ORIGINAL ARTICLE

Outcomes of Laparoscopic Versus Open Liver Resection:

A Case-control Study With Propensity Score Matching
Elvan Onur Kirimker, MD, Kerem Ozgu, MD, Siyar Ersoz, MD,
and Acar Tuzuner, MD, FEBS

associated increase in operative time are among the factors

Background: This study aimed to evaluate the perioperative out- that complicate laparoscopy. However, over the years, the
comes of patients with benign and malignant liver lesions scheduled establishment of laparoscopic techniques and the use of lap-
for laparoscopic and open surgery using a propensity score-matched aroscopic dissection and coagulation devices have enabled
approach to analyze additional cofactors influencing outcomes.
surgeons to overcome this concern. After the laparoscopic
Patients and Methods: In this study, we retrospectively reviewed 270 learning curve is completed, a decrease in the conversion rate
patients who underwent laparoscopic or open liver resection at our was observed.1,2 Therefore, knowledge of various hemostatic
institute between October 2016 and November 2021. Patients were methods, techniques, tools, and devices is essential for all
divided into open and laparoscopic liver resection groups and com- laparoscopic surgeons, and their continuing development is
pared according to the intention to treat principle. In the purification essential for the expansion of this surgical approach.
process for the nonrandom nature of the study, a matching analysis
Some comparative studies between open liver resections
was performed at a 1:1 case-control ratio. The PS model included
selected data on body mass index, additional data on the American and LLR have reported improved perioperative outcomes,
Society of Anesthesiology score, cirrhosis, lesion <2 cm from the such as reduced intraoperative blood loss, postoperative
hilum, lesion <2 cm from the hepatic vein or inferior vena cava, and complication rates, and length of postoperative hospital stay,
type of neoadjuvant chemotherapy. in favor of LLR.3–8 However, most of these studies were
retrospective, inevitably introducing a patient selection bias;
Results: The operation time and 30- and 90-day mortality rates were
similar between the groups. The average length of hospital stay was
thus, the results should be interpreted with caution.9 Several
11 days in the open surgery group and 9 days in the laparoscopic previous reports have not considered the difficulty of planned
surgery group after matching (P = 0.011). The 30-day morbidity rate liver resection, patient comorbidities, and tumor and liver
was statistically different between the groups before and after characteristics10; however, these factors affect the surgeon’s
matching, favoring the laparoscopic group (P = 0.001 and 0.006, choice of surgical approach and postoperative complications.
respectively). After the propensity score-matched approch, the open Laparoscopic hepatectomy (LH) has been established as
group’s Pringle time was shorter than that of the laparoscopic a safe treatment option for liver tumors at selected centers.
group. The total operative time was longer in the laparoscopic than Despite the potential clinical benefits of the laparoscopic
in the open surgery group. This did not change after matching (300 approach, its use remains limited because of insufficient
vs. 240 min).
surgical experience among surgeons.11
Conclusions: Laparoscopic surgery is a feasible and safe treatment This study aimed to assess the perioperative outcomes
option for patients with liver tumors, with promising results in terms of patients with benign and malignant liver lesions sched-
of morbidity and hospital stay. uled for laparoscopic and open surgery, using a propensity
score-matched (PSM) approach that analyzed additional
Key Words: laparoscopic liver resection, hepatobiliary, propensity
cofactors that influence outcomes.
score matching
(Surg Laparosc Endosc Percutan Tech 2023;33:375–381)

