Laparoscopic Liver Resection: An Ongoing Revolution
In the current issue of Annals of Surgery, Yoon et al6 report the largest series to date of pure laparoscopic right hepatectomy (LRH) that is compared with a control group of open right hepatectomy (ORH) operated on during the same period, all being performed for hepatocellular carcinoma (HCC). The reason for allocation to LRH or ORH was patient preference. Propensity 1:1 score matching was applied allowing for the comparison of 2 groups of 33 patients. On a technical point of view, Yoon et al have used a technique similar to the recently published one by Soubrane et al4 aiming at standardizing right hepatectomy. This included extrahepatic inflow division by individual right portal vein and artery dissection or Glisonnean en bloc dissection, followed by transection without previous mobilization, hepatic vein division, and completion specimen mobilization. Of note, the Pringle maneuver was used in >90% of the patients in each group.
The merit of this study lies in the fact that it addresses 1 procedure, right hepatectomy, performed for 1 disease, HCC in patients with cirrhosis. On a methodological point of view, the study sample is reasonably sized and its design with 1 primary endpoint, being morbidity, and 2 secondary end-points, operative details and oncologic outcomes, is appropriate. In addition, the authors have used the recently proposed Comprehensive Complication Index (CCI) that considers all complications and has been shown to be a more sensitive end-point than graded morbidity.7,8 The authors found that LRH was associated with a complication rate comparable to that of ORH, but a lower CCI, accounting for less severe overall morbidity. LRH was also associated with identical blood loss, longer operative times, reduced pain, and shorter hospital stay. Long-term outcomes were similar in both groups with identical 2-year overall and disease-free survival rates.