Long-term abdominal wall benefits of the laparoscopic approach in liver left lateral sectionectomy: a multicenter comparative study

Background: Laparoscopy is nowadays considered as the standard approach for hepatic left lateral sectionectomy (LLS), but its value in the prevention of incisional hernia (IH) has not been demonstrated. Methods: Between 2012 and 2017, patients undergoing laparoscopic (LLLS) or open LLS (OLLS) in 8 centers were compared. Patients undergoing a simultaneous major abdominal procedure were excluded. The incidence of IH was assessed clinically and morphologically on computed tomography (CT) using inverse probability of treatment weighting (IPTW) and multivariable regression analysis. Results: After IPTW, 84 LLLS were compared to 48 OLLS. Compared to OLLS, LLLS patients had reduced blood loss (100 [IQR: 50–200] ml vs. 150 [IQR: 50–415] ml, p= 0.023) and shorter median hospital stay (5 [IQR: 4–7] days vs. 7 [6–9] days, p< 0.001), but experienced similar rate of postoperative complications (mean comprehensive complication index: 12 ± 19 after OLLS versus 13 ± 20 after LLLS, p= 0.968). Long-term radiological screening was performed with a median follow-up of 27.4 (12.1–44.9) months. There was no difference between the two groups in terms of clinically relevant IH (10.7% [n= 9] after LLLS, 8.3% [n= 4] after OLLS, p= 0.768). The rate of IH detected on computed tomography was lower after LLLS than after OLLS (11.9% [n= 10] versus 29.2% [n= 14], p= 0.013). On multivariable analysis, the laparoscopic approach was the only independent factor influencing the risk of morphological IH (OR = 0.290 [95% CI: 0.094–0.891], p= 0.031). The 2 preferential sites for specimen extraction after LLLS were Pfannenstiel and midline incisions, with rates of IH across the extraction site of 2.3% [n= 1/44] and 23.8% [n= 5/21], respectively (p= 0.011). Conclusion: The laparoscopic approach for LLS decreases the risk of long-term IH as evidenced on morphological examinations, with limited clinical impact. Pfannenstiel’s incision should be preferred to midline incision for specimen extraction after LLLS.