PATIENTS AND METHODS

A retrospective review of prospective databases was
L aparoscopic surgery has become the standard technique
for many surgical procedures due to the evolution of
surgical technology and minimally invasive techniques.
performed in consecutive patients who underwent laparo-
scopic or open liver resection at our institution. Pediatric
patients and living liver donors were excluded. A total of
The initial concern with laparoscopic liver resection 270 patients who underwent surgery between October 2016
(LLR) is usually the inability to rapidly control potential and November 2021 were included in this study. Patients
significant intraoperative bleeding, which can lead to gas were divided into open and laparoscopic liver resection
embolism and mortality. In addition, adhesions and the groups and compared according to the intention to treat
principle. Informed consent was obtained from all patients
Received for publication November 3, 2022; accepted April 26, 2023. before surgery. The study methodology was approved by the
From the Department of Surgery, Ankara University School of Medi- Local Ethics Committee of the institute (I10-642-21).
cine, Ankara, Turkey.
The authors declare no conflicts of interest.
The biochemical profiles of all patients, including renal
Reprints: Acar Tuzuner, MD, FEBS, Professor of Surgery, Genel and hepatic function tests, complete blood count results,
Cerrahi AD Ibni Sina Hastanesi Akademik Yerleske K-4 Sihhiye, serological markers of hepatotropic viruses, and coagulation
Ankara 06230, Turkey (e-mail: [email protected]). tests, were extracted from the hospital’s computer database.
Supplemental Digital Content is available for this article. Direct URL
citations are provided in the HTML and PDF versions of this article
Computed tomography (CT) or magnetic resonance imaging
on the journal’s website, www.surgical-laparoscopy.com. was routinely performed for preoperative evaluation. Blood
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved. tests were routinely performed 1 to 5 days postoperatively.

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Kirimker et al Surg Laparosc Endosc Percutan Tech  Volume 33, Number 4, August 2023

The American Society of Anesthesiology (ASA) score,

Child-Pugh score, tumor size and location, age, body mass
index, and sex were recorded, together with the indications
for surgery and intraoperative data. Liver resections were
classified according to the Brisbane 2000 classification of
hepatic resections.12 Major hepatectomy was defined as
resection of ≥ 3 segments, while minor hepatectomy was
defined as resection of <3 segments. Patients underwent liver
resections, including right hepatectomy, left hepatectomy,
right posterior sectionectomy, left lateral sectionectomy,
central hepatectomy, right trisectionectomy, left trisectio- FIGURE 1. Pringle maneuver usage.
nectomy, bisegmentectomy, metastasectomy, extrahepatic
bile duct resection, and hepaticojejunostomy. relationships between categorical quartiles was investigated
Comorbidities and underlying liver diseases were also using the χ2 or Fisher exact tests. In the purification process for
recorded. Possible factors affecting the difficulty of surgery, the nonrandom nature of the study, a matching analysis was
including tumor size, distance to major vascular structures, performed at a 1:1 case-control ratio. The propensity score
and neoadjuvant chemotherapy, were noted. Postoperative (PS) model included selected data on body mass index, addi-
