showa University of Fujigaoka Hospital). We divided the main procedures of the TLH operation into five sections, and measured the time required for each section. These cases were divided into three groups, group 1, 2, and 3. Results: There were 54 cases of TLH over two years for a single surgeon, and 21 cases that included essential operative procedures were divided into three groups of seven cases each. The average duration of the surgery (min.) was 178.3 ± 48.2 in the group 1, 128.3 ± 15.6 in the group 2, and 111.3 ± 15.9 in the group 3. A significant reduction in the required time was observed between group 1, 2, and 3 groups. As the number of cases increased, the operation time became statistically significantly shorter for every section except B and D. The skill growth rate was different at each section. Conclusion: For a single surgeon, as the number of surgical cases increased, we recognized the increased skill with the procedure in every section and the rate of skill growth differed for different sections. The difference of growth rate for each section implied that the number of operative cases required for a surgeon in each section was different.

Cavernous Nerve Graft Reconstruction with a Novel Artificial Conduit during Robot-Assisted Laparoscopic Radical Prostatectomy

The interposition sural nerve graft has been attempted occasionally during radical prostatectomy for the recovery of continence and erectile function;however, nerve autograft may result in adverse events for the patient. Here, we present our initial experiences using NerbridgeTM, a novel conduit for peripheral nerve regeneration, rather than utilizing sural nerve grafting, in robot-assisted laparoscopic radical prostatectomy to overcome autograft problems such as prolongation of operation time and postoperative abnormal sensation. This novel artificial conduit interposition can be technically feasible when combined with robotic surgery, and prospective randomized controlled trials with high patients-numbers and long follow-up periods are warranted.

Long-term outcomes of postgastrectomy syndrome after total laparoscopic distal gastrectomy using the augmented rectangle technique

BACKGROUND For total laparoscopic distal gastrectomies for gastric cancer,the reconstruction method is critical to the clinical outcome of the procedure.However,which reconstruction technique is optimal remains controversial.We originally reported the augmented rectangle technique(ART)as a reconstruction option for total laparoscopic Billroth I reconstructions.Still,little is known about its effect on long-term outcomes,specifically the incidence of postgastrectomy syndrome and its impact on quality of life.AIM To analyze postgastrectomy syndrome and quality of life after ART using the Postgastrectomy Syndrome Assessment Scale-37(PGSAS-37)questionnaire.METHODS At Juntendo University,a total of 94 patients who underwent ART for Billroth I reconstruction with total laparoscopic distal gastrectomies for gastric cancer between July 2016 and March 2020 completed the PGSAS-37 questionnaire.Multidimensional analysis was performed,comparing those 94 ART cases from our institution(ART group)to 909 distal gastrectomy cases with a Billroth I reconstruction from other Japanese institutions who also completed the PGSAS-37 as part of a larger national database(PGSAS group).RESULTS Patients in the ART group had significantly better total symptom scores in all the symptom subscales(i.e.,esophageal reflux,abdominal pain,meal-related distress,indigestion,diarrhea,constipation,and dumping).The loss of body weight was marginally greater for those in the ART group than in the PGSAS group(-9.3%vs-7.9%,P=0.054).The ART group scored significantly lower in their dissatisfaction of ongoing symptoms,during meals,and with daily life.CONCLUSION ART for Billroth I reconstruction provided beneficial long-term results for postgastrectomy syndrome and quality of life in patients undergoing total laparoscopic distal gastrectomies for gastric cancer.

Combined endoscopy/laparoscopy/percutaneous transhepatic biliary drainage, hybrid techniques in gastrointestinal and biliary diseases

In recent years,a wide range of gastrointestinal endoscopy techniques have been developed,such as endoscopic submucosal dissection(ESD)and endoscopic retrograde cholangiopancreatography(ERCP).Although ESD and ERCP have an important role in gastrointestinal and biliary diseases,each technique has its limitations.Hybrid techniques that combine endoscopic and surgical procedures have emerged that have the advantages of different procedures and negate their limitations at the same time.Laparoscopic endoscopic cooperative surgery and modified laparoscopic endoscopic cooperative surgery combine ESD and laparoscopic techniques to resect submucosal tumors with minimum resection area.Air leak test by intraoperative endoscopy can effectively identify a mechanically insufficient anastomosis and decrease the complication rate.The rendezvous technique that combines percutaneous transhepatic biliary drainage and endoscopy can be performed as a rescue approach for the treatment of biliary obstruction,stenosis and bile duct injuries.For patients with simultaneous presence of stones in the gallbladder and the common bile duct,the laparoendoscopic rendezvous technique can perform ERCP and laparoscopic cholecystectomy at the same time and reduces the risk of pancreatic injury caused by ERCP.Biliobiliary and bilioenteric anastomosis using magnetic compression anastomosis is another choice for biliary obstruction.The most common used approach to deliver the magnets is by percutaneous-peroral tract.Laparoscopicassisted ERCP is a safe and highly effective therapy for patients who develop biliary diseases after Roux-en-Y gastric bypass surgery.

