Novel patient risk factors and validation of a difficulty scoring system in laparoscopic repeat hepatectomy

Validation of the Iwate scoring system for the stratification of laparoscopic liver resections: An international multicenter study

INTRODUCTION

The Iwate difficulty scoring system (DSS) is one of the most widely validated DSS for laparoscopic liver resection (LLR). However, these studies only validated the 4 difficulty levels and did not validate the 12-point difficulty index of the system. To address current limitations in the studies validating the Iwate difficulty scoring system (DSS), we performed an international multicenter study to validate the Iwate DSS across both its four difficulty levels and 12-point difficulty index.

METHODS

A retrospective cohort study of 22,252 patients undergoing LLR across 64 centers worldwide between 2005 and 2021 was performed. Baseline characteristics and perioperative outcomes were analyzed across the four difficulty levels and 12-point difficulty index of the Iwate DSS.

RESULTS

A total of 14,759 patients met the inclusion criteria. The main indications for LLR were hepatocellular carcinoma/intrahepatic cholangiocarcinoma (52.8 %), and metastatic tumors liver (26.5 %). In terms of underlying liver pathology, 5127 patients (34.8 %) had liver cirrhosis, and 1214 patients (8.3 %) had portal hypertension. Intraoperative outcomes (operation time, blood loss, blood transfusion, use of Pringles maneuver and open conversion) and postoperative outcomes (length of stay, morbidity, major complications, and 90-day mortality) significantly increased with stepwise increases across the four difficulty levels (P < 0.001) and 12-point difficulty index (P < 0.001). These trends remained significant following adjustment for baseline characteristics (P < 0.001).

CONCLUSION

The Iwate DSS 12-point difficulty index and four difficulty levels correlated well with LLR difficulty as determined by key surrogate perioperative measures.

Navigating Complexity in Liver Resection: A Narrative Review of Factors Influencing Intraoperative Difficulty

Background: Liver resection remains the cornerstone for curative management in primary liver malignancies. Liver surgery ranges from simple wedge resections to complex hepatectomies involving vascular or biliary reconstructions. The anatomical complexity of the liver and these varied surgical approaches create challenges in assessing operative difficulty. This literature review explores the key factors influencing operative difficulty in liver resection for primary liver malignancy across surgical techniques. Methods: A broad literature review was conducted to determine the factors that were associated with increased operative difficulty in liver resection using the Embase, PubMed, and Cochrane databases for studies published between 2000 and 2025. Results: This review identifies several patient, tumor, and surgical factors that influence operative difficulty in liver resection. Numerous difficult scoring systems were identified, yet their applicability across different operative approaches remains uncertain. Across open and minimally invasive techniques, tumor size and location are commonly used to determine complexity. However, debate remains regarding the optimal cutoff for tumor diameter. Other identified factors include the extent of resection, patient-specific variables (e.g., cirrhosis, body mass index, previous surgeries), and surgical technique. In addition, liver resection procedures classified based on the 2000 Brisbane terminology have been stratified into three groups of increasing difficulty. Conclusion: The ability to predict operative difficulty is useful for case selection, surgical planning, and risk stratification for meaningful shared decision-making. Future research should focus on refining predictive models by integrating composite measures, including patient-reported outcomes and long-term survival. A unified, validated scoring system applicable across surgical techniques could enhance consistency in clinical practice and research to improve outcomes.

A precise surgical planning system for hepatectomy coupled with liver tissue in the hepato-portal vein territories

Background

With the advancement of precise hepatic resection and three-dimensional (3D) reconstruction technology, there is a growing emphasis on precision in liver surgery. However, during hepatic resection, thick hepatic veins may appear in the portal vein basin, and injury to thick hepatic veins may cause residual hepatic stasis, resulting in impaired liver function, or even failure. Therefore, we developed a new computer-assisted hepatic surgical planning system that integrates the portal and hepatic vein basins. This system is designed to achieve oncological safety and preserve functional hepatic tissues by reducing ischemic volume (IV), congested volume (CV), and transection surface area (TSA), leaving the residual liver with less ischemic volume, sludge volume, and cross-sectional area, thereby optimizing postoperative outcomes.