analgesic requirements were obtained from postoperative tional data on ASA score, cirrhosis, lesion <2 cm from the
orders. Complications were graded according to the hilum, lesion <2 cm from the hepatic vein or inferior vena
Accordion Classification system.13,14 cava, and type of neoadjuvant chemotherapy. The caliper for
The primary endpoint of the study was postoperative the optimum PS was set to 0.18. Differences were considered
morbidity. The secondary endpoint was postoperative statistically significant at P <0.05.
mortality, defined as death within 30 days of liver resection.
Postoperative morbidity was defined as morbidity within
30 days of liver resection. The indications for surgery were RESULTS
hepatocellular carcinoma (HCC), cholangiocarcinoma, Of the 270 patients enrolled in this study, 190 under-
colorectal cancer liver metastases (CRLM), other meta- went open surgery (open group), and 80 underwent lapa-
stases, other primary malignancies, cystic disease of the roscopic surgery (laparoscopic group). There were 130
liver, hemangioma, hepatic adenoma, focal nodular hyper- (48.1%) females and 140 (51.9%) males, with a mean age of
plasia, bile duct injury, and other rare indications. 59.85 ± 13.94 years. The reasons for surgery were HCC (60),
cholangiocarcinoma (30), CRLM (76), other metastases
Surgical Technique (34), other primary malignancies (15), cystic disease of the
Resections were performed under ultrasonographic liver (21), hemangioma (15), hepatic adenoma (2), FNH (6),
guidance, and lesion localization was performed by a specialist bile duct injury (2), and other indications (2) (Fig. 4).
hepatobiliary surgeon. A tourniquet was routinely placed Of the 80 cases in which laparoscopy was started, 16
encircling the hepatoduodenal ligament at the beginning of the were converted to an open procedure. The reasons for
operation in preparation for a Pringle maneuver, which was conversion to open surgery were bleeding in 7 cases,
routinely used (Fig. 1). Laparoscopic parenchymal transection incomplete adhesiolysis in 7 cases, and concern for surgical
was initiated through an incision in the liver capsule with dia- margin and difficulty with laparoscopic progression in 2
thermy. Parenchymal dissection was performed either with an cases (Table 1).
ultrasonic aspirator or clamp-crush method, followed by liga- The mean age (P = 0.007), ASA score (P < 0.001), num-
tion and division of identified vessels, bile ducts, or pedicles ber of lesions (P = 0.001), rate of concurrent additional pro-
with titanium/polymer clips or a sealing energy device (Har- cedures (P = 0.01), and lesion size (< 2 cm) to major vascular
monic, Ligasure, Thunderbeat) (Fig. 2). A linear stapler was structures (P < 0.001) were statistically different between the
used to divide the hepatic veins during laparoscopic surgery study groups before matching (Tables 2, 3). The ratio of
(Fig. 3). The resected liver specimen was extracted in a plastic posterosuperior segments to total resections was not sig-
bag through the umbilical port site or a Pfannenstiel incision. nificantly different between the 2 groups. Before matching, 14
All operations were performed with a central venous pressure posterosuperior segments were involved in the laparoscopic
of <5 mm Hg and a pneumoperitoneum pressure of 10 to
14 mm Hg. Laparoscopic procedures were performed in the
French position, and open liver resections were in the supine
position (Supplementary Video, Supplemental Digital Content
1, http://links.lww.com/SLE/A389).

