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Brolese et al. Hepatoma Res 2020;6:34 I http://dx.doi.org/10.20517/2394-5079.2020.15 Page 3 of 15

Figure 1. Flow chart of literature selection and PICOT description. MILR: mini-invasive liver resection; OLR: open liver resection

for surgeons and anesthesiologists in this regard are as follows: longer operative times, pneumoperitoneum
and its physiological consequences, diminished functional reserve, and pre- or postoperative comorbidities.

In the last 10 years, only some single-center retrospective studies have analyzed the results of mini-invasive
surgery in elderly patients, and very few reports have focused on topics about mini-invasive surgical
treatment of the elderly with HCC.

The objective of this study was to perform a systematic review to compare mini-invasive liver resection
(MILR) (laparoscopic/robotic approach) and open liver resection (OLR) for HCC in the elderly, across a
comprehensive range of outcomes reported from both randomized and observational studies.

METHODS
Literature search strategy
Literature documenting a comparison of clinical and oncological outcomes in elderly patients who
underwent MILR vs. OLR therapy for HCC was analyzed by searching PubMed and Cochrane Library from
2009 to December 2019. The search terms, either independently or in combination, were used according
to PICOT framework [Figure 1]. A systematic search was conducted for relevant systematic reviews,
randomized controlled trials, and observational studies (prospective or retrospective cohort and case-control
or case-match studies) using a search strategy guided by oncological or surgical information, abstract and
keywords related to our research question. Only English language published articles were screened. When
more than one article was reported by the same institution or author, we selected either the one with the
largest series or the most recent, with the exception of multicenter studies.