Methods

Contrast-enhanced computed tomography (CT) datasets from 20 patients at The First Affiliated Hospital of Ningbo University were analyzed for 3D reconstruction. Using a pseudorandom number generator algorithm, 140 liver occupancy models were established with seven points selected from each case. Three distinct surgical simulation strategies were compared: hepatic-portal venous territory integration, anatomical portal territory resection, and non-anatomical resection (NAR) (1-cm margin), the liver occupancy models were compared with the three types of surgical planning. Quantitative parameters, including Resected Index (RI, resected volume/total liver volume), Ischemic Index (II, residual ischemic volume/total liver volume), Congestion Index (CI, residual CV/total liver volume), and transection surface ratio (TSR, cross-sectional area/total liver surface area), were analyzed to evaluate the value of the surgical planning system.

Results

Compared with portal vein basin anatomical hepatectomy, the integrated method had smaller RI [8.09 (3.00, 20.12) vs. 18.9 (2.84, 42.29), P<0.05], CI [1.14 (0.37, 3.68) vs. 3.39 (0.35, 13.26), P<0.05], II [2.28 (0.82, 7.10) vs. 3.39 (0.35, 13.26), P<0.05], and TSR [14,417.13 (7,462.02, 32,715.68) vs. 73,739.52 (47,559.78, 102,632.74), P<0.05]. When compared to NAR, the integration strategy achieved reduced II [1.15 (0.46, 3.43) vs. 7.63 (3.00, 24.16), P<0.05], CI [1.14 (0.37, 3.68) vs. 7.67 (2.16, 22.98), P<0.05], and RI [2.28 (0.82, 7.10) vs. 15.28 (4.46, 47.14), P<0.05].

Conclusions

In this study, we established a surgical planning system coordinating portal perfusion territories with hepatic venous drainage basins. The computational planning system significantly improves surgical precision by reducing residual ischemic volume, venous congestion, and parenchymal transection area.

Lapdoctor: Multicentre Validation of a Scoring System for Preoperative Evaluation of Difficulty of Laparoscopic Donor Nephrectomy

We previously developed and validated LAPDOCTOR (LAParoscopic-Donor-nephreCTomy-scORe), a novel scoring system for the preoperative assessment of the difficulty of living donor nephrectomy (LDN). To prove its significance, we extended our investigation to a prospective, multicenter, national study. Difficulty was assessed by the operating surgeon using a scale from 1 to 3 (1-standard, 2-moderately difficult, 3-very difficult) based on eight parameters: availability of laparoscopic space, mobilization of the colon, kidney, gonadal, adrenal and renal vein, renal artery, and ureter. Donor CT-scans were blindly reviewed by a radiologist, and the LAPDOCTOR scores were compared with the difficulty levels assigned by the surgeon to investigate the match rates. One hundred eighty-five donors were enrolled, with a mean age of 54 years (range 24-77), BMI 25 kg/m2 (range 17-35), and male/female 59/126. LDN was blindly scored as standard in 45% of the cases, moderately-difficult in 52%, and very-difficult in 3%. The agreement between the LAPDOCTOR and expert donor surgeons' rate in categorizing LDN into risk groups had a QWK of 0.711 (95% CI 0.577-0.844) with p < 0.001. The LAPDOCTOR enables precise preoperative determination of the difficulty of LDN, particularly in very difficult cases, and assessment of surgical risk in living kidney donors.

Clinical Trial Notation

https://ClinicalTrials.gov, Identifier NCT05769686.

Indication model for laparoscopic repeat liver resection in the era of artificial intelligence: machine learning prediction of surgical indication

BACKGROUND

Laparoscopic repeat liver resection (LRLR) is still a challenging technique and requires a careful selection of indications. However, the current difficulty scoring system is not suitable for selecting indications. The purpose of this study is to develop the indication model for LRLR using machine learning and to identify factors associated with open conversion (OC).

METHODS

Patients who underwent repeat hepatectomy (2017-2021) at Samsung Medical Center 2021 were investigated. Multiple indication models were developed using machine learning techniques (random forest, SVM, XGB) and logistic regression. The predictive performance of these models was compared, and risk factors associated with OC were analyzed.

RESULTS

Among 221 patients (110 LRLR, 111 ORLR), the ORLR group had a higher previous open approach rate (75.7% vs. 38.2%, p<0.001). Twice previous abdominal surgery was the only independent OC risk factor (OR 6.56, p=0.009). The indication model showed moderate predictive power (random forest AUC=0.779, logistic regression AUC=0.725, p=0.710). Important variables were previous laparoscopic approach, present subsegmentectomy, and left-sided tumor location.

