In this study, we retrospectively reviewed cases of LCH and OCH performed in our department to assess the safety and efficacy of laparoscopic surgery. Compared to the OCH group, the LCH group showed significantly less blood loss, lower transfusion rate, and no difference in operative time. Among postoperative complications, the rate of bile leakage was 33% in the LCH group and 42% in the OCH group, but the difference was not significant. The incidences of ascites and SSI were significantly lower in the LCH group, and postoperative hospital stay was significantly shorter in the LCH group. Univariate and multivariate analysis of risk factors for bile leakage after CH showed tumor proximity of < 1 cm to the right anterior Glissonean pedicle to be the significant risk factor.
Other previous studies have reported the outcomes of LCH compared to OCH [15–17]. Among the short-term surgical outcomes, there was no difference in blood loss and the incidence of postoperative complications between the LCH and OCH groups, whereas the LCH group had a longer operative time and shorter postoperative hospital stay [15–17]. Cho et al. reported an overall postoperative morbidity rate of 30% and a bile leakage rate of 15% in their LCH group [15]. In our study as well, the LCH group experienced less blood loss, lower incidences of ascites and SSI, and a shorter postoperative hospital stay, consistent with these previous reports. However, the incidence of postoperative bile leakage in our patients was higher than that previously reported, so we investigated the risk factors for bile leakage. To our knowledge, there have been no reports investigating the causes of bile leakage in LCH, making the present findings novel in this respect.
In general, LLR is reported to be associated with fewer complications compared to open hepatectomy, but the incidence of bile leakage has been reported to be comparable when limited to CH [7, 8, 15, 21]. CH is considered to be a surgical procedure with a high incidence of bile leakage [9–11]. Nanashima et al. reported an incidence rate of bile leakage of 37% [10], whereas Ueno et al. reported a rate of 44.8% [22]. Several reports have examined the risk factors for bile leakage in CH [9, 10, 22]. Ueno et al. examined the biliary complications in CH and reported that the tumor proximity to the right anterior Glissonean pedicle and a longer right hepatic duct were risk factors for biliary complications [22]. In our study as well, proximity of the tumor to the right anterior Glissonean pedicle was found to be the risk factor for bile leakage. This factor could be the potential cause for stenosis of the right posterior bile duct (RPBD) branch. Yoon et al. investigated the factors contributing to the occurrence of the RPBD stenosis in CH [23]. Approximately 80% of the RPBD is located supraportally distal to the bifurcation of the anterior and posterior Glissonean sheaths. When the anterior Glissonean sheath is ligated, injuries such as stricture and ischemic insult of the RPBD could occur. They reported that handling the Glissonean pedicle close to the right anterior Glissonean pedicle root could lead to stenosis of the RPBD. This stenosis increases the intraductal pressure in the RPBD, potentially causing bile leakage from the liver dissection plane. Additionally, in cases in which the tumor is closer to the hepatic hilum, there is a higher possibility of incising the caudate lobe and damaging its bile ducts. This is consistent with the findings of Nanashima et al., who reported that segment 1 resection and inferior vena cava compression were risk factors for bile leakage with CBS [10]. These may be the reasons why a tumor close to the root of the right anterior Glissonean pedicle were detected as risk factors for bile leakage.
The present study has several limitations. First, this is a single-center study with a small number of cases. Second, the operator was different in each case although the surgical team included expert board-certified surgeons. Third, long-term prognoses were not comparable because of the variety of diseases in the patients included in this study.