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Page 6 of 10 Cortes-Cerisuelo et al. Mini-invasive Surg 2019;3:1 I http://dx.doi.org/10.20517/2574-1225.2018.60

carried out laparoscopically and finished as an open resection, overall allowing for a smaller incision than
typically necessary for an open resection. Of all patients on the case series, 19 were females and the mean
age was 2.7 years (9 months to 17 years). While three of these patients were adolescents between 12-16 years
undergoing liver resection for benign tumors, two were under the age of 2 years undergoing liver resection
[47]
for hepatoblastoma . Of all resections carried out, 15 were for benign tumors and 21 were for malignant
tumors. Of the 21 children with malignant tumors, 20 had hepatoblastoma and the remaining one was an
adolescent of 17 years with a fibrolamellar HCC. All were unifocal lesions with a size ranging from 2-16 cm
in the benign tumor group and from 2-9 cm in the malignant tumor group. Of the 36 children, 31 (86%)
surgeries were performed as pure laparoscopic resections and 5 (14%) were carried out either as hand-assisted
or hybrid procedures. Of the 31 purely laparoscopically performed resections, 10 were segmentectomies, 5
were sectionectomies, and 16 were hemihepatectomies. Of the 5 hand-assisted or hybrid procedures, one was
a segmentectomy, and 4 were hemihepatectomies. The operative time correlated with the amount of liver
resected and was 74 (50-110) min for the segmentectomy group, 120 (48-200) min for the sectionectomies and
195 (55-450) min for the hemihepatectomies. Five patients required blood transfusion, 4 of which underwent
hemihepatectomy as hand-assist or hybrid procedure. Five patients suffered postoperative complications.
There was one seroma, one port site infection, one-line infection, one port dehiscence, and one hypertrophic
scar. The LOS was 3 days (2-6) for the segmentectomies, 4 days (2-5) for the sectionectomies, and 5 days
(2-9) for the hemihepatectomies. This LOS is shorter compared of what is published for open resection
[48]
of malignant tumors in children . All malignant tumors were removed with R0 margins. Follow-up for
children with malignant disease was 12-36 months and there were no local recurrences. One child had
pulmonary metastasis prior to resection, which had resolved on radioimaging following neoadjuvant
chemotherapy, however, this child had recurrence of the pulmonary lesions during the follow-up period
after the resection. In this same study, patients not considered for MILR were those that would not tolerate
laparoscopy, malignant lesions that could not be safely removed with adequate margins laparoscopically and
those with lesions too close to major vascular or biliary structures on imaging to allow safe laparoscopic
[47]
resection . Taken together, although their review does not include comparisons to contemporaneous
open controls, this comprehensive report for the first time shows that with appropriate patient selection
and the necessary expertise, MILR can safely be carried out in children with both benign and malignant
liver disease with excellent outcomes and minimal morbidity. Additionally, it clarifies that patients bearing
malignant tumors with PRETEXT III or above (three sections are involved, and no two adjoining sections
are free), with macrovascular invasion that require reconstruction of the vena cava or the portal vein, or with
doubts of resectability in whom liver transplantation is the next treatment option, may be poor candidates
for MILR.

OUTLOOK INTO THE FUTURE
Minimally-invasive hepatobiliary surgery in children requires not only specialized equipment but also
particular expertise in order to confine precision work in the enclosed space of the child’s abdominal cavity.
This is especially important for the consideration of MILR for pediatric tumors, because they typically
arise before the age of 3 years, when the entire abdominal cavity has the average size of an adult man’s liver.
Therefore, a hand-assisted approach, which is wide spread in adult MILR, is more difficult to perform in the
child due to the enclosed working space. Also, the incision required for the hand-port nearly confines the
incision necessary for open surgery, especially in a small child, therefore reducing the effect of “minimally-
invasive” surgery. However, it is important to note that the incision for a hand-port is usually vertical in
the midline of the upper abdomen and does not transect the rectus muscle, usually the main driver of
postoperative pain following typical open surgery. Nevertheless, unless operating on a large child or an
adolescent, hand-assisted MILR is unlikely to represent a breakthrough in pediatric oncological liver surgery.
On the contrary, other techniques widely spread in the pediatric population may be of great benefit when
considering MILR in this particular population. Perhaps its biggest value can be found in cases that are
elaborate and may otherwise not be completed safely without full conversion. Foremost, this includes SILS.