Expanding indications and regional diversity in laparoscopic liver resection unveiled by the International Survey on Technical Aspects of Laparoscopic Liver Resection (INSTALL) study.
Laparoscopic liver resection (LLR) has undergone widespread dissemination after the first international consensus conference in 2008, and specialized centers continue to report remarkable achievements. However, little is known about the global adoption of LLR. This study aimed to illuminate geographical variances in the indications and technical aspects of LLR and to delineate the evolution of this approach worldwide.



In advance of the Second International Consensus Conference in Morioka, Japan, a web-based, anonymous questionnaire comprising 46 questions, named the International Survey on Technical Aspects of Laparoscopic Liver Resection study, was sent via e-mail to the members of regional and International Hepato-Pancreato-Biliary Association offices. The results of the 13 questions concerning the global diffusion of LLR have been reported previously. Responses to the remaining 33 questions that corresponded to indications and surgical techniques used in LLR were collected and analyzed.



Survey responses were received from 412 LLR surgeons in 42 countries on five continents. The majority of surgeons in North America had no restrictions on the maximum size or number of tumors to be resected laparoscopically. Likewise, >50 % of surgeons in East Asia and North America performed LLR for the postero-superior 'difficult' segments. Major resection was performed in 40 to >60 % of centers in North America, Europe, and East Asia. Donor hepatectomy was performed only in specialized centers. More than 75 % of respondents had adopted a pure laparoscopic approach. A flexible laparoscope was most commonly used in East Asia. Most surgeons used pneumoperitoneal pressure at around 9-16 mmHg. Other techniques and devices were used at the discretion of each surgeon.



Indications for LLR continue to expand with some regional diversity. Surgical approaches and devices used in LLR are a matter of preference and availability, as in open liver resection.
Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan. taizohibi@keio.jp.
Taizo
T
Hibi
Hepatobiliary Center, Paul Brousse Hospital, Paris, France.
Daniel
D
Cherqui
University of Pittsburgh Medical Center, Liver Cancer Center, Pittsburgh, PA, USA.
David A
DA
Geller
Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
Osamu
O
Itano
Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
Yuko
Y
Kitagawa
Department of Surgery, Ageo Central General Hospital, Saitama, Japan.
Go
G
Wakabayashi
D003245:Consensus Statements as Topic; D003710:Demography; D004059:Diffusion of Innovation; D014943:Global Health; D006498:Hepatectomy / Q000379:methods*; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008107:Liver Diseases / Q000601:surgery*; D011795:Surveys and Questionnaires
IDEAL framework; INSTALL study; International questionnaire; Laparoscopic liver resection; Second International Consensus Conference on Laparoscopic Liver Resection; Surgical innovation