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Pais-Costa et al. Mini-invasive Surg 2018;2:33 I http://dx.doi.org/10.20517/2574-1225.2018.33 Page 7 of 11

relief. Histological examination confirmed negative surgical margins in all patients. Preoperative diagnosis
was confirmed in all but 2 patients (93%), who underwent oncological LH because of typical features
of hepatocellular carcinoma on preoperative imaging (wash-in/wash-out), but definitive pathological
evaluation showed HA in both cases. The median length of follow-up in this series was 48 months (range
2-120 months). Two patients experienced disease recurrence during follow-up. The first recurrence
occurred in a young woman two years after right posterior sectionectomy due to HA. She developed a new
HA in the left lobe and finally underwent a successful laparoscopic resection of segment III. The second
recurrence occurred ten years after left hepatectomy for PLA in a 78-year-old man. He presented a new
very large solid-cystic abscess in the right hepatic lobe (segments 7 and 8), for which he underwent open
unroofing and finally died due to postoperative infectious complications and sepsis.

We observed a statistically significant decrease of the overall QoL in seven measured variables (except
social) at early postoperative period until one month [Table 3]. However, after one month of the
postoperative period we observed a statistically significant increase of the all Qol variables. Thus all Qol
variables were similar between the preoperative and postoperative periods after 3 months from surgical
intervention. These variables were maintained similar until 12 months. Both role emotional and mental
health variables presented a great improvement after postoperative period [Table 3]. Application of the
questionnaire to evaluate esthetic body image after surgery showed that 93% of the patients considered that
their result was satisfactory. Only the two patients who underwent open conversion were dissatisfied with
their esthetic result.

DISCUSSION
Since initial experiences, LH has been proven to be a good choice for treating benign hepatic lesions,
especially for minor resections of lesions arising in easily accessible hepatic segments at anterolateral
[2-6]
positions, so-called “laparoscopic hepatic segments” . Since 2008, two major international expert
consensus conferences have been held to review the role of LH. The first of these was held in Louisville,
USA, where it was established that LH was best indicated for solitary lesions measuring 5 cm or less that
[6]
were located in segments 2 to 6 . At this meeting, it was accepted that laparoscopy should be considered
the standard approach for left lateral sectionectomy and that indications for surgical treatment of benign
hepatic lesions should not be widened simply because laparoscopic approach was feasible. Six years later,
a new consensus meeting involving many worldwide experts was held in Morioka, Japan, where hepatic
resections of greater complexity became more accepted, including major resections or resections of
[7]
posterosuperior liver segments, especially at referral centers . Therefore, LH is nowadays considered a safe
and feasible alternative to open operations, even for left or right major hepatectomies and malignant liver
lesions.

Given that LH is a complex laparoscopic procedure, laparoscopic left lateral sectionectomy has been
considered by many experts the ideal anatomical resection for initial training because of its anatomical
accessibility and the possibility of using the aid of staplers [18-22] . Therefore, laparoscopic left lateral
sectionectomy has been one of the most performed types of LH along the learning curve of many
authors [8,10,12] . Even though laparoscopic left lateral sectionectomy and right posterior sectionectomy were
the most frequent LHs performed in the present series, more complex LHs including left hepatectomy, right
hepatectomy and even mesohepatectomy were also performed, reflecting the strong trend in the literature
towards performing more complex procedures for treating hepatic lesions [2-13,15,23] .

Many studies, including meta-analyses, have confirmed the benefits of LH in comparison with open
hepatectomy, namely: lower levels of postoperative pain, fewer peritoneal adhesions, shorter hospital stay,
earlier return to daily activities, lower blood loss, reduced morbidity, fewer operative complications and
less mortality [2-15,18-29] . Among the short-term outcomes from our study, a low blood loss (mean 125 mL),