Recent advances in laparoscopic liver resection

Expansion of LLR indications

With the development of precision and minimally invasive liver surgery, along with continuous improvements in surgical instruments and operative technologies, the indications for LLR have progressively expanded. LLR is now increasingly applied to major hepatectomies involving technically demanding segments, as well as to complex procedures such as laparoscopic associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and laparoscopic living-donor hepatectomy, where it demonstrates pronounced minimally invasive advantages. Nevertheless, these expanded indications should be restricted to high-volume centers with substantial laparoscopic experience.

More comprehensive preoperative evaluation

Beyond conventional ultrasonography and computed tomography (CT), high-resolution CT–based three-dimensional visualization enables precise delineation of third-order and higher-order portal vein branches. This facilitates accurate mapping of tumor-bearing portal territories, identification of critical structures requiring preservation or transection, and assurance of adequate future liver remnant (FLR). Although the indocyanine green (ICG) retention rate at 15 min reflects global hepatic functional reserve, it does not offer a segment-specific functional assessment. Wang et al. reported that the uptake rate of hepatocyte-specific magnetic resonance imaging (MRI) contrast agents such as gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA) can be used to evaluate segmental liver function^[9]. When combined with volumetric assessment, this method allows preoperative prediction of functional FLR and the risk of postoperative liver failure^[9].

Advances in instruments and equipment

With continuous technological progress, the range of devices available for parenchymal transection and hemostasis in LLR has expanded considerably. In addition to conventional energy devices such as electrocautery and ultrasonic scalpel, specialized instruments such as the Cavitron Ultrasonic Surgical Aspirator (CUSA) and LigaSure Vessel Sealing System have become widely utilized. For hemostasis, in addition to monopolar and bipolar electrocautery, BiClamp and Aquamantys® system can also be employed. Sui et al. reported that the Aquamantys® system significantly reduced intraoperative blood loss (P = 0.005) and transfusion rates (P = 0.036), and provided improved local recurrence–free survival compared with conventional techniques (P = 0.011)^[10]. Surgeons should select transection and hemostatic tools based on device availability, institutional experience, and patient-specific factors such as the degree of cirrhosis. Recently, several manufacturers have introduced integrated 4K/3D/fluorescence laparoscopic imaging systems. These systems provide the high resolution and color fidelity of 4K imaging, the enhanced depth perception of 3D visualization, and real-time ICG fluorescence navigation. Their adoption is expected to further enhance the precision, safety, and overall efficiency of LLR.

Diversification of surgical approaches

Compared with open liver resection, LLR offers greater flexibility in approaches, allowing surgeons to operate via ventral, dorsal, cranial, or caudal routes. In addition to these classifications, surgical approaches can also be categorized into parenchyma-first and Glissonean approaches, depending on whether key structures such as the Glissonean pedicles are dissected before parenchymal transection. Surgeons may select the optimal approach based on the operative requirements, individual preference, and technical expertise, ensuring efficient and safe access to target anatomical structures. Importantly, laparoscopic in situ liver resection by anterior approach avoids excessive mobilization and rotation of the liver, thereby reducing the risk of tumor cell dissemination and aligning with the “no-touch” principle in oncologic surgery^[11]. In addition to the conventional transperitoneal approach, our group has innovatively explored retroperitoneal access and single-port transthoracic approaches for minimally invasive liver resection^[12,13]. These approaches provide safe and effective alternatives for lesions located in the right posterior sector or diaphragmatic dome, particularly in patients with anticipated severe intra-abdominal adhesions.

