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Cassese et al. Hepatoma Res 2022;8:24 https://dx.doi.org/10.20517/2394-5079.2022.15 Page 3 of 6

Nonetheless, several other issues about MILS and HCC are still open: in particular, LLR of postero-superior
(PS) segments and of giant or multiple tumors still represent challenges for both technical difficulty and
survival outcomes. However, more than 15 years ago, LLR for PS segments was already reported as feasible
in experienced high-volume centers, as well as laparoscopic caudate lobectomy [29-33] , and now it is
considered by Eastern and Western recommendations as a safe procedure, even if only for experienced
surgeons [34,35] . Improved laparoscopic technologies, such as flexible 3D scopes and ultrasonic cavitron
devices for transection of the deep liver parenchyma, lead to encouraging outcomes also for PS resections,
resulting in lower complication rates, reduced blood loss, and shorter postoperative hospital stay when
compared with OLR for the same segments [36-38] . To accompany the development of such difficult
procedures, strict quality control should be carried out to ensure the best oncological outcomes possible
despite the absence of randomized trials. Since there is no culture of negative reporting in the field of
surgery, we believe that a reasonable option for quality control comes from countries such as Japan, with the
[39]
introduction of mandatory nationwide registries .

Regarding tumor size, the question of feasibility depends primarily on center experience. Recently, Hong et
al. published good long-term oncological outcomes from a nationwide cohort of 466 patients with large
HCC in patients with tumor diameter > 10 cm . If technically feasible, the aforementioned advantages of
[40]
[41]
MILS have also been confirmed for giant tumors : Shelat et al., in 2015, reported the safety of LLR for large
[42]
malignant tumors, even if with higher blood loss and a longer operative time . From the technical point of
view, the trocars positioning, the mobilization of the liver, and the possibility of an accidental tumor
perforation by traction forces represent the biggest obstacles. Accordingly, we propose that the size of the
tumor should be taken into account in the difficulty scores . Thus, currently, most international guidelines
[43]
recommend surgery in the case of a resectable lesion regardless of its size [44-46] . According to our experience,
we recommend a Pfannenstiel incision for the extraction of large specimens, as it has proven to have low
rates of postoperative ileus, less postoperative pain, low incidence of surgical site infections, and a very low
incidence of incisional hernia (varying from 0% to 2%) . Furthermore, this incision preserves the muscles
[47]
and venous collaterals of the abdominal wall.

Regarding the number of tumors, a recent Japanese national series reported better results for Child-A
patients with multiple HCCs, when compared with radiofrequency or TACE in terms of OS, even if at the
cost of greater morbidity . However, the number of tumors is an independent risk factor for poor long-
[48]
term outcomes. Accordingly, Eastern countries do not consider the presence of multiple HCCs as a
[45]
contraindication .

Similarly, since the first series of robotic liver resections (RLR) reported by Giulianotti et al. in 2003, several
studies about its outcomes have been published, leading to the first international consensus statement on
RLR in 2018 [49,50] . RLR shows some technical advantages thanks to the ability to articulate the instruments in
all spatial planes, the magnified three-dimensional vision, and the ergonomic advantages, which may ideally
overcome traditional limitations of LLR, including inflexible fixation of the operating instruments and
greater oscillations and instability of the visual field [51,52] . After an initial phase of skepticism, several reports
have demonstrated the usefulness of RLS even in complex situations, such as resections of PS segment and
major hepatectomies [53,54] . Hu et al. reported how robotic hemi-hepatectomies were associated with less
intraoperative blood loss and a shorter operation time than LLR . A recent meta-analysis including 487
[41]
RLR and 902 LLR showed less bleedings for RLR at the cost of longer operation time than LLR . In this
[55]
special issue, Kato et al. showed in their study on 57 patients how RLR can also be safely performed for
[56]
anatomic resections (AR), even if technically more challenging than wedge resections . Finally, in the field
of living donor hepatectomy, huge steps forwards have also been taken, as widely reported and discussed in