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Page 8 of 11 Sawa et al. Mini-invasive Surg 2024;8:30 https://dx.doi.org/10.20517/2574-1225.2024.43

Figure 4. Surgical and postoperative outcomes compared between OLR and MIS groups in grade II. (A) Operation time is not
significantly different; (B) Blood loss, (C) complication of Clavien Dindo 2 or more, and (D) postoperative hospital stay are better in MIS
group. The numbers of cases of complication of Clavien Dindo 2 or more were 49 cases (28.5%) in OLR and 5 cases (10.6%) in MIS
group (C). OLR: Open liver resection; MIS: minimally invasive surgery.

postoperative complications and associated with scores of the classification by Wakabayashi et al. . The
[10]
classification by Kawaguchi et al. is reportedly useful in everyday clinical practice for evaluating training
pathways with graduated autonomy in liver resection , assessing outcomes stratified by surgical
[24]
complexity [25-27] , adjusting imbalance of surgical complexity between groups using propensity score
matching , and reporting intergroup differences in surgical complexity in real-world patients regardless of
[28]
geographical location .
[11]

A limitation of this study is that it was a single-center retrospective study. Furthermore, the background
demographics were not completely balanced between the groups. Additionally, repeat hepatectomy was not
assessed in the study. The current study does not show how much experiences of OLR and MISLR are
needed to safely expand the indication of MISLR toward grade II and III procedures. As such, careful
selection and indication expansion are needed. A recent study of our group with the cumulative sum
analysis showed that 40 cases of low complexity grade I procedures before starting intermediate complexity
grade II procedures, and 30 cases of intermediate complexity grade II procedures before starting high