Multimodal intraoperative navigation

Because laparoscopy lacks direct tactile feedback, intraoperative ultrasonography is indispensable for comprehensive hepatic assessment, lesion localization, and real-time adjustment of the transection plane. Moreover, intraoperative ICG fluorescence imaging facilitates tumor identification, detection of small or occult lesions, guidance of the transection plane, and evaluation for postoperative bile leakage^[14]. Furthermore, based on preoperative three-dimensional visualization and portal territory analysis, augmented-reality (AR) navigation allows superimposition of three-dimensional anatomical models onto the laparoscopic image, displaying transparent virtual representations of lesions, inflow/outflow territories, and critical vascular structures. Oh et al. demonstrated that the AR system achieved a mean registration time of 2.4 ± 1.7 min and an overall average accuracy of 93.8% ± 4.9%^[15]. Current evidence also indicates that AR can enhance the efficiency and safety of hepatic resections, and may also contribute to improved oncological outcomes and reduced surgical risk^[16]. However, soft-tissue mobility and deformation of the liver remain major challenges for maintaining accurate registration^[17,18]. To address these challenges, Une et al. have developed deep learning–based models capable of rapidly detecting hepatic vascular structures, thereby enabling high-precision, real-time navigation during LLR^[19]. Collectively, while intraoperative ultrasonography, three-dimensional visualization, and ICG fluorescence have become indispensable components of contemporary LLR, AR- and artificial intelligence (AI)-assisted navigation remain promising but technically immature, with unresolved challenges related to registration accuracy and liver deformation.

Laparoscopic vascular reconstruction

With the expanding indications for LLR, vascular reconstruction has been increasingly applied in minimally invasive liver surgery. Vascular reconstruction should be considered when unexpected intraoperative vascular injuries cannot be controlled by coagulation, when tumors involve major vascular structures, or when venous outflow reconstruction is required^[20,21]. Primary repair or end-to-end anastomosis should be the first choice. When direct reconstruction is not feasible, patch angioplasty or the use of artificial grafts may be necessary. From a practical standpoint, these procedures should be attempted only by surgeons with advanced laparoscopic expertise and adequate experience in open vascular reconstruction. Importantly, the selection of the reconstruction strategy should be individualized according to patient-specific conditions. Given the superior depth perception and spatial visualization afforded by stereoscopic imaging, three-dimensional laparoscopy is considered a preferable platform for complex intracorporeal suturing and vascular reconstruction.

Robot-assisted liver resection

Since the first robot-assisted liver resection (RLR) was reported in 2003, robotic surgical systems have gained increasing adoption owing to their articulated and stable robotic arms, natural three-dimensional visualization, and the advantage of a steady third arm that enhances traction and exposure. Collectively, these features enhance operative stability, precision, and safety during liver resection. Multiple studies have demonstrated that robot-assisted liver resection (RLR) achieves comparable outcomes to conventional LLR, with potential advantages including reduced intraoperative blood loss and lower conversion rates to open surgery^[22-24]. However, a balanced comparison must also acknowledge the well-established advantages of LLR. As a mature minimally invasive technique, LLR offers lower overall medical costs, broader accessibility across general medical centers, and a well-established global training and dissemination framework. In contrast, RLR remains associated with substantially higher costs, and high-quality randomized controlled trials with long-term oncological outcomes are still lacking. Consequently, the widespread adoption of RLR remains limited. Nevertheless, should these limitations be adequately addressed, RLR holds considerable promise for future development. In parallel with efforts to generate robust clinical evidence and reduce costs, technological innovations are also being introduced to overcome intrinsic limitations of robotic systems. To address the inherent lack of haptic feedback in robotic systems, Xue et al. recently developed an intelligent suture termed “sliputure”, in which the sliding knot releases automatically once a preset tension threshold is reached, thereby offering a surrogate form of tactile feedback^[25].

