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BACKGROUND: Laparoscopic and robotic minimally invasive liver surgery (MILS) is gaining popularity. Recent data and views on the implementation of laparoscopic and robotic MILS throughout Europe are lacking.METHODS: An anonymous survey consisting of 46 questions was sent to all members of the European-African Hepato-Pancreato-Biliary Association.RESULTS: The survey was completed by 120 surgeons from 103 centers in 24 countries. Median annual center volume of liver resection was 100 [IQR 50-140]. The median annual volume of MILS per center was 30 [IQR 16-40]. For minor resections, laparoscopic MILS was used by 80 (67%) surgeons and robotic MILS by 35 (29%) surgeons. For major resections, laparoscopic MILS was used by 74 (62%) surgeons and robotic MILS by 33 (28%) surgeons. The majority of the surgeons stated that minimum annual volume of MILS per center should be around 21-30 procedures/year. Of the surgeons performing robotic surgery, 28 (70%) felt they missed specific equipment, such as a robotic-CUSA. Seventy (66%) surgeons provided a formal MILS training to residents and fellows. In 5 years' time, 106 (88%) surgeons felt that MILS would have superior value as compared to open liver surgery.CONCLUSION: In the participating European liver centers, MILS comprised about one third of all liver resections and is expected to increase further. Laparoscopic MILS is still twice as common as robotic MILS. Development of specific instruments for robotic liver parenchymal transection might further increase its adoption.

Background Data on morbidity and mortality following liver resection after radioembolization (Y90) are limited and controversial. Therefore, the perioperative morbidity and mortality of liver resections after Y90 treatment were investigated with systematic review and meta-analysis. Methods A PubMed search was conducted to identify studies of liver resection after previous Y90 treatment. Systematic review and meta-analysis for perioperative morbidity and mortality were perfomed using the 2009 PRISMA guidelines and STATA 16.1 software. Results A total of 16 studies reporting on 276 patients who underwent liver resection after Y90 met the inclusion criteria and were included in the meta-analysis. Meta-analysis of 30-day mortality rates yielded pooled mortality of 0.5% (95% CI 0.0–3.2%). Six studies (155 patients) reported a pooled 90-day mortality of 3.0% (95% CI 0.3–7.4%). The median time to resection after Y90 ranged from 2 to 12.5 months in various studies. In all studies where the median resection was undertaken eight or more months after Y90, zero 30-day mortality was reported. A meta-analysis of overall grade 3 or higher morbidity noted a rate of 26% (95% CI 16–37%). Conclusions Liver resection after Y90 may be safe in very well selected patients. Delaying resection after Y90 may further decrease mortality.

Background Presently, data on the impact of enhanced recovery protocols on the outcomes of laparoscopic liver resection remain limited. We performed propensity matched analysis comparing the outcomes between patients undergoing laparoscopic liver resection before and after the introduction of an enhanced recovery protocol. Methods Between 2013 and 2019, 462 consecutive patients underwent laparoscopic liver resection by 3 surgeons of which 360 met the study inclusion criteria. There were 89 patients who underwent surgery under an enhanced recovery protocol and 271 without an enhanced recovery protocol. One-to-one propensity matched analysis was performed for 84 enhanced recovery protocol patients and 84 nonenhanced recovery protocol patients. Results Comparisons between propensity matched cohorts revealed that patients who received laparoscopic liver resection with enhanced recovery protocol had reduced median blood loss (200 vs 300 mL, P = .013), postoperative stay (3 vs 4 days, P = .003), and lower open conversion rates (0% vs 8.3%, P = .008). There was no difference in other key perioperative outcomes such as operation time, postoperative morbidity, postoperative major morbidity, and 30-day readmission rates. Conclusion A combined approach of enhanced recovery protocol and laparoscopic liver resection was associated with improved perioperative outcomes as opposed to laparoscopic liver resection alone.

Розроблена та застосована у 121 пацієнта оптимізована схема анестезії та інтенсивної терапії під час обширних резекцій печінки в онкохірургії, що включає застосування мультимодальної аналгезії, трансфузії автологічної крові, тромбопрофілактики низькомолекулярними гепаринами. Для оцінки адекватності застосовуваної методики використані: варіаційна пульсометрія, аналіз параметрів гемодинаміки, сироваткових концентрацій кортизолу, глюкози, анти-Х-фактора згортання крові пацієнтів, ступінь вираженості післяопераційного болю, частота післяопераційних ускладнень. Встановлено, що максимальну ефективність і безпеку для пацієнтів має схема анестезії, що включає комбіновану загальну інгаляційну анестезію севофлюраном, подовжену грудну епідуральну аналгезію і нормоволемічну гемодилюцію у поєднанні з трансфузією автологічної крові в періопераційному періоді. В одній з груп пацієнтів були зареєстровані оптимальні гемодинамічні показники, мінімальні рівні стресових маркерів і ступеня вираженості післяопераційного болю, зменшення частоти післяопераційних ускладнень.

BACKGROUND: Liver resection is high-risk surgery in particular in elderly patients. The aim of this study was to explore postoperative outcomes after liver resection in elderly patients.METHODS: In this nationwide study, all patients who underwent liver resection for primary and secondary liver tumours in the Netherlands between 2014 and 2019 were included. Age groups were composed as younger than 70 (70-), between 70 and 80 (septuagenarians), and 80 years or older (octogenarians). Proportion of liver resections per age group and 30-day major morbidity and 30-day mortality were assessed.RESULTS: In total, 6587 patients were included of whom 4023 (58.9%) were younger than 70, 2135 (32.4%) were septuagenarians and 429 (6.5%) were octogenarians. The proportion of septuagenarians increased during the study period (aOR:1.06, CI:1.02-1.09, p < 0.001). Thirty-day major morbidity was higher in septuagenarians (11%) and octogenarians (12%) compared to younger patients (9%, p = 0.049). Thirty-day mortality was higher in septuagenarians (4%) and octogenarians (4%) compared to younger patients (2%, p < 0.001). Cardiopulmonary complications occurred more frequently with higher age, liver-specific complications did not. Higher age was associated with higher 30-day morbidity and 30-day mortality in multivariable logistic regression.CONCLUSION: Thirty-day major morbidity and 30-day mortality are higher after liver resection in elderly patients, attributed mainly to non-surgical cardiopulmonary complications.

Background Laparoscopic redo resections for colorectal metastases are poorly investigated. This study aims to explore long-term results after second, third, and fourth resections. Material and methods Prospectively updated databases of primary and redo laparoscopic liver resections in six European HPB centers were analyzed. Procedure-related overall survival after first, second, third, and fourth resections were evaluated. Furthermore, patients without liver recurrence after first liver resection were compared to those with one redo, two or three redo, and patients with palliative treatment for liver recurrence after first laparoscopic liver surgery. Survival was calculated both from the date of the first liver resection and from the date of the actual liver resection. In total, 837 laparoscopic primary and redo liver resections performed in 762 patients were included (630 primary, 172 first redo, 29 second redo, and 6 third redo). Patients were bunched into four groups: Group 1—without hepatic recurrence after primary liver resection (n = 441); Group 2—with liver recurrence who underwent only one laparoscopic redo resection (n = 154); Group 3—with liver recurrence who underwent two laparoscopic redo resections (n = 29); Group 4—with liver recurrence who have not been found suitable for redo resections (n = 138). Results No significant difference has been found between the groups in terms of baseline characteristics and surgical outcomes. Rate of positive resection margin was higher in the group with palliative recurrence (group 4). Five-year survival calculated from the first liver resection was 67%, 62%, 84%, and 7% for group 1, 2, 3, and 4, respectively. Procedure-specific 5-year overall survival was 50% after primary laparoscopic liver resection, 52% after the 1st reoperation, 52% after the 2nd, and 40% after the 3rd reoperation made laparoscopic. Conclusions Multiple redo recurrences can be performed laparoscopically with good long-term results. Liver recurrence does not aggravate prognosis as long as the patient is suitable for reoperation.

