Short-term outcomes of laparoscopic central hepatectomy: A comparison with open surgery

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This study retrospectively evaluated short-term outcomes of laparoscopic versus open CH and assessed safety and efficacy of laparoscopic surgery. Methods CH included anterior sectionectomy (AS) and central bisectionectomy (CBS) (excluding cases with biliary reconstruction). The study comprised 38 patients receiving CH in our department from January 2010 to November 2023. Results The laparoscopic group included 14 cases and the open group 24. AS/CBS was performed in 14/10 open group cases and 6/8 laparoscopic group cases. Short-term surgical outcomes showed no significant between-group difference in operative time, but the laparoscopic group lost significantly less blood (250 vs. 985 mL; p=0.001) and the transfusion rate was lower (14% vs. 46%; p=0.004). Among postoperative outcomes, incidence of bile leakage was not significantly different (33% vs. 42%; p=0.42), but the laparoscopic group had significantly less postoperative ascites (0% vs. 17%; p=0.047), fewer surgical site infections (SSI) (0% vs. 21%; p=0.02), and shorter postoperative hospital stay (14 vs. 30 days; p=0.03). The risk factor for bile leakage in CH by univariate and multivariate analysis was tumor proximity to the right anterior Glissonean pedicle (OR=6.84; 95% CI=1.67-32.7; p=0.01). Conclusion Laparoscopic CH could be performed safely. Compared to open surgery, laparoscopic CH was effective in reducing blood loss, postoperative ascites, SSIs, and shortening postoperative hospital stay. However, tumors close to the root of the right anterior Glissonean pedicle were considered a risk factor for postoperative bile leakage and require caution. Laparoscopic central hepatectomy Laparoscopic anterior sectionectomy Laparoscopic central bisectionectomy Bile leakage INTRODUCTION Laparoscopic liver resection (LLR) was first reported in 1991 by Reich et al. [ 1 ]. With the rapid advancement of laparoscopic techniques and equipment, the rate of LLR has been increasing worldwide, and the indications for LLR have expanded [ 2 – 4 ]. Increasing numbers of authors have reported the efficacy of LLR, which is associated with reduced blood loss, lower transfusion requirements, and shorter length of hospital stay [ 5 – 8 ]. Centrally located tumors (in segments 4, 5, and 8) require central hepatectomy (CH), which involves central bisectionectomy (CBS) or right anterior sectionectomy (AS). Although CH has the advantage of preserving sufficient remnant liver volume, it involves two liver dissection planes, and the surgical procedure is therefore complicated. Thus, CH has been reported as a surgical procedure associated with a high risk of bile leakage due to exposure of major Glissonean structures and the extensive liver dissection planes [ 9 – 11 ]. There have been some recent reports on laparoscopic CH (LCH) [ 12 – 17 ], although LCH carries a high degree of difficulty [ 18 – 20 ]. Further, the safety and feasibility of this procedure have not been established yet. Therefore, the aim of this study was to retrospectively evaluate the short-term outcomes of laparoscopic vs. open CH cases in our department and assess the safety and efficacy of LCH. MATERIAL AND METHODS Patients and methods CH was defined as CBS and AS requiring resection of the right anterior Glissonean pedicle (excluding cases with biliary reconstruction). In total, 38 patients underwent CH at the Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine between January 2010 to November 2023. The operator was different in each case although the surgical team included expert surgeons who were board-certified by the Japanese Society of Hepato-Biliary-Pancreatic Surgery and/or the Japan Society for Endoscopic Surgery. We collected information on age, sex, body mass index (BMI), tumor characteristics, tumor proximity to the hepatic vein or the root of the right anterior Glissonean pedicle (< 1 cm), clinical data, histopathology, surgical methods, operative time, blood loss, length of postoperative hospital stay, and postoperative complications from the patients’ medical records. We retrospectively compared these data between the open CH (OCH) and LCH groups to assess the safety and efficacy of laparoscopic surgery. This study was approved by the Ethics Committee of Oita University Faculty of Medicine (No. 1601). Informed consent was obtained in the form of opt-out on the hospital web site. Surgical procedure In all laparoscopic cases, the operations were started with the patient in the left half-lateral decubitus position, and the first port was inserted through a supraumbilical incision by the open method. Four other ports were inserted in the right upper quadrant of the abdomen. At our institution, liver resection is performed with the intermittent Pringle maneuver in all cases. First, after cholecystectomy, the right anterior Glissonean pedicle is secured, and a clamp test is performed to confirm the demarcation line. For AS, the cranioventral approach is used to dissect the liver along the middle hepatic vein from its root toward the root of the right anterior Glissonean pedicle. For CBS, the left transection plane between segment 4 and the left lateral lobe is dissected along the falciform ligament on the surface of the liver. Then, branches of segment 4b and segment 4a are ligated and gradually transected. Dissection is continued toward the top of the left plane, and the roots of the left hepatic and middle hepatic veins are exposed. At the same time, at the hepatic hilum, dissection between segment 4 and the caudate lobes is advanced along the hepatic hilar plate toward the root of the right anterior Glissonean pedicle. After dissection around the root of the right anterior Glissonean pedicle is fully developed, the right anterior Glissonean pedicle is dissected with a stapling device. Finally, the liver is dissected in one direction toward the right side so as to connect the left wall of the right hepatic vein and the demarcation line on the surface, which then completes the dissection. Statistical analysis Continuous data are expressed as the median value and range (lowest and highest), and categorical data are expressed as counts, with the associated percentile value calculated. The Wilcoxon rank sum test was used to compare continuous data, and Pearson’s χ 2 test was used for categorical data. A multivariate analysis was performed using a Cox proportional hazard model to identify independent risk factors of bile leakage after CH. A p-value < 0.05 was considered to indicate statistical significance. Multivariate analysis was performed for factors with a p-value < 0.10 on univariate analysis. All statistical analyses were performed with JMP software version 17.2 for MAC (SAS Institute, Cary, NC, USA). RESULTS Comparison of patient clinical characteristics Clinical characteristics of the patients can be compared between the OCH and LCH groups in Table 1 . There were no differences in tumor condition and liver function between the two groups, although there were a greater number of males in the LCH group. Table 1 Patient characteristics Characteristic OCH LCH p Value (n = 24) (n = 14) Age 74 (50–83) 76.5 (61–89) 0.4 Gender (male/female), n (%) 19 (79)/5 (21) 6 (43)/8 (57) 0.02 BMI (kg/m 2 ) 23.4 (19.8–32.2) 23.2 (17.8–32.9) 0.53 ASA-PS (1–2/3), n (%) 17 (71)/7 (29) 11 (79)/3 (21) 0.6 Diagnosis (HCC/CRLM/IHCC/Other), n (%) 15 (63)/6 (25)/2 (8.3)/1 (4.2) 11 (79)/2 (14)/0/1 (7.1) 0.42 Tumor condition Maximal diameter of tumor (mm) 56.5 (13–140) 41 (5-100) 0.09 Number of tumors 1 (1–6) 1 (1–3) 0.36 Tumor proximity to the root of the anterior Glissonean pedicle, n (%) 11 (46) 3 (21) 0.12 Tumor proximity to the hepatic vein, n (%) 11 (46) 6 (42) 0.86 Liver function Child-Pugh A, n (%) 23 (96) 14 (100) 0.33 ICG-R15 (%) 11.9 (4.4–26.6) 7.8 (2.2–26.5) 0.06 Liver cirrhosis, n (%) 4 (17) 4 (31) 0.33 Legends: ASA-PS = American Society of Anesthesiologists physical status; BMI = body mass index; CRLM = colorectal liver metastasis; HCC = hepatocellular carcinoma; IHCC = intrahepatic cholangiocarcinoma; ICG = indocyanine green; LCH = laparoscopic central hepatectomy; OCH = open central hepatectomy. Comparison of surgical outcomes Surgical outcomes between the LCH and OCH groups can be compared in Table 2 . There was one case of open conversion in the LCH group. There was no difference in operative time between the two groups, but the LCH group had significantly less blood loss and lower transfusion rates. The postoperative outcomes are shown in Table 3 . There was no difference in the incidence of bile leakage between the two groups (33% vs. 42%; p = 0.42). The incidences of ascites (0% vs. 17%; p = 0.047) and surgical site infection (SSI) (0% vs. 21%; p = 0.02) were significantly lower in the LCH group. There were no significant differences in other complications. Postoperative hospital stay was significantly shorter in the LCH group (14 vs. 30 days; p = 0.03). Table 2 Surgical outcomes Outcome OCH LCH p Value (n = 24) (n = 14) Anterior sectionectomy/central bisectionectomy, n (%) 14 (58)/10 (42) 8 (57)/6 (43) 0.94 Open conversion, n (%) - 1 (7.1) - Operative time (min) 396 (265–550) 353.5 (261–569) 0.08 Blood loss (mL) 985 (310–5420) 250 (90-1000) < 0.001 Transfusion, n (%) 11 (46) 2 (14) 0.004 Legends: LCH = laparoscopic central hepatectomy; OCH = open central hepatectomy. Table 3 Postoperative outcomes Outcome OCH LCH p Value (n = 24) (n = 14) Complications after surgery (CD ≥ III) n (%) 11 (46) 5 (36) 0.54 Bile leakage, n (%) 10 (42) 3 (33) 0.42 Abdominal abscess, n (%) 7 (29) 1 (7.1) 0.17 Liver failure, n (%) 2 (8.3) 0 0.25 Ascites, n (%) 4 (17) 0 0.047 Renal failure, n (%) 1 (4.2) 1 (7.1) 0.69 Surgical site infections, n (%) 5 (21) 0 0.02 Pleural effusion, n (%) 2 (8.3) 0 0.17 Cardiovascular complication, n (%) 0 1 (7.1) 0.15 Gastrointestinal complication, n (%) 0 1 (7.1) 0.15 Postoperative stay (days) 30 (11–293) 14 (7–53) 0.005 Legends: CD = Clavien-Dindo classificatisn; LCH = laparoscopic central hepatectomy; OCH = open central hepatectomy. Table 4 Risk factors for bile leakage in central hepatectomy Univariable Multivariable Odds ratio 95% CI p Value Odds ratio 95% CI p Value BMI (kg/m 2 ) (≥ 25 vs < 25) 2.42 0.62–9.54 0.2 Number of tumors (≥ 2 vs 1) 0.97 0.23–4.17 0.97 Liver cirrhosis (Yes vs No) 1.04 0.21–5.2 0.97 Tumor size (≥ 50 mm vs < 50 mm) 1.4 0.37–5.27 0.62 Tumor proximity to the root of the anterior Glissonean pedicle (Yes vs No) 6.84 1.57–29.79 0.007 6.84 1.67–32.7 0.01 Tumor proximity to the hepatic vein (Yes vs No) 0.56 0.14–2.15 0.39 Laparoscopy vs Open 0.56 0.14–2.3 0.42 Anterior sectionectomy vs central bisectionectomy 1.05 0.27–3.99 0.94 Legends: BMI = body mass index, CI = confidence interval. Risk factors for bile leakage in central hepatectomy CH is a procedure associated with a high incidence of bile leakage, and thus the risk factors for bile leakage were investigated. Univariate and multivariate analysis both revealed proximity of the tumor to the right anterior Glissonean pedicle to be the significant risk factor for bile leakage (odds ratio, 6.84; 95% confidence interval, 1.67–32.7; p = 0.01). DISCUSSION In this study, we retrospectively reviewed cases of LCH and OCH performed in our department to assess the safety and efficacy of laparoscopic surgery. Compared to the OCH group, the LCH group showed significantly less blood loss, lower transfusion rate, and no difference in operative time. Among postoperative complications, the rate of bile leakage was 33% in the LCH group and 42% in the OCH group, but the difference was not significant. The incidences of ascites and SSI were significantly lower in the LCH group, and postoperative hospital stay was significantly shorter in the LCH group. Univariate and multivariate analysis of risk factors for bile leakage after CH showed tumor proximity of < 1 cm to the right anterior Glissonean pedicle to be the significant risk factor. Other previous studies have reported the outcomes of LCH compared to OCH [ 15 – 17 ]. Among the short-term surgical outcomes, there was no difference in blood loss and the incidence of postoperative complications between the LCH and OCH groups, whereas the LCH group had a longer operative time and shorter postoperative hospital stay [ 15 – 17 ]. Cho et al. reported an overall postoperative morbidity rate of 30% and a bile leakage rate of 15% in their LCH group [ 15 ]. In our study as well, the LCH group experienced less blood loss, lower incidences of ascites and SSI, and a shorter postoperative hospital stay, consistent with these previous reports. However, the incidence of postoperative bile leakage in our patients was higher than that previously reported, so we investigated the risk factors for bile leakage. To our knowledge, there have been no reports investigating the causes of bile leakage in LCH, making the present findings novel in this respect. In general, LLR is reported to be associated with fewer complications compared to open hepatectomy, but the incidence of bile leakage has been reported to be comparable when limited to CH [ 7 , 8 , 15 , 21 ]. CH is considered to be a surgical procedure with a high incidence of bile leakage [ 9 – 11 ]. Nanashima et al. reported an incidence rate of bile leakage of 37% [ 10 ], whereas Ueno et al. reported a rate of 44.8% [ 22 ]. Several reports have examined the risk factors for bile leakage in CH [ 9 , 10 , 22 ]. Ueno et al. examined the biliary complications in CH and reported that the tumor proximity to the right anterior Glissonean pedicle and a longer right hepatic duct were risk factors for biliary complications [ 22 ]. In our study as well, proximity of the tumor to the right anterior Glissonean pedicle was found to be the risk factor for bile leakage. This factor could be the potential cause for stenosis of the right posterior bile duct (RPBD) branch. Yoon et al. investigated the factors contributing to the occurrence of the RPBD stenosis in CH [ 23 ]. Approximately 80% of the RPBD is located supraportally distal to the bifurcation of the anterior and posterior Glissonean sheaths. When the anterior Glissonean sheath is ligated, injuries such as stricture and ischemic insult of the RPBD could occur. They reported that handling the Glissonean pedicle close to the right anterior Glissonean pedicle root could lead to stenosis of the RPBD. This stenosis increases the intraductal pressure in the RPBD, potentially causing bile leakage from the liver dissection plane. Additionally, in cases in which the tumor is closer to the hepatic