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Risk Factors and Outcomes of Open Conversion During Minimally Invasive Major Hepatectomies: An International Multicenter Study on 3880 Procedures Comparing the Laparoscopic and Robotic Approaches

  • Hepatobiliary Tumors
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Introduction

Despite the advances in minimally invasive (MI) liver surgery, most major hepatectomies (MHs) continue to be performed by open surgery. This study aimed to evaluate the risk factors and outcomes of open conversion during MI MH, including the impact of the type of approach (laparoscopic vs. robotic) on the occurrence and outcomes of conversions.

Methods

Data on 3880 MI conventional and technical (right anterior and posterior sectionectomies) MHs were retrospectively collected. Risk factors and perioperative outcomes of open conversion were analyzed. Multivariate analysis, propensity score matching, and inverse probability treatment weighting analysis were performed to control for confounding factors.

Results

Overall, 3211 laparoscopic MHs (LMHs) and 669 robotic MHs (RMHs) were included, of which 399 (10.28%) had an open conversion. Multivariate analyses demonstrated that male sex, laparoscopic approach, cirrhosis, previous abdominal surgery, concomitant other surgery, American Society of Anesthesiologists (ASA) score 3/4, larger tumor size, conventional MH, and Institut Mutualiste Montsouris classification III procedures were associated with an increased risk of conversion. After matching, patients requiring open conversion had poorer outcomes compared with non-converted cases, as evidenced by the increased operation time, blood transfusion rate, blood loss, hospital stay, postoperative morbidity/major morbidity and 30/90-day mortality. Although RMH showed a decreased risk of conversion compared with LMH, converted RMH showed increased blood loss, blood transfusion rate, postoperative major morbidity and 30/90-day mortality compared with converted LMH.

Conclusions

Multiple risk factors are associated with conversion. Converted cases, especially those due to intraoperative bleeding, have unfavorable outcomes. Robotic assistance seemed to increase the feasibility of the MI approach, but converted robotic procedures showed inferior outcomes compared with converted laparoscopic procedures.

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Acknowledgement

International robotic and laparoscopic liver resection study group investigators: Nicholas L. Syn (Yong Loo Lin School of Medicine, National University of Singapore and Ministry of Health Holdings, Singapore). Mikel Gastaca (Hepatobiliary Surgery and Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, University of the Basque Country, Bilbao, Spain). Juul Meurs (Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium). Celine De Meyere (Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium. Eric C.H. Lai (Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong SAR, China). Felix Krenzien (Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Corporate Member of Freie Universität Berlin, and Berlin Institute of Health, Berlin, Germany). Prashant Kadam (Department of Hepatopancreatobiliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK). Kit-Fai Lee (Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, New Territories, Hong Kong SAR, China). Diana Salimgereeva (Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Moscow, Russia). Ruslan Alikhanov (Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Moscow, Russia. Lip-Seng Lee (Hepatopancreatobiliary Unit, Department of Surgery, Changi General Hospital, Singapore). Jae Young Jang (Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea). Kevin P. Labadie (Department of Surgery, University of Washington Medical Center. Seattle, WA, USA). Masayuki Kojima (Department of Surgery, Fujita Health University School of Medicine, Aichi, Japan). Asmund Avdem Fretland (Interventional Centre and Department of HPB Surgery, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway). Jacob Ghotbi (Interventional Centre and Department of HPB Surgery, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway). Jaime Arthur Pirola Kruger (Liver Surgery Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil). Victor Lopez-Lopez (Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain). Paolo Magistri (HPB Surgery and Liver Transplant Unit, University of Modena and Reggio Emilia, Modena, Italy). Marco Colasanti (Division of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy). Margarida Casellas I Robert (Hepatobiliary and Pancreatic Surgery Unit, Department of Surgery, Dr. Josep Trueta Hospital, IdIBGi, Girona, Spain). Mansour Saleh (Department of Hepatobiliary Surgery, Assistance Publique Hopitaux de Paris, Centre Hepato-Biliaire, Paul-Brousse Hospital, Villejuif, France). Edoardo Poletto (General and Hepatobiliary Surgery, Department of Surgery, Dentistry, Gynecology and Pediatrics University of Verona, GB Rossi Hospital, Verona, Italy).