Laparoscopic radical resection for hilar cholangiocarcinoma

In recent years, advances in laparoscopic techniques and instruments have enabled the gradual implementation of laparoscopic radical resection for hilar cholangiocarcinoma (HCCA) in selected high-volume centers^[26]. With continued investigation and accumulated operative experience, the safety and feasibility of this approach have been further validated; however, high-quality evidence regarding its long-term oncological outcomes remains lacking. In clinical practice, careful attention must be paid to patient selection, including precise preoperative assessment of the relationship between the tumor, biliary confluence, and major vascular structures. Surgeons should progress in a stepwise manner from less complex to more challenging cases while strictly adhering to the oncologic principles and technical standards established for open surgery. Real-world studies have demonstrated that laparoscopic surgery achieves both short-term outcomes and long-term survival comparable to those of open surgery, and may be applied across all Bismuth–Corlette classifications of HCCA^[27]. We believe that laparoscopic radical resection for HCCA will become more precise and truly minimally invasive. This will be driven by the increasing dissemination of laparoscopic and robot-assisted surgery, the integration of multimodal intraoperative navigation, improved capabilities in vascular resection and reconstruction, and ongoing advances in systemic therapy. Meanwhile, as surgical volume accumulates and technical refinement continues, the long-term oncological outcomes of this approach still require validation through large-scale, multicenter comparative studies.

Future progress is likely to be characterized by three key directions: (1) function-guided hepatectomy based on quantitative assessment of segmental liver function rather than solely anatomical demarcation; (2) real-time adaptive navigation integrating AI, deformable organ modeling, and automated vascular recognition; and (3) increased procedural standardization supported by structured training pathways, and objective benchmarking of outcomes. Collectively, the convergence of high-resolution imaging, computational modeling, and intelligent surgical systems may support a progressive transition toward more data-informed and technology-assisted liver resection strategies, with the potential to improve oncological precision while preserving functional liver parenchyma.

Laparoscopic anatomic liver resection based on portal territory

Compared with classical anatomic liver resection, laparoscopic anatomic liver resection based on portal territory emphasizes resection along the tumor-bearing portal territory rather than traditional segmental boundaries^[28]. This approach involves prioritizing dissection at the root of the Glissonean pedicle, using intraoperative ICG fluorescence to delineate the tumor-bearing portal territory, and identifying key interterritorial veins to guide precise parenchymal transection^[29]. Emerging evidence suggests that this territory-oriented approach may enhance oncological radicality by ensuring complete clearance of potential portal venous tumor spread while preserving maximal functional liver parenchyma. However, it remains technically demanding, particularly in the laparoscopic setting, where precise hilar dissection and complex vascular exposure require advanced expertise. Standardization of procedural steps, objective assessment of learning curves, and validation through high-quality comparative studies are still needed before widespread implementation can be recommended. Looking forward, the integration of three-dimensional reconstruction, augmented reality-assisted navigation, and fluorescence-guided imaging is expected to further refine portal territory-guided resection. With continued technological evolution and accumulation of robust clinical data, this approach may represent an important step toward precision liver surgery.

Laparoscopic limited anatomic hepatectomy

Ho et al. first introduced the concept of laparoscopic limited anatomic hepatectomy (LLAH) for the treatment of hepatocellular carcinoma^[30]. The core principle of LLAH is to preserve maximal functional liver parenchyma while still achieving anatomic resection, thereby improving surgical safety^[30]. Theoretically, this approach offers dual advantages in both perioperative outcomes and oncologic control. Berardi et al. reported that with precise preoperative planning and standardized operative techniques, LLAH yields blood loss comparable to that of lobectomy or segmentectomy, without significant differences in R0 resection rates or margin width^[31]. Nevertheless, high-quality prospective studies remain necessary to determine its perioperative benefits and long-term oncologic outcomes.

We believe that both surgical concepts warrant further development and thoughtful dissemination, as they represent highly refined techniques that merit inclusion in the surgical armamentarium. Nevertheless, the operative approach for each individual patient should ultimately be guided by surgeon expertise and patient safety. Innovation and technical advancement must not compromise patient benefit. Accordingly, these techniques should be applied judiciously and selectively, grounded in sound clinical judgment rather than an indiscriminate pursuit of technical novelty, and their application should be based on rational appraisal and evidence-informed selection rather than generalized assumptions.