Minimally Invasive Anatomic Liver Resection for Hepatocellular Carcinoma Using the Extrahepatic Glissonian Approach: Surgical Techniques and Comparison of Outcomes with the Open Approach and between the Laparoscopic and Robotic Approaches

Abstract

Surgical techniques and outcomes of minimally invasive anatomic liver resection (AR) using the extrahepatic Glissonian approach for hepatocellular carcinoma (HCC) are undefined. In 327 HCC cases undergoing 185 open (OAR) and 142 minimally invasive (MIAR; 102 laparoscopic and 40 robotic) ARs, perioperative and long-term outcomes were compared between the approaches, using propensity score matching. After matching (91:91), compared to OAR, MIAR was significantly associated with longer operative time (643 vs. 579 min, p = 0.028); less blood loss (274 vs. 955 g, p < 0.0001); a lower transfusion rate (17.6% vs. 47.3%, p < 0.0001); lower rates of major 90-day morbidity (4.4% vs. 20.9%, p = 0.0008), bile leak or collection (1.1% vs. 11.0%, p = 0.005), and 90-day mortality (0% vs. 4.4%, p = 0.043); and shorter hospital stay (15 vs. 29 days, p < 0.0001). On the other hand, laparoscopic and robotic AR cohorts after matching (31:31) had comparable perioperative outcomes. Overall and recurrence-free survivals after AR for newly developed HCC were comparable between OAR and MIAR, with potentially improved survivals in MIAR. The survivals were comparable between laparoscopic and robotic AR. MIAR was technically standardized using the extrahepatic Glissonian approach. MIAR was safe, feasible, and oncologically acceptable and would be the first choice of AR in selected HCC patients.

Surgical Strategies Affect the Long-Term Prognosis of Patients with Hepatocellular Carcinoma Adjacent to the Left Branch of the Portal Vein

“…15 When patients have good liver function, anatomical liver resection is the preferred surgical approach for early-to-intermediate stage liver cancer, as it effectively reduces intrahepatic recurrence by removing the portal vein system and improves overall survival. [15][16][17][18][19] However, the surgical margin is also a key factor affecting long-term prognosis in patients undergoing anatomical liver resection. 20,21 Zhang et al study showed that among MVI-positive HCC patients undergoing anatomical liver resection, those with a surgical margin less than 1 cm had poorer 1-, 3-, and 5-year recurrence-free survival rates and overall survival rates compared to patients with a surgical margin greater than 1 cm.…”

What Is the Role of Minimally Invasive Liver Surgery in Treating Patients with Hepatocellular Carcinoma on Cirrhosis?

“…Additionally, the oncological outcomes of MILS may be further optimized by conducting more frequent anatomic liver resections when feasible. This is substantiated by recent randomized clinical trials [ 48 , 56 ] and the escalating utilization of innovative techniques, such as indocyanine green fluorescence navigation. This navigational approach has exhibited promise in enhancing the achievement of liver resections with tumor-free margins, as evidenced by a published study indicating increased disease-free survival after MILS with indocyanine green fluorescence navigation compared to MILS without it [ 57 ].…”

“…Nevertheless, the discussion surrounding the influence of MILS on long-term outcomes post HCC resection is characterized by nuanced debates, primarily resulting from the dearth of randomized trials and conflicting evidence among available studies. While a majority of studies report comparable outcomes between MILS and the open technique, emerging evidence suggests that the benefits of MILS may extend beyond the short term to positively impact long-term oncological endpoints [ 48 , 49 ]. A recent large cohort study with propensity score matching from Japan and Korea showed that laparoscopic liver resection had a better mid- and long-term disease-free survival than open hepatectomies [ 50 ].…”

“…The anticipation is that further advancements will be witnessed with the widespread adoption of new technologies. Table 1 provides a meticulous summary of key studies reporting HCC oncological outcomes treated with minimally invasive surgical techniques [46,[48][49][50][51][52][53][54][55]. Therefore, the answer to the third question is YES.…”

Impact of Minimally Invasive Surgery on Anatomic Liver Segmentectomy Using the Extrahepatic Glissonean Approach

“…In addition, the optimal approaches or techniques to expose the intersegmental hepatic veins are still undefined. We have previously reported our standardized techniques of MIAS using the extrahepatic Glissonean approach (EGA) and hepatic veinroot at first cranial-to-caudal parenchymal dissection, based on the anatomical background of Laennec's capsule of the liver [9,[11][12][13][14]. A few studies from other authors reported their techniques and favorable surgical outcomes of laparoscopic AS using EGA [15,16].…”