Funding

For this study, T. Peter Kingham was partially supported by the US National Cancer Institute MSKCC Core Grant number P30 CA008747.

Author information

Author notes

  1. Roberto Montalti and Mariano Cesare Giglio shared first authorship on this work.

  2. Roberto I. Troisi and Brian K. P. Goh shared senior authorship on this work.

Authors and Affiliations

  1. Department of Clinical Medicine and Surgery, Division of HPB, Minimally Invasive and Robotic Surgery, Federico II University Hospital Naples, Naples, Italy

    Roberto Montalti MD, PhD, Mariano Cesare Giglio MD, PhD, FEBS & Roberto I. Troisi MSc, MD, PhD, FEBS

  2. Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital/National Cancer Centre Singapore and Ministry of Health Holdings, Singapore, Singapore

    Andrew G. R. Wu MBBS

  3. Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Milan, Italy

    Federica Cipriani MD, PhD & Luca Aldrighetti MD, PhD

  4. Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea

    Mizelle D’Silva MD & Ho-Seong Han MD, PhD

  5. Department of Surgery, Fondazione Poliambulanza, Brescia, Italy

    Amal Suhool MD

  6. Department of Hepatopancreatobiliary Surgery, University Medical Center, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam

    Phan Phuoc Nghia MD & Tran Cong Duy Long MD, PhD

  7. Department of Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan

    Yutaro Kato MD, PhD & Atsushi Sugioka MD, PhD

  8. Department of Digestive, HBP and Liver Transplantation, Hopital Pitie-Salpetriere, Sorbonne Universite, Paris, France

    Chetana Lim MD, PhD & Olivier Scatton MD, PhD

  9. Liver Surgery Unit, Department of Gastroenterology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil

    Paulo Herman MD, PhD & Fabricio Ferreira Coelho MD, PhD

  10. Department of Surgery, Campus Charité Mitte and Campus Virchow-Klinikum, Charité-Universitätsmedizin, Corporate Member of Freie Universität Berlin, and Berlin Institute of Health, Berlin, Germany

    Moritz Schmelzle MD & Johann Pratschke MD

  11. The Intervention Centre and Department of HPB Surgery, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway

    Davit L. Aghayan MD, PhD & Bjørn Edwin MD, PhD

  12. Faculty of Hepatopancreatobiliary Surgery, The First Medical Center of Chinese People’s Liberation Army (PLA) General Hospital, Beijing, China

    Qiu Liu MD & Rong Liu MD, PhD

  13. General Surgery Department, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, and Oncologic Surgery Department, P. Giaccone University Hospital, Palermo, Italy

    Marco V. Marino MD, PhD, FACS, FEBS

  14. Division of Hepatopancreatobiliary Surgical Oncology, Department of Abdominal Oncology, National Cancer Center - IRCCS-G, Pascale, Naples, Italy

    Andrea Belli MD

  15. Hepatopancreatobiliary Unit, Department of Surgery, Changi General Hospital, Singapore, Singapore

    Adrian K. H. Chiow MBBS, MMed, FRCS

  16. AdventHealth Tampa, Digestive Health Institute, Tampa, FL, USA

    Iswanto Sucandy MD, FACS

  17. Department of Abdominal and General Surgery, University Medical Center Maribor, Maribor, Slovenia

    Arpad Ivanecz MD, PhD

  18. HPB Surgery and Liver Transplant Unit, University of Modena and Reggio Emilia, Modena, Italy

    Fabrizio Di Benedetto MD, PhD, FACS

  19. Department of General Surgery, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea

    Sung Hoon Choi MD

  20. Department of Surgery, Division of Hepato-Biliary and Pancreatic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

    Jae Hoon Lee MD, PhD

  21. Department of Surgery, University of Washington Medical Center, Seattle, WA, USA

    James O. Park MD

  22. Hepatobiliary Surgery and Liver Transplantation Unit, Biocruces Bizkaia Health Research Institute, Cruces University Hospital, University of the Basque Country, Bilbao, Spain

