Laparoscopic right hepatectomy is a technically challenging procedure that requires specific training and expertise. While it provides short-term benefits over open surgery such as reduced blood loss and hospital stay, it remains an innovative procedure that should be introduced cautiously. The requirements to perform a safe laparoscopic right hepatectomy include careful patient selection, specialized equipment, and following a standardized technique. Recommendations are that all liver surgery centers should implement laparoscopic liver resection programs after surgeons receive proper training through fellowships in high-volume centers.

1. Daniel Cherqui
Centre Hépato-Biliaire
Hôpital Paul Brousse – Unversité Paris Saclay
Hépatectomie droite laparoscopique
Un modèle de standardisation

2. Abbreviations:
LLR: Lap Liver Resection
LRH: Lap Right Hepatectomy

3. Pure Laparoscopy:
the most used technique
Extraction Incision

4. Hand Assisted Lap
Mainly North America
Laparoscopic assisted
or Hybrid
Mainly for donor hep Robotic assisted
growing numbers
little data
Other techniques of
Minimal Access Hepatectomy

5. ! Would we ask if all liver surgeons should be competent at (open) right
hepatectomy?
- Certainly not (maybe we should)
! Is LLR a separate branch of liver surgery?
- Definitely a new branch
! Should all liver surgeons perform LLR?
- They will definitely have to
! Will we ask this question in 5 or 10 years?
- Probably not
- We are in a generational transition
Why this question?

6. Is LRH different from other LLR?
! Definitely a difficult and potentially hazardous one (as in open surgery)
! Not for beginners (as in open surgery)
! Not the most complex hepatectomy (as in open surgery)

7. Agenda
! The current place of LRH
! Requirements to perform a safe LRH
! Recommendations

8. Agenda
! The current place of LRH
- Guidelines and Consensus
- Difficulty scores
- Personal experience
! Requirements to perform a safe LRH
! Recommendations

9. ! LLR should not be developed in isolation of an open liver program
! In view of short term advantages and comparable oncologic outcomes
in selected patients, all liver surgery centers should implement a
program of LLR

10. Procedure N %
Minor (≤ 2 segments) 6707 70
Major (≥ 3 segments) 2305 24
Complex (Anatomical
Segment, Sectionectomy)
1762 18
Ann Surg 2016
9527 cases
Right Hep:1297 =14%

12. 1. SHORT TERM OUTCOMES
" MINOR LLR: standard practice
• IDEAL 3: adopted by an increasing proportion of surgeons
• Recognized benefits: reduced morbidity and hospital stay
" MAJOR LLR: remains an innovative procedure
• Still in an exploration or learning phase (IDEAL 2b)
• Incompletely defined risks
• It should continue to be introduced cautiously
2. LONG TERM ONCOLOGIC OUTCOMES
" NON INFERIOR
The Morioka Conclusions in brief

14. Laparoscopic
Liver resection 2020
major
minor

15. Difficulty based on experience
HALS/Hybrid Extent of liver resection
Partial resection
Left lateral sectionectomy
Segmentectomy
Sectionectomy and more
Score
0
2
3
4
Tumor location (Couinaud segment)
II
III
IVa
VIII
V
VI
VII
1
2
4
3
2
5
5
IVb 3
Segment Score
Tumor size
Proximity to major vessel*
Liver function
≥3 cm
Score
Child Pugh B
Child Pugh A
<3 cm 0
1
Score
0
1
yes
Score
0
1
no
*Main or second branch of Glisson’s tree,
major hepatic vein, or inferior vena cava
Scoring system
yes
Score
0
－1
no
S1
S2
S3
S4a
S4b
S5
S6
S7
S8
4
2
1
4
3
3
2
5
5
I 4

16. Difficulty based on experience
HALS/Hybrid Extent of liver resection
Partial resection
Left lateral sectionectomy
Segmentectomy
Sectionectomy and more
Score
0
2
3
4
Tumor location (Couinaud segment)
II
III
IVa
VIII
V
VI
VII
1
2
4
3
2
5
5
IVb 3
Segment Score
Tumor size
Proximity to major vessel*
Liver function
≥3 cm
Score
Child Pugh B
Child Pugh A
<3 cm 0
1
Score
0
1
yes
Score
0
1
no
*Main or second branch of Glisson’s tree,
major hepatic vein, or inferior vena cava
Scoring system
yes
Score
0
－1
no
S1
S2
S3
S4a
S4b
S5
S6
S7
S8
4
2
1
4
3
3
2
5
5
I 4