As a result of the analysis of modern Russian and foreign literature, it was found that in the structure of postoperative complications after liver resections, biliary complications are the leading ones today. The main risk factors for the development of biliary complications and predictors of prognosis were determined at the different stages (preoperative, during the operation and postoperative period). The necessity to apply a complex of instrumental investigation methods in the postoperative period for early detection of bile leakage, clarification of its causes and forms of manifestation is determined; their importance for choosing a method of elimination is emphasized. The ways of improving the results of liver resections due to the prevention and effective elimination of bile leakage are outlined.Possibilities of prognosis of biliar complications after liver resections were analyzed. The available assessment systems can be considered uninformative, which demands development and implementation of more modern and more effective programs for predicting biliary complications after liver resections.

International audience; Objective: The aim of this study was to build a predictive model of operative difficulty in open liver resections (LRs). Summary Background Data: Recent attempts at classifying open-LR have been focused on postoperative outcomes and were based on predefined anatomical schemes without taking into account other anatomical/technical factors. Methods: Four intraoperative variables were perceived by the authors as to reflect operative difficulty: operation and transection times, blood loss, and number of Pringle maneuvers. A hierarchical ascendant classification (HAC) was used to identify homogeneous groups of operative difficulty, based on these variables. Predefined technical/anatomical factors were then selected to build a multivariable logistic regression model (DIFF-scOR), to predict the probability of pertaining to the highest difficulty group. Its discrimination/calibration was assessed. Missing data were handled using multiple imputation. Results: HAC identified 2 clusters of operative difficulty. In the ``Difficult LR'' group (20.8% of the procedures), operation time (401 min vs 243 min), transection time (150 vs.63 minute), blood loss (900 vs 400 mL), and number of Pringle maneuvers (3 vs 1) were higher than in the ``Standard LR'' group. Determinants of operative difficulty were body weight, number and size of nodules, biliary drainage, anatomical or combined LR, transection planes between segments 2 and 4, 4, and 8 or 7 and 8, nonanatomical resections in segments 2, 7, or 8, caval resection, bilioentric anastomosis and number of specimens. The c-statistic of the DIFF-scOR was 0.822. By contrast, the discrimination of the DIFF-scOR to predict 90-day mortality and severe morbidity was poor (c-statistic: 0.616 and 0.634, respectively). Conclusion: The DIFF-scOR accurately predicts open-LR difficulty and may be used for various purposes in clinical practice and research.

Background Complex liver resection is a risk factor for the development of AKI, which is associated with increased morbidity and mortality. Aim of this study was to assess risk factors for acute kidney injury (AKI) and its impact on outcome for patients undergoing complex liver surgery. Methods AKI was defined according to the KDIGO criteria. Primary endpoint was the occurrence of AKI after liver resection. Secondary endpoints were complications and mortality. Results Overall, 146 patients undergoing extended liver resection were included in the study. The incidence of AKI was 21%. The incidence of chronic kidney disease (CKD) and hepatocellular carcinoma were significantly higher in patients with AKI. In the AKI group, the proportion of extended right hepatectomies was the highest (53%), followed by ALPPS (43%). Increased intraoperative blood loss, increased postoperative complications and perioperative mortality was associated with AKI. Besides age and CKD, ALPPS was an independent risk factor for postoperative AKI. A small future liver remnant seemed to increase the risk of AKI in patients undergoing ALPPS. Conclusion Following extended liver resection, AKI is associated with an increased morbidity and mortality. ALPPS is a major independent risk factor for the development of AKI and a sufficient future liver remnant could avoid postoperative AKI.

The relationship between hospital volume and surgical outcomes is well-established; however, considerable socioeconomic and geographic barriers to high-volume care persist. This study assesses how the overall volume of hepatopancreaticobiliary (HPB) cancer operations impacts outcomes of liver resections (LRs).The National Cancer Database (2004-2014) was queried for patients who underwent LR for hepatocellular carcinoma. Hospital volume was determined separately for all HPB operations and LRs. Centers were dichotomized as low and high volume based on the median number of operations. The following study cohorts were created: low-volume hospitals (LVHs) for both LRs and HPB operations, mixed-volume hospitals (MVHs) with low-volume LRs but high-volume HPB operations, and high-volume LR hospitals (HVHs) for both LRs and HPB operations.Of 7,265 patients identified, 37.5%, 8.8%, and 53.7% were treated at LVHs, MVHs, and HVHs, respectively. On multivariable analysis, patients treated at LVHs had higher 30-day mortality compared with patients treated at HVHs (odds ratio 1.736; p0.001). However, patients treated at MVHs experienced 30-day mortality comparable with patients treated at HVHs (odds ratio 0.789; p = 0.318). Similar results were found for positive margin status, prolonged hospital stay, and overall survival.LR outcomes at low-volume LR centers that have substantial experience with HPB cancer operations are similar to those at high-volume LR centers. Our results demonstrate that the volume to outcomes curve for HPB operations should be assessed more holistically and that patients can safely undergo liver operations at low-volume LR centers if HPB volume criteria are met.

BACKGROUND This study aims to compare the short- and long-term outcomes of patients undergoing minimally invasive liver resection (MILR) versus open liver resection (OLR) for nonrecurrent hepatocellular carcinoma (HCC). METHODS Review of 204 MILR and 755 OLR without previous LR performed between 2005 and 2018. 1:1 coarsened exact matching (CEM) and 1:1 propensity-score matching (PSM) were performed. RESULTS Overall, 190 MILR were well-matched with 190 OLR by PSM and 86 MILR with 86 OLR by CEM according to patient baseline characteristics. After PSM and CEM, MILR was associated with a significantly longer operation time [230 min (interquartile range [IQR], 145-330) vs. 160 min (IQR, 125-210), p

Surgeons often remain reluctant to consider laparoscopic approach in multiple liver tumors. This study assessed feasibility and short-term results of patients who had more than 3 simultaneous laparoscopic liver resections (LLR). All consecutive patients who underwent LLR for primary or secondary malignancies between 2009 and 2019 were analyzed. After exclusion of major LLR, patients were divided into three groups: less than three (Group A), between three and five (Group B), and more than five resections (Group C) in the same procedure. Intraoperative details, postoperative outcomes, and textbook outcome (TO) were compared in the 3 groups. During study period, 463 patients underwent minor LLR. Among them, 412 (88.9%) had less than 3 resections, 38 (8.2%) between 3 and 5 resections, and 13 (2.8%) more than 5 resections. Despite a difficulty score according to IMM classification comparable in the 3 groups (with high difficulty grade 3 procedures of 16.5% vs. 15.7% vs. 23.1% in Group A, B, and C, respectively, p = 0.124), mean operative time was significantly longer in Group C (p = 0.039). Blood loss amount (p = 0.396) and conversion rate (p = 0.888) were similar in the 3 groups. Rate of R1 margins was not significantly different between groups (p = 0.078). Achievement of TO was not different between groups (p = 0.741). In multivariate analysis, non-achievement of TO was associated with difficulty according to IMM classification (OR = 2.29 (1.33–3.98)). Since intra- and post-operative outcomes and quality of resection are comparable, multiple liver resections should not preclude the laparoscopic approach.

Background: Indocyanine green (ICG) fluorescence imaging has been extensively used in a variety of applications in visceral surgery. In minimally invasive liver resections, the detection of small s...

Background The advantages of robotic liver surgery are strongest for minor resections, where incision size drives recovery time, but cost remains a concern. We hypothesized that patients who underwent robotic minor liver resections would have superior peri-operative outcomes resulting in decreased cost. Methods We queried the medical record and cost data for patients who underwent open or robotic minor (1–2 segment) liver resection from 1/2016–8/2019. Financial data were normalized to Medicare reimbursements. Results There were 87 patients who underwent minor liver resections (robotic n = 46, open n = 41). Specimen size (173 ± 203 vs 257 ± 481 cm3), surgical duration (233 ± 87 vs 227 ± 83 min), estimated blood loss (187 ± 236 vs 194 ± 165 mL), and margin status (89% vs 93% R0) were similar for robotic and open resections respectively, yet complications (3/46, 7% vs 10/41, 24%, p = 0.02) and length of stay (2.2 ± 2.2 vs 6.2 ± 2.9, p Conclusion Patients undergoing robotic minor hepatectomy had superior peri-operative outcomes resulting in lower total cost of care when compared to open minor hepatectomy. Financial considerations should not adversely influence selection of a robotic approach for minor hepatectomy.