Statistical Analyses
The data obtained in this study were analyzed using SPSS
vn. 22.0 software (SPSS Inc; licensed to the University). Cat-
egorical data are expressed as numbers (n) and percentages
(%). Continuous variables are expressed as mean ± SD and n
± interquartile range (IQR) based on the data. Conformity to
normal distribution was assessed using the Kolmogorov-
Smirnov and Shapiro-Wilk tests. For comparisons between 2
independent groups, the Student t test was used for data with
normal distribution, and the Mann-Whitney U test was used
for data with non-normal distribution. The table of FIGURE 2. Parenchymal dissection.

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Surg Laparosc Endosc Percutan Tech  Volume 33, Number 4, August 2023 Laparoscopic Versus Open Liver Resection Outcomes

(P = 0.006). After PSM, the open group Pringle time was

shorter than that in the laparoscopic group. There was no
mortality in the LLR group, and 2 patients died intra-
operatively in the open liver resection group.
The total erythrocyte suspension (ES) transfusion was
significantly different between the study groups intra-
operatively and postoperatively (P = 0.041). The total ES
transfusion was 1 ± 2 and 0 ± 1 in the open and laparoscopic
liver resection groups, respectively.
The total operative time was longer in the laparoscopic
group than in the open group, and this did not change after
matching (300 vs. 240 min).
In the laparoscopic group, 79 patients had ASA scores
of 1 or 2, and 1 had an ASA score of 3 or 4. Of the 170
patients in the open group, 159 had ASA scores of 1 or 2. To
FIGURE 3. Linear stapler used to divide the hepatic veins during reduce the difference between the groups, 74 patients with
laparoscopic surgery. ASA score of 1 or 2 were selected from the open group.
Neoadjuvant chemotherapy was administered to 7 of
190 patients in the open group and 8 of 80 patients in the
group, and 32 were in the open group (17.5% vs. 16.8%). These laparoscopic group. Cirrhosis was present in 7 patients in
variables were excluded from the PSM. The sociodemographic the laparoscopic group, and 8 of 80 patients in the open
and clinical features of the study groups were not significantly group with cirrhosis were selected to balance the groups.
different (P > 0.05) (Tables 2, 3).
After PSM, 80 patients remained in each group, con-
sisting of 77 females (48.1%) and 83 males (51.9%), with an DISCUSSION
overall average age of 57.53 ± 14.46 years (Table 4). The Hepatectomy is performed primarily using one of 3
sociodemographic and pathological characteristics were techniques: open, laparoscopic, and robotic. Previous case
similar in both groups after PSM (P > 0.05; Tables 2, 3). series and observational studies have reported the safety and
Hospital stay (P = 0.001), 30-day morbidity (P = 0.001), technical feasibility of open and laparoscopic procedures,
and pleural effusion (P = 0.045) rates were significantly dif- and liver resection surgery has become common in several
ferent between the study groups (Table 5). Operative time and centers worldwide. Recent advances in hepatectomy have
30- and 90-day mortality rates were similar in both groups. led to a focus on minimally invasive liver resection techni-
Before matching, the average length of hospital stay was ques. The first laparoscopic liver resection procedure was
13 days in the open surgery group and 9 days in the laparo- reported in 1992 by Gagner et al.15
scopic surgery group (P < 0.001). After matching, the average The first step in this study was to compare the demo-
length of hospital stay was 11 and 9 days in the open and graphics and patient characteristics of the laparoscopic and
laparoscopic groups, respectively (P = 0.011). The 30-day open liver resection groups. We hypothesize that the selec-
morbidity rate significantly differed between the groups tion of major and minor hepatectomy groups, as well as the
before and after matching (P = 0.001 and 0.006, respectively). tumor location and patient condition, may have influenced
The total pringle time significantly differed between the the study results. Patients were evaluated based on age, sex,
groups before and after matching. In the laparoscopic additional procedures, ASA score, cirrhosis, distance from
group, the mean Pringle clamp time was 45 minutes before the hilum, distance from major vascular structures, and type
and after matching (P = 0.09). In the open group, the prin- of neoadjuvant chemotherapy. These differences created a
gle-clamp time decreased to 25 minutes after matching need for case-matching.

FIGURE 4. Indications for hepatectomy.

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Many studies have reported lower complication rates in