hilum, there is a higher possibility of incising the caudate lobe and damaging its bile ducts. This is consistent with the findings of Nanashima et al., who reported that segment 1 resection and inferior vena cava compression were risk factors for bile leakage with CBS [ 10 ]. These may be the reasons why a tumor close to the root of the right anterior Glissonean pedicle were detected as risk factors for bile leakage. The present study has several limitations. First, this is a single-center study with a small number of cases. Second, the operator was different in each case although the surgical team included expert board-certified surgeons. Third, long-term prognoses were not comparable because of the variety of diseases in the patients included in this study. CONCLUSION Compared to OCH, LCH reduced blood loss and could be performed safely. Although the frequency of postoperative bile leakage was not different between these two procedures, there was less postoperative ascites and fewer SSIs with LCH, suggesting the potential for a shortened postoperative hospital stay. However, proximity of the tumor to the root of the right anterior Glissonean pedicle was considered a risk factor for postoperative bile leakage, and caution is required in such cases. Statements and Declarations Author’s Contributions Study conception and design: T.M., Y.E., and M.I.; acquisition of data: S.N., W.M., Y.N., H.O., M.K., A.F., Y.K., H.T., and T.H.; analysis and interpretation of data: T.M., Y.E., and M.I.; drafting of manuscript: T.M., Y.E., and M.I. Ethical approval and consent to participate All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was approved by the Ethics Committee of Oita University Faculty of Medicine (No. 1601). Informed consent was obtained in the form of opt-out on the hospital web site. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding Not applicable. Acknowledgements Not applicable. References Reich H, McGlynn F, DeCaprio J, Budin R (1991) Laparoscopic excision of benign liver lesions. Obstet Gynecol 78(5 Pt 2):956–958 Shiroshita H, Inomata M, Akira S, Kanayama H, Yamaguchi S, Eguchi S, Wada N, Kurokawa Y, Uchida H, Seki Y et al (2022) Current Status of Endoscopic Surgery in Japan: The 15th National Survey of Endoscopic Surgery by the Japan Society for Endoscopic Surgery. Asian J Endosc Surg 15(2):415–426. https://doi.org/10.1111/ases.13012 Nguyen KT, Gamblin TC, Geller DA (2009) World review of laparoscopic liver resection-2,804 patients. Ann Surg 250(5):831–841. https://doi.org/10.1097/SLA.0b013e3181b0c4df Wakabayashi G, Cherqui D, Geller DA, Abu Hilal M, Berardi G, Ciria R, Abe Y, Aoki T, Asbun HJ, Chan ACY et al (2022) The Tokyo 2020 terminology of liver anatomy and resections: Updates of the Brisbane 2000 system. J Hepatobiliary Pancreat Sci 29(1):6–15. https://doi.org/10.1002/jhbp.1091 Beppu T, Wakabayashi G, Hasegawa K, Gotohda N, Mizuguchi T, Takahashi Y, Hirokawa F, Taniai N, Watanabe M, Katou M 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 Hepatobiliary Pancreat Sci 22(10):711–720. https://doi.org/10.1002/jhbp.261 Zhang XL, Liu RF, Zhang D, Zhang YS, Wang T (2017) Laparoscopic versus open liver resection for colorectal liver metastases: a systematic review and meta-analysis of studies with propensity score-based analysis. Int J Surg 44:191–203. https://doi.org/10.1016/j.ijsu.2017.05.073 Wu X, Huang Z, Lau WY, Li W, Lin P, Zhang L, Chen Y (2019) Perioperative and long-term outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma with well-preserved liver function and cirrhotic background: a propensity score matching study. Surg Endosc 33(1):206–215. https://doi.org/10.1007/s00464-018-6296-8 Sposito C, Battiston C, Facciorusso A, Mazzola M, Muscarà C, Scotti M, Romito R, Mariani L, Mazzaferro V (2016) Propensity score analysis of outcomes following laparoscopic or open liver resection for hepatocellular carcinoma. Br J Surg 103(7):871–880. https://doi.org/10.1002/bjs.10137 Yamashita YI, Yamamoto H, Miyata H, Kakeji Y, Kitagawa Y, Yamaue H, Yamamoto M, Baba H (2021) Risk factors for bile leakage: Latest analysis of 10 102 hepatectomies for hepatocellular carcinoma from the Japanese national clinical database. J Hepatobiliary Pancreat Sci 28(7):556–562. https://doi.org/10.1002/jhbp.827 Nanashima A, Eguchi S, Hisaka T, Kawasaki Y, Yamashita YI, Ide T, Kuroki T, Yoshizumi T, Kitahara K, Endo Y et al (2023) Risk factors of complications from central bisectionectomy (H458) for hepatocellular carcinoma: a multi-institutional single-arm analysis. Cancers (Basel) 15(6):1740. https://doi.org/10.3390/cancers15061740 Ishii H, Ochiai T, Murayama Y, Komatsu S, Shiozaki A, Kuriu Y, Ikoma H, Nakanishi M, Ichikawa D, Fujiwara H et al (2011) Risk factors and management of postoperative bile leakage after hepatectomy without bilioenteric anastomosis. Dig Surg 28(3):198–204. https://doi.org/10.1159/000324042 Ide T, Matsunaga T, Tanaka T, Noshiro H (2021) Feasibility of purely laparoscopic right anterior sectionectomy. Surg Endosc 35(1):192–199. https://doi.org/10.1007/s00464-020-07379-w Birgin E, Hartwig V, Rasbach E, Seyfried S, Rahbari M, Reeg A, Jentschura S-L, Téoule P, Reißfelder C, Rahbari NN (2022) Minimally invasive mesohepatectomy for centrally located liver lesions–a case series. Surg Endosc 36(12):8935–8942. https://doi.org/10.1007/s00464-022-09342-3 Zheng Z, Xie H, Liu Z, Wu X, Peng J, Chen X, He J, Zhou J (2022) Laparoscopic central hepatectomy using a parenchymal-first approach: how we do it. Surg Endosc 36(11):8630–8638. https://doi.org/10.1007/s00464-022-09163-4 Cho CW, Rhu J, Kwon CHD, Choi GS, Kim JM, Joh JW, Koh KC, Kim GS (2017) Short-term outcomes of totally laparoscopic central hepatectomy and right anterior sectionectomy for centrally located tumors: a case-matched study with propensity score matching. World J Surg 41(11):2838–2846. https://doi.org/10.1007/s00268-017-4105-5 Chin KM, Linn YL, Cheong CK, Koh YX, Teo JY, Chung AYF, Chan CY, Goh BKP (2021) Minimally invasive versus open right anterior sectionectomy and central hepatectomy for central liver malignancies: a propensity-score-matched analysis. ANZ J Surg 91(4):E174–E182. https://doi.org/10.1111/ans.16719 Li W, Han J, Xie G, Xiao Y, Sun K, Yuan K, Wu H (2019) Laparoscopic versus open mesohepatectomy for patients with centrally located hepatocellular carcinoma: a propensity score matched analysis. Surg Endosc 33(9):2916–2926. https://doi.org/10.1007/s00464-018-6593-2 Ban D, Tanabe M, Ito H, Otsuka Y, Nitta H, Abe Y, Hasegawa Y, Katagiri T, Takagi C, Itano O et al (2014) A novel difficulty scoring system for laparoscopic liver resection. J Hepatobiliary Pancreat Sci 21(10):745–753. https://doi.org/10.1002/jhbp.166 Wakabayashi G (2016) What has changed after the Morioka consensus conference 2014 on laparoscopic liver resection? Hepatobiliary Surg Nutr 5(4):281–289. https://doi.org/10.21037/hbsn.2016.03.03 Kawaguchi Y, Fuks D, Kokudo N, Gayet B (2018) Difficulty of laparoscopic liver resection: proposal for a new classification. Ann Surg 267(1):13–17. https://doi.org/10.1097/sla.0000000000002176 Ratti F, Fiorentini G, Cipriani F, Catena M, Paganelli M, Aldrighetti L (2018) Laparoscopic vs open surgery for colorectal liver metastases. JAMA Surg 153(11):1028–1035. https://doi.org/10.1001/jamasurg.2018.2107 Ueno M, Hayami S, Miyamoto