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Adams et al. Mini-invasive Surg 2023;7:18 https://dx.doi.org/10.20517/2574-1225.2023.12 Page 3 of 12

selection biases.

OPEN VERSUS LAPAROSCOPIC APPROACHES
Short-term outcomes
Many retrospective cohort studies have compared short-term outcomes of LLR vs. OLR. A meta-analysis by
Regmi et al. compiled results from eight retrospective studies and compared short-term results of LLR vs.
OLR for ICC. Length of stay was demonstrated to be notably shorter (P = 0.05), and overall morbidity rates
were lower with LLR compared to OLR (P = 0.002). Duration of the operation and intraoperative blood loss
were comparable between groups (P = 0.10), but the need for intraoperative blood transfusion was lower in
[26]
the LLR group (P = 0.005). There was no difference in perioperative mortality between groups (P = 0.62) .

A more recent retrospective cohort study supports these findings, comparing consecutive patients between
2011 to 2021 undergoing LLR vs. OLR for ICC. Short-term outcomes, including operation duration, surgical
margins, and intra- and post-operative transfusion, did not differ significantly between the groups, but
length of stay was shorter for the LLR group (8.8 vs. 10.6 days, P = 0.031). Major complications were higher
in the OLR group, although not statistically different (3.3% vs. 12.3%, P > 0.05). Notably, however, there
were differences in the size of the tumors and the extent of hepatectomy. The tumor diameter was larger in
the OLR group (4.7 cm vs. 5.7 cm, P = 0.053). Larger resections were performed in the OLR group
compared to the LLR group, including more trisectionectomy and hemihepatectomy (0.0% vs. 3.1%, 56.7%
[27]
vs. 81.5%, P = 0.007) . This suggests that while short-term outcomes of LLR may be acceptable and even
superior to OLR, these findings are at least partially reflective of a patient selection process to choose the
appropriate LLR candidates.

This bias was again shown in a larger multicenter study from Europe by Sahakyan et al., which compared
LLR to OLR for ICC . Prior to matching, there was a significant difference in many baseline preoperative
[28]
characteristics: OLR was associated with a higher rate of bilobar disease (6% vs. 25%, P < 0.01) and major
liver resection (38% vs. 64.7%, P < 0.01). Cases were then matched for patient age, American Society of
Anesthesiologists (ASA) grade, size, location and number of tumors, and underlying liver disease. After
matching, rates of major complications and transfusions were similar between the two groups, but OLR was
associated with longer length of stay (5 vs. 8 days, P < 0.01), longer operative durations (209 vs. 294 minutes,
P < 0.01), more reoperations (4% vs. 16%, P = 0.046), and more overall complications (30% vs. 52%, P =
0.025) .
[28]
Multiple other cohort studies have examined these short-term outcomes between LLR and OLR and
demonstrated comparable operative durations, major complication rates, and mortality rates. The available
data seem to consistently support shorter length of stay and less intraoperative blood loss when comparing
LLR to OLR [Table 1]. Rates of R0 resection also remain comparable between approaches [Table 2].

Rates of lymphadenectomy
As previously mentioned, LND is recommended as standard of care in the surgical management of ICC at
the very least for staging and prognostication purposes and to guide decision-making vis-à-vis adjuvant
[24]
therapies [24,25] . Current guidelines propose a minimum of 6 lymph nodes for adequate LND . Locoregional
control and even survival may improve with the performance of LND [24,29,30] , although the survival benefits
remain debated [31,32] . Adequate LND generally includes stations 8 and 12 [Figure 1], with one study
demonstrating improved DFS and OS with inclusion of these stations, although this difference was not
statistically significant (P = 0.080 and P = 0.078, respectively) . Even in lymph node-positive disease,
[33]
surgical resection with LND may be associated with improved survival [34,35] . Yet, there is a general failure to