TABLE 1. Reasons of Conversion to Open laparoscopic surgery. Nguyen et al24 reported a complication
Reason of open conversion n (%) rate of 10.5% (n = 295) in 2804 patients. According to a study
Surgical margin concern 1 (6.3) by Bueno et al25 which included patients with similar charac-
Bleeding 7 (43.8) teristics, the severity of complications according to the Clavien-
Incomplete adhesiolysis 7 (43.8) Dindo scores was lower in laparoscopic patients. Koffron and
Difficulty in laparoscopic progression 1 (6.3) colleagues performed 300 laparoscopic liver resections in a
Open conversion 16 (20.5) single center and compared them with 100 open liver resections
performed at the same period in similar patients in terms of
age, type of resection, benign vs. malignant origin, and cir-
The length of hospital stay was significantly shorter in rhosis. Compared with the open resection group, the minimally
the laparoscopic group both before and after matching. invasive group had a lower rate of overall complications (9.3%
Before matching, the average length of hospitalization was vs. 22%).26 In the current study, 30-day morbidity was sig-
13 and 9 days in the open and laparoscopic groups, nificantly lower in the laparoscopic group before and after
respectively. After matching, the duration was 11 and matching. The role of pneumoperitoneum in homeostasis and
9 days, respectively. In a review of 1009 patients included in the ability of laparoscopic magnification to allow for metic-
17 studies, the length of hospital stay was shorter in the ulous dissection are also considered important factors in
laparoscopic than in the open group (8 vs. 10 d).16 In reducing complications during and after laparoscopic
another Chinese study that evaluated 516 liver resections for procedures.27 Rao and colleagues published a meta-analysis in
HCC, hospitalization time was shorter in the laparoscopic 2012 that included the 32 most relevant comparative studies
group than in the open group.17 Reduced surgical trauma, reported to date. They confirmed that laparoscopic hep-
discomfort, and pain following LLR may improve patient atectomy has a lower risk of complications than open hep-
recovery resulting in early discharge. In the current study, atectomy (P < 0.001).28 It was expected that laparoscopic sur-
patients in the laparoscopic group required less post- gery would provide benefits such as shorter hospital stay, better
operative analgesia and were, therefore, quickly mobilized cosmesis due to the small incision, less contamination and
and had a shorter hospital stay. This aspect of minimally infection risk, and less blood loss. According to Rao and col-
invasive liver surgery was reported in 2 previous studies of leagues, the 2 approaches had no significant difference in urine,
liver resection for CRLM and HCC.18,19 Smaller abdominal wound, or chest infections. In the current study, intra-
incisions caused less pain, and early oral intake may have abdominal collection was observed in 22 patients in the open
contributed to early recovery and wound healing. group and in just 1 patient in the laparoscopic group. Pleural
Numerous studies have demonstrated the negative effusion was also observed in 21 patients in the open group and
impact of intra- and postoperative blood transfusions on only one patient in the laparoscopic group. This was thought to
oncological outcomes. Transfusion of blood products is be due to postoperative pain resulting in the need for analge-
associated with increased mortality and higher recurrence sics, postoperative delayed mobilization, and a limitation of
rates after liver resection in patients with HCC.20–22 In the lung exercise. Furthermore, the liver mobilization technique
current study, after matching, the intraoperative and post- used in laparoscopic resection under the pneumoperitoneum
operative total erythrocyte transfusion rates were significantly may have contributed to this result. Differences between the
decreased in favor of laparoscopic surgery. However, the organ systems in which complications develop may be due to
amount of blood loss was similar between the groups. As the design of the studies included in the meta-analysis. Patient
mentioned earlier, this can be interpreted as a minor selection, bias, and the location of liver segment resection may
advantage of laparoscopy.23 Positive intra-abdominal pres- have affected the results of these studies. This problem can be
sure due to gas insufflation during laparoscopy has been overcome using PSM, as used in the current study.
suggested to prevent minor bleeding and provide better The total Pringle clamp time significantly differed
exposure for laparoscopy. In addition, early detection of between the laparoscopic and open liver resection groups
vascular structures through magnification may reduce intra- after PSM. The total Pringle clamp time was longer in the
operative blood loss. The disadvantages of gas insufflation laparoscopic group. In our practice, a laparoscopic tour-
may cause delayed bleeding. Therefore, a final check for niquet is usually prepared through a separate port at the
bleeding and bile leakage under lower intraabdominal pres- beginning of the procedure because the Pringle maneuver
sures is essential in laparoscopic liver resections. usually takes time and is difficult to prepare quickly in

TABLE 2. Comparison of Sociodemographic Characteristics of Patients Before and After Matching

Before propensity score matching After propensity score matching
Open Laparoscopic P Open Laparoscopic P
a
Age 61.33 ± 13.58 56.35 ± 14.23 0.007 58.71 ± 14.68 56.35 ± 14.23 0.303a
BMI 26.21 ± 5.18 26.78 ± 5.52 0.503b 26.12 ± 5.88 26.78 ± 5.52 0.675b
Sex, n (%)
Male 99 (52.1) 41 (51.2) 0.898c 42 (52.5) 41 (51.2) 0.874c
Female 91 (47.9) 39 (48.8) 38 (47.5) 39 (48.8)
a
Students’ t-test with Mean ± SD.
b
Mann-Whitney U test with Medyan ± IQR.
c
Chi-Square test with n(%).
BMI indicates body mass index.

