Optimisation of patient outcomes in the era of minimally invasive liver resections

Surgical resection is the only cure for primary, and secondary, neoplasms of the liver. A minimally invasive approach to liver resections improves post-operative outcomes and as a result the uptake of laparoscopic liver surgery is increasing worldwide. However, concerns persist regarding variations in practice, conversion rates and the protracted learning curve that are associated with worse patient outcomes. The absence of clinical guidelines, a limited comprehension of the risk factors for conversion and the lack of a pre-operative risk stratification tool to enable informed case selection hamper the safe expansion of laparoscopic liver surgery. To address the variations in clinical practice we created The Southampton Consensus Guidelines the first evidence-based, expert validated guidelines for laparoscopic liver surgery. Following this we defined the risk factors for conversion using the largest, international, multi-centre cohort of patients undergoing laparoscopic liver resections. This demonstrated that both patient and surgical factors affect the risk of conversion and highlighted that the timing of conversion had a significant impact on post-operative outcomes. In order to predict the complexity of a resection, and allow case selection based upon surgeon experience, we developed and validated The Southampton Laparoscopic Liver Difficulty Score. Finally, we demonstrated that specific training in the form of laparoscopic liver fellowships significantly reduces the learning curve for surgeons that in turn improves outcomes in those undergoing minimally invasive liver resections. In conclusion, contemporary clinical guidelines used in conjunction with specific training, informed case selection and a low threshold for conversion should result in improved patient outcomes in those undergoing laparoscopic liver resections.