A, Okada KI, Kitahata Y, Shimizu A, Motobayashi H, Matsumoto K, Kawai M (2024) Relationship between postoperative biliary complications and biliary anatomical aspects in performing right anterior‐ or central bisectionectomy: single‐center retrospective observational study. Ann Gastroenterol Surg 00:1–8. https://doi.org/10.1002/ags3.12805 Yoon KC, Yu YD, Kang WH, Jo HS, Kim DS (2022) Right posterior bile duct stricture after central bisectionectomy or anterior sectionectomy. Langenbecks Arch Surg 407(7):2873–2880. https://doi.org/10.1007/s00423-022-02586-6 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 20 Feb, 2025 Read the published version in Langenbeck's Archives of Surgery → Version 1 posted Editorial decision: Revision requested 28 Jan, 2025 Reviews received at journal 27 Jan, 2025 Reviewers agreed at journal 16 Jan, 2025 Reviews received at journal 30 Jul, 2024 Reviewers agreed at journal 30 Jul, 2024 Reviewers invited by journal 06 Jul, 2024 Editor assigned by journal 02 Jul, 2024 Submission checks completed at journal 28 Jun, 2024 First submitted to journal 26 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4642508","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":325787873,"identity":"ccb3518a-ee2c-47a1-9218-e6f13185ff28","order_by":0,"name":"Takashi 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Medicine","correspondingAuthor":false,"prefix":"","firstName":"Atsuro","middleName":"","lastName":"Fujinaga","suffix":""},{"id":325787881,"identity":"ba65859f-c73e-4d99-a86e-11f91cc09837","order_by":8,"name":"Hiroomi Takayama","email":"","orcid":"","institution":"Oita University Faculty of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Hiroomi","middleName":"","lastName":"Takayama","suffix":""},{"id":325787882,"identity":"ffdc40ad-6ee0-4d7d-834c-db62638e5c79","order_by":9,"name":"Yoko Kawano","email":"","orcid":"","institution":"Oita University Faculty of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yoko","middleName":"","lastName":"Kawano","suffix":""},{"id":325787885,"identity":"155d0dd0-53db-4a9a-a527-a4eb776f1105","order_by":10,"name":"Teijiro Hirashita","email":"","orcid":"","institution":"Oita University Faculty of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Teijiro","middleName":"","lastName":"Hirashita","suffix":""},{"id":325787886,"identity":"ffc195ad-e7e5-4cb1-939e-b85846e33002","order_by":11,"name":"Masafumi Inomata","email":"","orcid":"","institution":"Oita University Faculty of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Masafumi","middleName":"","lastName":"Inomata","suffix":""}],"badges":[],"createdAt":"2024-06-26 11:51:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4642508/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4642508/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00423-025-03645-4","type":"published","date":"2025-02-20T15:57:29+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":77052614,"identity":"373529d8-1519-4c0e-92d2-64d7a3ee68ca","added_by":"auto","created_at":"2025-02-24 16:18:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":702917,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4642508/v1/84669401-b255-402b-bd22-eb5bdc8b2cac.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Short-term outcomes of laparoscopic central hepatectomy: A comparison with open surgery","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eLaparoscopic liver resection (LLR) was first reported in 1991 by Reich et al. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. With the rapid advancement of laparoscopic techniques and equipment, the rate of LLR has been increasing worldwide, and the indications for LLR have expanded [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Increasing numbers of authors have reported the efficacy of LLR, which is associated with reduced blood loss, lower transfusion requirements, and shorter length of hospital stay [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCentrally located tumors (in segments 4, 5, and 8) require central hepatectomy (CH), which involves central bisectionectomy (CBS) or right anterior sectionectomy (AS). Although CH has the advantage of preserving sufficient remnant liver volume, it involves two liver dissection planes, and the surgical procedure is therefore complicated. Thus, CH has been reported as a surgical procedure associated with a high risk of bile leakage due to exposure of major Glissonean structures and the extensive liver dissection planes [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. There have been some recent reports on laparoscopic CH (LCH) [\u003cspan additionalcitationids=\"CR13 CR14 CR15 CR16\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], although LCH carries a high degree of difficulty [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Further, the safety and feasibility of this procedure have not been established yet.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eTherefore, the aim of this study was to retrospectively evaluate the short-term outcomes of laparoscopic vs. open CH cases in our department and assess the safety and efficacy of LCH.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"MATERIAL AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients and methods\u003c/h2\u003e \u003cp\u003eCH was defined as CBS and AS requiring resection of the right anterior Glissonean pedicle (excluding cases with biliary reconstruction). In total, 38 patients underwent CH at the Department of Gastroenterological and Pediatric Surgery, Oita University Faculty of Medicine between January 2010 to November 2023. The operator was different in each case although the surgical team included expert surgeons who were board-certified by the Japanese Society of Hepato-Biliary-Pancreatic Surgery and/or the Japan Society for Endoscopic Surgery. We collected information on age, sex, body mass index (BMI), tumor characteristics, tumor proximity to the hepatic vein or the root of the right anterior Glissonean pedicle (\u0026lt;\u0026thinsp;1 cm), clinical data, histopathology, surgical methods, operative time, blood loss, length of postoperative hospital stay, and postoperative complications from the patients\u0026rsquo; medical records. We retrospectively compared these data between the open CH (OCH) and LCH groups to assess the safety and efficacy of laparoscopic surgery.\u003c/p\u003e \u003cp\u003eThis study was approved by the Ethics Committee of Oita University Faculty of Medicine (No. 1601). Informed consent was obtained in the form of opt-out on the hospital web site.