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TABLE 3. Comparison of Characteristics of Patients and Surgical Procedures Before and After Matching
ASA score
1, 2 159 (83.7%) 79 (98.8%) < 0.001c 74 (92.5%) 79 (98.8%) 0.117d
3, 4 31 (16.3%) 1 (1.2%) 6 (7.5%) 1 (1.3%)
Postoperative analgesia (total analgesic drug amount ) 18 ± 27 17 ± 17 0.808b 17 ± 16 17 ± 17 0.384b
Additional procedures
Yes 76 (40%) 15 (18.8%) 0.001c 23 (28.7%) 15 (18.8%) 0.137c
No 114 (60%) 65 (81.3%) 57 (71.3%) 65 (81.3%)
Preoperative portal vein embolization
No 178 (94.7%) 73 (94.8%) 0.334c 77 (96.3%) 73 (94.8%) 0.178d
Classic 3 (1.6%) 3 (3.9%) 0 3 (3.9%)
ALPPS 7 (3.7%) 1 (1.3%) 3 (3.8%) 1 (1.3%)
Cirrhosis
Yes 18 (9.5%) 7 (8.8%) 0.851c 8 (10%) 7 (8.8%) 0.786c
No 172 (90.5%) 73 (91.3%) 72 (90%) 73 (91.3%)
Classification of Child Pugh
Child A 173 (90.5%) 79 (98.75%) 1.000d 78 (97.5%) 79 (98.75%) 1.000d
Child B 15 (7.85%) 1 (1.25%) 2 (2.5%) 1 (1.25%)
Diagnosis
HCC 34 (18.5%) 26 (32.9%) — 16 (20.3%) 26 (32.9%) 0.127d
Intrahepatic cholangiocarcinoma 25 (13.6%) 5 (6.3%) 8 (10.1%) 5 (6.3%)
CRCLM 57 (31%) 19 (24.1%) 23 (29.1%) 19 (24.1%)
Other metastasis 27 (14.7%) 7 (8.9%) 9 (11.4%) 7 (8.9%)
Other primary Malignant 13 (7.1%) 2 (2.5%) 6 (7.6%) 2 (2.5%)
Poly/multicystic liver/echinococcosis 15 (8.2%) 6 (7.6%) 9 (11.4%) 6 (7.6%)
Hemangioma 6 (3.3%) 9 (11.4%) 4 (5.1%) 9 (11.4%)
Adenoma 2 (1.1%) 0 1 (1.3%) 0
FNH 1 (0.5%) 5 (6.3%) 1 (1.3%) 5 (6.3%)
Other benign lesions 1 (0.5%) 0 0 0
Other İndications 2 (1.1%) 0 2 (2.5%) 0
Bile duct 1 (0.5%) 0 0 0
No. lesions
1 109 (61.2%) 60 (75.9%) 0.010c 48 (65.8%) 60 (75.9%) 0.119d
2 24 (13.5%) 6 (7.6%) 13 (17.8%) 6 (7.6%)
3 19 (10.7%) 11 (13.9%) 7 (9.6%) 11 (13.9%)
> 4 (multiple) 26 (14.6%) 2 (2.5%) 5 (6.8%) 2 (2.5%)
Largest lesion diameter 36 ± 52 35 ± 30 0.574b 40 ± 47 35 ± 30 0.272b
Is the lesion closer than 2 cm to the hilum?
Yes 53 (27.9%) 5 (6.3%) < 0.001c 11 (13.8%) 5 (6.3%) 0.114c
No 137 (72.1%) 75 (93.8%) 69 (86.3%) 75 (93.8%)
The lesion is <2 cm from the hepatic vein or IVC?
Yes 56 (29.5%) 6 (7.5%) < 0.001c 10 (12.5%) 6 (7.5%) 0.292c
No 134 (70.5%) 74 (92.5%) 70 (87.5%) 74 (92.5%)
Surgical margin
R0 141 (80.1%) 59 (77.6%) 0.655c 59 (81.9%) 59 (77.6%) 0.514c
R1 35 (19.9%) 17 (22.4%) 13 (18.1%) 17 (22.4%)
Distance to surgical margin 2.5 ± 5.25 3 ± 9.75 0.424b 3.5 ± 7.38 3 ± 9.75 0.982b
Neoadjuvant chemotherapy
No 183 (96.3%) 72 (90%) 0.076d 76 (95%) 72 (90%) 0.230c
Yes 7 (3.7%) 8 (10%) 4 (5%) 8 (10%)
Irinotecan
No 187 (98.4%) 9 (100%) 1.000d 80 (100%) 9 (100%) —
Yes 3 (1.6%) 0 0 0
Oxaliplatin
No 0 0 — 0 0 —
Yes 0 4 (100%) 0 4 (100%)

