Laparoscopic liver resections (LLRs) are steadily evolving. Any liver resection can be performed laparoscopically, depending on the experience of the surgical team and the hospital environment in which the practice is performed. There is scientific evidence that LLRs has better surgical outcomes than conventional hepatectomies, and the oncological results are noninferior^1,2,3. The study presented by Alesandrini A et al. shows the experience of a pioneering team in our country in minimally invasive liver surgery⁴. One of the most significant findings is the 75% applicability rate of the method. This percentage is really very high and is one of the highest in our region. We must keep in mind that these results cover the initial stage of their experience. According to a publication by J. Pekolj some years ago, reviewing the experience in South America, the average applicability rate of LLRs in the region ranges from 4 to 85%⁵.

The criteria for liver resections should not be altered solely based on the use of the laparoscopic approach. The well-known advantages of the minimally invasive approach should not modify the indication. This was clearly demonstrated in the study by Alesandrini A. et al., in which 79% of the indications were for malignancies. This does not mean that benign liver disorders have no indication for surgery. Diagnostic uncertainty, symptoms, or benign liver tumors with sustained growth during follow-up are indications for surgery⁶. Colorectal liver metastases are the most frequent indication in the Western world, whereas hepatocellular carcinoma is the primary indication in Asian countries⁷. The present study demonstrates this trend in indications. The authors demonstrate that the oncologic outcomes are not compromised using the minimally invasive approach. The R0 resections and long-term survival are excellent, in addition to the fact that the authors had to overcome their own learning curve.

We typically use the terms major and minor hepatectomies to indicate their level of complexity. With the introduction of parenchymal sparing resections, in addition to the increase in LLRs, we have observed that resection of less parenchyma is sometimes more difficult than resection of a liver lobe. We should avoid the mistake of conducting a larger or more complex liver resection merely because it may be simpler for us. The Morioka consensus conference highlighted the need to develop a difficulty scoring system to select patients for LLR⁸. The Iwate score is one of the methods currently used and considers tumor location, tumor size, proximity to major blood vessels, presence of cirrhosis, type of approach, and extent of liver resection. The total score ranges from 0 to 12. The difficulty level of LLRs is classified as low if the score is 0-3, intermediate if it is 4-6, advanced when it is 7-9, and expert at 10-12. The use of the Pringle maneuver, the conversion rate and the presence of morbidity are higher as the level of complexity increases. As a critique, the score fails to consider factors such as whether it is a repeat liver resection, the patient’s history of chemotherapy, or obesity, all of which add complexity to any hepatectomy. It does neither provide information on what to consider when performing multiple resections. Should we consider all lesions individually, the largest, the most complex to resect? As the authors suggest, the recommendation is to start performing minor resections of the anterior segments of the liver (segments 2, 3 4b, 5 and 6) which are considered easier and less complex⁹.

Beyond the technical difficulties, one of the major limitations of LLR is the need for technological equipment. We do not only need a good laparoscopy tower but also specific instruments, as laparoscopic ultrasound probe, energy devices, special clip applicators and mechanical stapler. Unfortunately, not all surgical centers count with these instruments, which remains a primary obstacle to the widespread adoption of this approach. In the absence of instruments or equipment, we must not forget the possibility of handassisted or hybrid approaches which are alternatives to the totally laparoscopic approach while maintaining the advantages of minimally invasive surgery. They are recommendedforsurgicalteamswithlimitedexperience, in cases of large tumors located in posterosuperior segments, and for repeat hepatectomies. The increased costs associated with the technology needed for the procedure are offset by the reduced risk of complications, shorter length of hospital stay, lower rate of readmissions, and fewer reoperations^10,11. As it happens in most published series, bleeding is the main reason for conversion to conventional surgery¹², which can occur during dissection of the portal pedicle, suprahepatic veins or parenchymal transection. A meticulous dissection of each element is the best means to prevent bleeding. Some authors recommend using the Pringle maneuver to dissect the portal pedicle. Oher authors, as Machado M. suggest the intrahepatic Glissonian approach and stapling of the pedicle without hilar dissection¹³. This approach is timesaving but demands thorough understanding of liver anatomy and poses a risk for injury to the contralateral hilar structures. Many authors recommend the use of energy devices to avoid bleeding during parenchymal transection. Ultrasonic surgical aspirator enables the identification of the vascular and biliary elements to ensure their effective control. We are decreasing our use of mechanical sutures for parenchymal transection, leaving their use for portal pedicle or suprahepatic vein transection. When the ultrasonic aspirator is not available, we can use the jaws of the energy devices to perform the Kelly clamp crushing technique¹⁴. The authors show that as the complexity of hepatectomies increases, they perform the Pringle maneuver more often. The same occurs with most of the published series. The authors use extracorporeal Pringle maneuver, but or group prefers the extracorporeal maneuver. Both options are highly effective in achieving their intended goals, therefore it is advisable to utilize the one that best suits the surgeon’s preferences. Other methods to reduce blood loss during parenchymal transection are to increase pneumoperitoneum pressure, lower central venous pressure, ask the anesthesiologist to minimize tidal volume, and position the patient in the inverted Trendelenburg position.

In summary, over the past few years, LLRs have become more prevalent in available treatment options for liver diseases. At present, we have sufficient scientific evidence to support its use and reassure us it is a safe procedure for patients.