Unplanned conversion during minimally invasive liver resection for hepatocellular carcinoma: risk factors and surgical outcomes

Abstract

Purpose: Unplanned conversion is sometimes necessary during minimally invasive liver resection (MILR) of hepatocellular carcinoma (HCC). The aims of this study were to compare surgical outcomes of planned MILR and unplanned conversion and to investigate the risk factors after unplanned conversion. Methods: We retrospectively analyzed 286 patients who underwent MILR with HCC from January 2006 to December 2017. All patients were divided into a MILR group and an unplanned conversion group. The clinicopathologic characteristics and outcomes were compared between the 2 groups. In addition, surgical outcomes in the conversion group were compared with the planned open surgery group (n = 505). Risk factors for unplanned conversion were analyzed. Results: Of the 286 patients who underwent MILR, 18 patients (6.7%) had unplanned conversion during surgery. The unplanned conversion group showed statistically more blood loss, higher transfusion rate and postoperative complication rate, and longer hospital stay compared to the MILR group, whereas no such difference was observed in comparison with the planned open surgery group. There were no significant differences in overall and disease-free survival among 3 groups. The right-sided sectionectomy (right anterior and posterior sectionectomy), central bisectionectomy and tumor size were risk factors of unplanned conversion. Conclusion: Unplanned conversion during MILR for HCC was associated with poor perioperative outcomes, but it did not affect long-term oncologic outcomes in our study. In addition, when planning right-sided sectionectomy or central bisectionectomy for a large tumor (more than 5 cm), we should recommend open surgery or MILR with an informed consent for unplanned open conversions.

Risk factors and long-term implications of unplanned conversion during laparoscopic liver resection for hepatocellular carcinoma located in anterolateral liver segments

“…Most previous studies on conversion during minimally invasive liver resection (MILR) included benign or malignant lesions located in all segments of the liver [ 10 , 11 , 13 – 18 ]. However, compared to laparoscopy for AL segments, the laparoscopic approach for PS segments is challenging with high conversion rates and is only recommended for experienced surgeons [ 3 ].…”

“…Accordingly, these factors might have caused bias in the assessment of perioperative outcomes and risk factors for unplanned conversion. Furthermore, there are only a few studies on the long-term oncologic outcomes of conversion during LLR for HCC, and the available results are controversial [ 13 , 14 , 17 ]. To the best of our knowledge, ours is the first study to analyze the long-term implications and risk factors for unplanned conversion in LLR for HCC located in AL segments, for which the laparoscopic approach is considered the standard procedure.…”

“…Several studies have reported that conversion is associated with poor perioperative outcomes [ 10 – 18 ], with conversion rates ranging from 0% to 55% [ 19 ]. However, the impact of conversion on long-term oncologic outcomes is controversial, and there are a limited number of published studies on this topic [ 13 , 14 , 17 ].…”

“…Several studies have reported that conversion is associated with poor perioperative outcomes [ 10 – 18 ], with conversion rates ranging from 0% to 55% [ 19 ]. However, the impact of conversion on long-term oncologic outcomes is controversial, and there are a limited number of published studies on this topic [ 13 , 14 , 17 ]. Moreover, most of the studies included lesions located in posterosuperior (PS) segments of the liver, which are known to be notably challenging for performing LLR [ 3 ], which may lead to bias in identifying risk factors for unplanned conversion.…”

How to minimize conversion to open surgery during laparoscopic liver resection: the point of view of hemostasis

“…As in this study [ 3 ], one of the most important reasons for conversion to open surgery is bleeding during surgery, and the causes of bleeding are various, such as the size, location, and number of tumors, and the degree of cirrhosis of the liver. Minimizing bleeding and, if there is bleeding, quick hemostasis can help to reduce unplanned conversion to open surgery [ 4 – 6 ]. In patients who are expected to have a high probability of conversion to open surgery, it is possible to minimize bleeding and reduce blood transfusion or operation time by making the decision to conversion to open surgery quickly [ 7 ].…”