17. IWATE Criteria
Difficulty index 0 1 2 3 4 5 6 7 8 9 10 11 12
Difficulty level Low Intermediate Advanced Expert
Index surgery
Left lateral sectionectomy Right hepatectomy
Simple and small partial hepatectomy in segment III Posterior sectionectomy for segment VII tumor > 3 cm
Difficulty based on experience

18. ee
Wedge
Ante
Wedge
Post
Left
lateral
Seg
Ant
Left
Hep
SegPost
Right
Hep
Ex-
Right
Hep
Right
post
Central
Hep
Ex-Left
Hep
N 94 59 38 49 26 31 98 27 7 11 12
Op Time 120 172 135 200 210 198 240 285 300 205 300
Blood Loss 0 50 15 100 120 110 215 250 350 300 610
Conversion 0% 1.7% 0% 2.0% 3.8% 6.5% 5.1% 11.1% 14.3% 18.2% 25.0%
Score 0 0 0 2 2 3 3 3 3 3 3
1 point = Time ≥ 190 min; Blood time ≥ 100 ml; Conversion ≥ 4.2%
Group I Group II Group III
Ann Surg, 2017
Difficulty based on outcomes

20. 0
5
10
15
20
25
30
35
40
45
2013 2014 2015 2016 2017 2018 2019
OPEN
LAP
Personal Data 2013-2018: 471 resections
Open 254 - Lap 217 (46%)

21. Proportion of lap per procedure 2013-2017
32% 21%

22. 0
5
10
15
20
25
OPEN
LAP
2018-2019: 150 résections

23. Blood loss 257 mL
Transfusions 1.2% (2)
Conversion 8%
Morbidity 32%
Severe (>IIIa) 5%
Mortality 0.6% (1)
Short term outcomes

24. Agenda
! The current place of LRH
! Requirements to perform a safe LRH
- Patient selection
- Equipment
- Standardized technique
! Recommendations

25. Lap Right Hepatectomy
HCC
Cholangio
HCC
CRLM

26. Lap Right Hepatectomy
HCC
CRLM
Adenoma
Adenoma

27. Huge, Central or Complex Tumor: Open
CRLM HCC Adenoma
CRLM HCC

28. No “for convenience“ right hepatectomy for difficult location
Parenchymal Sparing Priority

29. Agenda
! The current place of LRH
! Requirements to perform a safe LRH
- Patient selection
- Equipment
- Standardized technique
! Recommendations

30. Excellent video system

31. Excellent vision

36. Agenda
! The current place of LRH
! Requirements to perform a safe LRH
- Patient selection
- Equipment
- Standardized technique
! Recommendations

37. Standardized technique
" Hilar dissection* vs Glissonian approach¶
" Anterior approach*¶ vs Prior mobilization*
" Surgeon’s preference §
* Bryant… Cherqui. Ann Surg 2009
* Soubrane et al. Ann Surg 2015
¶ Yoon, Kim et al. Ann Surg 2017
§ Southampton guidelines Abu Hilal et al. Ann Surg 2018