CONCLUSION

The performance of the indication model for LRLR showed moderate predictive power in both machine learning and logistic regression. The important variables for LRLR were previous laparoscopic approach, present subsegmentectomy, and left side location.

Comparative analysis of the safety and feasibility of laparoscopic and open approaches for right anterior sectionectomy

Laparoscopic hepatectomy has minimally invasive advantages, but reports on laparoscopic right anterior sectionectomy (LRAS) are rare. Herein, we try to explore the benefits and drawbacks of LRAS by comparing it with open right anterior sectionectomy (ORAS). Between January 2015 and September 2023, 39 patients who underwent LRAS (n = 18) or ORAS (n = 21) were enrolled in the study. The patients' characteristics, intraoperative details, and postoperative outcomes were compared between the two groups. No significant differences in the preoperative data were observed between the two groups. The LRAS group had significantly lesser blood loss (P = 0.019), a shorter hospital stay (P = 0.045), and a higher rate of bile leak (P = 0.039) than the ORAS group. There was no significant difference in the operative time (P = 0.156), transfusion rate (P = 0.385), hospital expenses (P = 0.511), rate of other complications, postoperative white blood cell count, and alanine aminotransferase and aspartate aminotransferase levels between the two groups (P > 0.05). Beside, there was no significant difference in disease-free survival (P = 0.351) or overall survival (P = 0.613) in patients with hepatocellular carcinoma between the two groups. LRAS is a safe and feasible surgical procedure. It may be preferred for lesions in the right anterior lobe of the liver.

The role of artificial intelligence and image processing in the diagnosis, treatment, and prognosis of liver cancer: a narrative-review

Artificial intelligence (AI) and image processing are revolutionising the diagnosis and management of liver cancer. Recent advancements showcase AI's ability to analyse medical imaging data, like computed tomography scans and magnetic resonance imaging, accurately detecting and classifying liver cancer lesions for early intervention. Predictive models aid prognosis estimation and recurrence pattern identification, facilitating personalised treatment planning. Image processing techniques enhance data analysis by precise segmentation of liver structures, fusion of information from multiple modalities, and feature extraction for informed decision-making. Despite progress, challenges persist, including the need for standardised datasets and regulatory considerations.

A feasible and safe approach for repeat laparoscopic liver resection and patient selection based on standardized preoperative prediction of surgical difficulty

PURPOSE

This study was performed to propose a strategy for repeat laparoscopic liver resection (RLLR) and investigate the preoperative predictive factors for RLLR difficulty.

METHODS

Data from 43 patients who underwent RLLR using various techniques at 2 participating hospitals from April 2020 to March 2022 were retrospectively reviewed. Surgical outcomes, short-term outcomes, and feasibility and safety of the proposed techniques were evaluated. The relationship between potential predictive factors for difficult RLLR and perioperative outcomes was evaluated. Difficulties associated with RLLR were analyzed separately in two surgical phases: the Pringle maneuver phase and the liver parenchymal transection phase.

RESULTS

The open conversion rate was 7%. The median surgical time and intraoperative blood loss were 235 min and 200 mL, respectively. The Pringle maneuver was successfully performed in 81% of patients using the laparoscopic Satinsky vascular clamp (LSVC). Clavien-Dindo class ≥III postoperative complications were observed in 12% of patients without mortality. An analysis of the risk factors for predicting difficult RLLR showed that a history of open liver resection was an independent risk factor for difficulty in the Pringle maneuver phase.

CONCLUSION

We present a feasible and safe approach to address RLLR difficulty, especially difficulty with the Pringle maneuver using an LSVC, which is extremely useful in RLLR. The Pringle maneuver is more challenging in patients with a history of open liver resection.

Increasing incidence and severity of post-hepatectomy adhesion around the liver may be influenced by the hepatectomy-related operative procedures

BACKGROUND

The incidence of postoperative adhesions is directly correlated with the difficulty level of repeat hepatectomies. However, the incidence, location, and severity of postoperative adhesions in relation to hepatectomy-related operative procedures are yet unclear.

METHODS

First hepatectomy-induced hard dense adhesions were evaluated from the surgical records and/or videos of 168 patients who underwent second hepatectomies.

