Related Experiment Video
Updated: Mar 29, 2026
Application of the En Bloc Concept Combined with Anatomic Resection in Laparoscopic Hepatectomy
Published on: March 10, 2023
Study-International Multicentric Minimally Invasive Liver Resection (SIMMILR-5): A Comparison of Open, Conventional
Andrew A Gumbs1,2,3, Roland Croner2, David Fuks4
1Hôpital Antoine Béclère, Assistance Publique-Hôpitaux de Paris, 157 Rue de la Porte de Trivaux, 92140 Clamart, France.
Background:
The role of minimally invasive surgery (MIS) for hepatocellular carcinoma (HCC) remains controversial because of concerns regarding oncologic adequacy, particularly margin status. While robotic-assisted hepatectomy has gained adoption, its true perioperative advantages over conventional laparoscopy and open surgery remain unclear. SIMMILR-5 was designed to evaluate the short-term outcomes of open, laparoscopic, and tele-robotic laparoscopic hepatectomy for HCC using rigorous adjustment for confounding.
Methods:
A retrospective international multicenter study was conducted including patients undergoing liver resection for HCC between June 2004 and November 2024 at five high-volume hepatobiliary centers. Surgical approaches included open (O), conventional laparoscopy (L), and tele-robotic laparoscopy (TRL). Propensity score matching was performed using demographic, clinical, and tumor-related variables. The primary endpoint was short-term mortality (30 and 90 days). Secondary outcomes included estimated blood loss (EBL), operative time, length of stay (LOS), R0 resection status, and major complications.
Results:
A total of 904 patients were identified (302 O, 568 L, 34 TRL). After matching, conventional laparoscopy was associated with significantly lower EBL, shorter operative time, and shorter LOS compared with open surgery (all p < 0.00001). Compared with open surgery, TRL was associated with lower EBL but no improvement in operative time or LOS. Compared with laparoscopy, TRL was associated with longer operative time and longer LOS. Short-term oncologic surrogates were comparable across approaches.
Conclusions:
Minimally invasive hepatectomy offers perioperative advantages over open surgery for selected patients with HCC, driven primarily by conventional laparoscopy. Tele-robotic hepatectomy is feasible and safe in experienced centers but does not demonstrate superiority over advanced laparoscopic techniques.
