Ratti Francesca, Cipriani Federica, Fiorentini Guido, Catena Marco, Paganelli Michele, Aldrighetti Luca
Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milano, Italy.
Hepatobiliary Surg Nutr. 2022 Jun;11(3):363-374. doi: 10.21037/hbsn-20-562.
The implementation of minimally invasive liver resection surgery (MILS) programs starts from procedures with a low degree of technical difficulty. Data regarding the real short-term advantage of laparoscopy according to technical difficulty are still lacking. The aim of the present study is to evaluate the differential benefit of laparoscopic over open technique according to the technical difficulty of the procedures and to investigate if efforts associated with laparoscopic approach are always justified.
Nine hundred and thirty-six MILS resections performed between 2005 and 2018 were stratified according to technical complexity (low, intermediate and high difficulty) and to approach (MILS or open) and matched in a 1:1 ratio using propensity scores to obtain three pairs of groups (Pair 1: Low-MILS and Low-Open, including 274 cases respectively; Pair 2: Int-MILS and Int-Open, including 237 patients respectively; Pair 3: High-MILS and High-Open, including 226 patients respectively).
MILS approach resulted in a statistically significant lower blood loss, reduced morbidity, reduced and shorter time for functional recover and length of stay within all pairs. The evaluation of the differential benefit showed a greater advantage of laparoscopic approach in high degree procedures compared with intermediate and low degree, both in terms of blood loss (-250 and -200 mL respectively) and morbidity rate (-5.7% and -4.1% respectively).
The favorable biological scenario associated with laparoscopic approach allows to obtain significant benefits in the setting of technically complex procedures. The commitment towards MILS approach should be therefore stronger in this setting, where the advantage of laparoscopy seems to be enhanced.
微创肝切除手术（MILS）项目的实施始于技术难度较低的手术。根据技术难度划分，目前仍缺乏关于腹腔镜手术真正短期优势的数据。本研究的目的是根据手术的技术难度评估腹腔镜手术相对于开放手术的差异获益，并探讨与腹腔镜手术相关的努力是否总是合理的。
对2005年至2018年间进行的936例MILS切除术，根据技术复杂性（低、中、高难度）和手术方式（MILS或开放手术）进行分层，并使用倾向评分以1:1的比例进行匹配，从而获得三组配对组（配对1：低难度MILS组和低难度开放手术组，各包括274例；配对2：中等难度MILS组和中等难度开放手术组，各包括237例；配对3：高难度MILS组和高难度开放手术组，各包括226例）。
在所有配对组中，MILS手术方式在统计学上均显著减少了术中出血量、降低了发病率、缩短了功能恢复时间和住院时间。差异获益评估显示，在高难度手术中，腹腔镜手术方式在出血量（分别减少250 mL和200 mL）和发病率（分别降低5.7%和4.1%）方面比中等难度和低难度手术具有更大优势。
与腹腔镜手术方式相关的良好生物学环境使得在技术复杂的手术中能够获得显著益处。因此，在这种腹腔镜手术优势似乎更明显的情况下，对MILS手术方式的投入应该更大。