    Mikel Prieto MD

  23. General and Digestive Surgery, Hospital Clinic, IDIBAPS, CIBERehd, University of Barcelona, Barcelona, Spain

    Yoelimar Guzman MD & Constantino Fondevila MD

  24. General and Digestive Surgery, Hospital Universitario La Paz, IdiPAZ, CIBERehd, Madrid, Spain

    Constantino Fondevila MD

  25. Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Moscow, Russia

    Mikhail Efanov MD, PhD

  26. HPB and Liver Transplant Unit, Department of General Surgery, Clinica Universidad de Navarra, Universidad de Navarra and Institute of Health Research of Navarra (IdisNA), Pamplona, Spain

    Fernando Rotellar MD, PhD

  27. Division of Hepatopancreatobiliary Surgery, Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea

    Gi-Hong Choi MD

  28. Department of General, Visceral and Transplantation Surgery, Clinic and University Hospital Virgen de la Arrixaca, IMIB-ARRIXACA, El Palmar, Murcia, Spain

    Ricardo Robles-Campos MD, PhD

  29. Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai, China

    Xiaoying Wang MD, PhD

  30. Department of Hepatopancreatobiliary and Liver Transplant Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK

    Robert P. Sutcliffe MD, FRCS

  31. Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Hong Kong, SAR, China

    Chung Ngai Tang MBBS, FRCS

  32. Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, New Territories, Hong Kong, SAR, China

    Charing C. Chong MBChB, MSc, FRCS

  33. Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium

    Mathieu D’Hondt MD, PhD

  34. General and Hepatobiliary Surgery, Department of Surgery, Dentistry, Gynecology and Pediatrics University of Verona, GB Rossi Hospital, Verona, Italy

    Bernardo Dalla Valle MD & Andrea Ruzzenente MD

  35. Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA

    T. Peter Kingham MD

  36. The Liver Institute, Methodist Dallas Medical Center, Dallas, TX, USA

    Alejandro Mejia MD, FACS

  37. Center for Advanced Treatment of Hepatobiliary and Pancreatic Diseases, Ageo Central General Hospital, Saitama, Japan

    Kohei Mishima MD & Go Wakabayashi MD, PhD

  38. Hepatobiliary and Pancreatic Surgery Unit, Department of Surgery, Dr. Josep Trueta Hospital, IdIBGi, Girona, Spain

    Santiago Lopez-Ben MD

  39. Department of Hepatobiliary Surgery, Assistance Publique Hopitaux de Paris, Centre Hepato-Biliaire, Paul-Brousse Hospital, Villejuif, France

    Franco Pascual MD & Daniel Cherqui MD, PhD

  40. Department of General and Oncological Surgery, Mauriziano Hospital, Turin, Italy

    Fabio Forchino MD & Alessandro Ferrero MD

  41. Division of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy

    Giuseppe Maria Ettorre MD & Giovanni Battista Levi Sandri MD, PhD

  42. Department of Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong, SAR, China

    Tan-To Cheung MS, MD, FRCS

  43. Department of Surgery, University Hospital Southampton, Southampton, UK

    Mohammad Abu Hilal MD, PhD

  44. Department of Surgery, Fondazione Poliambulanza, Brescia, Italy

    Mohammad Abu Hilal MD, PhD

  45. Department of Digestive, Oncologic and Metabolic Surgery, Institute Mutualiste Montsouris, Universite Paris Descartes, Paris, France

