**6. Operative approach: open vs. laparoscopic hepatectomy**

Before the first laparoscopic hepatectomy (LH) was described as early as 1991, open hepatectomy (OH) was the only choice for surgical treatment of liver tumors. LH indications were initially based solely on tumor location, size, and type and was only used for partial resection of the anterolateral segments.

Several studies have been conducted comparing laparoscopic liver resection (LLR) versus open liver resection (OLR) for hepatocellular carcinoma (HCC), however, the optimal therapeutic approach has not been established [10, 14–20].

A 2019 systematic review and meta-analysis by the Department of Hepatobiliary Surgery of Bengbu Medical College analyzed 17 studies comparing OH and LH. This metanalysis included 2004 patients and showed the following findings: For shortterm outcomes, LH was associated with less blood loss, lower blood transfusion rates, reduced occurrence of postoperative complications, wider surgical margin, shorter postoperative hospital stay, and declined rate of mortality (all *P* < 0.05). However, there was no significant difference in operation time (*P* = 0.67) between the two groups, whereas tumor size was larger in OH (*P* = 0.004). As for long-term outcomes, 1-, 3-, 5-year OS and 1-year DFS were higher in LH group (all *P* < 0.05). Nevertheless, there were no significant differences in 3- and 5-year DFS (*P* = 0.23 and 0.83, respectively) [18].

Another 2018 European systematic review and meta-analysis of individual patient data by Meidai Kasai et al. also compared outcomes of LH and OH. A total of 917 patients were divided into the laparoscopic (427) and open (490) groups from 8 selected studies. Interestingly, the hospital stay was significantly shorter, and the total morbidity was lower in the laparoscopic group. When classified by severity, the incidence of postoperative minor complications was lower in the LH group, however, that of major complications was not significantly different. The operative time was longer in the laparoscopic group; however, intraoperative blood loss, perioperative mortality, and blood transfusions were comparable between the two groups. The overall survival in the patients with colorectal liver metastases and hepatocellular carcinoma was not significantly different between the two groups in this metaanalysis [20].

It is clear that LLR has the same benefits as other laparoscopic procedures, such as earlier, recovery and discharge, and reduced postoperative pain. It is also important to underline the many benefits of the laparoscopic approach are obtained while there are no differences in oncologic outcomes compared to OLR. Furthermore, the studies showed the specific advantages of LLR: lower volume of blood loss, shorter portal clamp time and less overall and liver-specific complications, for selected patients and within the technical capabilities of each experienced center. LLR also allows for better visibility and manipulation in a small operative field under some conditions, such as repeat hepatectomy with adhesions. Laparoscopic surgery makes subsequent abdominal operations easier by reducing adhesions. It was reported that the salvage transplantation after previous LLR is associated with reductions of operation time, blood loss, and transfusion requirements, compared to that after OLR. Therefore, it is advantageous not only in reducing future adhesions but also in decreasing the need for adhesiolysis in repeat abdominal exploration.

The safety and feasibility of LLR and its short-term benefits for the patients with HCC and CLD have also been well demonstrated. Reduction of surgery-induced stress by LLR, especially in the patients with HCC and CLD, decreases the risk of refractory ascites due to the preservation of venous and lymphatic collateral flows. In result, this reduces the risk of water or electrolyte imbalances and hypoproteinemia that could lead to liver failure.

Although currently there is no established adjuvant therapy for patients with hepatocellular carcinoma who undergo resection, patients do recover fully faster after laparoscopic hepatectomy. As such, when future effective adjuvant modalities emerge, patients who undergo laparoscopic resection will be fully recovered and ready to receive these much sooner than patients who undergo an open resection. This has been shown in patients with colorectal liver metastasis who undergo laparoscopic liver resection to have a prognostic benefit compared to patients who undergo an open resection.
