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Page 2 of 10 Cortes-Cerisuelo et al. Mini-invasive Surg 2019;3:1 I http://dx.doi.org/10.20517/2574-1225.2018.60

[4]
International Collaboration (CHIC) . One of the tasks in this collaboration is the standardization of the
surgical resection involved, by whatever means. In this article, we focus on reviewing the existing literature
on MILR in children and try to give an outlook of the possibilities and limitations of applying MILR in
children with cancer and how it could fit into current, standardized treatment strategies.

MILR IN ADULTS
MILR is now considered an established treatment option in adult liver tumor surgery with a curative
intent of both benign and malignant disease [1-3] . This advancement has been the result of increased
surgical experience, high-quality imaging laparoscopes with better visualization of the operative field
and the availability of specialized laparoscopic instruments for transecting the liver parenchyma [3,5,6] . In
large centers, outcomes and complication rates are similar to those of open resection, notwithstanding
[2,7]
the known benefits of a minimally-invasive surgical approach . Currently, there is an international
multicenter randomized controlled trial in Europe (ORANGE PLUS-II) comparing open vs. laparoscopic
right or left hemihepatectomies for malignancies with the main outcome being time to functional recovery
(https://clinicaltrials.gov/ct2/show/NCT01441856).

The knowledge acquired from minimally-invasive liver surgery (MILS) for liver tumors in adults has
opened the horizon for a variety of additional indications for MILS in the adult population. For example,
in addition to tumor resections, MILR has now gained acceptance as a means for resections carried out for
live donor liver transplant, especially in the setting where the recipient is a child and the intended graft is
that of a left lateral segment [8-13] . The first laparoscopic donor hepatectomies (left lateral section grafts) were
[14]
reported in 2002 and were performed for living donor liver transplantation (LDLT) in children . A recent
large series of 220 consecutive donations in pediatric live donor liver transplants showed similar recipient
[15]
outcomes including graft survival with better perioperative outcomes of the donors . The data on full lobe
resection for live donor liver transplant in the adult setting, especially concerning the right lobe, appear to
be less clear and are currently being discussed. However, at this time, many centers see encouraging results
with this approach [16,17] . It is likely that full laparoscopic right lobe hepatectomy, as is the case for the left
lateral segments, will become an accepted approach for adult live donor liver transplant as expertise with
MILR continues to grow. This approach has become the standard method in some large LDLT centers with
exceptionally high volume [18,19] .

CURRENT TREATMENT OF PEDIATRIC LIVER TUMORS
[20]
Pediatric liver tumors are uniquely different from adult liver tumors . While adult liver tumors typically
develop as carcinomas in cirrhotic or otherwise diseased livers, this type of growth is the exception in
the pediatric population. Rather, pediatric liver tumors are of embryonic origin and arise in otherwise
healthy livers, surrounded by healthy liver parenchyma. As will be explored later on, this understanding
has important implications for the resection of liver tumors in children, especially when considering a
minimally-invasive approach.

A wide variety of different tumors can arise in the pediatric liver. These include benign tumors such
as the infantile hepatic hemangioma as the most common benign liver tumor in children as well as
the mesenchymal harmatoma and the focal nodular hyperplasia [21,22] . Hepatoblastoma is not only the
most common malignant liver tumor in children, but also the most common liver tumor in children in
general [21,22] . Others, but considerably less common malignant liver tumors in the pediatric populations
are the undifferentiated embryonal sarcoma of the liver, the rhabdomyosarcoma of the biliary tree and
the hepatocellular carcinoma (HCC) of childhood [21,22] . It is of utmost importance that any surgeon
treating such tumors is intimately familiar with the details of the clinical development, their growth
pattern, their prognosis, as well as the up to date concerted interdisciplinary treatment algorithms of the