Minimally invasive hepatectomy is associated with decreased morbidity and resource utilization in the elderly



The aim of this study was to evaluate whether elderly patients undergoing elective hepatectomy experience increased morbidity/mortality and whether these outcomes could be mitigated by minimally invasive hepatectomy (MIH).


15,612 patients from 2014 to 2017 were identified in the Hepatectomy Targeted Procedure Participant Use File of the American College of Surgeons National Surgical Quality Improvement Program. Multivariable logistic regression models were constructed to examine the effect of elderly status (age ≥ 75 years, N = 1769) on outcomes with a subgroup analysis of elderly only patients by open (OH) versus MIH (robotic, laparoscopic, and hybrid, N = 4044). Propensity score matching was conducted comparing the effect of MIH to OH in elderly patients to ensure that results are not the artifact of imbalance in baseline characteristics.


Overall, elderly patients had increased risk for 30-day mortality, major morbidity, prolonged length of hospital stay, and discharge to destination other than home. In the elderly subgroup, MIH was associated with decreased major morbidity (OR 0.71, P = 0.031), invasive intervention (OR 0.61, P = 0.032), liver failure (OR 0.15, P = 0.011), bleeding (OR 0.46, P < 0.001), and prolonged length of stay (OR 0.46, P < 0.001). Propensity score-matched analyses successfully matched 4021 pairs of patients treated by MIH vs. OH, and logistic regression analyses on this matched sample found that MIH was associated with decreased major complications (OR 0.69, P = 0.023), liver failure (OR 0.14, P = 0.010), bile leak (OR 0.46, P = 0.009), bleeding requiring transfusion (OR 0.46, P < 0.001), prolonged length of stay (OR 0.46, P < 0.001), and discharge to destination other than home (OR 0.691, P = 0.035) compared to OH.


MIH is associated with decreased risk of major morbidity, liver failure, bile leak, bleeding, prolonged length of stay, and discharge to destination other than home among elderly patients in this retrospective study. However, MIH in elderly patients does not protect against postoperative mortality.

This is a preview of subscription content, access via your institution.


  1. 1.

    Buell JF, Cherqui D, Geller DA, O’Rourke N, Iannitti D, Dagher I et al (2009) The international position on laparoscopic liver surgery: the Louisville Statement, 2008. Ann Surg 250(5):825–830

    Article  Google Scholar 

  2. 2.

    He J, Amini N, Spolverato G, Hirose K, Makary M, Wolfgang CL et al (2015) National trends with a laparoscopic liver resection: results from a population-based analysis. HPB 17(10):919–926

    Article  Google Scholar 

  3. 3.

    Beppu T, Wakabayashi G, Hasegawa K, Gotohda N, Mizuguchi T, Takahashi Y et al (2015) Long-term and perioperative outcomes of laparoscopic versus open liver resection for colorectal liver metastases with propensity score matching: a multi-institutional Japanese study. J Hepato-Biliary-Pancreat Sci 22(10):711–720

    Article  Google Scholar 

  4. 4.

    Meguro M, Mizuguchi T, Kawamoto M, Ota S, Ishii M, Nishidate T et al (2015) Clinical comparison of laparoscopic and open liver resection after propensity matching selection. Surgery 158(3):573–587

    Article  Google Scholar 

  5. 5.

    Nguyen KT, Marsh JW, Tsung A, Steel JJ, Gamblin TC, Geller DA (2011) benefits of laparoscopic vs open hepatic resection: a critical appraisal. Arch Surg (Chicago, Ill: 1960) 146(3):348–356

    Article  Google Scholar 

  6. 6.

    Simillis C, Constantinides VA, Tekkis PP, Darzi A, Lovegrove R, Jiao L et al (2007) Laparoscopic versus open hepatic resections for benign and malignant neoplasms—a meta-analysis. Surgery 141(2):203–211

    Article  Google Scholar 

  7. 7.

    Rowe AJ, Meneghetti AT, Schumacher PA, Buczkowski AK, Scudamore CH, Panton ON et al (2009) Perioperative analysis of laparoscopic versus open liver resection. Surg Endosc 23(6):1198–1203

    Article  Google Scholar 

  8. 8.