Over the past 2 decades the minimally invasive liver resections have become preferable in liver tumors surgery in adult patients. Indications for minimally invasive operations in pediatric surgery are actively extending, but the number of such reports remains limited. The slow pace of broad application of laparoscopic hepatectomy in children is explained, first of all, by the limited space in abdominal cavity of children, and lower prevalence of liver tumors in the pediatric population. This review analyzes the evolution of laparoscopic liver resections in adults and possibilities of applying this experience to pediatric hepatic surgery.

Aim. To analyze the safety and advantages of central resection in comparison with extended hepatectomies. Methods. From June 2017 to May 2020 29 central and extended liver resections for children were performed. Central hepatic resections were carried out in 8, extended hepatectomies – in 21 patients. Preoperative investigations, intraoperative and postoperative data in both groups were analyzed.Results. The main indication for surgery was hepatoblastoma. Future liver remnant volume was significantly higher in central resections group (р = 0.003). No difference in median operative time (р = 0.94), intraoperative blood loss (р = 0.078) and blood transfusion rate (р = 0.057) were found between groups. There were no postoperative complications difference. Also no difference in hospital stay length (р = 0.3) were found.Conclusion. In comparison with extended procedures, central liver resection has similar complication rate. Central hepatectomy is a safe procedure in children with liver tumors, which allows to preserve more healthy parenchyma.

BACKGROUND Although included in surveillance programmes for colorectal cancer (CRC) metastases, elderly patients are susceptible to declines in health and quality of life that may render them unsuitable for further surveillance. Deciding when to cease surveillance is challenging. METHODS There are no publications focused on surveillance of elderly patients for CRC metastases. A systematic review of studies reporting treatment outcomes for CRC metastases in elderly patients was performed to assess the risk-benefit balance of the key objectives of surveillance; detecting and treating CRC metastases. RESULTS Sixty-eight eligible studies reported outcomes for surgery and chemotherapy in the elderly. Liver resections and use of chemotherapy, including biologics, are more conservative and have poorer outcomes in the elderly compared with younger patients. Selected studies demonstrated poorer quality-of-life (QoL) following surgery and chemotherapy. Studies of ablation in elderly patients are limited. DISCUSSION The survival benefit of treating CRC metastases with surgery or chemotherapy decreases with advancing age and QoL may decline in the elderly. The relatively lower efficacy and detrimental QoL impact of multimodal therapy options for detected CRC metastases in the elderly questions the benefit of surveillance in some elderly patients. Care of elderly patients should thus be customized based on their preference, formal geriatric assessment, natural life-expectancy, and the perceived risk-benefit balance of treating recurrent CRC metastases. Clinicians may consider surveillance cessation in patients aged 75 years and above if geriatric assessment is unsatisfactory, patients decline surveillance, or patient fitness deteriorates catastrophically.

Zusammenfassung Hintergrund Das hepatozelluläre Karzinom (HCC) ist der häufigste maligne Lebertumor in einer Leberzirrhose. Neben der Lebertransplantation stellt die Leberresektion in kompensierter Zirrhose eine kurative Therapieoption dar, die jedoch mit einer höheren postoperativen Morbidität und Mortalität einhergeht. Patienten Es wurden 108 Patienten identifiziert, die mit einer Leberzirrhose im Zeitraum von Januar 2008 bis Dezember 2019 an der Universitätsmedizin Mainz eine Leberresektion erhalten haben. Im gleichen Zeitraum wurden 185 Resektionen wegen eines HCC in nicht zirrhotischer Leber durchgeführt. Als weitere Kontrollgruppe dienten 167 Resektionen wegen kolorektaler Lebermetastasen (CRLM), die dem Ausmaß der Resektionen in Leberzirrhose entsprachen. Neben den generellen Patientencharakteristika wurde bei allen Patienten präoperativ der Charlson Comorbidity Index (CCI) erhoben und der MELD-/Child-Score bestimmt. Die perioperative Morbidität wurde nach der Clavien-Dindo-Klassifikation erfasst. Resektionen eines HCC in Zirrhose und kolorektaler Lebermetastasen wurden zudem in einer Match-Pair-Analyse verglichen. Ergebnisse Die 3 Gruppen waren hinsichtlich des Alters zum Operationszeitpunkt vergleichbar. Die präoperative Leberfunktion war bei Patienten mit CRLM signifikant besser (p Schlussfolgerung Resektionen in einer Leberzirrhose sind bei einer Begrenzung des Resektionsausmaßes und entsprechender Patientenselektion mit einem vertretbaren Risiko möglich. Komorbiditäten erhöhen zusätzlich zu einer Einschränkung der Leberfunktion die postoperative Mortalität, weshalb diese unbedingt in die Patientenselektion integriert werden sollten.

Background Laparoscopic anatomic hepatectomy (LAH) has gradually become a routine surgical procedure. However, how to expose the whole hepatic vein and avoid the hepatic vein laceration is still a challenge because of the caudate lobe, particularly in right hepatectomy. We adopted a dorsal approach combined with Glissionian appraoch to perform laparoscopic right anatomic hepatectomy (LRAH). Methods Twenty patients who underwent LRAH from January 2017 to November 2018 were retrospectively analysed. Of these patients, seven patients underwent laparoscopic right hemihepatectomy (LRH group), seven patients who underwent laparoscopic right posterior hepatectomy (LRPH group), and six patients who underwent laparoscopic hepatectomy for segment 7 (LS7 group). The paracaval portion of caudate lobe could be transected firstly through dorsal approach and the corresponding major hepatic vein could be exposed from its root to the peripheral branches safely. Due to exposure along the major hepatic vein trunk, the remaining liver parenchyma could be quickly transected from dorsal to cranial side. Results The mean age of the patients was 53.8 years and the male: female ratio was 8:12. The median operation time was 306.0 ± 58.2 min and the mean estimated volume of blood loss was 412.5 ± 255.4 mL. The mean duration of postoperative hospital stay was 10.2 days. The mean Pringle maneuver time was 64.8 ± 27.7 min. Five patients received transfusion of 2–4 U of red blood cells. Two patients suffered from transient hepatic dysfunction and one suffered from pleural effusion. None of the patients underwent conversion to an open procedure. The operative duration, volume of the blood loss, Pringle maneuver time, and postoperative hospital stay duration did not differ significantly among the LRH, LRPH, and LS7 groups (P > 0.05). Conclusions Dorsal approach combined with Glissonian approach for right lobe is feasible and effective in laparoscopic right anatomic liver resections.

Two-stage liver resections were described to increase the resectability of liver tumors in patients with insufficient future liver remnant. The ALPPS procedure, described in 2011, has represented a breakthrough in the field of hepato-pancreato-biliary surgery. This technique accelerates the hypertrophy of the future liver remnant and reduces the interval between the two surgeries compared with previous techniques. ALPPS has gained popularity rapidly, with more than 1200 patients included in the world registry. Recommendations about indications, patient selection and surgical standardization have been discussed twice in international expert meetings. Although ALPPS has proven to be superior in terms of resectability (80-100% versus 60-90% of twostage hepatectomy), its rapid implementation has been punished with high morbidity and mortality reaching up to 40% and 9%, respectively, in the published series. The current evidence on the possible benefits and disadvantages is mainly based on observational studies. We present a historical review, describing the different technical modifications that have been carried out since its description, with a rigorous review in terms of morbidity, mortality, and oncological outcomes.

Backgrounds/Aims Laparoscopic major liver resections are still considered innovative procedures despite the recent development of laparoscopic liver surgery. Robotic surgery has been introduced as an innovative system for laparoscopic surgery. In this study, we investigated surgical outcomes after major liver resections using robotic systems. Methods From January 2009 to October 2018, 70 patients underwent robotic major liver resections, which included conventional major liver resections and right sectionectomy. The short-term and long-term outcomes were compared with 252 open major resections performed during the same period. Results Operative time was longer in the robotic group (472 min vs. 349 min, p

Living related liver transplantation has proved to be an effective, safe and radical method for treating end-stage liver diseases. In the last decade, a laparoscopic approach to donor hepatectomy has been gradually introduced into clinical practice. According to world literature, there are presently no uniform standards for performing laparoscopic liver resections in living donors. This literature review considers almost all methods for performing this surgery in living donors. These methods are described in transplant centers around the world.