RESULTS

The incidence of postoperative hard dense adhesions around the liver was significantly associated with locations, such as the hepatic cut surface, dissected areas around the liver, and peri-incision peritoneum, and hepatectomy-related operative procedures, such as Pringle maneuver and cholecystectomy. The incidence of hard dense adhesions after dissection was higher around the right liver than in the left infraphrenic space. Further, the incidence of hard dense adhesions around the hepatoduodenal ligament or Morison pouch was greater than 30% even in patients who did not undergo Pringle maneuver, cholecystectomy, or hepatorenal ligament dissection. Although the incidence of hard dense adhesions of the peritoneum around the incision was higher after open hepatectomy than after laparoscopic hepatectomy, adhesion barrier use reduced the incidence of such adhesions in patients after open hepatectomy.

CONCLUSION

Hepatectomy-related operative procedures such as peri-hepatic dissection, Pringle maneuver and cholecystectomy are directly associated with postoperative hard dense adhesions. However, the incidence of postoperative hard dense adhesions around the hepatoduodenal ligament and Morison pouch was high even when the above-mentioned operative procedures were not performed. These findings may help inform clinical decisions regarding the indications and sites for adhesion barrier use during hepatectomies.

Surgical outcomes of laparoscopic versus open repeat liver resection for liver cancers: A report from a nationwide surgical database in Japan

BACKGROUND/PURPOSE

Laparoscopic (repeat) liver resection (LRLR) is a well-established liver tumor treatment. However, since its outcomes and comparison with open repeat liver resection (ORLR) in recurrent liver cancer remain inadequately studied, this study then aimed to compare their short-term outcomes for liver cancers (hepatocellular carcinoma, intrahepatic cholangiocellular carcinoma, and metastatic liver cancer).

METHODS

Repeat liver resection cases between 2013 and 2017 from Japan's National Clinical Database were extracted. We used propensity score matching (PSM) to compare the proportion of patients with postoperative complications of Clavien-Dindo classification grade II or higher (CD2+) (primary endpoint), as well as the operative time, intraoperative bleeding volume, and intraoperative transfusion implementation rate (secondary endpoints).

RESULTS

Of 2,902 patients (ORLR, 2,476; LRLR, 426), 712 (356 per type) with comparable backgrounds remained via PSM. Before and after PSM, the postoperative CD2+ complication rate was significantly lower in the LRLR group, who had shorter operative time, smaller intraoperative bleeding volume, and lower intraoperative transfusion rate, than in the ORLR group (after matching, 7.6% vs. 18.3%, p < 0.0001).

CONCLUSIONS

LRLR showed better short-term outcomes than ORLR, making it a safer and more effective liver cancer treatment.

Predicting Complications following Surgical Resection of Hepatocellular Carcinoma Using Newly Developed Neo-Glasgow Prognostic Score with ALBI Grade: Comparison of Open and Laparoscopic Surgery Cases

Background/Aim: Nutritional assessment is known to be important for predicting prognosis in patients with malignant diseases. This study examined the usefulness of a prognostic predictive nutritional assessment tool for hepatocellular carcinoma (HCC) patients treated with surgical resection. Materials/Methods: HCC patients (n = 429) classified as Child−Pugh A who underwent an R0 resection between 2010 and 2020 were retrospectively analyzed (median age 73 years, males 326 (76.0%), Child−Pugh score 5:6 = 326:103, single tumor 340 (79.2%), median tumor size 3.5 cm, open:laparoscopic = 304:125). Glasgow prognostic score (GPS) and the newly developed neo-GPS method, which uses albumin−bilirubin grade 1 instead of albumin, were evaluated to compare their usefulness for prognosis prediction. Results: Median survival time for patients with a GPS score of 0, 1, and 2 was 120, 51, and 20 months, respectively. As for neo-GPS, that for those with a score of 0, 1, and 2 was not applicable (NA), 53 months, and 35 months, respectively (each p < 0.001; c-index: 0.556 and 0.611, respectively). Furthermore, median progression-free survival was 33, 22, and 9 months, and 41, 24, and 15 months, respectively (each p < 0.001; c-index: 0.539 and 0.578, respectively). As compared to patients with a high GPS (≥1), those with a high neo-GPS (≥1) showed a greater rate of high Clavien−Dindo classification (≥3) (39.2% vs. 65.1%). A comparison of patients with a high GPS (≥1) with those with a high neo-GPS (≥1) showed no significant difference regarding frequency of open or laparoscopic hepatectomy (17.4% vs. 15.2%, p = 0.670; 44.7% vs. 43.2%, p = 0.831, respectively), while the frequency of high Clavien−Dindo classification (≥3) was lower in patients who underwent a laparoscopic hepatectomy (11.2% vs. 22.7%, p = 0.007). Conclusion: The present findings suggest that the newly developed neo-GPS based on ALBI grade is an effective prognostic nutritional assessment tool and can be used for prediction of postoperative complications.

