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Sawa et al. Mini-invasive Surg 2024;8:30 https://dx.doi.org/10.20517/2574-1225.2024.43 Page 3 of 11

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Figure 1. Three-level liver resection complexity classification. AL segments are defined as Couinaud segments 2, 3, 4b, 5, and 6. PS
[12]
segments are defined as Couinaud segments 1, 4a, 7, and 8. AL: Anterolateral; PS: posterosuperior. Citation with permission .
Copyright 2020, Clinics in liver disease.
Surgical procedure
We used a J-shaped or inverse L-shaped incision in most patients undergoing OLR and a midline or
subcostal incision in others. For patients undergoing MISLR, we used a reduced port approach . A
[13]
multiple access device was placed at the umbilicus via a 4-cm incision, and a camera port and assistant port
were created. On the basis of the tumor location, 2-3 trocars were placed via these ports. The clamp
crushing method was used in all the approaches. The intermittent inflow occlusion method (15 min of
clamping followed by 5 min of release) was used for all the patients undergoing OLR in general. In contrast,
it was used in selected patients undergoing LLR and RLR because pneumoperitoneum helps to control
[14]
bleeding . A drainage tube was generally placed.
Definition
Surgical margin was determined on the basis of pathological evaluation. The complications were graded
using Clavien–Dindo (CD) classification .
[15]