BACKGROUND Minimally invasive approaches are spreading in every field of surgery, including liver surgery. However, studies comparing robotic hepatectomy with the conventional open approach regarding oncologic outcomes for hepatocellular carcinoma are limited. MATERIALS AND METHODS We retrospectively reviewed demographics characteristics, pathologic features, surgical, and oncological outcomes of patients who underwent robotic and conventional open liver resection for hepatocellular carcinoma. RESULTS No significant differences in demographics features, tumor size, tumor location, and type of liver resection were found. The morbidity rate was similar, 23% for the open group versus 17% of the robotic group (P=0.605). Perioperative data analysis showed a greater estimated blood loss in patients who underwent open resection, if compared with robotic group (P=0.003). R0 resection and disease-free resection margins showed no statistically significant differences. The 3-year disease-free survival of the robotic group was comparable with that of the open group (54% vs. 37%; P=0.592), as was the 3-year overall survival (87% vs. 78%; P=0.203). CONCLUSIONS The surgical and the oncological outcomes seem to be comparable between minimally invasive and open hepatectomy. Robotic liver resections are effective, and do not compromise the oncological outcome, representing a reasonable alternative to the open approach.

The aim of this study was to evaluate the short- and long-term results and risk factors of liver surgery in patients over the age of 70 following liver resection for colorectal liver metastases. A total of 650 patients with an average age of 63.8 ± 9.3 years were evaluated. We compared groups of patients younger and older than 70 years of age. Time of hospitalisation, 30-day postoperative morbidity and mortality, overall and recurrence-free survival, the number and largest diameter of metastases, small and large liver resections, and the interval between primary colorectal and liver surgery were evaluated according to the results of liver resections. Length of hospitalisation, 30-day postoperative morbidity and mortality, and long-term results did not differ between groups of patients. Pulmonary embolism and confusion had a higher incidence in patients ≥70 years old (p

Background In patients with colorectal liver metastases, the possibility for radical liver resection can be limited by oxaliplatin-induced sinusoidal obstruction syndrome (SOS). This study investigates the potential of mesenchymal stem cells (MSC) to improve the outcome of liver resections in pigs with SOS. Materials and methods SOS was induced in all animals (n=20) on day 0. Animals in the experimental group (n=8) received allogeneic MSC on day 7. Liver resection was performed in all animals on day 14 and the animals were observed until day 28. Ultrasound volumetry, biochemical analysis and histological examination of liver parenchyma was performed during the follow-up period. Results Six animals from the control group died prematurely, while all animals survived in the experimental group. According to histology, biochemical analysis and ultrasound volumetry, there were no significant differences between the groups documenting the effect of MSC. Conclusion Single dose allogeneic MSC administration improved survival of animals with SOS undergoing partial liver resection. Further experiments with different timing of liver resection and MSC administration should be performed to investigate the effect of MSC in more detail.

Background Aims of this study were to describe the stepwise implementation and expansion of robotic HPB surgery in a high volume HPB unit in the Netherlands and to analyze clinical outcomes of all robotic liver resections and robotic pancreatoduodenectomies performed within this program. Methods After proctoring by expert international surgeons, HPB surgeons were introduced to robotic liver resection and robotic pancreatoduodenectomy in a stepwise fashion. Data from two prospective databases containing all consecutive patients who underwent robotic liver resection or robotic pancreatoduodenectomy between August 1st, 2015 and March 1st, 2019 were analyzed post hoc. Results In total, 77 consecutive robotic liver resections and 68 consecutive robotic pancreatoduodenectomies were performed. Five surgeons were consecutively introduced to robotic HPB surgery. Mean operative time for robotic liver resection was 160 ± 78 min. Mean operative time for robotic pancreatoduodenectomy was 420 ± 67 min. Operative times remained stable over time and were not affected by the introduction of new surgeons. Conclusion Stepwise implementation and expansion of robotic HPB surgery within one unit over a three-and-half year period is feasible and associated with good clinical outcomes. Despite introducing new surgeons to the technique, operative times, an indicator of the learning process, remained stable over time.

Background The aim of the study was to determine the value of synchronous liver resection in patients with oligo-metastatic gastric cancer and the prognostic factors in these patients. Patients and methods We compared the results of 21 gastric patients with liver metastases and synchronous liver resection (LMR) to 21 propensity score-matched patients with gastric cancer and liver metastases in whom liver resection was not performed (LM0) and to a propensity score-matched control group of 21 patients without liver metastases and stage III and IV resectable gastric cancer (CG). Results The overall 5-year survival of LMR, LM0 and CG were 14.3%, 0%, and 19%, respectively (p = 0.002). Five-year survival was 47.5% for well-differentiated tumour compared to 0% in patients with moderate or poor tumour differentiation (p = 0.006). In addition, patients with R0 resection and TNM stage N0–1 had a significantly better survival compared to patients with TNM N stage N2–3 (5-year survival: 60% for N0–1 vs. 7.7% for N2–3; p = 0.007). Conclusions The results presented in the study support synchronous liver resections in gastric patients and provide additional criteria for patient selection.

The impact of liver cirrhosis on the difficulty of minimal invasive liver resection (MILR) remains controversial and current difficulty scoring systems do not take in to account the presence of cirrhosis as a significant factor in determining the difficulty of MILR. We hypothesized that the difficulty of MILR is affected by the presence of cirrhosis. Hence, we performed a 1:1 matched-controlled study comparing the outcomes between patients undergoing MILR with and without cirrhosis including the Iwate system and Institut Mutualiste Montsouris (IMM) system in the matching process. Between 2006 and 2019, 598 consecutive patients underwent MILR of which 536 met the study inclusion criteria. There were 148 patients with cirrhosis and 388 non-cirrhotics. One-to-one coarsened exact matching identified approximately exact matches between 100 cirrhotic patients and 100 non-cirrhotic patients. Comparison between MILR patients with cirrhosis and non-cirrhosis in the entire cohort demonstrated that patients with cirrhosis were associated with a significantly increased open conversion rate, transfusion rate, need for Pringles maneuver, postoperative, stay, postoperative morbidity and postoperative 90-day mortality. After 1:1 coarsened exact matching, MILR with cirrhosis were significantly associated with an increased open conversion rate (15% vs 6%, p = 0.03), operation time (261 vs 238 min, p

Laparoscopic segment 7 segmentectomy and segment 6–7 bisegmentectomy are challenging resections because of the posterior position and the lack of landmarks. The anatomy of the right posterior Glissonean pedicle and the caudal view of laparoscopy make such resections suitable for the Glissonean pedicle-first approach. The study population included all consecutive patients treated with laparoscopic liver resection from August 2019 to February 2020. The approach is based on the ultrasonographic identification of the right posterior or segmental pedicle from the dorsal side of the liver after complete mobilization. The pedicle of interest is isolated through mini-hepatotomy and clamped. The segment anatomy is defined by ischemia. The transection starts from the ventral side, close to the right hepatic vein that is exposed and followed craniocaudally. Ten patients underwent anatomical laparoscopic resection of right posterolateral segments. There were 7 colorectal liver metastases, 2 hepatocellular carcinoma, and 1 biliary cysto-adenoma. Five patients underwent Sg7 resection, one patient underwent a Sg7 subsegmentectomy, and 4 underwent Sg6-7 bisegmentectomy. The Glissonean pedicle-first approach was feasible in eight patients. The craniocaudal approach to the RHV was feasible in six patients, not indicated in three cases and was abandoned in one patient for technical difficulty. There was no operative morbidity or mortality. Median post-operative hospital stay was 5 days. The Glissonean pedicle-first approach is safe and effective for laparoscopic anatomic resections of the right posterior sector. The craniocaudal approach to right hepatic vein from the ventral side is a convenient procedure to follow the segmental anatomy deep in the parenchyma.

