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Robichaux et al.                                                                                                                                                                                    LLR in the cirrhotic patient

           hepatitis. Multiple studies have confirmed the benefits   open resection of  cirrhotic tumors,  these challenges
           of laparoscopic liver resection in decreasing operative   have  resulted  in  greater  difficulty  in  achieving  wide
           times, bleeding,  complications and length of stay  in   resection  margins  and  performing  formal anatomical
           non cirrhotic patients. [22-25]  Most cirrhotic resection data   resections,  as  well  as  increasing  the  difficulties  in
           has been included into larger hepatocellular  cancer   mobilization and in particular parenchymal transection,
           reports making assessment of this data questionable at   with risk of massive  bleeding.  These concerns  and
           best. However, a recent meta analysis of laparoscopic   potential issues have been the major obstacles to the
           resection of hepatocellular cancer in cirrhotic patients   widespread adoption of laparoscopic liver resection in
           confirmed this approach was associated with a reduced   the management of liver tumors in cirrhotics.
           risk of transfusion, decreased length of stay and wider
           surgical margins  but  failed to  identify a  difference in   In  conclusion,  laparoscopic  liver  resection  in  cirrhotic
           operative times, and morbidity.  This is in contrast to   patients appears safe and efficacious in experienced
                                       [26]
           a smaller French case-controlled study that identified   centers  resulting  in  overall  significantly  shorter
           laparoscopic  resection resulted in shorter operative   operative times, lower blood loss, and shorter hospital
           times, hospital stays and lower morbidity rates. [27]  stays and few complications. In subset analysis several
                                                              advantages of the laparoscopic approach are lost
           Our  current  data  presented  in  this  study  confirms   including lower blood loss and few complications. Our
           laparoscopic  resection  in cirrhotics provide  shorter   current experience in  laparoscopic major  resections
           operative times, blood loss, transfusion, intensive   in cirrhotics has leaded us to reconsider the learning
           care utilization, length  of stay, and  post operative   curve and temper our enthusiasm for major resection
           complications.  However, when operative  outcomes   in cirrhotics. Perhaps with increasing experience
           were analyzed in regard to the extent of resection the   these benefits will be realized but currently our group
           laparoscopic group persisted in shorter operative times   advocates a tempered and highly selective approach to
           with less intensive  care utilization  while  reduction  of   the laparoscopic approach to major cirrhotic resections.
           blood loss and shorter lengths of stay were not realized
           in the major resection group.                      Financial support and sponsorship
                                                              None.
           Multiple  studies have attributed the advantages  of   Conflicts of interest
           laparoscopic  liver  resections  to a less aggressive   There are no conflicts of interest.
           approach,  minimizing  peritoneal  dissection,  and
           bleeding leading to lower incidence of ascites and post-  Patient consent
           hepatectomy liver failure. [19-22]  Two authors have even   Not involved.
           suggested  laparoscopic  liver  resection  may extend
           the indication  of liver resection into selected  Child   Ethics approval
           B patients. [20,28]  Our experience with would  support   Approved by an institutional review board at authors’
           this supposition in well selected Child B patients. An   institution.
           additional advantage of laparoscopic liver resection of
           was reduction in postoperative adhesions  facilitating   REFERENCES
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