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical procedure\u003c/h2\u003e \u003cp\u003eIn all laparoscopic cases, the operations were started with the patient in the left half-lateral decubitus position, and the first port was inserted through a supraumbilical incision by the open method. Four other ports were inserted in the right upper quadrant of the abdomen. At our institution, liver resection is performed with the intermittent Pringle maneuver in all cases. First, after cholecystectomy, the right anterior Glissonean pedicle is secured, and a clamp test is performed to confirm the demarcation line. For AS, the cranioventral approach is used to dissect the liver along the middle hepatic vein from its root toward the root of the right anterior Glissonean pedicle. For CBS, the left transection plane between segment 4 and the left lateral lobe is dissected along the falciform ligament on the surface of the liver. Then, branches of segment 4b and segment 4a are ligated and gradually transected. Dissection is continued toward the top of the left plane, and the roots of the left hepatic and middle hepatic veins are exposed. At the same time, at the hepatic hilum, dissection between segment 4 and the caudate lobes is advanced along the hepatic hilar plate toward the root of the right anterior Glissonean pedicle. After dissection around the root of the right anterior Glissonean pedicle is fully developed, the right anterior Glissonean pedicle is dissected with a stapling device. Finally, the liver is dissected in one direction toward the right side so as to connect the left wall of the right hepatic vein and the demarcation line on the surface, which then completes the dissection.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous data are expressed as the median value and range (lowest and highest), and categorical data are expressed as counts, with the associated percentile value calculated. The Wilcoxon rank sum test was used to compare continuous data, and Pearson\u0026rsquo;s χ\u003csup\u003e2\u003c/sup\u003e test was used for categorical data. A multivariate analysis was performed using a Cox proportional hazard model to identify independent risk factors of bile leakage after CH. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance. Multivariate analysis was performed for factors with a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.10 on univariate analysis. All statistical analyses were performed with JMP software version 17.2 for MAC (SAS Institute, Cary, NC, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eComparison of patient clinical characteristics\u003c/h2\u003e \u003cp\u003eClinical characteristics of the patients can be compared between the OCH and LCH groups in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. There were no differences in tumor condition and liver function between the two groups, although there were a greater number of males in the LCH group.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e Patient characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOCH\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLCH\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (50\u0026ndash;83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.5 (61\u0026ndash;89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (male/female), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (79)/5 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (43)/8 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.4 (19.8\u0026ndash;32.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.2 (17.8\u0026ndash;32.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.53\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA-PS (1\u0026ndash;2/3), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (71)/7 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (79)/3 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnosis (HCC/CRLM/IHCC/Other), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (63)/6 (25)/2 (8.3)/1 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (79)/2 (14)/0/1 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor condition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximal diameter of tumor (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56.5 (13\u0026ndash;140)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (5-100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of tumors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1\u0026ndash;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.36\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor proximity to the root of the anterior Glissonean pedicle, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor proximity to the hepatic vein, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver function\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChild-Pugh A, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICG-R15 (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.9 (4.4\u0026ndash;26.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.8 (2.2\u0026ndash;26.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver cirrhosis, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eLegends: \u003cem\u003eASA-PS\u003c/em\u003e\u0026thinsp;=\u0026thinsp;American Society of Anesthesiologists physical status; \u003cem\u003eBMI\u003c/em\u003e\u0026thinsp;=\u0026thinsp;body mass index; \u003cem\u003eCRLM\u003c/em\u003e\u0026thinsp;=\u0026thinsp;colorectal liver metastasis; \u003cem\u003eHCC\u003c/em\u003e\u0026thinsp;=\u0026thinsp;hepatocellular carcinoma; \u003cem\u003eIHCC\u003c/em\u003e\u0026thinsp;=\u0026thinsp;intrahepatic cholangiocarcinoma; \u003cem\u003eICG\u003c/em\u003e\u0026thinsp;=\u0026thinsp;indocyanine green; \u003cem\u003eLCH\u003c/em\u003e\u0026thinsp;=\u0026thinsp;laparoscopic central hepatectomy; \u003cem\u003eOCH\u003c/em\u003e\u0026thinsp;=\u0026thinsp;open central hepatectomy.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eComparison of surgical outcomes\u003c/h2\u003e \u003cp\u003eSurgical outcomes between the LCH and OCH groups can be compared in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. There was one case of open conversion in the LCH group. There was no difference in operative time between the two groups, but the LCH group had significantly less blood loss and lower transfusion rates. The postoperative outcomes are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. There was no difference in the incidence of bile leakage between the two groups (33% vs. 42%; p\u0026thinsp;=\u0026thinsp;0.42). The incidences of ascites (0% vs. 17%; p\u0026thinsp;=\u0026thinsp;0.047) and surgical site infection (SSI) (0% vs. 21%; p\u0026thinsp;=\u0026thinsp;0.02) were significantly lower in the LCH group. There were no significant differences in other complications. Postoperative hospital stay was significantly shorter in the LCH group (14 vs. 30 days; p\u0026thinsp;=\u0026thinsp;0.03).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e Surgical outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOCH\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLCH\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior sectionectomy/central bisectionectomy, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (58)/10 (42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (57)/6 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpen conversion, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e396 (265\u0026ndash;550)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e353.5 (261\u0026ndash;569)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (mL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e985 (310\u0026ndash;5420)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e250 (90-1000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTransfusion, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eLegends: \u003cem\u003eLCH\u003c/em\u003e\u0026thinsp;=\u0026thinsp;laparoscopic central hepatectomy; \u003cem\u003eOCH\u003c/em\u003e\u0026thinsp;=\u0026thinsp;open central hepatectomy.