Meta-analysis of short-term and long-term outcomes of laparoscopic vs open hepatectomy for hepatocellular carcinoma

BACKGROUNDHepatocellular carcinoma (HCC) represents the most prevalent liver malignancy, resulting in about 75%-85% of all primary liver cancers worldwide, with an estimated 906000 new cases and 830000 deaths per year.For patients with resectable HCC, surgical resection continues to be the first-line treatment.In the last 20 years, laparoscopic hepatectomy (LH) became a possible alternative to open hepatectomy (OH), but LH has not gained universal acceptance due to concerns around safety and efficacy and some authors have cited improvements in outcomes with LH including less blood loss, shorter hospital stay and faster postoperative recovery.Nevertheless, it is still an open question whether LH provides equivalent or even better long-term oncological outcomes in terms of overall survival (OS) and progression-free survival (PFS). AIMTo systematically evaluate and quantitatively synthesize all evidence from randomized controlled trials (RCTs) published through March 2026 comparing the short-and longterm outcomes of laparoscopic vs OH for HCC with respect to postoperative complications, 3-month recurrence, 5-year OS, and PFS. METHODSA systematic review was performed in accordance with the PRISMA guidelines.Detailed searches were conducted in PubMed, EMBASE, and the Cochrane Library until March 2026.Ultimately, only RCTs comparing laparoscopic vs OH in patients with histologically confirmed HCC were included.The primary outcomes were complication rate and recurrence at 1 month postoperatively, and 3-months post resection, respectively.The secondary outcomes were 5-year OS and PFS.Data were analysed 3 / 34 using RevMan 5.3 software with random-effects models for meta-analysis.We used the I 2 statistic and Cochran's Q tests to evaluate heterogeneity.Funnel plot analysis was employed to assess for publication bias. RESULTSA total of ten RCTs were included involving 587 patients (laparoscopic: 239; open: 348).In the meta-analysis, LH showed a lower postoperative complication rate at 1 month than OH [odds ratio (OR) = 0.52, 95% confidence interval (95%CI): 0.38-0.71,P < 0.01; I 2 = 31.4%].There was no significant difference on 3-month recurrence rates between the two groups (OR = 0.84, 95%CI: 0.66-1.07,P = 0.15; I 2 = 25.8%).However, the laparoscopic group had significantly lower 5-year OS than the OH group [hazard ratios (HR) = 1.34; 95%CI: 1.10-1.63;P < 0.01; I 2 = 44.7%].The difference in PFS between groups achieved borderline statistical significance (HR = 1.28, 95%CI: 1.01-1.63,P = 0.04; I 2 = 38.2%).Funnel plot analysis was suggestive of possible publication bias for short-term outcomes.CONCLUSION LH presents sizeable short-term benefits and is supplemented by a lower postoperative complication rate; nevertheless, this meta-analysis of RCTs shows the more invasive laparoscopic approach may be justified next to prolonged long-term oncological results with respect to 5-year OS compared to OH in HCC patients.These results highlight the importance of careful selection of patients, rigorous quality control and long-term follow-up in prospective trials to establish which surgical procedure is best for HCC treatment.