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Background: Despite evidence of benefits on postoperative outcomes, minimally invasive liver surgery (MILS) had a very low diffusion up to 2014, and recent evolution is unknown. Our aim was to analyze the recent diffusion and adoption of MILS and compare the trends in indications, extent of resection, and institutional practice with open liver surgery (OLS). Methods: We analyzed the French nationwide, exhaustive cohort of all patients undergoing a liver resection in France between January 1, 2013 and December 31, 2022. Average annual percentage changes (AAPC) in the incidence of MILS and OLS were compared using mixed-effects log-linear regression models. Time trends were analyzed in terms of extent of resection, indication, and institutional practice. Results: MILS represented 25.2% of 74,671 liver resections and year incidence doubled from 16.5% in 2013 to 35.4% in 2022. The highest AAPC were observed among major liver resections [+ 22.2% (19.5; 24.9) per year], primary [+ 10.2% (8.5; 12.0) per year], and secondary malignant tumors [+ 9.9% (8.2; 11.6) per year]. The highest increase in MILS was observed in university hospitals [+ 14.7% (7.7; 22.2) per year] performing 48.8% of MILS and in very high-volume (> 150 procedures/year) hospitals [+ 12.1% (9.0; 15.3) per year] performing 19.7% of MILS. OLS AAPC decreased for all indications and institutions and accelerated over time from – 1.8% (– 3.9; – 0.3) per year in 2013–2018 to – 5.9% (– 7.9; – 3.9) per year in 2018–2022 (p= 0.013). Conclusions: This is the first reported trend reversal between MILS and OLS. MILS has considerably increased at a national scale, crossing the 20% tipping point of adoption rate as defined by the IDEAL framework.

Introduction: Surgeons often remain reluctant to consider laparoscopic approach in multiple liver tumors. This study assessed feasibility and short-term results of patients who had more than 3 simultaneous laparoscopic liver resections (LLR). Methods: All consecutive patients who underwent LLR for primary or secondary malignancies between 2009 and 2019 were analyzed. After exclusion of major LLR, patients were divided into three groups: less than three (Group A), between three and five (Group B), and more than five resections (Group C) in the same procedure. Intraoperative details, postoperative outcomes, and textbook outcome (TO) were compared in the 3 groups. Results: During study period, 463 patients underwent minor LLR. Among them, 412 (88.9%) had less than 3 resections, 38 (8.2%) between 3 and 5 resections, and 13 (2.8%) more than 5 resections. Despite a difficulty score according to IMM classification comparable in the 3 groups (with high difficulty grade 3 procedures of 16.5% vs. 15.7% vs. 23.1% in Group A, B, and C, respectively, p= 0.124), mean operative time was significantly longer in Group C (p= 0.039). Blood loss amount (p= 0.396) and conversion rate (p= 0.888) were similar in the 3 groups. Rate of R1 margins was not significantly different between groups (p= 0.078). Achievement of TO was not different between groups (p= 0.741). In multivariate analysis, non-achievement of TO was associated with difficulty according to IMM classification (OR = 2.29 (1.33–3.98)). Conclusion: Since intra- and post-operative outcomes and quality of resection are comparable, multiple liver resections should not preclude the laparoscopic approach.

Background: The surgical difficulty and postoperative outcomes of laparoscopic liver resection (LLR) are related to the size of the cut liver surface. This study assessed whether the estimated parenchymal transection surface area could predict intraoperative difficulty and postoperative outcomes. Methods: LLRs performed between 2008 and 2018, for whom a preoperative CT scan was available for 3D review, were included in the study. The area of scheduled parenchymal transection was measured on the preoperative CT scan and cut-off values that could predict intraoperative difficulty were analyzed. Results: 152 patients who underwent left lateral sectionectomy (n= 27, median estimated area 30.1 cm2[range 16.6–65.9]), left/right hepatectomy (n= 17 and n= 70, 76.8 cm2[range 43.9–150.9] and 72.2 cm2[range 39.4–124.9], respectively), right posterior sectionectomy (n= 7, 113.3 cm2[range 102.1–136.3]), central hepatectomy (n= 11, 109.1 cm2[range 66.1–186.1]) and extended left/right hepatectomy (n= 6 and n= 14, 115.3 cm2[range 92.9–128.9] and 50.7 cm2[range 13.3–74.9], respectively) were included. An estimated parenchymal transection surface area ≥ 100 cm2was associated with significant increase in operative time (AUC 0.81, 95% CI [0.70, 0.93], p< 0.001) and estimated blood loss (AUC 0.92, 95% CI [0.86, 0.97], p< 0.001), as well as a higher conversion rate (22.2% vs. 4.0%, p< 0.001). Overall (p= 0.017) and major morbidity (p= 0.003), biliary leakage (p< 0.001) and pulmonary complications (p< 0.001) were significantly higher in patients with an estimated parenchymal transection surface area ≥ 100 cm2. Conclusions: An estimated parenchymal transection surface area ≥ 100 cm2is a relevant indicator of surgical difficulty and postoperative complications in LLR.

Introduction: The advantages of laparoscopic liver resection (LLR) are well known, but their financial costs are poorly evaluated. The aim of this study was to analyze the economic impact of surgical difficulty on LLR costs, and to identify clinical factors that most affect global charges. Methods: All patients who underwent LLR from 2014 to 2018 in a single French center were included. The IMM classification was used to stratify surgical difficulty, from group I through group III. The costing method was done combining top-down and bottom-up approaches. A multivariate analysis was performed in order to identify clinical factors that most affect global charges. Results: Two hundred seventy patients were included (Group I: n?=?136 (50%), Group II: n?=?60 (22%), Group III: n?=?74 (28%)). Total expenses significantly increased (p?<?0.001) from Group I to Group III, but there was no difference regarding financial income (p?=?0.133). Technical platform expenses significantly increased (p?<?0.001) from Group I to Group III and represented the main expense among all costs with a total of 4 930?±?2 601€. Among technical platform expenses, the anesthesia platform represented the main expense. In multivariate analysis, the four clinical factors that affected global charges in the whole study population were operating time (p?<?0.001), length of stay (p?<?0.001), admission in ICU (p?<?0.001) and the occurrence of major complication (p?<?0.05). An admission in ICU was the clinical factor that affected most global charges, as an ICU stay had a 39.1% increase effect on global charges in the whole study population. Conclusion: LLR is a cost-effective procedure. The more complex is the LLR, the higher is the hospital cost. An admission in ICU was the clinical factor that most affected global charges.