Meta-Analysis of Trials Comparing Minimally-Invasive and Open Liver Resections for Hepatocellular Carcinoma Alessandro Fancellu, M.D.,* ,1 Alan S. Rosman, M.D., F.A.C.P.,† Valeria Sanna, M.D.,‡ Giuseppe R. Nigri, M.D.,§ Luigi Zorcolo, M.D.,k Michele Pisano, M.D.,{ and Marcovalerio Melis, M.D.# *Department of Surgery-Institute of Clinica Chirurgica, University of Sassari, SS, Italy; †Section of Gastroenterology and Medicine Program, Mount Sinai School of Medicine and Bronx VAMC, New York, New York; ‡Department of Oncology, ASL n.1 Sassari, SS, Italy; §Department of Surgery, St. Andrea Hospital, Sapienza University of Rome, RM, Italy; kDepartment of Surgery, University of Cagliari, CA, Italy; {Department of Surgery, Ospedali Riuniti di Bergamo, BG, Italy; and #Division of Surgical Oncology, New York University School of Medicine, NY Harbor Healthcare System VAMC, New York, New York Originally submitted March 27, 2011; accepted for publication July 7, 2011 Background. Recent literature suggests that minimally-invasive hepatectomy (MIH) for hepatocel- lular carcinoma (HCC) is associated with better perio- perative results and similar oncologic outcomes compared to open hepatectomy (OH). However, previ- ous reports have been limited by small sample size and single-institution design. Methods. To overcome these limitations, we per- formed a meta-analysis of studies comparing MIH and OH in patients with HCC using a random-effects model. Results. Nine eligible studies were identified that included 227 patients undergoing MIH and 363 under- going OH. Patients were similar respect to age, gender, rates of cirrhosis, hepatitis C infection, tumour size, and American Society of Anesthesiology classification. The MIH group had lower rates of hepatitis B infection. There were no differences in type of resection (ana- tomic or non-anatomic), use of Pringle’s maneuver, and operative time. Patients undergoing MIH had less blood loss [difference L217 mL; 95% confidence in- terval (CI), –314 to L121], lower rates of transfusion [odds ratio (OR), 0.38; 95% CI, 0.24 to 0.59], shorter post- operative stay (difference L5 days; 95% CI, –7.84 to L2.25), lower rates of positive margins (OR, 0.30; 95% CI, 0.12 to 0.69) and perioperative complications (OR, 0.45; 95% CI, 0.31 to 0.66). Survival outcomes were similar in the two groups. Conclusions. Although patient selection might have influenced some of the observed outcomes, MIH was associated with decreased blood loss, transfusions, rates of positive resection margins, overall and specific morbidity, and hospital stay. Survival outcomes did not differ between MIH and OH, although further stud- ies are needed to evaluate the impact of MIH on long- term results. Ó 2011 Elsevier Inc. All rights reserved. Key Words: hepatocellular carcinoma; minimally invasive; laparoscopy; open hepatectomy. INTRODUCTION Hepatocellular carcinoma (HCC) is the most common primary liver cancer and one of the most common ma- lignancies in the world, accounting for approximately one million deaths per year [1]. Curative options for HCC include resection and liver transplantation. Per- cutaneous ablative techniques are accepted as an attractive alternative to surgery in patients with small-size HCC; however, large studies suggest that resection is associated with lower tumor recurrence and better survival [2–5]. Open hepatectomy (OH) has traditionally been the primary treatment for re- sectable HCC in patients with preserved liver function or well compensated cirrhosis who are not transplant candidates [5–7]. In recent years, advances in minimally-invasive liver resection techniques have led to a surge in minimally- invasive hepatectomy (MIH) for HCC [8–10]. Benefits of laparoscopic liver resection may include reduced postoperative pain, decreased length of recovery, and lower complication rates [8–12]. However, most of the studies reporting on MIH are retrospective, 1 To whom correspondence and reprint requests should be ad- dressed at Department of Surgery-Institute of Clinica Chirurgica, University of Sassari, V.le San Pietro, 43, 07100 Sassari, Italy. E-mail: afancel@uniss.it. 0022-4804/$36.00 Ó 2011 Elsevier Inc. All rights reserved. e33 Journal of Surgical Research 171, e33–e45 (2011) doi:10.1016/j.jss.2011.07.008