Minimally invasive isolated anatomic liver segmentectomy for hepatocellular carcinoma using extrahepatic Glissonian approach: surgical techniques and outcomes

Aim: To standardize surgical techniques for and define the safety, feasibility and oncologic validity of minimally invasive anatomic liver segmentectomy for hepatocellular carcinoma (HCC). Methods: We retrospectively studied perioperative and long-term outcomes of isolated anatomic segmentectomy (IA-Seg) using the extrahepatic Glissonian approach in 157 HCC cases, including 77 open and 80 minimally invasive (59 laparoscopic and 21 robotic) cases. Surgical outcomes were compared between the approaches using propensity score matching (PSM). Results: After matching (46:46), compared with open IA-Seg, minimally invasive IA-Seg was significantly associated with less blood loss (274 vs. 955 g), a lower transfusion rate (21.7% vs. 45.7%), the lower postoperative serum total bilirubin (TB) level (1.5 vs. 2.2 mg/dL) and shorter length of hospital stay (LOS) (17 vs. 27 days), while the latter had a significantly higher rate of Pringle maneuver application (15.2% vs. 2.2%) and a higher aspartate aminotransferase (AST) level (669 vs. 402 IU/L). Additionally, laparoscopic and robotic IA-Seg before and after matching (16:16) had comparable perioperative outcomes. Long-term outcomes after IA-Seg for newly developed HCC in matched cohorts were comparable, either between open and minimally invasive IA-Seg (36:36) or between laparoscopic and robotic IA-Seg (12:12). Conclusion: Although minimally invasive IA-Seg is technically demanding, it could be standardized using the extrahepatic Glissonian approach. This procedure for HCC was safe, feasible and oncologically acceptable, with several perioperative outcomes superior to those in open IA-Seg and with comparable long-term outcomes. By expert hands, the laparoscopic or robotic approach could be a reliable option for IA-Seg in selected HCC patients.