Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Validation of difficulty scoring system for laparoscopic liver resection in patients who underwent laparoscopic left lateral sectionectomy



A difficulty scoring system (DSS) based on the extent of liver resection, tumor location, liver function, tumor size, and tumor proximity to major vessels was recently developed to assess the difficulty of various laparoscopic liver resection procedures. We validated DSS in patients who underwent laparoscopic left lateral sectionectomy (LLS).


We reviewed the clinical data of 124 patients who underwent laparoscopic LLS between July 2003 and November 2015 and validated the DSS in 90 patients who underwent laparoscopic LLS for tumor according to their surgical outcomes. We also developed and evaluated the modified DSS in 34 patients who underwent LLS for intrahepatic duct (IHD) stones.


The DSS score ranged from 3 to 6 in laparoscopic LLS for tumors. The median blood loss (P = 0.002) was significantly different among patients divided into subgroups by DSS score. We made modified DSS for IHD stones using factors influencing longer operation time, including stone location (P = 0.002), atrophy of liver parenchyma (P = 0.012), ductal stricture <1 cm from the bifurcation (P = 0.047), and combined choledochoscopic examination for remnant IHD (P < 0.001). The modified DSS score for IHD stones ranged from 3 to 7. Blood loss (P = 0.02) and operation time (P < 0.001) were significantly different among subgroups of patients divided by their difficulty scores. The median hospital stay (P = 0.004) and operation time (P = 0.039) were significantly longer and the complication rate (P = 0.025) and complication grade (P = 0.021) were significantly greater in patients with IHD stones than in patients with tumors.


The surgical difficulty varies among patients undergoing the same laparoscopic LLS procedure. The modified DSS developed here can also be applied to patients with IHD stones.

This is a preview of subscription content, log in to check access.


  1. 1.

    Ban D, Kudo A, Ito H, Mitsunori Y, Matsumura S, Aihara A, Ochiai T, Tanaka S, Tanabe M, Itano O, Kaneko H, Wakabayashi G (2015) The difficulty of laparoscopic liver resection. Updates Surg 67:123–128

  2. 2.

    Vivek MA, Augustine AJ, Rao R (2014) A comprehensive predictive scoring method for difficult laparoscopic cholecystectomy. J Minim Access Surg 10:62–67

  3. 3.

    Adnet F, Borron SW, Racine SX, Clemessy JL, Fournier JL, Plaisance P, Lapandry C (1997) The intubation difficulty scale (IDS): proposal and evaluation of a new score characterizing the complexity of endotracheal intubation. Anesthesiology 87:1290–1297

  4. 4.

    Khoshrang H, Falahatkar S, Heidarzadeh A, Abad M, Rastjou Herfeh N, Naderi Nabi B (2014) Predicting difficulty score for spinal anesthesia in transurethral lithotripsy surgery. Anesth Pain Med 4:e16244

  5. 5.

    Osborne SA, Severn P, Bunce CV, Fraser SG (2006) The use of a pre-operative scoring system for the prediction of phacoemulsification case difficulty and the selection of appropriate cases to be performed by trainees. BMC Ophthalmol 6:38

  6. 6.

    Lee MKt, Gao F, Strasberg SM (2015) Perceived complexity of various liver resections: results of a survey of experts with development of a complexity score and classification. J Am Coll Surg 220:64–69

  7. 7.

    Muangkaew P, Cho JY, Han HS, Yoon YS, Choi Y, Jang JY, Choi H, Jang JS, Kwon SU (2016) Defining surgical difficulty according to the perceived complexity of liver resection: validation of a complexity classification in patients with hepatocellular carcinoma. Ann Surg Oncol. doi:10.1245/s10434-015-5058-2.

  8. 8.

    Osborne SA, Adams WE, Bunce CV, Fraser SG (2006) Validation of two scoring systems for the prediction of posterior capsule rupture during phacoemulsification surgery. Br J Ophthalmol 90:333–336

  9. 9.

    Ban D, Tanabe M, Ito H, Otsuka Y, Nitta H, Abe Y, Hasegawa Y, Katagiri T, Takagi C, Itano O, Kaneko H, Wakabayashi G (2014) A novel difficulty scoring system for laparoscopic liver resection. J Hepatobiliary Pancreat Sci 21:745–753

  10. 10.

    Kim HM, Kim H, Park YN (2015) Sarcomatoid cholangiocarcinoma with osteoclast-like giant cells associated with hepatolithiasis: a case report. Clin Mol Hepatol 21:309–313

  11. 11.

    Kim HJ, Kim JS, Joo MK, Lee BJ, Kim JH, Yeon JE, Park JJ, Byun KS, Bak YT (2015) Hepatolithiasis and intrahepatic cholangiocarcinoma: a review. World J Gastroenterol 21:13418–13431

  12. 12.

    Han HS, Cho JY, Yoon YS (2009) Techniques for performing laparoscopic liver resection in various hepatic locations. J Hepatobiliary Pancreat Surg 16:427–432

  13. 13.

    Yoon YS, Han HS, Shin SH, Cho JY, Min SK, Lee HK (2009) Laparoscopic treatment for intrahepatic duct stones in the era of laparoscopy: laparoscopic intrahepatic duct exploration and laparoscopic hepatectomy. Ann Surg 249:286–291

  14. 14.

    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213

  15. 15.

    Yoon YS, Han HS, Choi YS, Lee SI, Jang JY, Suh KS, Kim SW, Lee KU, Park YH (2006) Total laparoscopic left lateral sectionectomy performed in a child with benign liver mass. J Pediatr Surg 41:e25–e28

  16. 16.

