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Published on: May 23, 2025
Current difficulty scoring systems may underestimate the technical complexity of segment 6 laparoscopic hepatectomy
Yi-Hsuan Lee1, Hsiu-Hsien Lin1, Tsai-Ling Kuo1,2
1Division of General Surgery, Department of Surgery, Hualien Tzu Chi Hospital,, Buddhist Tzu Chi Medical Foundation, 707, Section 3, Chung-Yang Road, Hualien, Taiwan.
Insights
Laparoscopic hepatectomy for Hepatocellular carcinoma (HCC) in segment 6 (S6) is more complex than current scoring systems suggest. This study found S6 resections had longer operative times and hospital stays, indicating a need for revised difficulty assessments.
Area of Science:
- Hepatobiliary surgery
- Minimally invasive surgery
- Surgical oncology
Background:
- Laparoscopic hepatectomy is a standard treatment for Hepatocellular carcinoma (HCC).
- Segment 6 (S6) is considered a favorable location, but its deep transection plane and proximity to major vessels can increase surgical difficulty.
- Existing scoring systems may not accurately reflect the technical challenges of S6 resections.
Purpose of the Study:
- To reassess the technical complexity of laparoscopic hepatectomy for Hepatocellular carcinoma (HCC) in segment 6 (S6).
- To compare perioperative outcomes and established scoring systems for S6 resections against favorable (FL) and unfavorable (UFL) locations.
- To evaluate the accuracy of current anatomical classifications and difficulty scoring systems for S6 HCC resections.
Main Methods:
- Retrospective analysis of 153 patients undergoing laparoscopic hepatectomy for primary HCC.
- Comparison of S6, FL, and UFL groups using IWATE, Hasegawa, IMM, and SHH scoring systems.
- Univariable and multivariable analyses to assess perioperative outcomes and complication rates.
Main Results:
- Segment 6 (S6) HCC resections showed longer operative times (246 min), prolonged Pringle times (78 min), greater blood loss (300 mL), and longer hospital stays (6 days) compared to FL and UFL groups.
- Despite longer operative parameters, S6 resections had comparable major complication rates (3.1%) to UFL (4.4%) and FL (0%).
- Current scoring systems (IWATE, Hasegawa, IMM, SHH) classified S6 as low-to-intermediate difficulty, underestimating its actual operative complexity.
Conclusions:
- Laparoscopic hepatectomy for HCC in segment 6 (S6) presents greater operative complexity than predicted by current difficulty scoring systems.
- Existing anatomical classifications may oversimplify segment-specific surgical challenges.
- There is a need for more precise difficulty assessment models for S6 resections to better reflect surgical demands.
Introduction:
Laparoscopic hepatectomy is a standard treatment for selected Hepatocellular carcinoma (HCC) patients. Although segment 6 (S6) is generally classified as a favorable location, its deep transection plane, restricted working angle, and proximity to major vessels may increase operative difficulty. This study reassesses the technical complexity of S6 by comparing perioperative outcomes and established scoring systems across liver segments.
Methods:
We retrospectively analyzed patients undergoing laparoscopic hepatectomy for primary HCC and compared S6, favorable location (FL), and unfavorable location (UFL) groups using the IWATE, Hasegawa, IMM, and SHH scoring systems. Univariable and multivariable analyses were performed to strengthen the robustness of our findings.
Results:
Among 153 patients undergoing laparoscopic hepatectomy for HCC, 32 were in the S6 group, 68 in the UFL group, and 53 in the FL group. S6 was consistently classified as low-to-intermediate difficulty with IWATE scores 6 vs. 9 vs. 6, Hasegawa 3 vs. 4 vs. 1, IMM 2 vs. 2 vs. 1, and SHH 4 vs. 6 vs. 4 (S6 vs. UFL vs. FL). However, S6 showed longer operative time (246 vs. 198 vs. 171 min, p = 0.005), prolonged Pringle time (78 vs. 62 vs. 46 min, p = 0.036), greater blood loss (300 vs. 200 vs. 150 mL, p = 0.011), longer hospital stay (6 vs. 7 vs. 6 days, p = 0.022), and comparable major complication rates (3.1% vs. 4.4% vs. 0%, p = 0.314). These findings suggest that current scoring systems may underestimate the true technical complexity of S6 resections.
Conclusions:
Although S6 has conventionally been considered a favorable anterolateral segment, laparoscopic hepatectomy for HCC in this location demonstrated greater operative complexity than predicted by existing difficulty scoring systems. These results suggest that current anatomical classifications may oversimplify segment-specific challenges and support the need for more precise difficulty assessment models that better reflect actual surgical demands.
