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Page 2 of 8                                          Golhar et al. Mini-invasive Surg 2019;3:9  I  http://dx.doi.org/10.20517/2574-1225.2018.58


               Table 1. Salient features of recommendations by the First European Guidelines Meeting on Laparoscopic Liver Surgery
                Indications for LLR                              Comments
                1. CRLM          LLR is a valid alternative to OLR in experienced hands for CRLM. As compared to OLR, LLR has better short term
                                 outcomes and equivalent oncological and long term survival outcomes for CRLM
                                 When feasible parenchyma sparing approach should be adopted during LLR, but it should not lead to alteration in the
                                 present indications for liver resection in CRLM
                                 Combined liver and colon resection should be adopted in highly selected cases only for CRLM. Timing of colon and
                                 liver resection in synchronous disease is similar to OLR
                2. Benign tumors and   Benign tumors and tumors with malignant potential are suitable for LLR with satisfactory short term post-operative
                non-colorectal liver   outcomes. LLR should not alter the indications for liver resection in such tumors
                metastases       LLR is an acceptable approach for metastases from neuroendocrine and non-colorectal liver metastases
                3. HCC           In selected patients LLR offers better short term post-operative outcomes such as decreased morbidity and hospital
                                 stay without compromising oncological outcomes
                                 Indications LLR are similar to those for OLR in case of HCC. Laparoscopic resection for tumors located in postero-
                                 superior (Segment 1, 4a, 7, 8) segments should be done only at experienced centers
                                 In experienced hands major LLR is appropriate option to OLR in highly selected patients
                                 Outcomes of left and right laparoscopic hepatectomy should be reported separately as they vary significantly.
                                 Laparoscopic right hepatectomy should be further developed in major liver centers
                                 In patients with HCC, as for other indications, selective use of intermittent Pringle’s maneuver may help decrease the
                                 blood loss without detrimental effect on liver function
                                 In patients with cirrhosis, LLR may be associated with less risk of post-operative ascites and liver decompensation.
                                 Minor LLR for single and peripheral HCC in selected Child B patients warrants cautious approach and further
                                 evaluation is needed
                4. LDH           LDH requires expertise in both liver transplantation and laparoscopic liver surgery
                                 Laparoscopic left lateral sectionectomy for pediatric liver transplantation offers reduction in blood loss, morbidity and
                                 hospital stay and should be considered equivalent to OLR
                                 Adult liver transplantation: LDH is not yet standardized in terms of donor selection and surgical technique. Its safety
                                 and postoperative outcomes needs to be evaluated in experienced center further
               CRLM: colorectal liver metastases; LLR: laparoscopic liver resection; OLR: open liver resection; LDH: laparoscopic donor hepatectomy;
               HCC: hepatocellular carcinoma


               recently, the second international consensus conference held at Morioka (Japan) in 2014, recommended
               that minor LLR to be considered as a standard practice and major LLR as an innovative procedure, under
                         [2]
               exploration . The first European Guidelines Meeting on Laparoscopic Liver Surgery at Southampton in
               February 2017 summarized available evidence for LLR for different liver tumors, types of resections and
                                                                                              [3]
               clinical situations. Few salient points relevant to this article have been summarized in Table 1 .


               TECHNICAL CHALLENGES IN LAPAROSCOPIC LIVER SURGERY
               Detailed understandings of the hilar and segmental anatomy of the liver and adequate experience with
                                                     [3]
               OLR are pre-requisites for performing LLR . The laparoscopic view is caudo-cranial for hilar dissection
                                                                                            [4]
               as well as the parenchymal transection compared to the antero-posterior view in OLR . Liver being a
               heavy and deep seated organ, especially its right lobe, may be difficult to maneuver. Liver tumors most
               often develop in a background of liver cirrhosis with stiff parenchymal tissue and collaterals due to portal
                                                                                                [4]
               hypertension, which makes the operation more difficult and increases the risk of bleeding . Tumors
               located in postero-superior or central segments, large tumors and intra-abdominal adhesions secondary
                                                                                             [4]
               to previous hepato-pancreato-biliary (HPB) surgeries can further make LLR more difficult . The learning
               curve for LLR is steep requiring about 45 to 60 cases before improvements in operative time, blood loss
                                                      [5,6]
               and post-operative complications are apparent .

               TECHNIQUE OF LAPAROSCOPIC LIVER SURGERY
               LLR may be performed purely laparoscopic, hand-assisted, using the hybrid technique or by robotic
               assisted approaches [4,5,7,8] . Port placement varies by tumor location, type of resection planned, patient
                                               [7]
               positioning and surgeon’s preference . Generally an umbilical port is used for the camera and directed
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