39. A Conceptual Technique for Laparoscopic Right Hepatectomy
Based on Facts and Oncologic Principles
The Caudal Approach
Olivier Soubrane, MD,∗
Lilian Schwarz, MD,∗
Franc¸ois Cauchy, MD,∗
Laura Ornella Perotto, MD,∗
Raffaele Brustia, MD,∗
Denis Bernard, MD,† and Olivier Scatton, MD, PhD∗
Objective: To evaluate a new conceptual technique of laparoscopic right hep-
atectomy.
Background: Despite significant improvements in surgical care in the last
decades, morbidity is still high after major hepatectomy. Blood loss and trans-
fusions are known to significantly increase the risk of postoperative compli-
cations and cancer recurrence after liver resection. A laparoscopic approach
may improve perioperative outcomes in these cases, but data in literature are
limited and the surgical technique is not yet standardized.
Methods: A new conceptual technique of right hepatectomy was designed us-
ing evidence-based facts and oncologic rules: laparoscopy with pneumoperi-
toneum, low central venous pressure, intermittent pedicle clamping, anterior
approach without mobilization, and parenchymal section with ultrasonic dis-
sector. Thirty patients were prospectively enrolled between October 2011 and
September 2013. Primary endpoint was intraoperative blood loss.
Results: Eighty percent of patients underwent surgery for malignant disease
and cirrhosis was present in 11 patients. Benign lesions accounted for 13%
of indications, whereas living liver donation was performed in 2 cases. Me-
dian blood loss was 100 mL (50–700) and transfusion rate was 7%. Five
patients (16.6%) required conversion to laparotomy, including 2 using hybrid
technique. The median operative time was 360 minutes (210–510). R0 re-
section rate was 87% (21/24). Postoperative morbidity rate was 23% (7/30)
with 8 complications including 6 Clavien III-IV. No respiratory complication
occurred. The median hospital stay was 8 days. No patient died.
Conclusions: This study showed that several evidence-based facts could be
combined to define a new conceptual technique of laparoscopic right hepate-
ctomy allowing for low blood loss and morbidity.
Keywords: hepatectomy, laparoscopy, liver cancer
(Ann Surg 2014;00:1–6)
Right hepatectomy is the most frequently performed major liver
resection, usually representing one third of the total number of
resections in most series. This is why this operation is often consid-
Even in healthy subjects such as live donors, mortality may reach
0.2%,4
and morbidity 40%.5
Among various factors associated with
morbidity, blood loss and transfusions are well known to increase the
risk of postoperative complications after liver resection6
as well as
those of tumor recurrence after resection of primary or secondary
liver malignancies.7
In this setting, any new surgical technique of
liver resection should focus on dramatically limiting intraoperative
blood loss in an attempt to decrease morbidity. Recent reports have
underlined that laparoscopy may be associated with such a decrease
in blood loss due to the pressure of pneumoperitoneum and the metic-
ulous section of liver parenchyma.8,9
The technique of major liver resections is not standardized even
through laparotomy. Indeed, countless techniques including those fo-
cusing on vascular control,10
strategy of resection11,12
with primary
mobilization of the right liver or anterior approach without mobiliza-
tion, or parenchymal transection13
have been reported. Among those
numerous techniques, variously associated with each other, few or
very few are however evidence-based. The same comments apply to
laparoscopic right hepatectomy (LRH). Although first reports mainly
described practical solutions aiming at overcoming challenging dif-
ficulties, they represent more surgical “know-how” or “savoir-faire”
rather than evidence-based techniques and the technique of LRH
still remains to be standardized.14–18
To promote standardization, and
demonstrate safety and reproducibility of LRH, we decided to report
a new conceptual technique with a strong rationale based on facts and
oncologic rules.
PATIENTS AND METHODS
The goal of this study was to conceptualize a technique of
LRH based as much as possible on facts demonstrating a reduction
in blood loss on one hand and on oncological rules on the other to
avoid any tumor manipulation and risk of tumor cells circulation. This
technique should be usable for all types of liver cancer occurring on
normal or pathological liver but also for benign indications, including

41. IVC
RHV
Hilum
Transection
Mobilization
MHV

42. Partial Lateral Decubitus

43. Port placement

44. Port placement
Camera port aligned with transection line
Working port
Camera
Working port
Exposure
Mobilization
Exposure
Mobilization

45. LRH: Steps
! Hilar dissection
! Pringle
! Parenchymal transection
- MHV
- Bile duct division
- RHV
! Specimen mobilization
! Near misses
! ICG

52. Courtesy of Xiaoying WANG, Shanghai

53. Outline
! The current place of LRH
! Requirements to perform a safe LRH
! Recommendations

54. Laparoscopic Liver Resection Today
! Because of recognized benefits, all centers should offer LLR
as part of multidisciplinary management of liver tumors
! It requires support from senior colleagues and institution
! Specific training required
- The era of self-taught surgeons is over
- Fellowships in high volume centers

55. Laparoscopic Right Hepatectomy Today
! Now well standardized
! But remains a difficult procedure
- Commitment required
- Mastery of minor resection: case load (60 cases)
- Possible role for external proctoring
! Not for all patients: selection required
! Not for all surgeons at the moment: Team Work

56. ! Eventually, all liver surgeons will do it
! In 10 years, we might wonder if all liver surgeons will still be
competent at open right hepatectomy
! The new challenge could then be the teaching open liver
surgery ☺
Laparoscopic Right Hepatectomy Tomorrow

57. New techniques must bring meaningful
improvement in patient care
! LLR achieves that goal when performed
- In properly selected patients
- By properly trained surgeons
! I believe this is true for all surgeries from the simplest
to the most complex, including liver surgery open or
lap

58. Living Donors

59. The Pre-Laparoscopic Era