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e Postoperative outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOCH\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLCH\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications after surgery (CD\u0026thinsp;\u0026ge;\u0026thinsp;III) n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBile leakage, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbdominal abscess, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver failure, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAscites, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal failure, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.69\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical site infections, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.02\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePleural effusion, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (8.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCardiovascular complication, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGastrointestinal complication, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative stay (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (11\u0026ndash;293)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (7\u0026ndash;53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003eLegends: \u003cem\u003eCD\u003c/em\u003e\u0026thinsp;=\u0026thinsp;Clavien-Dindo classificatisn; \u003cem\u003eLCH\u003c/em\u003e\u0026thinsp;=\u0026thinsp;laparoscopic central hepatectomy; \u003cem\u003eOCH\u003c/em\u003e\u0026thinsp;=\u0026thinsp;open central hepatectomy.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e Risk factors for bile leakage in central hepatectomy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eUnivariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c9\" namest=\"c7\"\u003e \u003cp\u003eMultivariable\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOdds ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOdds ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ep Value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e) (\u0026ge;\u0026thinsp;25 vs\u0026thinsp;\u0026lt;\u0026thinsp;25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.62\u0026ndash;9.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of tumors (\u0026ge;\u0026thinsp;2 vs 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.23\u0026ndash;4.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiver cirrhosis (Yes vs No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.21\u0026ndash;5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor size (\u0026ge;\u0026thinsp;50 mm vs\u0026thinsp;\u0026lt;\u0026thinsp;50 mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.37\u0026ndash;5.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor proximity to the root of the anterior Glissonean pedicle (Yes vs No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.57\u0026ndash;29.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.67\u0026ndash;32.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor proximity to the hepatic vein (Yes vs No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.14\u0026ndash;2.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLaparoscopy vs Open\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.14\u0026ndash;2.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior sectionectomy vs central bisectionectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.27\u0026ndash;3.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003eLegends: \u003cem\u003eBMI\u003c/em\u003e\u0026thinsp;=\u0026thinsp;body mass index, \u003cem\u003eCI\u003c/em\u003e\u0026thinsp;=\u0026thinsp;confidence interval.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eRisk factors for bile leakage in central hepatectomy\u003c/h2\u003e \u003cp\u003eCH is a procedure associated with a high incidence of bile leakage, and thus the risk factors for bile leakage were investigated. Univariate and multivariate analysis both revealed proximity of the tumor to the right anterior Glissonean pedicle to be the significant risk factor for bile leakage (odds ratio, 6.84; 95% confidence interval, 1.67\u0026ndash;32.7; p\u0026thinsp;=\u0026thinsp;0.01).\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this study, we retrospectively reviewed cases of LCH and OCH performed in our department to assess the safety and efficacy of laparoscopic surgery. Compared to the OCH group, the LCH group showed significantly less blood loss, lower transfusion rate, and no difference in operative time. Among postoperative complications, the rate of bile leakage was 33% in the LCH group and 42% in the OCH group, but the difference was not significant. The incidences of ascites and SSI were significantly lower in the LCH group, and postoperative hospital stay was significantly shorter in the LCH group. Univariate and multivariate analysis of risk factors for bile leakage after CH showed tumor proximity of \u0026lt;\u0026thinsp;1 cm to the right anterior Glissonean pedicle to be the significant risk factor.\u003c/p\u003e \u003cp\u003eOther previous studies have reported the outcomes of LCH compared to OCH [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Among the short-term surgical outcomes, there was no difference in blood loss and the incidence of postoperative complications between the LCH and OCH groups, whereas the LCH group had a longer operative time and shorter postoperative hospital stay [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Cho et al. reported an overall postoperative morbidity rate of 30% and a bile leakage rate of 15% in their LCH group [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In our study as well, the LCH group experienced less blood loss, lower incidences of ascites and SSI, and a shorter postoperative hospital stay, consistent with these previous reports. However, the incidence of postoperative bile leakage in our patients was higher than that previously reported, so we investigated the risk factors for bile leakage. To our knowledge, there have been no reports investigating the causes of bile leakage in LCH, making the present findings novel in this respect.