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Sawa et al. Mini-invasive Surg 2024;8:30 https://dx.doi.org/10.20517/2574-1225.2024.43 Page 9 of 11

Figure 5. Surgical and postoperative outcomes compared between OLR and MIS groups in grade III. (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 193 cases (50.1%) in OLR and 2 cases (10.0%) in MIS
group (C). OLR: Open liver resection; MIS: minimally invasive surgery.

complexity grade III procedures may ensure a safe implementation of high complexity LLR procedures .
[29]
Nonetheless, our study emphasized the importance to assess outcomes of liver resection by taking into
account the difference in intergroup liver resection complexity. Finally, although the rate of intermediate-
or high-complexity MISLRs increased, the majority of the highly complex liver resections classified as grade
III procedures were performed via OLR.

In conclusion, careful selection and gradual expansion of MIRLR ensured the implementation of MISLR for
highly complex liver resections without mortality. The postoperative complications of intermediate- and
high-complexity resections were similar to those of low-complexity resections in patients undergoing
MISLR. However, the postoperative complications increased with the rise in surgical complexity in patients
undergoing OLR. MISLR should be used for liver resections if there are no contraindications.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study and performed data analysis and
interpretation: Sawa Y, Kawaguchi Y
Performed data acquisition and provided administrative, technical, and material support: Sawa Y,
Kawaguchi Y, Miyata A, Nishioka Y, Ichida A, Akamatsu N, Kaneko J, Hasegawa K