BACKGROUND Controversy exists regarding the safety and feasibility of minimally invasive resection for lesions in segments 7 or 8. We compare outcomes of minimally invasive surgery (MIS) and Open parenchymal sparing liver resections at two high-volume centers. METHODS From 2003 to 2016 we identified patients who underwent MIS or Open resections for lesions in segments 7 or 8 at two institutions (MSKCC and SGH). Outcomes were compared using univariate and multivariate analyses. RESULTS Two-hundred and forty-five patients underwent resection of lesions in segments 7 or 8 (MIS 30% and Open 70%). Compared to the Open group, the MIS group had longer operative time (223 ± 88 vs 188 ± 72 minutes, P = .003), lower blood loss (297 ± 287 vs 448 ± 670 mL, P = .03), and shorter mean length of stay (5.2 ± 7.4 vs 8.3 ± 11.7 days, P

Background: Theoretical advantages of robotic surgery compared to conventional laparoscopic surgery include improved instrument dexterity, 3D visualization, and better ergonomics. This systematic review and meta-analysis aimed to determine advantages of robotic surgery over laparoscopic surgery in patients undergoing liver resections. Method: A systematic literature search was conducted for studies comparing robotic assisted or totally laparoscopic liver resection. Meta-analysis of intraoperative (operative time, blood loss, transfusion rate, conversion rate), oncological (R0 resection rates), and postoperative (bile leak, surgical site infection, pulmonary complications, 30-day and 90-day mortality, length of stay, 90-day readmission and reoperation rates) outcomes was performed using a random effects model. Result: Twenty-six non-randomized studies including 2630 patients (950 robotic and 1680 laparoscopic) were included, of which 20% had major robotic liver resection and 14% had major laparoscopic liver resection. Intraoperatively, robotic liver resection was associated with significantly less blood loss (mean: 286 vs 301 mL, p Conclusions: Robotic liver resection appears to offer some advantages compared to conventional laparoscopic surgery, although both techniques appear equivalent. Importantly, the quality of evidence is generally limited to cohort studies and a high-quality randomized trial comparing both techniques is needed.

Background The debate over the surgical strategy optimization in colorectal cancer patients with liver metastases (mCRC) has been ongoing in the last 20 years. However, parenchyma sparing surgery (PPS) in cases of hard to reach liver cites (HTRLC) remain to be controversial. Methods A prospective analysis of 185 mCRC patients performed who were devided in two groups depending by predominant liver cite localization. Peripherally localized metastases (PLM) (n = 107) (S2, S3, S6, S7, Spiegel lobe and subcapsular area 1–2 cm below the liver surface). Group 2 included those with metastases localized in HTRLC (n = 78) - metastatic lesions of the “right venous core”, portal and caval hilum, paracaval part of S1, “deep” parenchyma cites of S5, S8 and S4. Results In 26 (33,3%) and 32 (29,9%) patients of HTRLC and PLM, respectively, performed one liver re-resection (0,62). In HTRLC group 2 and more re-resection were performed in 7 (8,9%) cases while in PLM in 11 (10,3%), p = 0,76. Postoperative major morbidity was 24,4%, 21,8% (p = 0,15) and mortality 8,9%, 4,6% for HTRLC and PLM groups, respectively. R1v principles were implemented in 24 (30,7%) cases with centrally located metastases and in only 6 cases (5.6%) with peripheral localized metastases (p = 0,001). Cumulative 3-year disease-free survival (DSF) for PLM and HTRLC groups was 63% and 41% (p = 0,008). DFS for R1v (n = 24) and R0 (54) cochorts in HTRLC group was 33% and 43%, respeсtively (p = 0,44). Conclusions Principles of the PPS tactic provides an adequate removal of metastatic lesions in hard to reach liver cites allowing to maintain organ functions and increases the feasibility of the repeated liver resections in case of the initial disease progression., Highlights • The parenchymal preserving surgery allows to remove adequately metastatic lesions in “hard to reach liver cites”. • Сumulative 3-year disease-free survival between groups PLM and HTRLC was was in total 63% and 41%, respectively (p=0,008). • R1v detachment in combination with modern chemotherapy may be an effective method to reduce the cohort of unresectable cases.

Background Laparoscopic techniques have become the standard approach for most liver resections. Clinical studies providing conclusive evidence which patients benefit most from minimal-invasive surgery remain limited. Methods We retrospectively analyzed data of all consecutive cases of laparoscopic liver resection between 2015 and 2018 at our center. We compared patients with and without prior abdominal surgeries with respect to postoperative complications (Clavien-Dindo score), length of operation, length of ICU stay and length of hospitalization in univariate and multivariate analyses. Results Within the study period 319 patients underwent laparoscopic liver resections, 44% of which had a history of abdominal surgeries. Pre-operative characteristics were similar to patients without prior surgeries. Both groups showed comparable rates of post-operative complications (Clavien-Dindo score ≥3a; 12% in patients without vs. 16% with prior surgeries, p = 0,322). There were no significant differences in length of surgery or length of stay in the ICU or in the hospital. Conclusion Our data suggest that history of prior abdominal surgery is not a risk factor for post-operative complications after laparoscopic liver resection. We conclude that prior abdominal surgery should not be considered a contra-indication for laparoscopic approach in liver resection.

Severe ischemic changes of the liver remnant after hepatectomy could expedite tumor recurrence on the residual liver. Our study aimed at assessing the effect of warm ischemic/reperfusion (I/R) injuries on surgery-to-local recurrence interval and patient overall survival, during major hepatectomies under inflow and outflow vascular control.One hundred and eighteen patients were subjected to liver resection under total inflow and outflow vascular clamping and were assigned as study group. These individuals were retrospectively matched to 112 counterparts, who underwent liver surgery applying inflow and outflow vascular clamping only of the segment harboring the tumor, sparing the liver remnant from any I/R injury (control group). The two cohorts were compared regarding recurrence-free survival and overall survival.Reversible I/R injuries of the liver remnant subjected to vascular clamping were manifested, with increase of AST values at postoperative day 2 in the study group, as compared to the control group (603 ± 270 U/L vs. 450 ± 290 U/L, p 0.001), reversing to normal by day 7. Recurrence-free survival and overall survival were no significantly different between the two groups (log rank statistic p = 0.298 and 0.639, respectively).Reversible I/R injuries of the liver remnant do not seem to be implicated in the precipitation of local malignant recurrence or in shorter long-term survival, in comparison to a technique sparing the residual liver of I/R injury. This retrospective cohort study was registered at clinicaltrials.gov under unique identifying number: NCT04257240.

Summary Aim of the study Fourteen to seventeen percent of patients suffering from colorectal cancer have synchronous liver metastases (sCRLM) at the time of diagnosis. There are currently three possible strategies for curative management of sCRLM: “classic”, “combined”, and “liver-first”. The aim of our research was to analyze the effects of the three surgical management strategies for sCRLM on postoperative morbidity and mortality and overall and recurrence-free survival. Patients and Methods Patients treated for sCRLM between October 2000 and May 2015 were included. We defined three groups: (1) “classic”: surgery of primary tumor and then surgery of sCRLM; (2) “combined”: combined surgery of primary tumor and sCRLM: and (3) “liver-first”: surgery of sCRLM and then surgery of primary tumor. Results During this period, 170 patients who underwent 209 hepatectomies were included (“classic”: 149, “combined”: 34, “liver-first”: 26). The rate of severe complications was higher in the “combined” group compared to the “classic” group (35% vs. 12%, P = 0.03), and the “liver-first” group (35% vs. 19%, P = 0.25), while there were significantly fewer liver resections. Overall survival at 5 years in our cohort was 46%, without significant differences between the groups, and a median survival of 54 months. Recurrence-free survival of the patients in our cohort was 24% at 5 years, with a median survival time without recurrence of 14 months, without significant differences between the groups. Conclusion All three strategies were feasible and there were no differences regarding overall and recurrence-free survivals between the three approaches. The “combined” strategy group had significantly more severe complications and did not provide better oncological results, despite less aggressive liver disease and more limited liver resections.

This study aimed to externally validate the Iwate scoring model and its prognostic value for predicting the risks of intra- and postoperative complications of laparoscopic liver resection. Consecutive patients who underwent pure laparoscopic liver resection between 2008 and 2019 at a single tertiary center were included. The Iwate scores were calculated according to the original proposition (four difficulty levels based on six indices). Intra- and postoperative complications were compared across difficulty levels. Fitting the obtained data to the cumulative density function of the Weibull distribution and a linear function provided the mean risk curves for intra- and postoperative complications, respectively. The difficulty levels of 142 laparoscopic liver resections were scored as low, intermediate, advanced, and expert level in 41 (28.9%), 53 (37.3%), 32 (22.5%), and 16 (11.3%) patients, respectively. Intraoperative complications were detected in 26 (18.3%) patients and its rates (2.4%, 7.5%, 34.3%, and 62.5%) increased gradually with statistically significant values among difficulty levels (P ˂ 0.001). Major postoperative complications occurred in 21 (14.8%) patients and its rates (4.8%, 5.6%, 28.1%, 43.7%; P ˂ 0.001) showed the same trend as for intraoperative complications. Then, the mean risk curves of both complications were obtained. Due to outliers, a new threshold for a tumor size index was proposed at 38 mm. The repeated analysis showed improved results. The Iwate scoring model predicts the probability of complications across difficulty levels. Our proposed tumor size threshold (38 mm) improves the quality of the prediction. The model is upgraded by a probability of complications for every difficulty score.

