Laparoscopic extended liver resection: are postoperative outcomes different?

  • Daniel Pietrasz
  • David Fuks
  • Daren Subar
  • Gianfranco Donatelli
  • Carlotta Ferretti
  • Christian Lamer
  • Luca Portigliotti
  • Marc Ward
  • Jane Cowan
  • Takeo Nomi
  • Marc Beaussier
  • Brice Gayet



Although laparoscopic major hepatectomy (LMH) is becoming increasingly common in specialized centers, data regarding laparoscopic extended major hepatectomies (LEMH) and their outcomes are limited. The aim of this study was to compare the perioperative characteristics and postoperative outcomes of LEMH to standard LMH.


All patients who underwent purely laparoscopic anatomical right or left hepatectomy and right or left trisectionectomy between February 1998 and January 2016 are enrolled. Demographic, clinicopathological, and perioperative factors were collected prospectively and analyzed retrospectively. Perioperative characteristics and postoperative outcomes in LEMH were compared to those of standard LMH.


Among 195 patients with LMH, 47 (24.1%) underwent LEMH, colorectal liver metastases representing 66.7% of all indications. Preoperative portal vein embolization was undertaken in 31 (15.9%) patients. Despite more frequent vascular clamping, blood loss was higher in LEMH group (400 vs. 214 ml; p = 0.006). However, there was no difference in intraoperative transfusion requirements. Thirty-one patients experienced liver failure with no differences between LMH and LEMH groups. Postoperative mortality was comparable in the two groups [3 (2.5%) LMH patients vs. 2 (5%) LEMH patients (p = 0.388)]. Overall morbidity was higher in the LEMH group [49 LMH patients (41.5%) vs. 24 LEMH patients (60%) (p = 0.052)]. Patients treated with left LEMH experienced more biliary leakage (p = 0.011) and more major pulmonary complications (p = 0.015) than left LMH.


LEMH is feasible at the price of important morbidity, with manageable and acceptable outcomes. These exigent procedures require high-volume centers with experienced surgeons.


Laparoscopic liver resection Extended hepatectomy Trisectionectomy 


Compliance with ethical standards


Dr. Daniel Pietrasz, Pr. David Fuks, Drs. Daren Subar, Gianfranco Donatelli, Carlotta Ferretti, Christian Lamer, Luca Portigliotti, Marc Ward, Jane Cowan, Takeo Nomi, and Prs. Marc Beaussier, and Brice Gayet have no conflicts of interest or financial ties to disclose.


