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Page 2 of 15 Otsuka et al. Hepatoma Res 2021;7:5 I http://dx.doi.org/10.20517/2394-5079.2020.112

Results: There were no significant differences in patient’s background and operative outcome. Operative duration,
blood loss, and postoperative morbidity tended to be larger in DIG, mainly due to tumor factor, than in FIG.
However, TLHHs were performed without any severe perioperative complications beyond Clavien-Dindo grade IIIb
or mortality.

Conclusion: We believe that hemi-hepatectomies can safely be stylized by totally laparoscopic fashion and
correspondence for difficulty can be made through technical standardization.

Keywords: Laparoscopic liver resection, major hepatectomy, laparoscopic hepatectomy, hemi-hepatectomy, liver
tumor

INTRODUCTION
Laparoscopic liver resection (LLR) has been recognized as a minimally invasive surgery offering disease
curability for liver tumors including hepatocellular carcinoma (HCC). Moreover, recent publications
suggest that systematic liver resections including hemi-hepatectomies have been performed safely in high
[1-5]
volume centers . However, technical standardization of laparoscopic major hepatectomies has remained
varied, depending on each institution, and has not been well established.

Surgical indication of laparoscopic approach for liver resection should be decided by patient’s factors, and
it should also be expanded based on the ability of each surgical unit. We introduced laparoscopic liver
[6]
resection in 1993 with stringent patient selection and have applied laparoscopic major hepatectomies
[7]
since 2006 by using a hybrid technique . Thereafter, the totally laparoscopic approach for major
hepatectomies has been performed since 2008.
In this paper, we describe our indication, standardized technique, and surgical outcome of TLHHs.
Moreover, we hypothesize that TLHHs can be performed feasibly, as well as discuss the technical
correspondence of technically difficult cases which have marginal indication for TLHHs.

METHODS
From September 2008 to July 2020, in total, 222 LLRs including 21 TLHHs for liver tumors were
performed at Toho University Omori Medical Center. Perioperative data from patient record were collected
retrospectively, as approved by the institutional ethical committee of Toho University Omori Medical
Center (ID number M19056).

Surgical indications of totally laparoscopic hemi-hepatectomies
We indicate hemi-hepatectomies for single to multiple tumors, which are limited within hemi-liver,
requiring hemi-hepatectomy for curative resection.

We invented the favorable indication of TLHH is locally resectable tumor or disease without involvement
into hepatic hilus, confluence of hepatic veins, inferior vena cava (IVC), or extrahepatic organs in disease
factor. Tumors smaller than 7 cm in diameter are favorable. Sufficient hepatic functional reserve, which
is tolerable for open hemi-hepatectomies calculated by Indocyanine green retention at 15 min (ICGR15),
[8]
age, and volumetric CT are needed. Preoperative portal vein embolization performed for enlargement of
remnant liver is not a contraindication for TLHH.

On the other hand, our current absolute contraindications for TLHH are tumor with significant invasion
including tumor thrombus on hepatic hilus, confluence of the major hepatic veins, and IVC; requirement