IMPORTANCE Textbook outcome (TO) is a composite measure that captures the most desirable surgical outcomes as a single indicator, yet to date TO has not been defined and assessed in the field of laparoscopic liver resection (LLR) and open liver resection (OLR).OBJECTIVE To obtain international agreement on the definition of TO in liver surgery (TOLS) and to assess the incidence of TO in LLR and OLR in a large international multicenter database using a propensity-score matched analysis.DESIGN, SETTING, AND PARTICIPANTS Patients undergoing LLR or OLR for all liver diseases between January 2011 and October 2019 were analyzed using a large international multicenter liver surgical database. An international survey was conducted among all members of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA) and International Hepato-Pancreato-Biliary Association (IHPBA) to reach agreement on the definition of TOLS. The rate of TOLS was assessed for LLR and OLR before and after propensity-score matching. Factors associated with achieving TOLS were investigated.MAIN OUTCOMES AND MEASURES Textbook outcome, with TOLS defined as the absence of intraoperative incidents of grade 2 or higher, postoperative bile leak grade B or C, severe postoperative complications, readmission within 30 days after discharge, in-hospital mortality, and the presence of R0 resection margin.RESULTS A total of 8188 patients (4559 LLR; median age, 65 years [interquartile range, 55-73 years]; 2529 were male [55.8%] and 3629 OLR; median age, 64 years [interquartile range, 56-71 years]; 2204 were male [60.7%]) were included in the analysis of whom 69.1% achieved TOLS; 74.8% for LLR and 61.9% for OLR (P < .001). On multivariable analysis, American Society of Anesthesiologists grade III, previous abdominal surgery, histological diagnosis of colorectal liver metastases (odds ratio [OR], 0.656 [95% CI, 0.457-0.940]; P = .02), cholangiocarcinoma, non-CRLM, a tumor size of 30 mm or more, minor resection of posterior/superior segments (OR, 0.716 [95% CI, 0.577-0.887]; P = .002), anatomically major resection (OR, 0.579 [95% CI, 0.418-0.803]; P = .001), and nonanatomical resection (OR, 0.612 [95% CI, 0.476-0.788]; P < .001) were associated with a worse TOLS rate after LLR. For OLR, only histological diagnosis of cholangiocarcinoma (OR, 0.360 [95% CI, 0.214-0.607]; P < .001) and a tumor size of 30 mm or more (30-50 mm = OR, 0.718 [95% CI, 0.565-0.911]; P = .01; 50.1-100 mm = OR, 0.729 [95% CI, 0.554-0.960]; P = .02; >10 cm = OR, 0.550 [95% CI, 0.366-0.826]; P = .004) were associated with a worse TOLS rate. CONCLUSIONS AND RELEVANCEIn this multicenter study, TOLS was found to be a useful tool for assessing patient-level hospital performance and may have utility in optimizing patient outcomes after LLR and OLR.

My special appreciation goes to a talented surgeon, my colleague and friend Dr. Åsmund Fretland, who has been a remarkable co-supervisor to me. Your research and surgical skills, positiveness and the ability to solve problems quickly have always impressed me. Thank you for letting me to take over your work in the OSLO-COMET trial and for introducing me to all the details. It is always my great pleasure to draft articles together with you, be your assistant at liver surgery and attend conferences together with you. My classmate, colleague and friend Dr. Mushegh Sahakyan deserves my deepest gratitude. You are a role model for me as a young talented and hard-working researcher. I have learned a lot from our discussions about surgical procedures, article drafting, methodologies and statistics in research. I am very glad that you are back to Norway and our research group. I look forward to continuing our fruitful cooperation and Armenian barbeques together. I would like to thank Prof. Erik Fosse for the opportunity to work at the Intervention Centre, where you have created an outstanding multi-speciality research team. Communication with multidisciplinary research teams and professionals at IVS have extended my horizons. It was my pleasure to work alongside Marianne Berg, Linda Engvik, nurses and radiology team.