  1. 1.
    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 250:825–830CrossRefGoogle Scholar
  2. 2.
    Abu Hilal M, Di Fabio F, Teng MJ, Lykoudis P, Primrose JN, Pearce NW (2011) Single-centre comparative study of laparoscopic versus open right hepatectomy. J Gastrointest Surg 15:818–823CrossRefPubMedGoogle Scholar
  3. 3.
    Berardi G, Van Cleven S, Fretland AA, Barkhatov L, Halls M, Cipriani F, Aldrighetti L, Abu Hilal M, Edwin B, Troisi RI (2017) Evolution of laparoscopic liver surgery from innovation to implementation to mastery: perioperative and oncologic outcomes of 2,238 patients from 4 European Specialized Centers. J Am Coll Surg 225:639–649CrossRefPubMedGoogle Scholar
  4. 4.
    Dagher I, O’Rourke N, Geller DA, Cherqui D, Belli G, Gamblin TC, Lainas P, Laurent A, Nguyen KT, Marvin MR, Thomas M, Ravindra K, Fielding G, Franco D, Buell JF (2009) Laparoscopic major hepatectomy: an evolution in standard of care. Ann Surg 250:856–860CrossRefPubMedGoogle Scholar
  5. 5.
    Belli G, Limongelli P, Fantini C, D’Agostino A, Cioffi L, Belli A, Russo G (2009) Laparoscopic and open treatment of hepatocellular carcinoma in patients with cirrhosis. Br J Surg 96:1041–1048CrossRefPubMedGoogle Scholar
  6. 6.
    Ito K, Ito H, Are C, Allen PJ, Fong Y, DeMatteo RP, Jarnagin WR, D’Angelica MI (2009) Laparoscopic versus open liver resection: a matched-pair case control study. J Gastrointest Surg 13:2276–2283CrossRefPubMedGoogle Scholar
  7. 7.
    Laurent A, Cherqui D, Lesurtel M, Brunetti F, Tayar C, Fagniez PL (2003) Laparoscopic liver resection for subcapsular hepatocellular carcinoma complicating chronic liver disease. Arch Surg 138:763–769, discussion 769CrossRefPubMedGoogle Scholar
  8. 8.
    Chang S, Laurent A, Tayar C, Karoui M, Cherqui D (2007) Laparoscopy as a routine approach for left lateral sectionectomy. Br J Surg 94:58–63CrossRefPubMedGoogle Scholar
  9. 9.
    Bryant R, Laurent A, Tayar C, Cherqui D (2009) Laparoscopic liver resection-understanding its role in current practice: the Henri Mondor Hospital experience. Ann Surg 250:103–111CrossRefPubMedGoogle Scholar
  10. 10.
    Castaing D, Vibert E, Ricca L, Azoulay D, Adam R, Gayet B (2009) Oncologic results of laparoscopic versus open hepatectomy for colorectal liver metastases in two specialized centers. Ann Surg 250:849–855CrossRefPubMedGoogle Scholar
  11. 11.
    Tranchart H, Di Giuro G, Lainas P, Roudie J, Agostini H, Franco D, Dagher I (2010) Laparoscopic resection for hepatocellular carcinoma: a matched-pair comparative study. Surg Endosc 24:1170–1176CrossRefPubMedGoogle Scholar
  12. 12.
    Buell JF, Thomas MT, Rudich S, Marvin M, Nagubandi R, Ravindra KV, Brock G, McMasters KM (2008) Experience with more than 500 minimally invasive hepatic procedures. Ann Surg 248:475–486PubMedGoogle Scholar
  13. 13.
    Fuks D, Cauchy F, Fteriche S, Nomi T, Schwarz L, Dokmak S, Scatton O, Fusco G, Belghiti J, Gayet B, Soubrane O (2015) Laparoscopy decreases pulmonary complications in patients undergoing major liver resection: a propensity score analysis. Ann Surg 263:353–361CrossRefGoogle Scholar
  14. 14.
    Gayet B, Cavaliere D, Vibert E, Perniceni T, Levard H, Denet C, Christidis C, Blain A, Mal F (2007) Totally laparoscopic right hepatectomy. Am J Surg 194:685–689CrossRefPubMedGoogle Scholar
  15. 15.
    Gumbs AA, Gayet B (2007) Totally laparoscopic left hepatectomy. Surg Endosc 21:1221CrossRefPubMedGoogle Scholar
  16. 16.
    Xu H, Liu F, Li H, Wei Y, Li B (2017) Outcomes following laparoscopic versus open major hepatectomy: a meta-analysis. Scand J Gastroenterol 52:1307–1314CrossRefPubMedGoogle Scholar
  17. 17.
    Yoon YI, Kim KH, Kang SH, Kim WJ, Shin MH, Lee SK, Jung DH, Park GC, Ahn CS, Moon DB, Ha TY, Song GW, Hwang S, Lee SG (2017) Pure laparoscopic versus open right hepatectomy for hepatocellular carcinoma in patients with cirrhosis: a propensity score matched analysis. Ann Surg 265:856–863CrossRefPubMedGoogle Scholar
  18. 18.
    Komatsu S, Brustia R, Goumard C, Perdigao F, Soubrane O, Scatton O (2015) Laparoscopic versus open major hepatectomy for hepatocellular carcinoma: a matched pair analysis. Surg Endosc 30:1965–1974CrossRefPubMedGoogle Scholar
  19. 19.