    Han HS, Yoon YS, Cho JY, Hwang DW (2013) Laparoscopic liver resection for hepatocellular carcinoma: korean experiences. Liver Cancer 2:25–30

  17. 17.

    Kaneko H, Takagi S, Shiba T (1996) Laparoscopic partial hepatectomy and left lateral segmentectomy: technique and results of a clinical series. Surgery 120:468–475

  18. 18.

    Rao A, Rao G, Ahmed I (2011) Laparoscopic left lateral liver resection should be a standard operation. Surg Endosc 25:1603–1610

  19. 19.

    Aldrighetti L, Pulitano C, Catena M, Arru M, Guzzetti E, Casati M, Comotti L, Ferla G (2008) A prospective evaluation of laparoscopic versus open left lateral hepatic sectionectomy. J Gastrointest Surg 12:457–462

  20. 20.

    Kim SJ, Jung HK, Lee DS, Yun SS, Kim HJ (2014) The comparison of oncologic and clinical outcomes of laparoscopic liver resection for hepatocellular carcinoma. Ann Surg Treat Res 86:61–67

  21. 21.

    Buell JF, Cherqui D, Geller DA, O’Rourke N, Iannitti D, Dagher I, Koffron AJ, Thomas M, Gayet B, Han HS, Wakabayashi G, Belli G, Kaneko H, Ker CG, Scatton O, Laurent A, Abdalla EK, Chaudhury P, Dutson E, Gamblin C, D’Angelica M, Nagorney D, Testa G, Labow D, Manas D, Poon RT, Nelson H, Martin R, Clary B, Pinson WC, Martinie J, Vauthey JN, Goldstein R, Roayaie S, Barlet D, Espat J, Abecassis M, Rees M, Fong Y, McMasters KM, Broelsch C, Busuttil R, Belghiti J, Strasberg S, Chari RS, World Consensus Conference on Laparoscopic S (2009) The international position on laparoscopic liver surgery: the louisville statement, 2008. Ann Surg 250:825–830

  22. 22.

    Beller S, Eulenstein S, Lange T, Niederstrasser M, Hunerbein M, Schlag PM (2009) A new measure to assess the difficulty of liver resection. Eur J Surg Oncol 35:59–64

  23. 23.

    Han HS, Shehta A, Ahn S, Yoon YS, Cho JY, Choi Y (2015) Laparoscopic versus open liver resection for hepatocellular carcinoma: case-matched study with propensity score matching. J Hepatol 63:643–650

  24. 24.

    Kim YK, Han HS, Yoon YS, Cho JY, Lee W (2015) Laparoscopic approach for right-sided intrahepatic duct stones: a comparative study of laparoscopic versus open treatment. World J Surg 39:1224–1230

  25. 25.

    Shin YC, Jang JY, Kang MJ, Jung W, Chang J, Chang YR, Kim SW (2016) Comparison of laparoscopic versus open left-sided hepatectomy for intrahepatic duct stones. Surg Endosc 30:259–265

  26. 26.

    Jeong CY, Kim KJ, Hong SC, Jeong SH, Ju YT, Lee YJ, Choi SK, Ha WS, Park ST, Jung EJ (2012) Laparoscopic left hemihepatectomy for left intrahepatic duct stones. J Korean Surg Soc 83:149–154

  27. 27.

    Tan J, Tan Y, Chen F, Zhu Y, Leng J, Dong J (2015) Endoscopic or laparoscopic approach for hepatolithiasis in the era of endoscopy in China. Surg Endosc 29:154–162

  28. 28.

    Liu X, Miao X, Liu X, Zhong D, Yao H, Wen Y, Dai W, Liu G (2014) Laparoscopic left hemihepatectomy for treatment of left intrahepatic duct stones. Am Surg 80:E350–E351

  29. 29.

    Suzuki Y, Mori T, Yokoyama M, Nakazato T, Abe N, Nakanuma Y, Tsubouchi H, Sugiyama M (2014) Hepatolithiasis: analysis of Japanese nationwide surveys over a period of 40 years. J Hepatobiliary Pancreat Sci 21:617–622

  30. 30.

    Yang T, Lau WY, Lai EC, Yang LQ, Zhang J, Yang GS, Lu JH, Wu MC (2010) Hepatectomy for bilateral primary hepatolithiasis: a cohort study. Ann Surg 251:84–90

  31. 31.

    Lai EC, Ngai TC, Yang GP, Li MK (2010) Laparoscopic approach of surgical treatment for primary hepatolithiasis: a cohort study. Am J Surg 199:716–721

  32. 32.

    Cai X, Wang Y, Yu H, Liang X, Peng S (2007) Laparoscopic hepatectomy for hepatolithiasis: a feasibility and safety study in 29 patients. Surg Endosc 21:1074–1078

  33. 33.

    Gough V, Stephens N, Ahmed Z, Nassar AH (2012) Intrahepatic choledochoscopy during trans-cystic common bile duct exploration; technique, feasibility and value. Surg Endosc 26:3190–3194

Download references


This work was supported by Grant No. 13-2015-024 from the SNUBH Research Fund.

Author information

Correspondence to Jai Young Cho.

Ethics declarations


Drs. Chami Im, Jai Young Cho, Ho-Seong Han, Yoo-Seok Yoon, YoungRok Choi, Jae Yool Jang, Hanlim Choi, Jae Seong Jang, and Seong Uk Kwon have no conflicts of interest or financial ties to disclose.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Im, C., Cho, J.Y., Han, H. et al. Validation of difficulty scoring system for laparoscopic liver resection in patients who underwent laparoscopic left lateral sectionectomy. Surg Endosc 31, 430–436 (2017).

Download citation


  • Outcome
  • Complication
  • Hepatectomy
  • Hepatolithiasis
  • Hepatocellular carcinoma