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ready as a backup in case the tumor can be successfully resected. Reviewing the results of this study section
of the PHITT trial will hopefully clarify which patients will benefit more from extended resection vs.
transplantation and vice versa. For children who undergo resection, the study does not distinguish between
an open and a laparoscopic approach. However, it is clear that any innovative surgical technique such as
MILR must be properly integrated in a way that respects these surgical parameters.

MINIMALLY-INVASIVE HEPATOBILIARY SURGERY IN THE PEDIATRIC POPULATION
Minimally-invasive hepatobiliary surgery has long been established in the pediatric population. As is the
case for adults, one of the most commonly performed minimally-invasive hepatobiliary surgeries carried out
in children is cholecystectomy. This surgery can be safely performed by single-incision laparoscopic surgery
[28]
(SILS) . More complex operations of reconstructive nature are similarly standard of care in pediatric
surgery. Resection of a choledochal cyst and reconstruction of bile flow with hepaticojejunostomy is routinely
carried out in pediatric surgery, although some centers report higher complication rate compared to open
[31]
surgery [29,30] . This operation has been carried out successfully with a SILS approach . One of the major long-
term complications of choledochal cyst resection is, independent of the surgical approach, stenosis of the
hepaticojejunal anastomosis requiring dilation by the interventional radiologist or surgical revision. Redo
hepaticojejunostomy for children with choledochal cyst can - in experienced hands - be carried out safely as
a minimally-invasive approach [32,33] . Other indication in which laparoscopic hepatobiliary surgery has been
advocated in the pediatric population is the resection of hepatic cysts, even in the neonates [34,35] . Although
these cysts rarely require intervention, if they do they usually do not require formal liver resections but
simple cyst resection.

While the above-mentioned indications have withheld the test of time and are widely accepted amongst
pediatric surgeons around the world, one indication remains controversial. The excitement for the early
success of laparoscopic hepatobiliary surgery in children, especially that of choledochal cyst resection, has
lead to the laparoscopic reconstruction of biliary atresia over open reconstruction, which was until then the
mainstay therapy of this disease as a bridge to liver transplant. Despite the initial enthusiasm, increasing
evidence shows inferior outcomes for the laparoscopic approach of this sophisticated procedure [36-38] , which
is currently not considered standard of care. Nevertheless, a recent study with a large sample size has shown,
for the first time, an equal outcome for the laparoscopic approach when looking at 3 and 5-year native liver
[39]
survival, confusing the interpretation of current data . At our center, we perform the Kasai procedure open
for all cases of biliary atresia unless primary liver transplant is necessary.

Laparoscopic correction of extra-hepatic congenital portosystemic shunts (CPS) in children has also
[40]
been described . CPS is a rare entity and may lead to the development of jaundice, encephalopathy and
[41]
pulmonary hypertension . Obliteration of the shunt by the interventional radiologist by coiling or with a
vascular plug is not always an option, especially in large shunts or in those with flow directed to the inferior
vena cava with risk of migration of the foreign body into the heart. While the laparoscopic approach could
be an option, open laparotomy is generally required in these cases.

MILR FOR PEDIATRIC LIVER TUMORS
Although laparoscopic hepatobiliary surgery is commonplace in pediatric surgery, anatomical liver resection
in the pediatric population remains one of the last ambitions in the evolution of laparoscopic surgery.
This understanding is explained partially by the low frequency of liver tumors in children, which makes it
difficult for surgeons to accumulate experience with this technique.

Thus far, most laparosocopic hepatectomies reported in children are case reports and small case series of
[34]
non-anatomical resections for small, peripheral and isolated lesions [34,42-46] . Tabrizian and Midulla and