Laparoscopic 肝切除术: 当前的角色和限制

Laparoscopic liver resection (LLR) for the treatment of benign and malignant liver lesions is often performed at specialized centers. Technological advances, such as laparoscopic ultrasonography and electrosurgical tools, have afforded surgeons simultaneous improvements in surgical technique. The utilization of minimally invasive techniques for liver resection has been reported to reduce operative time, decrease blood loss, and shorten length of hospital stay with equivalent postoperative mortality and morbidity rates compared to open liver resection (OLR). Non-anatomic liver resection and left lateral sectionectomy are now routinely performed laparoscopically at many institutions. Furthermore, major hepatic resections are performed by pure laparoscopy, hand-assisted technique, and the hybrid method. In addition, robotic surgery and single port surgery are revealing early promising results. The consensus recommendation for the treatment of benign liver disease and malignant lesions remains unchanged when considering a laparoscopic approach, except when comorbidities and anatomic limitations of the liver lesion preclude this technique. Disease free and survival rates after LLR for hepatocellular carcinoma and metastatic colon cancer correspond to OLR. Patient selection is a significant factor for these favorable outcomes. The limitations include LLR of superior and posterior liver lesions; however, adjustments in technique may now consider a laparoscopic approach as a viable option. As growing data continue to reveal the feasibility and efficacy of laparoscopic liver surgery, this skill is increasingly being adopted by hepatobiliary surgeons. Although the full scope of laparoscopic liver surgery remains infrequently used by many general surgeons, this technique will become a standard in the treatment of liver diseases as studies continue to show favorable outcomes.

Superiority of laparoscopic rectal surgery:Towards a new era

While laparoscopic colon surgery has been established to some degree over this decade,laparoscopic rectal surgery is not standard yet because of the difficulty of making a clear surgical field,the lack of precise anatomy of the pelvis,immature procedures of rectal transaction and so on.On the other hand,maintaining a clear surgical field via the magnified laparoscopy may allow easier mobilization of the rectum as far as the levetor muscle level and may result less blood loss and less invasiveness.However,some unique techniques to keep a clear surgical field and knowledge about anatomy of the pelvis are required to achieve the above superior operative outcomes.This review article discusses how to keep a clear operative field,removing normally existing abdominal structures,and how to transact the rectum and restore the discontinuity based on anatomical investigations.According to this review,laparoscopic rectal surgery will become a powerful modality to accomplish a more precise procedure which has been technically impossible so far,actually entering a new era.

精力的文学评论为执行 laparoscopic colorectal 外科采购原料

Laparoscopic surgery for colorectal disease has become widespread as a minimally invasive treatment.This is important because the increasing availability of new devices allows us to perform procedures with a reduced length of surgery and decreased blood loss.We herein report the results of a literature review of energy sources for laparoscopic colorectal surgery,focused especially on 6 studies comparing ultrasonic coagulating shears(UCS) and other instruments.We also describe our laparoscopic dissection techniques using UCS for colorectal cancer.The short-term outcomes of surgeries using UCS and Ligasure for laparoscopiccolorectal surgery were superior to conventional electrosurgery.Some authors have reported that the length of surgery or blood loss when Ligasure was used for laparoscopic colorectal surgery is less than when UCS was used.On the other hand,a recent study demonstrated that there were no significant differences between the short-term outcomes of UCS and Ligasure for laparoscopic colorectal surgery.It is therefore suggested that the choice of technique used should be made according to the surgeon’s preference.We also describe our laparoscopic dissection techniques using UCS(Harmonic ACE) for colorectal cancer with regard to the retroperitoneum dissection,dissection technique,dissection technique around the feeding artery,and various other dissection techniques.We therefore review the outcomes of using various energy sources for laparoscopic colorectal surgery and describe our laparoscopic dissection techniques with UCS(Harmonic ACE) for colorectal cancer.