    Ciria R, Cherqui D, Geller DA, Briceno J, Wakabayashi G (2016) Comparative short-term benefits of laparoscopic liver resection: 9000 cases and climbing. Ann Surg 263:761–777CrossRefPubMedGoogle Scholar
  20. 20.
    Abu Hilal M, Aldrighetti L, Dagher I, Edwin B, Troisi RI, Alikhanov R, Aroori S, Belli G, Besselink M, Briceno J, Gayet B, D’Hondt M, Lesurtel M, Menon K, Lodge P, Rotellar F, Santoyo J, Scatton O, Soubrane O, Sutcliffe R, Van Dam R, White S, Halls MC, Cipriani F, Van der Poel M, Ciria R, Barkhatov L, Gomez-Luque Y, Ocana-Garcia S, Cook A, Buell J, Clavien PA, Dervenis C, Fusai G, Geller D, Lang H, Primrose J, Taylor M, Van Gulik T, Wakabayashi G, Asbun H, Cherqui D (2017) The Southampton consensus guidelines for laparoscopic liver surgery: from indication to implementation. Ann Surg. CrossRefPubMedGoogle Scholar
  21. 21.
    Gumbs AA, Bar-Zakai B, Gayet B (2008) Totally laparoscopic extended left hepatectomy. J Gastrointest Surg 12:1152CrossRefPubMedGoogle Scholar
  22. 22.
    Gumbs AA, Gayet B (2008) Multimedia article. Totally laparoscopic extended right hepatectomy. Surg Endosc 22:2076–2077CrossRefPubMedGoogle Scholar
  23. 23.
    Azoulay D, Castaing D, Krissat J, Smail A, Hargreaves GM, Lemoine A, Emile JF, Bismuth H (2000) Percutaneous portal vein embolization increases the feasibility and safety of major liver resection for hepatocellular carcinoma in injured liver. Ann Surg 232:665–672CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Nomi T, Fuks D, Govindasamy M, Mal F, Nakajima Y, Gayet B (2015) Risk factors for complications after laparoscopic major hepatectomy. Br J Surg 102:254–260CrossRefPubMedGoogle Scholar
  25. 25.
    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 240:205–213CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Balzan S, Belghiti J, Farges O, Ogata S, Sauvanet A, Delefosse D, Durand F (2005) The “50–50 criteria” on postoperative day 5: an accurate predictor of liver failure and death after hepatectomy. Ann Surg 242:824–828, discussion 828–829CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Ishizawa T, Hasegawa K, Kokudo N, Sano K, Imamura H, Beck Y, Sugawara Y, Makuuchi M (2009) Risk factors and management of ascites after liver resection to treat hepatocellular carcinoma. Arch Surg 144:46–51CrossRefPubMedGoogle Scholar
  28. 28.
    Koch M, Garden OJ, Padbury R, Rahbari NN, Adam R, Capussotti L, Fan ST, Yokoyama Y, Crawford M, Makuuchi M, Christophi C, Banting S, Brooke-Smith M, Usatoff V, Nagino M, Maddern G, Hugh TJ, Vauthey JN, Greig P, Rees M, Nimura Y, Figueras J, DeMatteo RP, Buchler MW, Weitz J (2011) Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery 149:680–688CrossRefPubMedGoogle Scholar
  29. 29.
    Dagher I, Gayet B, Tzanis D, Tranchart H, Fuks D, Soubrane O, Han HS, Kim KH, Cherqui D, O’Rourke N, Troisi RI, Aldrighetti L, Bjorn E, Abu Hilal M, Belli G, Kaneko H, Jarnagin WR, Lin C, Pekolj J, Buell JF, Wakabayashi G (2014) International experience for laparoscopic major liver resection. J Hepato-Biliary-Pancreat Sci 21:732–736CrossRefGoogle Scholar
  30. 30.
    Medbery RL, Chadid TS, Sweeney JF, Knechtle SJ, Kooby DA, Maithel SK, Lin E, Sarmiento JM (2014) Laparoscopic vs open right hepatectomy: a value-based analysis. J Am Coll Surg 218:929–939CrossRefPubMedGoogle Scholar
  31. 31.
    Cauchy F, Fuks D, Nomi T, Dokmak S, Scatton O, Schwarz L, Barbier L, Belghiti J, Soubrane O, Gayet B (2016) Benefits of laparoscopy in elderly patients requiring major liver resection. J Am Coll Surg 222:174–184 e110CrossRefPubMedGoogle Scholar
  32. 32.
    Kawaguchi Y, Fuks D, Kokudo N, Gayet B (2018) Difficulty of laparoscopic liver resection: proposal for a new classification. Ann Surg 267:13–17CrossRefPubMedGoogle Scholar
  33. 33.
    Hanazaki K, Kajikawa S, Shimozawa N, Matsushita A, Machida T, Shimada K, Yazawa K, Koide N, Adachi W, Amano J (2005) Perioperative blood transfusion and survival following curative hepatic resection for hepatocellular carcinoma. Hepato-Gastroenterology 52:524–529PubMedGoogle Scholar
  34. 34.
    Melendez J, Ferri E, Zwillman M, Fischer M, DeMatteo R, Leung D, Jarnagin W, Fong Y, Blumgart LH (2001) Extended hepatic resection: a 6-year retrospective study of risk factors for perioperative mortality. J Am Coll Surg 192:47–53CrossRefPubMedGoogle Scholar
