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Hokuto et al. Hepatoma Res 2020;6:81 I http://dx.doi.org/10.20517/2394-5079.2020.78 Page 3 of 7

ADVANCES IN LAPAROSCOPIC REPEAT LIVER RESECTION
Progress in surgical procedures and devices has enabled the expansion of surgical indications for LLR [30-32] .
However, laparoscopic RLR demands a more advanced technique due to adhesion formation following
prior liver resection, changes in anatomical landmarks, and deformity of the remnant liver. In 2009,
[33]
Belli et al. reported 12 patients who underwent laparoscopic RLR for recurrent HCC. The authors
concluded that laparoscopic RLR was feasible and that the degree of adhesion was mild in patients
[34]
undergoing LLR as initial liver resection. In 2011, Hu et al. reported six patients who underwent
laparoscopic RLR for recurrent HCC. No intra- or postoperative complications were observed; however,
the authors noted that the patients were carefully selected. Another report in 2011 was a tri-institutional
[35]
analysis of 76 patients undergoing laparoscopic RLR . The study cohort comprised 63, 3, and 10 patients
with metastatic liver tumors, HCC and benign tumors, respectively. Seven patients (9.2%) were converted
to open surgery, and there were no perioperative deaths. The patients who underwent OLR as initial liver
resection experienced higher intraoperative blood loss compared to those who underwent LLR. In 2016, a
[36]
review by Goh et al. , which included 103 patients who underwent laparoscopic RLR for recurrent HCC,
reported that only 2 patients (1.9%) were converted to open surgery. These retrospective analyses have
provided evidence for the feasibility and safety of LLR in select patients.

[37]
[38]
In 2018, Noda et al. , and Ome et al. , reported their findings on the comparison between laparoscopic
RLR and open RLR in their institutions indicating that blood loss was less and hospital stay shorter with
laparoscopic RLR; there were no differences in operative duration and postoperative complications.
Thereafter, similar results have been reported from several single centers [7,12,39] . In 2019, a multicenter
[40]
propensity score-matched study compared laparoscopic and open RLR for colorectal liver metastasis .
After matching, 105 pairs were extracted from the initial cohort of 271 patients who underwent
laparoscopic RLR and 154 patients who underwent open RLR. Laparoscopic RLR was associated with a
significantly shorter operative duration (200 min vs. 256 min), less intraoperative blood loss (200 mL vs.
300 mL), and shorter postoperative hospital stay (5 days vs. 6 days), whereas postoperative morbidity and
mortality rates were similar between the groups. Similar results of laparoscopic RLR for HCC were reported
[11]
in another multicenter propensity score based study . Table 1 summarizes the comparison between
laparoscopic RLR and open RLR of these reports.

Although no randomized controlled trials to date have compared laparoscopic RLR and open RLR,
evidence from previous studies indicate that laparoscopic RLR is feasible and safe as long as the indications
are within the capabilities of institutions and surgeons.

DIFFICULTY CLASSIFICATION OF LAPAROSCOPIC REPEAT LIVER RESECTION
Several factors affect the level of difficulty in laparoscopic LLR. Previous OLR was reported to increase
[16]
difficulty in laparoscopic RLR [33,35] . In 2014, Ban et al. described the first difficulty scoring system for LLR.
The difficulty score was based on tumor location, extent of liver resection, tumor size, tumor proximity
to major vessels and liver function. The difficulty of LLR was classified into low, intermediate and high
levels. This score can be effortlessly utilized for risk assessment in patients undergoing laparoscopic RLR.
[15]
Recently, Kinoshita et al. reported on difficulty classification of laparoscopic RLR. They reviewed 60
cases of laparoscopic RLR in their institution and analyzed the factors accounting for prolonged operative
duration or severe adhesion. As a result, an intermediate or high LLR difficulty score, two or more previous
liver resections, a history of previous major liver resection, and tumor location near the resected surface
of previous liver resection were identified. These five factors were reported to be correlated with operative
duration in laparoscopic RLR. The authors then classified the patients undergoing RLR into low-risk
(score, 0-1), intermediate-risk (score, 2-3), and high-risk (score, 4-5) categories and found that the risk was
significantly correlated with operative duration .
[15]