The Comparison of Laparoscopy and Fluorescent Laparoscopy in Anatomical Liver Resection in Hepatocellular Carcinoma Patients: A Systematic Review and Meta-Analysis

Anatomic liver resection (AR) is a surgical technique that aims to completely remove the tumor-bearing portal territory (PT) and improve the oncological efficacy of hepatocellular carcinoma (HCC). However, the classical AR technology system has some limitations in achieving this goal. Indocyanine green (ICG) fluorescence laparoscopy is an emerging technology that can accurately delineate the PT and guide the AR. However, the evidence of its efficacy compared to conventional laparoscopy is scarce. This systematic review and meta-analysis aims to compare the effectiveness of laparoscopy and ICG fluorescence laparoscopy in AR for HCC patients. This systematic review was registered on the International Prospective Register of Systematic Reviews platform (ID: CRD42023456121). Empirical research comparing perioperative effectiveness between ICG fluorescence laparoscopy and conventional laparoscopy published from inception to 26th November 2023 in several academic literature databases was included. Cochrane risk-of-bias tool (RoB) and the Newcastle-Ottawa scale (NOS) were used for study quality evaluations. Information on clinical characteristics, operative, postoperative, prognosis, and pathological outcomes was retrieved for review. Publication bias and heterogeneity were tested for each outcome. The effect size odds ratio (OR) and standard mean difference (SMD) were calculated and synthesized. The quality of evidence was evaluated using the GRADE system. A total of 13 studies were included. Clinical characteristics were comparable between the ICG fluorescence laparoscopy group and the conventional laparoscopy group. Compared with conventional laparoscopy, ICG fluorescence laparoscopy is associated with superior short- and long-term clinical outcomes in HCC patients undergoing hepatectomy. Especially in the aspects of reduced intraoperative blood loss (SMD=-0.743, P=0.002), decreased risks of blood transfusion (OR=0.459, P=0.004), and shorter postoperative hospitalization times (SMD=-0.391, P<0.001). ICG fluorescence laparoscopy also showed implications for fewer postoperative complications (OR=0.657, P=0.071), higher R0 resection rates (OR=3.013, P=0.068), greater margin distances (SMD=0.559, P=0.072), and longer recurrence-free survival, although these findings were not statistically significant and require further investigation. ICG fluorescence laparoscopy is a safe and effective technique for AR in HCC patients. It can achieve accurate and complete resection of tumor-bearing PT and Glisson systems, as well as preserve the function and venous outflow of the future remaining liver. This study provides valuable evidence to support the clinical application of ICG fluorescence laparoscopy in AR for HCC.