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Page 14 of 15 Otsuka et al. Hepatoma Res 2021;7:5 I http://dx.doi.org/10.20517/2394-5079.2020.112

Liver transection technique based on the appropriate selection of devices is essential to achieve successful
[18]
surgery .

[19]
Incidence of gas embolism in laparoscopic major liver resection has been reported to ranged 0.2%-1.5% .
To avoid gas embolism in LH, therefore, we customarily use caution, maintaining intraperitoneal pressure
[11]
around 10 mmHg, with fluctuation of the IVC in half-filled state .
Intraoperative cholangiography prior to division of hepatic ducts is introduced to reveal anatomical
variation or bile leakages. The recently developed Indocyanine green fluorescence imaging can be used in
intraoperative cholangiography [20,21] .

The hand-assisted laparoscopic procedure and the laparoscopy-assisted hybrid procedure should remain
[22]
options against unexpected trouble due to technical or oncological reason . A conversion case to hybrid
technique due to intraoperative hemorrhage in our series was safely coped with by prompt decision.

Although further improvement is necessary in our result of TLHHs in operative duration, blood loss,
or postoperative morbidity, we believe TLHHs can be technically standardized. Additionally, technical
modifications from stylized procedure, such as changes in the order of procedures, use of additional trocars
for manipulation of surgical devices, or laparoscope, could contribute to performing TLHHs in difficult
cases.

However, further accumulation of experience is necessary to improve the outcome of TLHHs and overcome
the limitations.

We conclude that stringent patient selection for TLHHs is a notably important aspect, and, thereby, TLHHs
can safely be stylized by totally laparoscopic fashion in daily practice. Ascertainment and correspondence
for difficulty can be made through technical stylization of totally laparoscopic procedure in hemi-
hepatectomies. However, there is an important limitation in this study due to the small number cases in
each group, and further investigation is needed to clarify the feasibility of TLHHs in FIG and DIG.

DECLARATIONS
Authors’ contributions
Conception and design of the study and performed data analysis and interpretation, drafting the article:
Otsuka Y
Critical revise of the article: Kaneko H
Read and approved the final version of the manuscript: Otsuka Y, Ito Y, Matsumoto Y, Kimura K, Kajiwara Y,
Okubo K, Tsuchiya M, Okada R, Ishii J, Maeda T, Funahashi K, Kaneko H

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.