Page 40 - Read Online

Page 2 of 7 Giacca et al. Hepatoma Res 2018;4:47 I http://dx.doi.org/10.20517/2394-5079.2018.79

various diseases including primary and secondary liver cancer on normal or diseased underlying liver.
Furthermore, different types of resections including major and minor hepatectomies can be performed,
which include various procedures according to tumor type and location in the liver segments. The only
available Randomized Control Trial (RCT) concerns LLR for colorectal liver metastases . Results from
[2]
this RCT confirmed previous retrospective reviews and meta-analyses by demonstrating benefits of LLR
compared to open resection, such as reduced blood loss, morbidity and hospital stay. Two international
consensus conferences on laparoscopic liver surgery were held in Louisville (USA) in 2008 and in Morioka
(Japan) in 2014 . The conclusions of the Morioka meeting validated minor LLRs as standard practice
[3,4]
in surgery, while complex anatomical resections and major LLRs were still in an exploratory phase. The
Morioka consensus also focused on underlining how major LLRs require high-level skills and emphasizing
that a structured training should be performed, together with the establishment of a scoring system to
evaluate difficulty before surgery. Currently, a laparoscopic approach seems applicable in 20%-50% of liver
resections, certainly depending on local experience and skills . Authors of the largest review and meta-
[5]
analysis published so far , with data from 9000 patients, propose LLRs as a feasible alternative to open
[6]
liver resection (OLR) mainly in patients undergoing a minor resection or in those undergoing a major liver
resection without biliary or vascular reconstruction. At present, LLR is accepted worldwide, with favorable
outcomes compared to OLR, mainly in terms of length of stay, blood loss and post-operative complications,
with comparable oncological and survival outcomes.

Almost 90% of HCCs evolve from chronic liver disease, with different prevalent etiologies in the Eastern
and Western world. Several medical and surgical approaches or, more often, combinations of these, are
used to treat HCC, but surgical resection and liver transplant play the main role. Sixty-five percent of LLRs
are performed for malignant disease, with HCC remaining the main indication. This is in part attributable
to the large contribution of Asian literature where HCC resection is very common, and also the accurate
surveillance and screening programs which allow detection, in a growing number of cases, of small single
tumors which are the best candidates for LLR .
[5]

OPERATIVE AND POST-OPERATIVE OUTCOMES
The first series of LLRs for HCC on cirrhosis studying both short-term outcomes and survival rates was
published in 2006 . It concluded that LLR in selected patients with peripheral HCC on chronic liver disease
[7]
was a safe procedure with good midterm results. More recent studies confirmed these results especially in
cirrhotic patients [8-14] . Meta-analyses proved that patients with HCC undergoing LLR have reduced intra-
operative blood loss and length of stay when compared to those undergoing OLR [15,16] . A systematic review
and meta-analysis on LLR vs. OLR for HCC was published in 2013 by Yin et al. This study included 1238
[11]
patients from 15 studies, all requiring left lateral or right peripheral resection. Together with reduced intra-
operative blood loss, it showed a lower rate of post-operative morbidity in patients undergoing laparoscopic
resections. There was no significant difference in terms of survival, both overall survival (OS) and disease-
free survival (DFS). Two studies comparing laparoscopic and open resections for HCC using the propensity
score were published in 2015 [17,18] . The one by Han et al. showed no inferiority of LLR, with similar 1, 3 and
[17]
5-year OS and DFS rates, lower post-operative morbidity and post-operative transient liver failure. These
groups of patients had comparable operative times. A study by Takahara et al. showed similar results with
[18]
reduced blood loss, post-operative morbidity, ascites and liver failure in patients who underwent LLR. In this
group of patients operative time was longer and oncological results comparable.

MAJOR HEPATECTOMIES
In recent years the laparoscopic approach has extended to major hepatectomies. In 2017, Yoon et al. in a
[13]
propensity-score analysis comparing patients who had laparoscopic and open right hepatectomy for HCC