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Introduction: Despite the advances in minimally invasive (MI) liver surgery, most major hepatectomies (MHs) continue to be performed by open surgery. This study aimed to evaluate the risk factors and outcomes of open conversion during MI MH, including the impact of the type of approach (laparoscopic vs. robotic) on the occurrence and outcomes of conversions., Methods: Data on 3880 MI conventional and technical (right anterior and posterior sectionectomies) MHs were retrospectively collected. Risk factors and perioperative outcomes of open conversion were analyzed. Multivariate analysis, propensity score matching, and inverse probability treatment weighting analysis were performed to control for confounding factors., Results: Overall, 3211 laparoscopic MHs (LMHs) and 669 robotic MHs (RMHs) were included, of which 399 (10.28%) had an open conversion. Multivariate analyses demonstrated that male sex, laparoscopic approach, cirrhosis, previous abdominal surgery, concomitant other surgery, American Society of Anesthesiologists (ASA) score 3/4, larger tumor size, conventional MH, and Institut Mutualiste Montsouris classification III procedures were associated with an increased risk of conversion. After matching, patients requiring open conversion had poorer outcomes compared with non-converted cases, as evidenced by the increased operation time, blood transfusion rate, blood loss, hospital stay, postoperative morbidity/major morbidity and 30/90-day mortality. Although RMH showed a decreased risk of conversion compared with LMH, converted RMH showed increased blood loss, blood transfusion rate, postoperative major morbidity and 30/90-day mortality compared with converted LMH., Conclusions: Multiple risk factors are associated with conversion. Converted cases, especially those due to intraoperative bleeding, have unfavorable outcomes. Robotic assistance seemed to increase the feasibility of the MI approach, but converted robotic procedures showed inferior outcomes compared with converted laparoscopic procedures., (© 2023. Society of Surgical Oncology.)

Introduction: Although tumor size (TS) is known to affect surgical outcomes in laparoscopic liver resection (LLR), its impact on laparoscopic major hepatectomy (L-MH) is not well studied. The objectives of this study were to investigate the impact of TS on the perioperative outcomes of L-MH and to elucidate the optimal TS cutoff for stratifying the difficulty of L-MH., Methods: This was a post-hoc analysis of 3008 patients who underwent L-MH at 48 international centers. A total 1396 patients met study criteria and were included. The impact of TS cutoffs was investigated by stratifying TS at each 10-mm interval. The optimal cutoffs were determined taking into consideration the number of endpoints which showed a statistically significant split around the cut-points of interest and the magnitude of relative risk after correction for multiple risk factors., Results: We identified 2 optimal TS cutoffs, 50 mm and 100 mm, which segregated L-MH into 3 groups. An increasing TS across these 3 groups (≤ 50 mm, 51-100 mm, > 100 mm), was significantly associated with a higher open conversion rate (11.2%, 14.7%, 23.0%, P < 0.001), longer operating time (median, 340 min, 346 min, 365 min, P = 0.025), increased blood loss (median, 300 ml,  ml, 400 ml, P = 0.002) and higher rate of intraoperative blood transfusion (13.1%, 15.9%, 27.6%, P < 0.001). Postoperative outcomes such as overall morbidity, major morbidity, and length of stay were comparable across the three groups., Conclusion: Increasing TS was associated with poorer intraoperative but not postoperative outcomes after L-MH. We determined 2 TS cutoffs (50 mm and 10 mm) which could optimally stratify the surgical difficulty of L-MH., (© 2023. Society of Surgical Oncology.)

Background: The procedure of choice for the resection of ampullary tumors comprises transduodenal ampullectomy (TDA), endoscopic papillectomy (EP), and pancreaticoduodenectomy (PD). 1 For neoplasms with low-grade dysplasia, TDA and EP have equivalent efficacies and lower morbidities than PD 1 . Compared with EP, also as an organ-preserving procedure, TDA could be applicable for tumors involving the pancreatic ducts or common bile ducts. 2 Because TDA has a lower incidence of postoperative gastrointestinal bleeding and a higher R0 resection rate, its use could avoid the need to use multiple endoscopic procedures for larger lesions. 3 Furthermore, during TDA, surgeons could convert to PD as necessary. However, TDA has rarely been performed using a minimally invasive approach that addresses the shortcomings of both the endoscopic and open surgical techniques without adding significant morbidity or compromising outcomes. 2,4 Conventional laparoscopic TDA (LTDA) remains limited due to the complexity of the surgical anatomy of the ampulla and the reconstruction required compared with robot-assisted procedures. 2-5 However, robot-assisted surgery is less popular and much more expensive than laparoscopic surgery. This report with a video describes the LTDA approach to standardize and simplify the surgical processes., Methods: A 48-year-old man was admitted to the hospital with epigastric pain. He had a history of cholecystolithiasis with chronic cholecystitis. A tumor approximately 2.2 cm in diameter located in the duodenal papilla was diagnosed by an enhanced computed tomography (CT) scan. The endoscopic biopsy result indicated a villous adenoma with moderate dysplasia. Laparoscopic TDA and cholecystectomy were planned. However, if the frozen sample analysis showed adenocarcinoma, laparoscopic PD (LPD) would be applied. The patient was placed in the supine position with both legs apart. Trocars were distributed in the same manner as in the authors' previous study to facilitate conversion to LPD. 6 The procedure began with kocherization and dissection of the gastrocolic ligament to explore the second and third portions of the duodenum. A figure-eight suture was made using 4-0 prolene in the seromuscular layer, and then the duodenum was retracted to the left side of the patient. A longitudinal duodenotomy was made, and the ampulla of Vater was identified. A transfixing suture was placed through the tumor. Submucosal injection of norepinephrine (1:500) was performed to divide the mucosa from the muscular planes. Ampullectomy was performed by first dissecting in the submucosal plane with a harmonic scalpel at the 6 o'clock position until the pancreatic duct was reached. A 6-Fr plastic catheter was inserted into the pancreatic duct for subsequent reconstruction. Continued dissection around the tumor identified the bile duct. Another 6-Fr plastic catheter was inserted into the bile duct. The dissection was completed in the submucosal plane, and the specimen was retrieved for frozen sectioning. After confirmation of villous adenoma with moderate dysplasia and the proximal margin without residual tumor on frozen biopsy, reconstruction was performed. The septum between the ducts was plastered, and the bile and pancreatic ducts were reconstructed on the duodenal wall with 5-0 PDS-II interrupted sutures to ensure that these ducts remained patent and connected. After reconstruction, the plastic catheter was kept in the pancreatic duct but removed from the bile duct. Then, cholecystectomy was applied. Finally, the duodenum was closed obliquely in two layers, and two drains were routinely placed., Results: The operation time was 139 min, and the estimated blood loss was 50 ml. Final pathology confirmed villous adenoma with mild to moderate dysplasia. The postoperative course was uneventful, with a hospital stay of 9 days. There was no evidence of recurrence or patency of the reimplanted ducts 5 months after surgery. From February 2022 to May 2022, four cases of LTDA with the same surgical processes were managed by the authors, and all the patients recovered quickly without any postoperative complications., Conclusion: After standardization of the surgical processes, laparoscopic TDA was safe for highly selected patients. However, long-term follow-up is required to observe the quality of life and survival of patients., (© 2022. Society of Surgical Oncology.)