Totally intracorporeal robot-assisted urinary diversion for bladder cancer(part 2).Review and detailed characterization of the existing intracorporeal orthotopic ileal neobladder

Objective:To review the most used intracorporeal orthotopic ileal neobladder(ICONB)after radical cystectomy for bladder cancer and create a unified compendium of the different alternatives,including new consistent images.Methods:We performed a non-systematic review of the literature with the keywords“bladder cancer”,“urinary diversion”,“radical cystectomy”,and“neobladder”.Results:Forty studies were included in the analysis.The most frequent type of ICONB was the modified Studer“U”neobladder(70%)followed by the Hautmann“W”modified neobladder(7.5%),the“Y”neobladder(5%),and the Padua neobladder(5%).The operative time to perform a urinary diversion ranged from 124 to 553 min.The total estimated blood loss ranged from 200 to 900 mL.The rate of positive surgical margins ranged from 0%to 8.1%.Early minor and major complication rates ranged from 0%to 100%and from 0%to 33%,respectively.Late minor and major complication rates ranged from 0%to 70%and from 0%to 25%,respectively.Conclusion:The most frequent types of ICONB are Studer“U”neobladder,Hautmann“W”neobladder,“Y”neobladder,and the Padua neobladder.Randomized studies comparing the performance of the different types of ICONB,the performance in an intra or extracorporeal manner,or the performance of an ICONB versus ICIC are lacking in the literature.To this day,there are not sufficient quality data to determine the supremacy of one technique.This manuscript represents a compendium of the most used ICONB with detailed descriptions of the technical aspects,operative and perioperative outcomes,and new consistent images of each technique.

Totally intracorporeal robot-assisted urinary diversion for bladder cancer(Part 1).Review and detailed characterization of ileal conduit and modified Indiana pouch

Objective:To review the most used robot-assisted cutaneous urinary diversion(CUD)after radical cystectomy for bladder cancer and create a unified compendium of the different alternatives,including new consistent images Methods:A non-systematic review of the literature with the keywords“bladder cancer”,“cutaneous urinary diversion”,and“radical cystectomy”was performed.Results:Twenty-four studies of intracorporeal ileal conduit(ICIC)and two of intracorporeal Indiana pouch(ICIP)were included in the analysis.Regarding ICIC,the patients’age ranged from 60 to 76 years.The operative time to perform a urinary diversion ranged from 60 to 133 min.The total estimated blood loss ranged from 200 to 1117 mL.The rate of positive surgical margins ranged from 0%to 14.3%.Early minor and major complication rates ranged from 0%to 71.4%and from 0%to 53.4%,respectively.Late minor and major complication rates ranged from 0%to 66%and from 0%to 32%,respectively.Totally ICIP data are limited to one case report and one clinical series.Conclusion:The most frequent type of CUD is ICIC.Randomized studies comparing the performance of the different types of CUD,the performance in an intra-or extracorporeal manner,or the performance of a CUD versus orthotopic ileal neobladder are lacking in the literature.To this day,there are not enough quality data to determine the supremacy of one technique.This manuscript represents a compendium of the most used CUD with detailed descriptions of the technical aspects,operative and perioperative outcomes,and new consistent images for each technique.

The Application of Laparoscopic B-Ultrasound Microwave Ablation Technology in Liver Metastasis of Colorectal Cancer

Liver is the most common metastasis target organ in the late stage of colorectal cancer. More than 50% of colorectal cancer patients will have simultaneous or heterochronous liver metastasis. The survival time of patients with colorectal cancer and liver metastasis (CRLM) is short;not all patients can get radical resection of liver metastasis. For this part of patients, microwave ablation technology has been proved to be one of the effective methods for the treatment of liver metastasis. Laparoscopic B-ultrasound ablation also highlights a lot of minimally invasive advantages;this paper reviews the relevant literature of PubMed database, Wanfang database and CNKI database, in order to provide the treatment basis for clinical application of microwave ablation technology under laparoscopic B-ultrasound in the treatment of CRLM. The results showed that the safety and effectiveness of microwave ablation for liver metastases under the location of B-ultrasonic laparoscopy were confirmed, and patients with liver metastases of colorectal cancer who could not be resected could choose this treatment.

First quarter century of laparoscopic liver resection

The beginnings of laparoscopic liver resection(LLR)were at the start of the 1990s,with the initial reports being published in 1991 and 1992.These were followed by reports of left lateral sectionectomy in 1996.In the years following,the procedures of LLR were expanded to hemi-hepatectomy,sectionectomy,segmentectomy and partial resection of posterosuperior segments,as well as the parenchymal preserving limited anatomical resection and modified anatomical(extended and/or combining limited)resection procedures.This expanded range of LLR procedures,mimicking the expansion of open liver resection in the past,was related to advances in both technology(instrumentation)and technical skill with conceptual changes.During this period of remarkable development,two international consensus conferences were held(2008 in Louisville,KY,United States,and 2014 in Morioka,Japan),providing up-to-date summarizations of the status and perspective of LLR.The advantages of LLR have become clear,and include reduced intraoperative bleeding,shorter hospital stay,and-especially for cirrhotic patients-lower incidence of complications(e.g.,postoperative ascites and liver failure).In this paper,we review and discuss the developments of LLR in operative procedures(extent and style of liver resections)during the first quarter century since its inception,from the aspect of relationships with technological/technical developments with conceptual changes.