ASA indicates American Society of Anesthesiology; ALPPS, Associated liver partition and portal vein ligation for staged hepatectomy; CRCLM, Colorectal
cancer liver metastasis; FNH, Focal Nodular Hyperplasia; HCC, hepatocellular carcinoma; IVC, inferior vena cava.
b
Mann-Whitney U test with Medyan±IQR.
c
Chi-Square test with n(%).
d
Fisher’s Exact test with n(%).

TABLE 4. Comparison of Minor and Major Hepatectomy Rates in Groups Before and After Propensity Score Matching
Before propensity score matching After propensity score matching

Open Laparoscopic P Open Laparoscopic P

Minor hepatectomy 109 (57.4%) 57 (71.3%) 0.032c 49 (61.3%) 57 (71.3%) 0.181c
Major hepatectomy 81 (42.6%) 23 (28.7%) 31 (38.8%) 23 (28.7%)
c
Chi-Square test with n(%).

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TABLE 5. Comparison of Results Before and After Matching

Operation time 240 ± 160 300 ± 220 0.599b 240 ± 200 300 ± 220 0.400b
Surgical procedure time 180 ± 150 220 ± 215 0.960b 180 ± 230 220 ± 215 0.874b
Length of hospital stay (d) 13 ± 14 9±6 < 0.001b 11 ± 10 9±6 0.011b
Mortality (30 d)
No 184 (96.8%) 80 (100%) 0.496d 77 (96.3%) 80 (100%) 0.245d
Due to surgical complications 3 (1.6%) 0 2 (2.5%) 0
Other 3 (1.6%) 0 1 (1.3%) 0
Morbidity (30 d)
No 144 (75.8%) 75 (93.8%) 0.001c 63 (78.8%) 75 (93.8%) 0.006c
Yes 46 (24.2%) 5 (6.3%) 17 (21.3%) 5 (6.3%)
Causes of morbidity(30 d)
Bleeding
No 0 1 (100%) 0.333d 0 1 (100%) 0.333d
Yes 2 (100%) 0 2 (100%) 0
Intraabdominal collection
No 0 1 (50%) 0.083d 0 1 (50%) 0.182d
Yes 22 (100%) 1 (50%) 9 (100%) 1 (50%)
Failure of liver
No 0 0 — 0 0 —
Yes 3 (100%) 0 2 (100%) 0
Ascites
No 0 0 — 0 0 —
Yes 9 (100%) 0 4 (100%) 0
Vascular thrombosis
No 0 0 — 0 0 —
Yes 4 (100%) 0 0 0
Lung problems
No 0 0 — 0 0 —
Yes 19 (100%) 0 7 (100%) 0
Pleural effusion
No 0 1 (100%) 0.045d 0 1 (100%) 0.111d
Yes 21 (100%) 0 8 (100%) 0
Wound infections
No 0 0 — 0 0 —
Yes 3 (100%) 0 2 (100%) 0
Other
No 0 0 — 0 0 —
Yes 3 (100%) 0 1 (100%) 0
30-d degree of morbidity—Accordion Classification
Grade 1 139 (73.2%) 6 (75%) 0.050d 60 (75%) 6 (75%) 0.013d
Grade 2 41 (21.6%) 0 17 (21.3%) 0
Grade 3 5 (2.6%) 2 (25%) 0 2 (25%)
Grade 4 2 (1.1%) 0 1 (1.3%) 0
Grade 6 3 (1.6%) 0 2 (2.5%) 0
Mortality (90 d)
No 180 (96.3%) 79 (97.5%) 1.000d 76 (96.2%) 78 (97.5%) 0.873d
Due to surgical complications 4 (2.1%) 1 (1.2%) 1 (1.3%) 1 (1.3%)
Oncological disease progression 1 (0.5%) 0 1 (1.3%) 0
Other 2 (1.1%) 1 (1.2%) 1 (1.3%) 1 (1.3%)
Blood loss 250 ± 400 200 ± 175 0.412b 200 ± 375 200 ± 175 0.962b
Usage of Pringle
No 108 (57.4%) 48 (62.3%) 0.463c 46 (58.2%) 48 (62.3%) 0.600c
Yes 80 (42.6%) 29 (37.7%) 33 (41.8%) 29 (37.7%)
Total Pringle clamp time 45 ± 60 45 ± 15 0.090b 25 ± 49 45 ± 15 0.006b
Intraoperative death
No 2 (1.1%) 0 1.000d 1 (1.3%) 0 1.000d
Yes 188 (98.9%) 80 (100%) 79 (98.8%) 80 (100%)
Total (intraoperative + postoperative) erythrocyte transfusion (units) 0±2 0±1 0.143b 1±2 0±1 0.041b
b
Mann-Whitney U test with Medyan±IQR.
c
Chi-Square test with n(%).
d
Fisher’s Exact test with n(%).

