Short-term Outcomes of "Difficult" Laparoscopic Liver Resection at Specialized Centers Report From INSTALL (International Survey on Technical Aspects of Laparoscopic Liver Resection)-2 on 4478 Patients

Objective: To define the current status of "difficult" LLR, a global database was created and investigated. Background: In the Second International Consensus Conference in 2014, minor LLR was considered as a standard practice and major LLR remained an innovative procedure. Since then, no updates on worldwide trends have been available. Methods: A questionnaire on all consecutive patients who underwent difficult LLR (major hepatectomy, posterosuperior segmentectomy, sectionec-tomy, living donor hepatectomy, tumor size >= 10 cm, Child-Pugh grade >= B, combined with biliary reconstruction, and Iwate criteria difficulty score >= 7) in 2014-2018 was distributed via email to 65 high-volume LLR centers worldwide. individual data on patient and tumor demographics, surgical information, and short-term outcomes were obtained to create a large-scale international registry for analyses. Results: Overall, 58 centers in 19 countries performed 4478 difficult LLR (median, 58.5; range, 5-418) during the study period. Hepatocellular carcinoma accounted for >= 40% of all indications. Half of the patients underwent major hepatectomy, followed by sectionectomy, posterosuperior segmentectomy, and living donor hepatectomy. in the vast majority of procedures, Clavien-Dindo grade >= IIIa complication rates of approximate to 10% and 90-day mortality rates of approximate to 1% were achieved. Left or right trisectionectomy had the worst Clavien-Dindo grade >= IIIa complication rate of >= 10% and 90-day mortality rate of 5%-10%. No significant correlation was observed between center volume and short-term outcomes. Conclusions: Total 4478 patients underwent difficult LLR worldwide in 2014-2018. Most procedures are safe and feasible when conducted in specialized centers.