  35. 35.
    Cherqui D, Alon R, Lauzet JY, Salvat A, De Salles De Hys C, Rotman N, Duvoux C, Julien M, Fagniez PL (1996) Limitation of blood transfusions during hepatectomies. Study of 150 consecutive hepatic resections on healthy and pathological livers. Gastroenterol Clin Biol 20:132–138PubMedGoogle Scholar
  36. 36.
    Lang H, Sotiropoulos GC, Brokalaki EI, Radtke A, Frilling A, Molmenti EP, Malago M, Broelsch CE (2006) Left hepatic trisectionectomy for hepatobiliary malignancies. J Am Coll Surg 203:311–321CrossRefPubMedGoogle Scholar
  37. 37.
    Halazun KJ, Al-Mukhtar A, Aldouri A, Malik HZ, Attia MS, Prasad KR, Toogood GJ, Lodge JP (2007) Right hepatic trisectionectomy for hepatobiliary diseases: results and an appraisal of its current role. Ann Surg 246:1065–1074CrossRefPubMedGoogle Scholar
  38. 38.
    Nishio H, Hidalgo E, Hamady ZZ, Ravindra KV, Kotru A, Dasgupta D, Al-Mukhtar A, Prasad KR, Toogood GJ, Lodge JP (2005) Left hepatic trisectionectomy for hepatobiliary malignancy: results and an appraisal of its current role. Ann Surg 242:267–275CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Takahara T, Wakabayashi G, Konno H, Gotoh M, Yamaue H, Yanaga K, Fujimoto J, Kaneko H, Unno M, Endo I, Seto Y, Miyata H, Miyazaki M, Yamamoto M (2016) Comparison of laparoscopic major hepatectomy with propensity score matched open cases from the National Clinical Database in Japan. J Hepato-Biliary-Pancreat Sci 23:721–734CrossRefGoogle Scholar
  40. 40.
    Otsubo T, Takasaki K, Yamamoto M, Katsuragawa H, Katagiri S, Yoshitoshi K, Hamano M, Ariizumi S, Kotera Y (2004) Bleeding during hepatectomy can be reduced by clamping the inferior vena cava below the liver. Surgery 135:67–73CrossRefPubMedGoogle Scholar
  41. 41.
    Nomi T, Fuks D, Agrawal A, Govindasamy M, Araki K, Gayet B (2015) Modified Pringle maneuver for laparoscopic liver resection. Ann Surg Oncol 22:852CrossRefGoogle Scholar
  42. 42.
    Kobayashi S, Honda G, Kurata M, Tadano S, Sakamoto K, Okuda Y, Abe K (2016) An experimental study on the relationship among airway pressure, pneumoperitoneum pressure, and central venous pressure in pure laparoscopic hepatectomy. Ann Surg 263:1159–1163CrossRefPubMedGoogle Scholar
  43. 43.
    Nagino M, Kamiya J, Arai T, Nishio H, Ebata T, Nimura Y (2006) “Anatomic” right hepatic trisectionectomy (extended right hepatectomy) with caudate lobectomy for hilar cholangiocarcinoma. Ann Surg 243:28–32CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Farid SG, White A, Khan N, Toogood GJ, Prasad KR, Lodge JP (2016) Clinical outcomes of left hepatic trisectionectomy for hepatobiliary malignancy. Br J Surg 103:249–256CrossRefPubMedGoogle Scholar
  45. 45.
    Vauthey JN, Pawlik TM, Abdalla EK, Arens JF, Nemr RA, Wei SH, Kennamer DL, Ellis LM, Curley SA (2004) Is extended hepatectomy for hepatobiliary malignancy justified? Ann Surg 239:722–730; discussion 730–722CrossRefPubMedPubMedCentralGoogle Scholar
  46. 46.
    Esaki M, Shimada K, Nara S, Kishi Y, Sakamoto Y, Kosuge T, Sano T (2013) Left hepatic trisectionectomy for advanced perihilar cholangiocarcinoma. Br J Surg 100:801–807CrossRefPubMedGoogle Scholar
  47. 47.
    Hong J, Zhang X, Luo R, Cai X (2016) The clinical risk factors associated with postoperative bile leakage after hepatectomy: a meta-analysis. Minerva Medica 107:39–53PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Daniel Pietrasz
    • 1
  • David Fuks
    • 1
  • Daren Subar
    • 1
    • 2
  • Gianfranco Donatelli
    • 1
  • Carlotta Ferretti
    • 1
  • Christian Lamer
    • 3
  • Luca Portigliotti
    • 1
  • Marc Ward
    • 1
  • Jane Cowan
    • 1
  • Takeo Nomi
    • 1
  • Marc Beaussier
    • 4
  • Brice Gayet
    • 1
  1. 1.Department of Digestive, Oncological and Metabolic Surgery, Institut Mutualiste MontsourisUniversity René Descartes Paris 5ParisFrance
  2. 2.Department of General and HPB SurgeryRoyal Blackburn HospitalLancashireUK
  3. 3.Department of Intensive Care Unit – Institut Mutualiste MontsourisUniversity René Descartes Paris 5ParisFrance
  4. 4.Department of Anesthesiology – Institut Mutualiste MontsourisUniversity René Descartes Paris 5ParisFrance

Personalised recommendations