Impact of Tumor Size on the Difficulty of Laparoscopic Major Hepatectomies: An International Multicenter Study

Yutaro Kato, Atsushi Sugioka, Masayuki Kojima, Nicholas L. Syn, Wang Zhongkai, Rong Liu, Federica Cipriani, Thomas Armstrong, Davit L. Aghayan, Tiing Foong Siow, Chetana Lim, Olivier Scatton, Paulo Herman, Fabricio Ferreira Coelho, Marco V. Marino, Vincenzo Mazzaferro, Adrian K.H. Chiow, Iswanto Sucandy, Arpad Ivanecz, Sung Hoon ChoiJae Hoon Lee, Mikel Gastaca, Marco Vivarelli, Felice Giuliante, Bernardo Dalla Valle, Andrea Ruzzenente, Chee Chien Yong, Constantino Fondevila, Mikhail Efanov, Fabrizio Di Benedetto, Andrea Belli, James O. Park, Fernando Rotellar, Gi Hong Choi, Ricardo Robles-Campos, Xiaoying Wang, Robert P. Sutcliffe, Moritz Schmelzle, Johann Pratschke, Eric C.H. Lai, Charing C.N. Chong, Mathieu D’Hondt, Kazuteru Monden, Santiago Lopez-Ben, T. Peter Kingham, Fabio Forchino, Alessandro Ferrero, Giuseppe Maria Ettorre, Giovanni Battista Levi Sandri, Franco Pascual, Daniel Cherqui, Olivier Soubrane, Go Wakabayashi, Roberto I. Troisi, Tan To Cheung, Zewei Chen, Mengqiu Yin, Mizelle D’Silva, Ho Seong Han, Phan Phuoc Nghia, Tran Cong duy Long, Bjørn Edwin, David Fuks, Kuo Hsin Chen, Mohammad Abu Hilal, Luca Aldrighetti, Brian K.P. Goh

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Introduction: Although tumor size (TS) is known to affect surgical outcomes in laparoscopic liver resection (LLR), its impact on laparoscopic major hepatectomy (L-MH) is not well studied. The objectives of this study were to investigate the impact of TS on the perioperative outcomes of L-MH and to elucidate the optimal TS cutoff for stratifying the difficulty of L-MH. Methods: This was a post-hoc analysis of 3008 patients who underwent L-MH at 48 international centers. A total 1396 patients met study criteria and were included. The impact of TS cutoffs was investigated by stratifying TS at each 10-mm interval. The optimal cutoffs were determined taking into consideration the number of endpoints which showed a statistically significant split around the cut-points of interest and the magnitude of relative risk after correction for multiple risk factors. Results: We identified 2 optimal TS cutoffs, 50 mm and 100 mm, which segregated L-MH into 3 groups. An increasing TS across these 3 groups (≤ 50 mm, 51–100 mm, > 100 mm), was significantly associated with a higher open conversion rate (11.2%, 14.7%, 23.0%, P < 0.001), longer operating time (median, 340 min, 346 min, 365 min, P = 0.025), increased blood loss (median, 300 ml, ml, 400 ml, P = 0.002) and higher rate of intraoperative blood transfusion (13.1%, 15.9%, 27.6%, P < 0.001). Postoperative outcomes such as overall morbidity, major morbidity, and length of stay were comparable across the three groups. Conclusion: Increasing TS was associated with poorer intraoperative but not postoperative outcomes after L-MH. We determined 2 TS cutoffs (50 mm and 10 mm) which could optimally stratify the surgical difficulty of L-MH.

Original languageEnglish
Pages (from-to)6628-6636
Number of pages9
JournalAnnals of Surgical Oncology
Issue number11
StatePublished - Oct 2023
Externally publishedYes


  • Difficulty
  • Laparoscopic liver resection
  • Major hepatectomy
  • Minimally invasive liver
  • Size


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