Summary Introduction Laparoscopic liver resection (LLR) has been developed and is daily practiced by many expert teams. However, very few data are available on the experience of low volume centres. The aim of our study was to report and discuss the operative results of LLR performed in three low volume centres. Methods Records of patients who underwent a LLR in three low volume centres in France between May 2014 and November 2017 were collected. Endpoints studied were indications, intra and postoperative outcomes as well as short-term outcomes. Results A total of 46 patients (57 specimen resected) underwent a LLR during this period, representing 29.6% of total liver resections. Indications of LLR were benign lesions in 26%, primitive malignant lesions in 32.6% and metastatic tumours in 41.3%. Median size of lesions was 22 mm (range 11–100). Most liver resections were non-anatomic (64.7%), while left lateral sectionectomies represented 19.2%. Five patients required conversion and there were at the end 3 specimen with margins inferior to 1 mm resected laparoscopically. Postoperative mortality was nil and morbidity rate was 17.3%. Median hospital stay was 6 days (3–15). Conclusion Although LLR have gained acceptance in surgeons’ arsenal, it remains concentrated in referral centres. Our results suggest the feasibility of LLR in non-academic centres when it comes to small accessible lesions. Further studies would provide data about the long-term safety of this procedure in those centres.

Background: the aim of the present study is to analyze the outcomes of laparoscopic and open liver resections for (Intrahepatic CholangioCarcinoma) ICC in the modern era of laparoscopic liver surgery.Methods: patients undergoing laparoscopic and open liver resections for ICC in two European referral centers were included. Finally, 104 patients from the open group and 104 patients from the laparoscopic group were compared after propensity scores matching according to seven covariates representative of patients and disease characteristics. Indications to surgery and short- and long-term outcomes were compared.Results: operative time, number of retrieved nodes, rate, and depth of negative resection margins were comparable between the two groups. Blood loss was lower in the MILS (150 ± 100 mL, mean ± SD) compared with the Open group (350 ± 250 mL, p = 0.030). Postoperative complications occurred in 14.4% of patients in the MILS and in the 24% of patients in the Open group (p = 0.02). There were no significant differences in long-term outcomes between groups.Conclusions: our results confirm feasibility, safety, and oncological efficiency of the laparoscopic approach in the management of ICC. However, this surgery is often complex and should be only considered in centers with large experience in laparoscopic liver surgery.

The “Small-for-Size” syndrome is defined as a liver failure after a liver transplant with a reduced graft or after a major hepatectomy. The later coined “Small-for-Flow” syndrome describes the same situation in liver resections but based on hemodynamic intraoperative parameters (portal pressure > 20 mmHg and/or portal flow > 250 ml/min/100 g). This focuses on the damage caused by the portal hyperafflux related to the volume of the remnant. Relevant studies were reviewed using Medline, PubMed, and Springer databases. Portal hypertension after partial hepatectomies also leads to a higher morbidity and mortality. There are plenty of experimental studies focusing on flow rather than size. Some of them also perform different techniques to modulate the portal inflow. The deleterious effect of high posthepatectomy portal venous pressure is known, and that is why the idea of portal flow modulation during major hepatectomies in humans is increasing in everyday clinical practice. Considering the extensive knowledge obtained with the experimental models and good results in clinical studies that analyze the “Small-for-Flow” syndrome, we believe that measuring portal flow and portal pressure during major liver resections should be performed routinely in extended liver resections. Applying these techniques, the knowledge of hepatic hemodynamics would be improved in order to advance against posthepatectomy liver failure.

Radical tumor removal remains the key task in hepatoblastoma surgery. Patients who need extended resection and have a risk of posthepatectomy liver failure are particularly difficult. In cases with insufficient future liver volume, the method of choice is a two-staged hepatectomy or liver transplantation. Despite the wide spread of laparoscopic liver surgery in adults, the minimally invasive approach has not been studied in pediatrics, and the literature on this issue is scarce. In current publication a case of successful partial associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) in a child, firstly accomplished pure laparoscopically. Described experience suggests the feasibility of laparoscopic liver resections in children and effectiveness of partial in situ liver splitting to reach appropriate future liver remnant volume and to avoid liver transplantation and its disadvantages.

Major liver resections are limited by the volume of future liver (FLR) remnant with the risk of subjecting patient to post surgery liver failure. This increases morbidity and mortality of the patients. However, the technique of ipsilateral portal vein embolisation (PVE) has given surgeons extra mileage to consider major liver resections previously thought to be unresectable. Al cases should be discussed in a multidisciplinary setting. A good knowledge of portal anatomy and variations should be known as part of selection procedure for PVE. Base liver functional status should be reviewed before consideration given to PVE. CT volumetry assessment should be made before and after PVE to assess for resectability. Multiple embolic materials are used in current practice, but none have shown superiority. Several complications are related to application of PVE, however it is generally regarded a safe procedure. Atleast four weeks are required to assess for FLR with repeat abdominal cross-sectional imaging. Patients with normal liver function tests achieve maximum hypertrophy in four weeks versus patients with underlying liver disease. Liver surgery is scheduled upto 2 to 6 weeks following embolisation. The aim of this article is to provide an overview of current indications, technique, complications and outcomes following PVE.

Introduction Laparoscopic resection has become an accepted approach to liver tumour surgery. However, it is considered difficult, especially in unfavourably located lesions. Aim To compare the outcomes of laparoscopic (LLR) and open liver resection (OLR) of posterolateral segments. Material and methods We searched the PubMed, EMBASE, and Scopus databases from inception to 30 September 2019. Full text articles and conference abstracts were included for further analysis. This review follows the PRISMA guidelines. Results From 643 articles, 15 studies (N = 1196 patients) were included in the meta-analysis. All of them were non-randomised. Our findings showed that LLR had significantly lowered overall morbidity compared to OLR (MD = 0.66; 95% CI: 0.51–0.86; p = 0.002). Length of hospital stay (MD = 2.48; 95% CI: –3.87, –1.08; p < 0.001) was also shorter in the LLR group. Operative time (MD = 55.65; 95% CI: 24.14–87.16; p < 0.001) was significantly shorter in the OLR group. In terms of blood loss, major complications, R0 resection rates, and resection margin, there were no significant differences. Conclusions Our meta-analysis showed that the laparoscopic approach to resections of posterolateral liver segments is beneficial. However, the results are based on non-randomised trials, and further research is needed to fully establish their clinical application.

[EN] Background Whereas the usefulness of radiofrequency (RF) energy as haemostatic method in liver surgery has become well established in the last decades, its intentional application on resection margins with the aim of reducing local recurrence is still debatable. Our goal was to compare the impact of an additional application of RF energy on the top of the resection surface, namely additional margin coagulation (AMC), on local recurrence (LR) when subjected to a subcentimeter margin. Methods We retrospectively analyzed 185 patients out of a whole cohort of 283 patients who underwent radical hepatic resection with subcentimetric margin. After propensity score adjustment, patients were classified into two balanced groups according to whether RF was applied or not. Results No significant differences were observed within groups in baseline characteristics after PSM adjustment. The LR rate was significantly higher in the Control than AMC Group: 12 patients (14.5%) vs. 4 patients (4.8%) (p = 0.039). The estimated 1, 3, and 5-year LR-free survival rates of patients in the Control and AMC Group were: 93.5%, 86.0%, 81.0% and 98.8%, 97.2%, 91.9%, respectively (p = 0.049). Univariate Cox analyses indicated that the use of the RF applicator was significantly associated with lower LR (HR = 0.29, 95% confidence interval 0.093¿0.906, p = 0.033). The Control Group showed smaller coagulation widths than the AMC group (p < 0.001). Conclusions An additional application of RF on the top of the resection surface is associated with less local hepatic recurrence than the use of conventional techniques., This work was partially supported by the Spanish Ministerio de Ciencia, Innovación y Universidades under "Programa Estatal de I+D+i Orientada a los Retos de la Sociedad", Grants Nº "RTI2018-094357-B-C21" and "RTI2018-094357-B-C22"

