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Background: Artificial intelligence (AI) is becoming more useful as a decision-making and outcomes predictor tool. We have developed AI models to predict surgical complexity and the postoperative course in laparoscopic liver surgery for segments 7 and 8. Methods: We included patients with lesions located in segments 7 and 8 operated by minimally invasive liver surgery from an international multi-institutional database. We have employed AI models to predict surgical complexity and postoperative outcomes. Furthermore, we have applied SHapley Additive exPlanations (SHAP) to make the AI models interpretable. Finally, we analyzed the surgeries not converted to open versus those converted to open. Results: Overall, 585 patients and 22 variables were included. Multi-layer Perceptron (MLP) showed the highest performance for predicting surgery complexity and Random Forest (RF) for predicting postoperative outcomes. SHAP detected that MLP and RF gave the highest relevance to the variables “resection type” and “largest tumor size” for predicting surgery complexity and postoperative outcomes. In addition, we explored between surgeries converted to open and non-converted, finding statistically significant differences in the variables “tumor location,” “blood loss,” “complications,” and “operation time.” Conclusion: We have observed how the application of SHAP allows us to understand the predictions of AI models in surgical complexity and the postoperative outcomes of laparoscopic liver surgery in segments 7 and 8.

Purposes of this study are to evaluate the main changes that have occurred in the Italian MILS activity in the last decade in terms of indications, approaches and outcomes as reported in the national registry and to provide specific details on the main areas of development of MILS. Data from patients undergoing minimally invasive liver resections at centers included in the I Go MILS Registry from its start-up (November 2014) to March 2023 were analyzed for the purposes of this study. The registry is intention-to-treat and prospective. Global recruitment trends stratified by indication to surgery and type of approach were analysed. 7413 MILS procedures were performed across all centers (median number of procedures per center: 63). Years (2020–2023) displayed a significantly higher proportion of treated patients diagnosed with hepatocellular carcinoma (HCC) (38.2% vs. 28.9% and 33.9%, p< 0.001) and cholangiocarcinoma (6.7% vs. 6.5% and 4.2%, p< 0.001) compared to the preceding triennial periods. Additionally, technical complexity demonstrated an increased prominence in Years (2019–2023) with a significantly higher percentage of grade III cases compared to the earlier periods (39.3% vs. 21.7% and 25.6%, p< 0.001). Annual case trends focusing on laparoscopic and robotic techniques demonstrated a steadily increase in the use of these techniques for complex case mix of indications. Overall, attitude and attention to MILS approach has evolved, so that currently indications to hepatic mini-invasiveness have expanded and surgical technique has been refined: Areas mainly involved in increasing growth trends are hepatocellular carcinoma, possible applications of MILS in transplant setting, intrahepatic cholangiocarcinoma and robotic approach.

Background: Since 2012, Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) has encountered several modifications of its original technique. The primary endpoint of this study was to analyze the trend of ALPPS in Italy over a 10-year period. The secondary endpoint was to evaluate factors affecting the risk of morbidity/mortality/post-hepatectomy liver failure (PHLF). Methods: Data of patients submitted to ALPPS between 2012 and 2021 were identified from the ALPPS Italian Registry and evaluation of time trends was performed. Results: From 2012 to 2021, a total of 268 ALPPS were performed within 17 centers. The number of ALPPS divided by the total number of liver resections performed by each center slightly declined (APC= − 2.0%, p= 0.111). Minimally invasive (MI) approach significantly increased over the years (APC= + 49.5%, p= 0.002). According to multivariable analysis, MI completion of stage 1 was protective against 90-day mortality (OR= 0.05, p= 0.040) as well as enrollment within high-volume centers for liver surgery (OR= 0.32, p= 0.009). Use of interstage hepatobiliary scintigraphy (HBS) and biliary tumors were independent predictors of PHLF. Conclusions: This national study showed that use of ALPPS only slightly declined over the years with an increased use of MI techniques, leading to lower 90-day mortality. PHLF still remains an open issue.