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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
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