The aim — to determine the role and effectiveness of various surgical treatment methods for liver echinococcosis, depending on the type of echinococcal cyst, its location and size.Materials and methods. A treatment results analysis of 56 patients with liver echinococcosis who were treated in the clinic from 2008 to 2018 was performed. There were 42.9 % of men and 57.1 % of women. The mean age of the patients was 48 ± 2.3 years. The standard examination algorithm included mandatory contrast enhanced CT and the detection of antibodies to echinococcus in blood serum in addition to routine laboratory and instrumental tests. CL type of cysts were detected in 3 patients (5.4 %), type CE1 in 27 patients (48.2 %), type CE2 in 10 cases (17.9 %), type CE3 in 12 cases (21.4 %), type CE4 — 5 — in 4 patients (7.2 %). Patients underwent various surgical interventions, depending on the type of echinococcal cyst. PAIR was used in 3 patients (5.4 %), PAIRD was used in 7 patients (12.5 %). Echinococcectomy was performed in 17 patients (30.4 %) The open approach was performed in 8 patients (14.3 %), and laparoscopic approach — in 9 cases (16.1 %). Pericystectomy was performed in 19 patients (33.8 %)/The open approach was used in 16 cases (28.4 %), and laparoscopic approach — in 3 cases (5.4 %). In another 10 cases (17.9 %), liver resections varying from segmentectomy to hemihepatectomy were performed.Results and discussion.Bile leakage via the drainages of the abdominal cavity was observed in 7 cases (12.5 %). Allergic reactions of varying severity were observed in 3 cases (5.6 %). The recurrence of decease was noted in 2 patients (4 %). There was no lethality in this group of patients.Conclusions. The absence of a unified surgical tactics for liver echinococcosis requires the use of an individualized approach. The choice of treatment method depends on the location and size of the cyst, the stage of parasite development. Postoperative therapy with albendazole (mebendazole) in the presence of a live parasite is required. In the presence of a non‑living parasite (cysts of type CE4 — CE5) it is advisable to use observant tactics., Цель работы — определить роль и эффективность разных способов хирургического лечения эхинококкоза печени в зависимости от типа эхинококковых кист, их локализации и размера.Материалы и методы. Проанализированы результаты лечения в клинике Института общей и неотложной хирургии имени В. Т. Зайцева НАМН Украины в период с 2008 по 2018 г. 56 больных с эхинококкозом печени. Среди них мужчин было 42,9 %, женщин — 57,1 %. Средний возраст пациентов составил (48,0 ± 2,3) года. Стандартный алгоритм исследования, кроме рутинных лабораторных и инструментальных исследований, предусматривал обязательное выполнение компьютерной томографии с контрастным усилением и выявление антител к эхинококку в сыворотке крови. Кисты типа CL диагностированы у 3 (5,4 %) больных, типа CE1 — у 27 (48,2 %), типа СЕ2 — у 10 (17,9 %), типа СЕ3 — у 12 (21,4 %), типа СЕ4 и СЕ5 — у 4 (7,2 %). Пациентам были выполнены разные оперативные вмешательства в зависимости от типа эхинококковой кисты. Методика PAIR применена у 3 (5,4 %) больных, PAIRD — у 7 (12,5 %). Эхинококкэктомия выполнена у 17 (30,4 %) пациентов, в частности в открытом варианте — у 8 (14,3 %), в лапароскопическом — у 9 (16,1 %), перицистэктомия — у 19 (33,8 %), в частности в открытом варианте — у 16 (28,4 %), с использованием лапароскопического доступа — у 3 (5,4 %). Еще в 10 (17,9 %) наблюдениях проведены разные по объему резекции печени (от сегментэктомии до гемигепатэктомии).Результаты и обсуждение. Желчеистечение по дренажам брюшной полости отмечено в 7 (12,5 %) наблюдениях, аллергические реакции разной степени выраженности — в 3 (5,6 %), рецидив — в 2 (4,0 %). Случаев летального исхода не было.Выводы. Отсутствие единой хирургической тактики при эхинококкозе печени требует использования индивидуального подхода. Выбор метода лечения зависит от локализации и размера кисты, стадии развития паразита. Послеоперационная терапия альбендазолом (мебендазолом) при наличии живого паразита обязательна. В случае неживого паразита (кисты типа СЕ4 — СЕ5) целесообразно использовать выжидательную тактику., Мета роботи — визначити роль та ефективність різних способів хірургічного лікування ехінококозу печінки залежно від типу ехінококових кіст, їх локалізації та розміру.Матеріали і методи. Проаналізовано результати лікування в клініці Інституту загальної та невідкладної хірургії імені В. Т. Зайцева НАМН України в період з 2008 до 2018 р. 56 хворих з ехінококозом печінки. Серед них чоловіків було 42,9 %, жінок — 57,1 %. Середній вік пацієнтів становив (48,0 ± 2,3) року. Стандартний алгоритм дослідження, крім рутинних лабораторних та інструментальних досліджень, передбачав обов’язкове виконання комп’ютерної томографії з контрастним посиленням і виявлення антитіл до ехінококу в сироватці крові. Кісти типу CL діагностовано у 3 (5,4 %) хворих, типу CE1 — у 27 (48,2 %), типу СЕ2 — у 10 (17,9 %), типу СЕ3 — у 12 (21,4 %), типу СЕ4 та СЕ5 — у 4 (7,2 %). Пацієнтам були виконані різні оперативні втручання залежно від типу кісти. Методику PAIR застосовано у 3 (5,4 %) хворих, PAIRD — у 7 (12,5 %). Ехінококектомію виконано у 17 (30,4 %) пацієнтів, зокрема у відкритому варіанті — у 8 (14,3 %), в лапароскопічному — у 9 (16,1 %), перицистектомію — у 19 (33,8 %), зокрема у відкритому варіанті — у 16 (28,4 %), з використанням лапароскопічного доступу — у 3 (5,4 %). Ще в 10 (17,9 %) спостереженнях проведено різні за обсягом резекції печінки (від сегментектомії до гемігепатектомії).Результати та обговорення. Жовчовитікання по дренажах черевної порожнини відзначено в 7 (12,5 %) спостереженнях, алергічні реакції різного ступеня вираження — в 3 (5,6 %), рецидив — у 2 (4,0 %). Випадків летального наслідку не було.Висновки. Відсутність єдиної хірургічної тактики при ехінококозі печінки потребує використання індивідуального підходу. Вибір методу лікування залежить від локалізації та розміру кісти, стадії розвитку паразита. Післяопераційна терапія альбендазолом (мебендазолом) за наявності живого паразита обов’язкова. У разі неживого паразита (кісти типу СЕ4 — СЕ5) доцільно використовувати вичікувальну тактику.

Aim. To compare survival after open liver resections and laparoscopic liver resection based on the experience of two large Russian surgical centers using the propensity score matching. Material and methods. The primary point of the study was the assessment of long-term overall and disease-free survival after laparoscopic and open liver resection. The secondary point were immediate outcomes. Propensity score matching was used for balancing covariates and reducing the drawbacks of observational study. Results. The study included data from 185 patients after 93 laparoscopic liver resection and 92 open liver resection. The immediate outcomes of 176 patients (95%) were analyzed. Long-term results were evaluated in 157 patients (85%) with propensity score based analysis. Forty-three pairs were matched. The blood loss and the hospital stay were less in the group of laparoscopic liver resection before matching. After matching, the blood loss was equal in both groups. The length of hospital stay remained significantly shorter in laparoscopic liver resection group after matching. No differences in severe morbidity was observed between groups. No death was registered after open and laparoscopic liver resection. The overall 5-year survival rate in the laparoscopic and open liver resection groups did not differ before and after matching (56%/68% and 72%/76%, respectively). Disease-free 5- and 4-year survival did not differ either, but revealed the trend to be longer after laparoscopic liver resection before and after matching (52%/10% and 58%/28%, respectively). Conclusion. Laparoscopic liver resection for colorectal liver metastases reduced the hospital stay. The overall survival of patients did not depend on the type of approach. Disease-free survival discovered the trend to improve after laparoscopic liver resection.

