Minimally invasive versus open liver resection for hepatocellular carcinoma in older adults: A systematic review and meta-analysis

Backgrounds/Aims: As the population ages, an increasing number of older adults are diagnosed with resectable hepatocellular carcinoma (HCC). Although minimally invasive liver resection (MILR) has shown perioperative advantages, its safety and efficacy in older patients are not fully established. This meta-analysis evaluated the outcomes of MILR compared to open liver resection (OLR) in older adults (≥ 65 years) with HCC. Methods: A search was conducted in Medline, Embase, CINAHL, and The Cochrane Library from their inception until November 20, 2025. The review adhered to PRISMA guidelines and was prospectively registered on PROSPERO (CRD420251239665). Results: Fourteen retrospective studies comprising 3,092 older adults were included (1,367 MILR, 1,725 OLR). MILR was associated with lower overall (odds ratio [OR] = 0.47; 95% confidence interval [CI] 0.38-0.58; I² = 0%) and major complications (OR = 0.61; 95% CI 0.45-0.83; I² = 15%). However, no statistically significant difference was detected in 90-day mortality (OR = 0.75; 95% CI 0.41-1.38; I² = 0%), disease-free survival (hazard ratio [HR] = 0.83; 95% CI 0.60-1.15; I² = 72%), or overall survival (HR = 0.80; 95% CI 0.56-1.16; I² = 80%). Conclusions: In selected older adults with HCC, MILR was associated with fewer perioperative complications than OLR, while no statistically significant difference was detected in 90-day mortality or long-term survival. Residual confounding, predominance of minor resections, absence of validated frailty assessment, and limited octogenarian data preclude causal inference or confirmation that the association persists with advancing age.