    David Fuks MD, PhD

  46. Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore, Singapore

    Brian K. P. Goh MBBS, MMed, FRCS

  47. Surgery Academic Clinical Programme, Duke National University Singapore Medical School, Singapore, Singapore

    Brian K. P. Goh MBBS, MMed, FRCS

Authors
  1. Roberto Montalti MD, PhD
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  2. Mariano Cesare Giglio MD, PhD, FEBS
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  3. Andrew G. R. Wu MBBS
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  4. Federica Cipriani MD, PhD
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  5. Mizelle D’Silva MD
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  6. Amal Suhool MD
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  7. Phan Phuoc Nghia MD
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  8. Yutaro Kato MD, PhD
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  9. Chetana Lim MD, PhD
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  10. Paulo Herman MD, PhD
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  11. Fabricio Ferreira Coelho MD, PhD
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  12. Moritz Schmelzle MD
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  13. Johann Pratschke MD
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  14. Davit L. Aghayan MD, PhD
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  15. Qiu Liu MD
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  16. Marco V. Marino MD, PhD, FACS, FEBS
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  17. Andrea Belli MD
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  18. Adrian K. H. Chiow MBBS, MMed, FRCS
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  19. Iswanto Sucandy MD, FACS
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  20. Arpad Ivanecz MD, PhD
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  21. Fabrizio Di Benedetto MD, PhD, FACS
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  22. Sung Hoon Choi MD
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  23. Jae Hoon Lee MD, PhD
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  24. James O. Park MD
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  25. Mikel Prieto MD
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  26. Yoelimar Guzman MD
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  27. Constantino Fondevila MD
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  28. Mikhail Efanov MD, PhD
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  29. Fernando Rotellar MD, PhD
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  30. Gi-Hong Choi MD
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  31. Ricardo Robles-Campos MD, PhD
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  32. Xiaoying Wang MD, PhD
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Consortia

International Robotic and Laparoscopic Liver Resection Study Group Investigators

  • Nicholas L. Syn
  • , Mikel Gastaca
  • , Juul Meurs
  • , Celine De Meyere
  • , Eric C. H. Lai
  • , Felix Krenzien
  • , Prashant Kadam
  • , Kit-Fai Lee
  • , Diana Salimgereeva
  • , Ruslan Alikhanov
  • , Lip-Seng Lee
  • , Jae Young Jang
  • , Kevin P. Labadie
  • , Masayuki Kojima
  • , Asmund Avdem Fretland
  • , Jacob Ghotbi
  • , Jaime Arthur Pirola Kruger
  • , Victor Lopez-Lopez
  • , Paolo Magistri
  • , Marco Colasanti
  • , Margarida Casellas I Robert
  • , Mansour Saleh
  •  & Edoardo Poletto

Contributions

All authors confirm they are accountable for all aspects of this work and report the following disclosures: BKPG has received travel grants and honorarium from Johnson and Johnson, Olympus and Transmedic, the local distributor for the Da Vinci Robot, outside the submitted work. MVM is a consultant for CAVA Robotics LLC. AAF reports receiving speaker fees from Bayer. JP reports a research grant from Intuitive Surgical Deutschland GmbH, and personal fees or non-financial support from Johnson & Johnson, Medtronic, AFS Medical, Astellas, CHG Meridian, Chiesi, Falk Foundation, La Fource Group, Merck, Neovii, NOGGO, pharma-consult Peterson, and Promedicis. FR reports speaker fees and support from Integra, Medtronic, Olympus, Corza, Sirtex and Johnson & Johnson, outside the submitted work. MS reports personal fees or other support from Merck, Bayer, ERBE, Amgen, Johnson & Johnson, Takeda, Olympus, Medtronic, and Intuitive, outside the submitted work. RIT reports speaker fees and support from Integra, Stryker, Medtronic, Medistim, and MSD, outside the submitted work. CF declares research fund from Guangdong Shunde Innovation Design Institute.

Corresponding authors

Correspondence to Roberto I. Troisi MSc, MD, PhD, FEBS or Brian K. P. Goh MBBS, MMed, FRCS.

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Montalti, R., Giglio, M.C., Wu, A.G.R. et al. Risk Factors and Outcomes of Open Conversion During Minimally Invasive Major Hepatectomies: An International Multicenter Study on 3880 Procedures Comparing the Laparoscopic and Robotic Approaches. Ann Surg Oncol 30, 4783–4796 (2023). https://doi.org/10.1245/s10434-023-13525-0

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