\u003c/p\u003e \u003cp\u003eIn general, LLR is reported to be associated with fewer complications compared to open hepatectomy, but the incidence of bile leakage has been reported to be comparable when limited to CH [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. CH is considered to be a surgical procedure with a high incidence of bile leakage [\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Nanashima et al. reported an incidence rate of bile leakage of 37% [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], whereas Ueno et al. reported a rate of 44.8% [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Several reports have examined the risk factors for bile leakage in CH [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Ueno et al. examined the biliary complications in CH and reported that the tumor proximity to the right anterior Glissonean pedicle and a longer right hepatic duct were risk factors for biliary complications [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In our study as well, proximity of the tumor to the right anterior Glissonean pedicle was found to be the risk factor for bile leakage. This factor could be the potential cause for stenosis of the right posterior bile duct (RPBD) branch. Yoon et al. investigated the factors contributing to the occurrence of the RPBD stenosis in CH [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Approximately 80% of the RPBD is located supraportally distal to the bifurcation of the anterior and posterior Glissonean sheaths. When the anterior Glissonean sheath is ligated, injuries such as stricture and ischemic insult of the RPBD could occur. They reported that handling the Glissonean pedicle close to the right anterior Glissonean pedicle root could lead to stenosis of the RPBD. This stenosis increases the intraductal pressure in the RPBD, potentially causing bile leakage from the liver dissection plane. Additionally, in cases in which the tumor is closer to the hepatic hilum, there is a higher possibility of incising the caudate lobe and damaging its bile ducts. This is consistent with the findings of Nanashima et al., who reported that segment 1 resection and inferior vena cava compression were risk factors for bile leakage with CBS [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These may be the reasons why a tumor close to the root of the right anterior Glissonean pedicle were detected as risk factors for bile leakage.\u003c/p\u003e \u003cp\u003eThe present study has several limitations. First, this is a single-center study with a small number of cases. Second, the operator was different in each case although the surgical team included expert board-certified surgeons. Third, long-term prognoses were not comparable because of the variety of diseases in the patients included in this study.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eCompared to OCH, LCH reduced blood loss and could be performed safely. Although the frequency of postoperative bile leakage was not different between these two procedures, there was less postoperative ascites and fewer SSIs with LCH, suggesting the potential for a shortened postoperative hospital stay. However, proximity of the tumor to the root of the right anterior Glissonean pedicle was considered a risk factor for postoperative bile leakage, and caution is required in such cases.\u003c/p\u003e"},{"header":"Statements and Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor’s Contributions \u0026nbsp;\u003c/strong\u003eStudy conception and design: T.M., Y.E., and M.I.; acquisition of data: S.N., W.M., Y.N., H.O., M.K., A.F., Y.K., H.T., and T.H.; analysis and interpretation of data: T.M., Y.E., and M.I.; drafting of manuscript: T.M., Y.E., and M.I.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u0026nbsp;\u003c/strong\u003e All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\u0026nbsp;This study was approved by the Ethics Committee of Oita University Faculty of Medicine (No. 1601). Informed consent was obtained in the form of opt-out on the hospital web site.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication \u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials \u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests \u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding \u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements \u0026nbsp;\u003c/strong\u003eNot applicable.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eReich H, McGlynn F, DeCaprio J, Budin R (1991) Laparoscopic excision of benign liver lesions. Obstet Gynecol 78(5 Pt 2):956\u0026ndash;958\u003c/li\u003e\n \u003cli\u003eShiroshita H, Inomata M, Akira S, Kanayama H, Yamaguchi S, Eguchi S, Wada N, Kurokawa Y, Uchida H, Seki Y et al (2022) Current Status of Endoscopic Surgery in Japan: The 15th National Survey of Endoscopic Surgery by the Japan Society for Endoscopic Surgery. Asian J Endosc Surg 15(2):415\u0026ndash;426. https://doi.org/10.1111/ases.13012\u003c/li\u003e\n \u003cli\u003eNguyen KT, Gamblin TC, Geller DA (2009) World review of laparoscopic liver resection-2,804 patients. Ann Surg 250(5):831\u0026ndash;841. https://doi.org/10.1097/SLA.0b013e3181b0c4df\u003c/li\u003e\n \u003cli\u003eWakabayashi G, Cherqui D, Geller DA, Abu Hilal M, Berardi G, Ciria R, Abe Y, Aoki T, Asbun HJ, Chan ACY et al (2022) The Tokyo 2020 terminology of liver anatomy and resections: Updates of the Brisbane 2000 system. J Hepatobiliary Pancreat Sci 29(1):6\u0026ndash;15. https://doi.org/10.1002/jhbp.1091\u003c/li\u003e\n \u003cli\u003eBeppu T, Wakabayashi G, Hasegawa K, Gotohda N, Mizuguchi T, Takahashi Y, Hirokawa F, Taniai N, Watanabe M, Katou M 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 Hepatobiliary Pancreat Sci 22(10):711\u0026ndash;720. https://doi.org/10.1002/jhbp.261\u003c/li\u003e\n \u003cli\u003eZhang XL, Liu RF, Zhang D, Zhang YS, Wang T (2017) Laparoscopic versus open liver resection for colorectal liver metastases: a systematic review and meta-analysis of studies with propensity score-based analysis. Int J Surg 44:191\u0026ndash;203. https://doi.org/10.1016/j.ijsu.2017.05.073\u003c/li\u003e\n \u003cli\u003eWu X, Huang Z, Lau WY, Li W, Lin P, Zhang L, Chen Y (2019) Perioperative and long-term outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma with well-preserved liver function and cirrhotic background: a propensity score matching study. Surg Endosc 33(1):206\u0026ndash;215. https://doi.org/10.1007/s00464-018-6296-8\u003c/li\u003e\n \u003cli\u003eSposito C, Battiston C, Facciorusso A, Mazzola M, Muscar\u0026agrave; C, Scotti M, Romito R, Mariani L, Mazzaferro V (2016) Propensity score analysis of outcomes following laparoscopic or open liver resection for hepatocellular carcinoma. Br J Surg 103(7):871\u0026ndash;880. https://doi.org/10.1002/bjs.10137\u003c/li\u003e\n \u003cli\u003eYamashita YI, Yamamoto H, Miyata H, Kakeji Y, Kitagawa Y, Yamaue H, Yamamoto M, Baba H (2021) Risk factors for bile leakage: Latest analysis of 10 102 hepatectomies for hepatocellular carcinoma from the Japanese national clinical database. J Hepatobiliary Pancreat Sci 28(7):556\u0026ndash;562. https://doi.org/10.1002/jhbp.827\u003c/li\u003e\n \u003cli\u003eNanashima A, Eguchi S, Hisaka T, Kawasaki Y, Yamashita YI, Ide T, Kuroki T, Yoshizumi T, Kitahara K, Endo Y et al (2023) Risk factors of complications from central bisectionectomy (H458) for hepatocellular carcinoma: a multi-institutional single-arm analysis. Cancers (Basel) 15(6):1740. https://doi.org/10.3390/cancers15061740\u003c/li\u003e\n \u003cli\u003eIshii H, Ochiai T, Murayama Y, Komatsu S, Shiozaki A, Kuriu Y, Ikoma H, Nakanishi M, Ichikawa D, Fujiwara H et al (2011) Risk factors and management of postoperative bile leakage after hepatectomy without bilioenteric anastomosis. Dig Surg 28(3):198\u0026ndash;204. https://doi.org/10.1159/000324042\u003c/li\u003e\n \u003cli\u003eIde T, Matsunaga T, Tanaka T, Noshiro H (2021) Feasibility of purely laparoscopic right anterior sectionectomy. Surg Endosc 35(1):192\u0026ndash;199. https://doi.org/10.1007/s00464-020-07379-w\u003c/li\u003e\n \u003cli\u003eBirgin E, Hartwig V, Rasbach E, Seyfried S, Rahbari M, Reeg A, Jentschura S-L, T\u0026eacute;oule P, Rei\u0026szlig;felder C, Rahbari NN (2022) Minimally invasive mesohepatectomy for centrally located liver lesions\u0026ndash;a case series. Surg Endosc 36(12):8935\u0026ndash;8942. https://doi.org/10.1007/s00464-022-09342-3\u003c/li\u003e\n \u003cli\u003eZheng Z, Xie H, Liu Z, Wu X, Peng J, Chen X, He J, Zhou J (2022) Laparoscopic central hepatectomy using a parenchymal-first approach: how we do it. Surg Endosc 36(11):8630\u0026ndash;8638. https://doi.org/10.1007/s00464-022-09163-4\u003c/li\u003e\n \u003cli\u003eCho CW, Rhu J, Kwon CHD, Choi GS, Kim JM, Joh JW, Koh KC, Kim GS (2017) Short-term outcomes of totally laparoscopic central hepatectomy and right anterior sectionectomy for centrally located tumors: a case-matched study with propensity score matching. World J Surg 41(11):2838\u0026ndash;2846. https://doi.org/10.1007/s00268-017-4105-5\u003c/li\u003e\n \u003cli\u003eChin KM, Linn YL, Cheong CK, Koh YX, Teo JY, Chung AYF, Chan CY, Goh BKP (2021) Minimally invasive versus open right anterior sectionectomy and central hepatectomy for central liver malignancies: a propensity-score-matched analysis. ANZ J Surg 91(4):E174\u0026ndash;E182. https://doi.org/10.1111/ans.16719\u003c/li\u003e\n \u003cli\u003eLi W, Han J, Xie G, Xiao Y, Sun K, Yuan K, Wu H (2019) Laparoscopic versus open mesohepatectomy for patients with centrally located hepatocellular carcinoma: a propensity score matched analysis. Surg Endosc 33(9):2916\u0026ndash;2926. https://doi.org/10.1007/s00464-018-6593-2\u003c/li\u003e\n \u003cli\u003eBan D, Tanabe M, Ito H, Otsuka Y, Nitta H, Abe Y, Hasegawa Y, Katagiri T, Takagi C, Itano O et al (2014) A novel difficulty scoring system for laparoscopic liver resection. J Hepatobiliary Pancreat Sci 21(10):745\u0026ndash;753. https://doi.org/10.1002/jhbp.166\u003c/li\u003e\n \u003cli\u003eWakabayashi G (2016) What has changed after the Morioka consensus conference 2014 on laparoscopic liver resection? Hepatobiliary Surg Nutr 5(4):281\u0026ndash;289. https://doi.org/10.21037/hbsn.2016.03.03\u003c/li\u003e\n \u003cli\u003eKawaguchi Y, Fuks D, Kokudo N, Gayet B (2018) Difficulty of laparoscopic liver resection: proposal for a new classification. Ann Surg 267(1):13\u0026ndash;17. https://doi.org/10.1097/sla.0000000000002176\u003c/li\u003e\n \u003cli\u003eRatti F, Fiorentini G, Cipriani F, Catena M, Paganelli M, Aldrighetti L (2018) Laparoscopic vs open surgery for colorectal liver metastases. JAMA Surg 153(11):1028\u0026ndash;1035. https://doi.org/10.1001/jamasurg.2018.2107\u003c/li\u003e\n \u003cli\u003eUeno M, Hayami S, Miyamoto A, Okada KI, Kitahata Y, Shimizu A, Motobayashi H, Matsumoto K, Kawai M (2024) Relationship between postoperative biliary complications and biliary anatomical aspects in performing right anterior‐ or central bisectionectomy: single‐center retrospective observational study. Ann Gastroenterol Surg 00:1\u0026ndash;8. https://doi.org/10.1002/ags3.12805\u003c/li\u003e\n \u003cli\u003eYoon KC, Yu YD, Kang WH, Jo HS, Kim DS (2022) Right posterior bile duct stricture after central bisectionectomy or anterior sectionectomy. Langenbecks Arch Surg 407(7):2873\u0026ndash;2880. https://doi.org/10.1007/s00423-022-02586-6\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Laparoscopic central hepatectomy, Laparoscopic anterior sectionectomy, Laparoscopic central bisectionectomy, Bile leakage ","lastPublishedDoi":"10.21203/rs.3.rs-4642508/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4642508/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose \u003c/strong\u003eLaparoscopic central hepatectomy (CH) remains challenging, with safety and efficacy unclear. This study retrospectively evaluated short-term outcomes of laparoscopic versus open CH and assessed safety and efficacy of laparoscopic surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e CH included anterior sectionectomy (AS) and central bisectionectomy (CBS) (excluding cases with biliary reconstruction). The study comprised 38 patients receiving CH in our department from January 2010 to November 2023.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eThe laparoscopic group included 14 cases and the open group 24. AS/CBS was performed in 14/10 open group cases and 6/8 laparoscopic group cases. Short-term surgical outcomes showed no significant between-group difference in operative time, but the laparoscopic group lost significantly less blood (250 vs. 985 mL; p=0.001) and the transfusion rate was lower (14% vs. 46%; p=0.004). Among postoperative outcomes, incidence of bile leakage was not significantly different (33% vs. 42%; p=0.42), but the laparoscopic group had significantly less postoperative ascites (0% vs. 17%; p=0.047), fewer surgical site infections (SSI) (0% vs. 21%; p=0.02), and shorter postoperative hospital stay (14 vs. 30 days; p=0.03). The risk factor for bile leakage in CH by univariate and multivariate analysis was tumor proximity to the right anterior Glissonean pedicle (OR=6.84; 95% CI=1.67-32.7; p=0.01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e Laparoscopic CH could be performed safely. Compared to open surgery, laparoscopic CH was effective in reducing blood loss, postoperative ascites, SSIs, and shortening postoperative hospital stay. However, tumors close to the root of the right anterior Glissonean pedicle were considered a risk factor for postoperative bile leakage and require caution.\u003c/p\u003e","manuscriptTitle":"Short-term outcomes of laparoscopic central hepatectomy: A comparison with open surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-22 05:56:40","doi":"10.21203/rs.3.rs-4642508/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-28T06:35:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-27T18:37:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"280609979932939419047094318701800903067","date":"2025-01-16T14:36:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-30T07:18:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"190677478643060487977597668268550186906","date":"2024-07-30T07:08:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-06T17:01:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-02T04:18:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-28T11:05:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"Langenbeck's Archives of Surgery","date":"2024-06-26T11:49:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"langenbecks-archives-of-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"laos","sideBox":"Learn more about [Langenbeck's Archives of Surgery](http://link.springer.com/journal/423)","snPcode":"423","submissionUrl":"https://submission.nature.com/new-submission/423/3","title":"Langenbeck's Archives of Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"8c0e5ad9-3e03-4d98-94d8-788fdc8f4c79","owner":[],"postedDate":"July 22nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-24T16:02:11+00:00","versionOfRecord":{"articleIdentity":"rs-4642508","link":"https://doi.org/10.1007/s00423-025-03645-4","journal":{"identity":"langenbecks-archives-of-surgery","isVorOnly":false,"title":"Langenbeck's Archives of Surgery"},"publishedOn":"2025-02-20 15:57:29","publishedOnDateReadable":"February 20th, 2025"},"versionCreatedAt":"2024-07-22 05:56:40","video":"","vorDoi":"10.1007/s00423-025-03645-4","vorDoiUrl":"https://doi.org/10.1007/s00423-025-03645-4","workflowStages":[]},"version":"v1","identity":"rs-4642508","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4642508","identity":"rs-4642508","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}