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Golhar et al. Mini-invasive Surg 2019;3:9 I http://dx.doi.org/10.20517/2574-1225.2018.58 Page 5 of 8

Table 2. Previous studies comparing laparoscopic and open liver resection
Operative Hospital Resection
Author Type Blood loss Transfusion Complications
time stay margin
Simillis et al. [28] Meta-analysis LLR < OLR No significant No significant LLR < OLR No significant No significant
(2007) 8 studies difference difference difference difference
Zhou et al. [29] Meta-analysis LLR < OLR LLR < OLR No significant LLR < OLR LLR < OLR No significant
(2011) 21 studies difference difference
Rao et al. [30] Systematic review LLR < OLR LLR < OLR No significant LLR < OLR LLR < OLR No significant
(2012) 10 studies difference difference
Fancellu et al. Meta-analysis LLR < OLR LLR < OLR No significant LLR < OLR LLR < OLR No significant
[31]
(2011) 9 studies difference difference
Li et al. [32] Meta-analysis LLR < OLR LLR < OLR No significant LLR < OLR LLR < OLR No significant
(2012) 10 studies difference difference
Xiong et al. [33] Meta-analysis LLR < OLR LLR < OLR No significant LLR < OLR LLR < OLR No significant
(2012) 16 studies difference difference
Yin et al. [34] Meta-analysis LLR < OLR LLR < OLR No significant LLR < OLR LLR < OLR No significant
(2013) 15 studies difference difference
Fretland et al. [35] RCT No significant No significant No significant LLR < OLR LLR < OLR No significant
(2018) difference difference difference difference

LLR: laparoscopic liver resection; OLR: open liver resection; RCT: randomized controlled trials

Colorectal liver metastases
Recently published meta-analysis on LLR for colorectal liver metastases (CRLM) concluded that LLR
is a beneficial alternative to OLR in selected patients and does not compromise oncological outcomes
including surgical margins, tumor recurrence, disease-free survival or 5-year overall survival, with even a
[40]
possibility of better 3-year overall survival . Even though this meta-analysis used propensity matching for
compensating for selection bias, differences in proportions of major and minor resections and studies with
[40]
low statistical power might be a potential source of bias . In a recently completed randomized control
trial (OSLO-COMET trial) of 280 patients with CRLM, randomized either to laparoscopic (n = 133) or open
[38]
(n = 147) liver resection; blood loss, operative time and resection margins were similar in both groups
while the post-operative hospital stay was shorter with laparoscopic surgery (53 h vs. 96 h), complications
were significantly less (19% vs. 31%), costs were similar at four months while patients in the laparoscopic
[35]
group gained 0.011 quality adjusted life years .

ADVANCES IN LLR
The scope for LLR is increasing with improvements in LLR skills, availability of surgical gadgets and
[41]
use of the robotic platform . Robotic assistance is promising to aid difficult LLRs such as postero-
superior resections, non-anatomical resections along angulated or curvilinear resection planes, those
requiring complex vascular and biliary reconstructions, but these need further refinement in skills and
[41]
prospective validation . Even single incision laparoscopic liver resection has been reported in very
suitable tumors [42-44] . Few surgeons have reported the feasibility and safety of laparoscopic re-resections
for malignant liver tumors, with a satisfactory conversion rate of 15%, although with significantly greater
blood loss and operative time compared to primary LLR [45,46] . Laparoscopic re-resection of liver tumors
may be feasible even after previous OLR, up to two prior LLRs, after previous major hepatectomy, even in
[47]
cirrhotic livers and postero-superiorly located tumors . Recent advances in LLR also include laparoscopic
living donor hepatectomy and laparoscopic associating liver partition and portal vein ligation amongst
[48]
others .

SUMMARY
LLR is becoming widely accepted for the treatment of both benign and malignant liver tumors especially
HCC and CRLM. Laparoscopic left lateral sectionectomy and minor laparoscopic liver resection are now