title: Laparoscopic vs open approach to resection of hepatocellular carcinoma in patients with known cirrhosis: systematic review and meta-analysis.
abstract: OBJECTIVE
  To review the currently available literature comparing laparoscopic to open resection of hepatocellular carcinoma (HCC) in patients with known liver cirrhosis.
  
  
  METHODS
  A literature search of MEDLINE, EMBASE, and Cochrane databases was conducted. The search terms used included (laparoscopic OR laparoscopy) AND (hepatic or liver) AND (surgery or resection) AND "hepatocellular carcinoma" AND (cirrhosis or cirrhotic). Furthermore, to widen the search, we also used the "related articles" section. Studies reporting a comparison of outcomes and methods of open vs laparoscopic hepatic resection for HCC in patients with liver cirrhosis were included. Meta-analysis of results was performed using a random effects model to compute relative risk (RR) and for dichotomous variables and standard mean differences (SMD) for continuous variables.
  
  
  RESULTS
  A total of 420 patients from 4 cohort studies were included in final analysis. Patients undergoing laparoscopic procedures had statistically less blood loss compared to the open cohort, SMD of -1.01 (95%CI: -1.23-0.79), P < 0.001, with a reduced risk of transfusion, RR = 0.19 (95%CI: 0.09-0.38), P < 0.001. A wider clearance at tumour resection margins was achieved following a laparoscopic approach, SMD of 0.34 (95%CI: 0.08-0.60), P = 0.011. No significant difference was noted between laparoscopic and open resection operative times, SMD of -0.15 (95%CI: 0.35-0.05), P = 0.142. The overall RR of suffering from postoperative morbidity is 0.25 in favour of the open surgery cohort (95%CI: 0.17-0.37), P < 0.001. Patients under-going laparoscopic surgery had significantly shorter length of stays in hospital compared to the open cohort, SMD of -0.53 (95%CI: -0.73 to -0.32), P < 0.001.
  
  
  CONCLUSIONS
  This review suggests that laparoscopic resection of hepatocellular carcinoma in patients with cirrhosis is safe and may provide improved patient outcomes when compared to the open technique.
authors.affiliation: Ahmed Twaij, Philip H Pucher, Mikael H Sodergren, Ara Darzi, Department of Surgery and Cancer, QEQM Building, St Mary's Hospital, Imperial College, London W2 1NY, United Kingdom.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Twaij
authors.affiliation: Ahmed Twaij, Philip H Pucher, Mikael H Sodergren, Ara Darzi, Department of Surgery and Cancer, QEQM Building, St Mary's Hospital, Imperial College, London W2 1NY, United Kingdom.
authors.forename: Philip H
authors.initials: PH
authors.lastname: Pucher
authors.affiliation: Ahmed Twaij, Philip H Pucher, Mikael H Sodergren, Ara Darzi, Department of Surgery and Cancer, QEQM Building, St Mary's Hospital, Imperial College, London W2 1NY, United Kingdom.
authors.forename: Mikael H
authors.initials: MH
authors.lastname: Sodergren
authors.affiliation: Ahmed Twaij, Philip H Pucher, Mikael H Sodergren, Ara Darzi, Department of Surgery and Cancer, QEQM Building, St Mary's Hospital, Imperial College, London W2 1NY, United Kingdom.
authors.forename: Tamara
authors.initials: T
authors.lastname: Gall
authors.affiliation: Ahmed Twaij, Philip H Pucher, Mikael H Sodergren, Ara Darzi, Department of Surgery and Cancer, QEQM Building, St Mary's Hospital, Imperial College, London W2 1NY, United Kingdom.
authors.forename: Ara
authors.initials: A
authors.lastname: Darzi
authors.affiliation: Ahmed Twaij, Philip H Pucher, Mikael H Sodergren, Ara Darzi, Department of Surgery and Cancer, QEQM Building, St Mary's Hospital, Imperial College, London W2 1NY, United Kingdom.
authors.forename: Long R
authors.initials: LR
authors.lastname: Jiao
mesh_terms: D016063:Blood Loss, Surgical / Q000517:prevention & control; D001803:Blood Transfusion; D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D006498:Hepatectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D006801:Humans; D010535:Laparoscopy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D007902:Length of Stay; D008103:Liver Cirrhosis / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008113:Liver Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D018365:Neoplasm, Residual; D016017:Odds Ratio; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: Cirrhosis; Hepatic resection; Hepatobiliary; Hepatocellular carcinoma; Laparoscopic; Surgery; Surgical oncology