MODIFIED LAPAROSCOPIC CHOLECYSTECTOMY

To furtherly reduce the subxiphoid port site pain,improve the cosmetic result and patient satisfaction,and increase the safety for patients underwent laparoscopic cholecystectomy by advanced laparoscopic knotting skill.Methods:Among our 1500 patients underwent laparoscopic cholecystectomy since 1991,120 cases of modified laparoscopic cholecystectomy (MLC) were performed with three 5-mm ports and one 10-mm port(for laparoscope and sepcien withdrawn).There were 25 male and 95 female patients with an average age of 55 years (24～77years).The indications for MLC included polypoid lesions of gallbladder (21),simple cholecystitis(3),cholecystolithiasisi with chronic cholecystitis(84),with acute suppurative cholecystitis(7),with atrophic cholecystitis(5).Results:There were 5 patients underwent combined laparoscopic appendectomy(3),fenestration of hepatic cyst(1),and drainge for liver abscess(1).The average operative time for MLC was 55 minutes(30～150min),blood loss was 10ml(3～50ml),and postoperative stay was 3 days(1～5days).There were no conversion from MLC to either LC or open surgery,without mortality.Complications were limited to two patients(1.7%).One was retained common bile duct stone and another was port site bleeding after operation.They were treated by transduodenal endoscopic stone retrieval and simple suture ligation,respecrtively.Conclusions:The advantages of MLC conducted mainly by advanced laparoscopic knotting techniques were no more laparoscope (either 2-mm or 5-mm)needed,no sacrifice of good illumination and laproscopic image.Most of all,its costeffective and operative safety were all improved furtherly.

Laparoscopic liver resection:Wedge resections to living donor hepatectomy, are we heading in the right direction?

Despite inception over 15 years ago and over 3000 completed procedures, laparoscopic liver resection has remained mainly in the domain of selected centers and enthusiasts. Requirement of extensive open liver resection(OLR) experience, in-depth understanding of anatomy and considerable laparoscopic technical expertise may have delayed wide application. However healthy scepticism of its actual benefits and presence of a potential publication bias; concern about its safety and technical learning curve, are probably equally responsible. Given that a large proportion of our work, at least in transplantation is still OLR, we have attempted to provide an entirely unbiased, mature opinion of its pros and cons in the current invited review. We have dividedthis review into two sections as we believe they merit separate attention on technical and ethical grounds. The first part deals with laparoscopic liver resection(LLR) in patients who present with benign or malignant liver pathology, wherein we have discussed its overall outcomes; its feasibility based on type of pathology and type of resection and included a small section on application of LLR in special scenarios like cirrhosis. The second part deals with the laparoscopic living donor hepatectomy(LDH) experience to date, including its potential impact on transplantation in general. Donor safety, graft outcomes after LDH and criterion to select ideal donors for LLR are discussed. Within each section we have provided practical points to improve safety in LLR and attempted to reach reasonable recommendations on the utilization of LLR for units that wish to develop such a service.

Laparoscopic distal pancreatectomy: Up-to-date and literature review

Pancreatic surgery represents one of the most challenging areas in digestive surgery. In recent years, an increasing number of laparoscopic pancreatic procedures have been performed and laparoscopic distal pancreatectomy (LDP) has gained world-wide acceptance because it does not require anastomosis or other reconstruction. To date, English literature reports more than 300 papers focusing on LDP, but only 6% included more than 30 patients. Literature review confirms that LDP is a feasible and safe procedure in patients with benign or low grade malignancies. Decreased blood loss and morbidity, early recovery and shorter hospital stay may be the main advantages. Several concerns still exist for laparoscopic pancreatic adenocarcinoma excision. The individual surgeon determines the technical conduction of LDP, with or without spleen preservation; currently robotic pancreatic surgery has gained diffu- sion. Additional researches are necessary to determine the best technique to improve the procedure results.

Heminephrectomy for a large renal mass in a horseshoe kidney: A case report outlining a robotic assisted laparoscopic approach

With an incidence of 1/500,a horseshoe kidney is not uncommon.Tumours discovered in horseshoe kidney however are quite rare,and prove difficult to surgically manage due to complex vascular anatomy.With variable surgical approaches previously described,only a select few robot-assisted cases have been reported.This case describes one such robot-assisted laparoscopic heminephrectomy,with the use of indocyanine green and an endovascular stapler to successfully demarcate ischemia and achieve hemostasis intraoperatively.No complications were encountered,and pathology revealed a pT1bN0 clear cell renal cell carcinoma with negative surgical margins,demonstrating the feasibility of our approach.

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

AIM To assess the impact of laparoscopic liver resection(LLR) on surgical blood loss(SBL),especially in patients with antithrombotics for thromboembolic risks.METHODS Consecutive 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.RESULTS This 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.CONCLUSION LLR 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.