Background: While most of the evidence on minimally invasive liver surgery (MILS) is derived from expert centers, nationwide outcomes remain underreported. This study aimed to evaluate the implementation and outcome of MILS on a nationwide scale. Methods: Electronic patient files were reviewed in all Dutch liver surgery centers and all patients undergoing MILS between 2011 and 2016 were selected. Operative outcomes were stratified based on extent of the resection and annual MILS volume. Results: Overall, 6951 liver resections were included, with a median annual volume of 50 resections per center. The overall use of MILS was 13% (n = 916), which varied from 3% to 36% (P < 0.001) between centers. The nationwide use of MILS increased from 6% in 2011 to 23% in 2016 (P < 0.001). Outcomes of minor MILS were comparable with international studies (conversion 0–13%, mortality

Objective: The authors present outcomes of robotic liver resections in comparison with open technique questioning the need to have experience of laparoscopy for such procedures before transition to robotic assisted. Materials and methods: Retrospective review of liver resections done robotically from February 2015 to June 2017 compared to matched control cohort of open cases from January 2012 to December 2016. Results: Twenty-one patients in the study group were compared with matched control of 42 open cases (1:2 ratio). The types of procedure were similar in both the groups. There were 4 left lateral hepatectomy, 3 left hepatectomy, and 1 left hepatectomy with hepatico-jejunostomy, 3 right hepatectomy, 3 right posterior sectorectomy, 4 bisegmentectomy and 4 mono-segmentectomy. There were 9 patients with primary liver cancer, 2 each with liver metastasis and carcinoma gall bladder and 8 patients had benign liver disease. Mean blood loss was 370 ± 311 ml in the robotic group compared to 451 ± 330 ml in control group (p = 0.06). Minor complications developed in 19.0% of robotic cases compared to 40.5% in open surgery, while major complications occurred in 4.7% of robotic cases compared to 7.1% of open cases. Mean hospital stay was 5.3 ± 0.8 days for the robotic group and 7.7 ± 4.2 days for open group (p = 0.02). Local tumor recurrence occurred in 1 out of 13 resections done for malignancy in the robotic group and 7 out of 26 in the open group. Conclusion: This study highlights the utility of surgical robots for segmental and complex liver resections with equivalent outcomes and decreased length of hospital stay compared to open surgery without having experience of same with the laparoscopy. Keywords: Robotic, Liver resection, Open surgery

To study the risk factors of severe blood loss in extensive liver resections, consequences of hemorrhagic problems and their correction.The study included 374 patients. Group 1 comprised 282 patients (118 men and 164 women aged 54.1±0.7 years) who underwent surgery between 2000 and 2012. Group 2 included 92 patients (34 women and 58 men aged 53.6±1.3 years) operated on for the period 2013-2019.Technical equipment for mobilization and dissection of hepatic parenchyma has fundamentally changed for the period 2013-2019. This processes reduced blood loss by more 50% and consumption of donor blood components (red blood cells by 2.8 times, FFP by 1.8 times). Compression of hepatoduodenal ligament (Pringle maneuver) and tumor type did not affect intraoperative blood loss. Neoplasms over 10 cm increased blood loss. An increase in the number of resected segments by 2 times contributed to increase of blood loss by 2.7 times. Body mass index25 kg/mОценить факторы риска массивной кровопотери при обширных резекциях печени, последствия развития этого осложнения и возможности их устранения.Наблюдали 374 пациента: 152 мужчин и 222 женщины в возрасте 18—81 года, которым выполнили обширную резекцию печени. В 1-ю группу вошли 282 пациента, оперированные в 2000—2012 гг., во 2-ю — 92 пациента, оперированные в 2013—2019 гг. Резецировали 3—6 сегментов печени. Оценивали объем кровопотери и использованных донорских гемокомпонентов в зависимости от техники диссекции паренхимы печени и применения маневра Прингла. Анализировали зависимость величины кровопотери от характера и размеров образований, объема удаленной печеночной ткани, индекса массы тела. Исследуемые группы сравнивали по количеству и характеру послеоперационных осложнений, продолжительности послеоперационного нахождения в стационаре, летальности. Для оценки результатов исследования использовали методы вариационной и непараметрической статистики.Характер новообразования не влиял на объем кровопотери (Использование высокотехнологичных методов диссекции паренхимы печени позволило значительно сократить объем кровопотери, расход донорских гемокомпонентов и улучшить течение послеоперационного периода.

BACKGROUND In April 2018, a dedicated hepatobiliary unit was established in a tertiary hospital in North Queensland. Changes included the employment of a hepatobiliary-trained surgeon, centralized referrals, and formalized multidisciplinary team meetings. This study aimed to evaluate the impact of establishing a hepatobiliary unit on outcomes after liver resection, in a regional centre where such procedures were previously performed by non-specialist general surgeons. METHODS Adult patients who underwent elective liver resection in Townsville from 2013 to 2020 were included in the study. Outcomes after liver resection were collected across two study periods - before and after the hepatobiliary unit was established. The primary end points were a before and after comparison of the 90-day morbidity and mortality and the R1 margin rates. RESULTS Across the two study periods, 76 and 77 patients, respectively, underwent liver resection. Rates of R1 resection, 90-day mortality and major complications were not significantly different between the two study periods. Primary tumours (14.5% before versus 50.6% after) and cirrhosis (1.3% before versus 14.3% after) were significantly higher in the latter period, as was the median length of stay (4 days before versus 6 days after). Annual surgical volume increased by 75% in the period after 2018 compared to the 5 years preceding it. CONCLUSION Establishing a centralized hepatobiliary unit in a tertiary regional centre resulted in increased surgical volume and case complexity, with no change in early outcomes after liver resection. Overall, this dedicated unit improved the accessibility of a subspecialty surgical service in regional Australia.

Background: The use of a successful Enhanced Recovery After Surgery (ERAS) in colorectal surgery favored its application in other organs, and hepatic resections were not excluded from this tendency. Some authors suggest that the laparoscopic approach is a central element to obtain better results. Aim: To compare the laparoscopic vs. open hepatic resections within an ERAS to evaluate if there are any differences between them. Methods: In a descriptive study 80 hepatic resections that were divided into two groups, regarding to whether they were submitted to laparoscopy or open surgery. Demographic data, those referring to the hepatectomy and the ERAS was analyzed. Results: Forty-seven resections were carried out in open surgery and the rest laparoscopically; in the first group there was only one conversion to open surgery. Of the total, 17 resections were major hepatectomies and in 18 simultaneous resections. There were no differences between procedures regarding hospital stay and number of complications. There was a greater adherence to the ERAS (p=0.046) and a faster ambulation (p=0.001) in the open surgery. Conclusion: The procedure, whether open or laparoscopically done in hepatic resections, does not seem to show differences in an ERAS evaluation. RESUMO Racional: O uso do protocolo Recuperação Otimizada Após Cirurgia (ERAS/ACERTO) com sucesso na cirurgia colorretal favoreceu a aplicação dele em outros órgãos; as ressecções hepáticas não foram excluídas dessa tendência. Alguns autores sugerem que a abordagem laparoscópica é elemento central para a obtenção de melhores resultados. Objetivo: Comparar as ressecções hepáticas laparoscópicas e abertas dentro de um ACERTO para avaliar se existem diferenças entre as duas técnicas. Métodos: Estudo descritivo comparando 80 ressecções hepáticas divididas em dois grupos, as realizadas por laparoscopia e aquelas por laparotomia. Foram analisados dados demográficos, referentes à hepatectomia e ao ACERTO. Resultados: Foram realizadas 47 ressecções por laparotomia e o restante por laparoscopia; houve apenas uma conversão para laparotomia no grupo da laparoscopia. Do total, 17 ressecções foram hepatectomias maiores e em 18 ressecções simultâneas. Não houve diferenças entre os procedimentos quanto ao tempo de internação e número de complicações. Houve maior adesão ao ACERTO (p=0,046) e deambulação mais rápida (p=0,001) na operação aberta. Conclusão: O procedimento, seja laparotômico ou laparoscópico nas ressecções hepáticas, não parece mostrar diferenças em uma avaliação ERAS/ACERTO.