Indications of Laparoscopic Repeat Liver Resection for Recurrent Hepatocellular Carcinoma

AIM

This study aimed to evaluate the indications of laparoscopic repeat liver resection (LRLR) for recurrent hepatocellular carcinoma from the viewpoint of its difficulty.

METHODS

One hundred and one patients who underwent LRLR and 59 patients who underwent open repeat liver resection (ORLR) were included. The difficulty was classified according to the preoperative predictive factors for difficult LRLR, including an open approach during previous liver resection, history of two or more previous liver resections, history of previous major liver resection, tumor near the resected site of the previous liver resection, and intermediate or high difficulty with the difficulty scoring system. We compared the surgical outcomes between the LRLR and ORLR groups based on the difficulty class (low- or intermediate difficiulty class, 0 to 3 predictive factors; high difficiulty class, 4 or 5 factors).

RESULTS

In the low- or intermediate difficiulty class, intraoperative blood loss and the proportion of patients with postoperative complications were significantly lower in LRLR than in ORLR, and the duration of the postoperative hospital stay was significantly shorter in LRLR than in ORLR. In the high difficiulty class, total operative time and operative time before starting hepatic parenchymal resection were significantly longer in LRLR than in ORLR, and there were no significant differences in other surgical outcomes between the two groups.

CONCLUSION

LRLR is recommended for patients in the low or intermediate difficulty class. However, LRLR does not have an advantage with longer operative time for patients in the high difficulty class compared with ORLR.

Laparoscopic liver resection: indications, limitations, and economic aspects

Background

Minimally invasive techniques have increasingly found their way into liver surgery in recent years. A multitude of mostly retrospective analyses suggests several advantages of laparoscopic over open liver surgery. Due to the speed and variety of simultaneous technical and strategic developments, it is difficult to maintain an overview of the current status and perspectives in laparoscopic liver surgery.

Purpose

This review highlights up-to-date aspects in laparoscopic liver surgery. We discuss established indications with regard to their development over time as well as continuing limitations of applied techniques. We give an assessment based on the current literature and according to our own center experiences, not least with regard to a highly topical cost discussion.

Conclusions

While in the beginning mainly benign tumors were laparoscopically operated on, liver metastasis and hepatocellular carcinoma are now among the most frequent indications. Technical limitations remain and should be evaluated with the overall aim not to endanger quality standards in open surgery. Financial aspects cannot be neglected with the necessity of cost-covering reimbursement.

A novel difficulty grading system for laparoscopic living donor nephrectomy

Background

Several difficulty grading systems have been developed as a useful tool for selecting patients and training surgeons in laparoscopic procedures. However, there is little information on predicting the difficulty of laparoscopic donor nephrectomy (LDN). The aim of this study was to develop a grading system to predict the difficulty of LDN.

Methods

Data of 1741 living donors, who underwent pure or hand-assisted LDN between 1994 and 2018 were analyzed. Multivariable analyses were performed to identify factors associated with prolonged operative time, defined as a difficulty index with 0 to 8. The difficulty of LDN was classified into three levels based on the difficulty index.

Results

Multivariable analyses identified that male (odds ratio [OR] 1.69, 95% CI 1.37–2.09, P < 0.001), BMI > 28 (OR 1.36, 95% CI 1.08–1.72, P = 0.009), pure LDN (OR 1.99, 95% CI 1.53–2.60, P < 0.001), multiple renal arteries (OR 2.38, 95% CI 1.83–3.10, P < 0.001) and multiple renal veins (OR 2.18, 95% CI 1.52–3.16, P < 0.001) were independent risk factors influencing prolonged operative time. The difficulty index based on these factors was calculated and categorized into three levels: low (0–2), intermediate (3–5), and high (6–8) difficulty. Operative time was significantly longer in the high difficulty group (225 min) than in the low (169 min, P < 0.001) and intermediate difficulty group (194 min, P < 0.001). The conversion rate was higher in the high difficulty group (4.4%) than in the low (2.1%, P = 0.04) and the intermediate difficulty group (3.0%, P = 0.27). No significant difference in major complications was found between the groups.

Conclusion

We developed a novel grading system with simple preoperative donor factors to predict the difficulty of LDN. This grading system may help surgeons in patient selection to advance their experiences and/or teach fellows from simple to difficult LDN.