    Bagante F, Spolverato G, Strasberg SM, Gani F, Thompson V, Hall BL et al (2016) Minimally invasive vs. open hepatectomy: a comparative analysis of the national surgical quality improvement program database. J Gastrointest 20(9):1608–1617

    Article  Google Scholar 

  9. 9.

    Nota CL, Rinkes IHB, Molenaar IQ, van Santvoort HC, Fong Y, Hagendoorn J (2016) Robot-assisted laparoscopic liver resection: a systematic review and pooled analysis of minor and major hepatectomies. HPB 18(2):113–120

    Article  Google Scholar 

  10. 10.

    Montalti R, Berardi G, Patriti A, Vivarelli M, Troisi RI (2015) Outcomes of robotic vs laparoscopic hepatectomy: a systematic review and meta-analysis. World J Gastroenterol 21(27):8441–8451

    Article  Google Scholar 

  11. 11.

    Sulpice L, Rayar M, Campillo B, Pery C, Guillaud A, Meunier B et al (2014) Advanced age remains an achilles heel for liver resections. World J Surg 38(4):918–926

    Article  Google Scholar 

  12. 12.

    Tzeng CW, Cooper AB, Vauthey JN, Curley SA, Aloia TA (2014) Predictors of morbidity and mortality after hepatectomy in elderly patients: analysis of 7621 NSQIP patients. HPB 16(5):459–468

    Article  Google Scholar 

  13. 13.

    Chan AC, Poon RT, Cheung TT, Chok KS, Dai WC, Chan SC et al (2014) Laparoscopic versus open liver resection for elderly patients with malignant liver tumors: a single-center experience. J Gastroenterol Hepatol 29(6):1279–1283

    Article  Google Scholar 

  14. 14.

    Martinez-Cecilia D, Cipriani F, Vishal S, Ratti F, Tranchart H, Barkhatov L et al (2017) Laparoscopic versus open liver resection for colorectal metastases in elderly and octogenarian patients: a multicenter propensity score based analysis of short- and long-term outcomes. Ann Surg 265(6):1192–1200

    Article  Google Scholar 

  15. 15.

    Nomi T, Fuks D, Louvet C, Nakajima Y, Gayet B (2016) Outcomes of laparoscopic liver resection for patients with large colorectal liver metastases: a case-matched analysis. World J Surg 40(7):1702–1708

    Article  Google Scholar 

  16. 16.

    Andreou A, Vauthey JN, Cherqui D, Zimmitti G, Ribero D, Truty MJ et al (2013) Improved long-term survival after major resection for hepatocellular carcinoma: a multicenter analysis based on a new definition of major hepatectomy. J Gastrointest Surg 17(1):66–77

    Article  Google Scholar 

  17. 17.

    Buettner S, Wagner D, Kim Y, Margonis GA, Makary MA, Wilson A et al (2016) Inclusion of sarcopenia outperforms the modified frailty index in predicting 1-year mortality among 1,326 patients undergoing gastrointestinal surgery for a malignant indication. J Am Coll Surg 222(4):397–407

    Article  Google Scholar 

  18. 18.

    Badawy A, Seo S, Toda R, Fuji H, Fukumitsu K, Ishii T et al (2019) A propensity score-based analysis of laparoscopic liver resection for liver malignancies in elderly patients. J Invest Surg 32(1):75–82

    Article  Google Scholar 

  19. 19.

    Tsui C, Klein R, Garabrant M (2013) Minimally invasive surgery: national trends in adoption and future directions for hospital strategy. Surg Endosc 27(7):2253–2257

    Article  Google Scholar 

Download references


We thank Ms. Marcie White and Ms. Jennie Ver Steeg from the Des Moines University, Mercy Medical Center Library, for their assistance in performing a thorough literature search of all major reference databases for this study.


American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.

Author information



Corresponding author

Correspondence to May C. Tee.

Ethics declarations


Drs. Tee, Peightal, Franko, Kim, Brahmbhatt, Raman, Scudamore, Chung, Segedi, and Mr. Chen have no conflicts of interest or financial ties to disclose.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Tee, M.C., Chen, L., Peightal, D. et al. Minimally invasive hepatectomy is associated with decreased morbidity and resource utilization in the elderly. Surg Endosc 34, 5030–5040 (2020).

Download citation


  • Laparoscopic/robotic hepatectomy
  • Elderly
  • Outcomes
  • Propensity score