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Objective: Hepatic surgery was once relegated solely to an open operative approach. Technical advances have made minimally invasive hepatic resection and ablation feasible. This study reviews our experience with over 500 minimally invasive hepatic procedures.
Methods: The indications, demographics and outcomes of these procedures were examined. This included analysis of peri-operative mortality and cancer recurrence with minimally invasive radiofrequency ablation (RFA) and hepatic resection (HR).
Results: 519 minimally invasive hepatic procedures were performed in 472 patients; 173 (36.6%) of these were cirrhotics. ( 207 hepatocellular, 41 non-colorectal, 36 colorectal and 12 cholangiocarcinomas, 153 benign tumours and 23 others). 35 patients underwent laparoscopic intra-operative ultrasound and confirmatory biopsy alone; 195 patients underwent laparoscopically-assisted RFA, and 242 patients underwent 289 minimally invasive resections. 69 in the resection group underwent major hepatectomy while the remaining 173 underwent single or multiple segmental resections. The complication (p=0.03) and mortality (p=0.001) rates were higher in cirrhotic patients in the HR group. Local recurrence rates were higher in the RFA group compared to the HR group (p=0.054) approaching statistical significance.

	Intra-op US	RFA	HR
# of patients	35	195	242
# of procedures	35	195	289
# of Cirrhotic patients Child’s A or B	0	120	28
Conversions to open operation	0	4 (2.17%)	6 (2.5%)
Complications (total)	2 (6%)	23 (12%)	36 (14%)
Complications (in cirrhotics)	N/A	18 (15%) (p = NS, compared to RFA in non-cirrhotics)	8 (29%) (p = 0.03, compared to HR in non-cirrhotics)
Mortality (total)	0	2 (1.0%)	4 (1.7%)
Mortality (in cirrhotics)	N/A	2 (1.7%) (p = NS, compared to RFA in non-cirrhotics)	3 (10.7%) (p = 0.001, compared to HR in non-cirrhotics)
Recurrence (total)	0	57 (29%)	16 (1.3%)
Recurrence (local)	N/A	14 (7.2%) (p=0.054 compared to HR)	2 (1.9%)

Conclusions: Minimally invasive hepatic surgery has become a viable alternative to open hepatic surgery. These data are equivalent to those encountered in any large open series. Minimally invasive hepatic resections are associated with significantly higher mortality and complication rates in cirrhotics. Local recurrence rates may be higher with RFA compared to resections,.

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