an emergency condition during laparoscopy. A minor decrease the risk of excessive intraoperative bleeding and
peripheral resection is an exception to this procedure. If provide a safer surgical approach.30
the inflow is restricted by hepatic pedicle clamping, The present study had some limitations. First, it was
intraoperative blood loss is reduced, and plane disruption not a prospective and randomized controlled study, but
is prevented.29 The Pringle maneuver is encouraged to the aim was to present all our experiences retrospectively.

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Surg Laparosc Endosc Percutan Tech  Volume 33, Number 4, August 2023 Laparoscopic Versus Open Liver Resection Outcomes

However, we attempted to overcome this by forming 11. Jia C, Li H, Wen N, et al. Laparoscopic liver resection: a review
groups with the intention-to-treat principle and PSM, and of current indications and surgical techniques. Hepatobiliary
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benign. Finally, the study was conducted in a single center, 13. Strasberg SM, Linehan DC, Hawkins WG. The accordion
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The conversion rate in this cohort was high (20%). 2009;250:177–186.
However, these were the initial cases reported at our 14. Krige JE, Jonas E, Thomson SR, et al. Resection of complex
center. The reasons for conversion to open surgery were pancreatic injuries: benchmarking postoperative complications
bleeding in 7 cases, incomplete adhesiolysis in 7 cases, and using the Accordion classification. World J Gastrointest Surg.
surgical margin concern and difficulty in laparoscopic 2017;9:82–91.
progression in 2 cases. We converted to open surgery 15. Gagner M, Himal HS. Pioneers in laparoscopic solid organ
because the surgeons could not proceed safely due to surgery [1] (multiple letters). Surgical Endoscopy and Other
Interventional Techniques. 2003;17:1853–1855.
adhesion and bleeding, and believed that the operation 16. Mirnezami R, Mirnezami AH, Chandrakumaran K, et al.
time would be too long. In our clinic, laparoscopic liver Short- and long-term outcomes after laparoscopic and open
surgery has been performed over the past 15 years; how- hepatic resection: systematic review and meta-analysis. HPB
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resection for 3 years. 17. Chen J, Li H, Liu F, et al. Surgical outcomes of laparoscopic
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