Implementation and short-term outcomes of minimally invasive liver surgery in France

Laparoscopic surgery has been well documented for most digestive procedures and has become the standard of care for many procedures. However, laparoscopic liver surgery was implemented slowly1,2. Reasons include difficulties of liver surgery and long learning curves, but also initial concerns regarding oncological inferiority1,3. Nevertheless, minimally invasive liver surgery has gained higher acceptance during recent years. According to the Southampton consensus guidelines, laparoscopy is now the standard for minor liver resections4. Several retrospective studies, reviews, and some recent RCTs have already documented short-term advantages of laparoscopic liver resection (LLR) compared with open liver resection (OLR), including advantages with regard to postoperative morbidity, intraoperative blood loss, and length of stay1,5–7. RCTs are often criticized for their limited generalizability to real-world populations because of selection bias and rigid inclusion criteria. Indeed, literature-derived mortality rates have been reported to be one and a half to two times lower than reported population-based perioperative mortality rates8. Reasons seem to be diverse and are most probably related to reporting biases (positive outcomes more likely to be published compared with negative outcomes) and results being derived most frequently from specialized (academic and high-volume) hospitals8,9. As such, there is little evidence of the benefits of LLR outside expert centres. In France, more than half (59%) of LLR procedures are performed in low-volume (1–10 resections/year) and middle-volume (11–50 resections/year) hospitals and nearly two-thirds (62%) are performed outside academic centres2,10. Estimation of the benefit of LLR with regard to mortality and morbidity at a population-based level has important implications in the coordination of healthcare at a national level and establishing centre regulations (still absent for LLR in France) to perform high-risk surgery11. The Dutch Liver Collaborative Group has recently reported their nationwide laparoscopic and robotic liver resection outcomes in the Netherlands, where complex surgery is centralized, although no comparison with open resections was made12,13.