Impact of Tumor Size on the Difficulty of Laparoscopic Major Hepatectomies: An International Multicenter Study.

INTRODUCTION: Although tumor size (TS) is known to affect surgical outcomes in laparoscopic liver resection (LLR), its impact on laparoscopic major hepatectomy (L-MH) is not well studied. The objectives of this study were to investigate the impact of TS on the perioperative outcomes of L-MH and to elucidate the optimal TS cutoff for stratifying the difficulty of L-MH. METHODS: This was a post-hoc analysis of 3008 patients who underwent L-MH at 48 international centers. A total 1396 patients met study criteria and were included. The impact of TS cutoffs was investigated by stratifying TS at each 10-mm interval. The optimal cutoffs were determined taking into consideration the number of endpoints which showed a statistically significant split around the cut-points of interest and the magnitude of relative risk after correction for multiple risk factors. RESULTS: We identified 2 optimal TS cutoffs, 50 mm and 100 mm, which segregated L-MH into 3 groups. An increasing TS across these 3 groups (≤ 50 mm, 51-100 mm, > 100 mm), was significantly associated with a higher open conversion rate (11.2%, 14.7%, 23.0%, P < 0.001), longer operating time (median, 340 min, 346 min, 365 min, P = 0.025), increased blood loss (median, 300 ml,  ml, 400 ml, P = 0.002) and higher rate of intraoperative blood transfusion (13.1%, 15.9%, 27.6%, P < 0.001). Postoperative outcomes such as overall morbidity, major morbidity, and length of stay were comparable across the three groups. CONCLUSION: Increasing TS was associated with poorer intraoperative but not postoperative outcomes after L-MH. We determined 2 TS cutoffs (50 mm and 10 mm) which could optimally stratify the surgical difficulty of L-MH.

Utility of the Iwate difficulty scoring system for laparoscopic right posterior sectionectomy: do surgical outcomes differ for tumors in segments VI and VII?

INTRODUCTION: The Iwate Score (IS) have not been well-validated for specific procedures, especially for right posterior sectionectomy (RPS). In this study, the utility of the IS was determined for laparoscopic (L)RPS and the effect of tumor location on surgical outcomes was investigated. METHODS: Post-hoc analysis of 647 L-RPS performed in 40 international centers of which 596L-RPS cases met the inclusion criteria. Baseline characteristics and perioperative outcomes of patients stratified based on the Iwate score were compared to determine whether a correlation with surgical difficulty existed. A 1:1 Mahalanobis distance matching was utilized to investigate the effect of tumor location on L-RPS outcomes. RESULTS: The patients were stratified into 3 levels of difficulty (31 intermediate, 143 advanced, and 422 expert) based on the IS. When using a stepwise increase of the IS excluding the tumor location score, only Pringle's maneuver was more frequently used in the higher surgical difficulty level (35.5%, 54.6%, and 65.2%, intermediate, advanced, and expert levels, respectively, Z = 3.34, p = 0.001). Other perioperative results were not associated with a statistical gradation toward higher difficulty level. 80 of 85 patients with a segment VI lesion and 511 patients with a segment VII lesion were matched 1:1. There were no significant differences in the perioperative outcomes of the two groups including open conversion, operating time, blood loss, intraoperative blood transfusion, postoperative stay, major morbidity, and mortality. CONCLUSION: Among patients undergoing L-RPS, the IS did not significantly correlate with most outcome measures associated with intraoperative difficulty and postoperative outcomes. Similarly, tumor location had no effect on L-RPS outcomes.

Advanced donor age does not increase risk of hepatocellular carcinoma recurrence after liver transplantation: a retrospective two-centre analysis using competing risk analysis.

The impact of donor age on the recurrence of hepatocellular carcinoma (HCC) after liver transplantation is still debated. Between 2002 and 2014, all patients transplanted for HCC in 2 European liver transplantation tertiary centres were retrospectively reviewed. Risk factors for HCC recurrence were assessed using competing risk analysis, and the impact of donor age < or ≥65 years and < or ≥80 years was specifically evaluated after propensity score matching. 728 patients transplanted with a median follow-up of 86 months were analysed. The 1-, 3- and 5-year recurrence rates were 4.9%, 10.7% and 13.9%, respectively. In multivariable analysis, recipient age (sHR: 0.96 [0.93; 0.98], P < 0.01), number of lesions (sHR: 1.05 [1.04; 1.06], P < 0.001), maximum size of the lesions (sHR: 1.37 [1.27; 1.48], P < 0.01), presence of a hepatocholangiocarcinoma (sHR: 6.47 [2.91; 14.38], P < 0.01) and microvascular invasion (sHR: 3.48 [2.42; 5.02], P < 0.01) were significantly associated with HCC recurrence. After propensity score matching, neither donor age ≥65 (P = 0.29) nor donor age ≥80 (P = 0.84) years increased the risk of HCC recurrence. In conclusion, donor age was not found to be a risk factor for HCC recurrence. Patients listed for HCC can receive a graft from an elderly donor without compromising the outcome.

Laparoscopic liver resection of hepatocellular carcinoma located in unfavorable segments: a propensity score-matched analysis from the I Go MILS (Italian Group of Minimally Invasive Liver Surgery) Registry.

OBJECTIVE: Laparoscopic liver resection (LLR) for Hepatocellular Carcinoma (HCC) is one of the most important indications for the minimally invasive approach. Our study aims to analyze the experience of the Italian Group of Minimally Invasive Liver Surgery with laparoscopic surgical treatment of HCC, with a focus on tumor location and how it affects morbidity and mortality. METHODS: 38 centers participated in this study; 372 cases of LLR for HCC were prospectively enrolled. Patients were divided into two groups according to the HCC nodule location. Group 1 favorable location and group 2 unfavorable location. Perioperative outcomes were compared between the two groups before and after a propensity score match (PS) 1:1. RESULTS: Before PS in group 2 surgical time was longer; conversion rate was higher; postoperative transfusion and comprehensive complication index were also higher. PS was performed with a cohort of 298 patients (from 18 centers), with 66 and 232 patients with HCC in unfavorable and favorable locations, respectively. After PS matching, 62 patients from group 1 and group 2 each were compared. Operative and postoperative course were similar in patients with HCC in favorable and unfavorable LLR locations. Surgical margins were found to be identical before and after PS. CONCLUSIONS: These results show that LLR in patients with HCC can be safely performed in all segments because of the extensive experience of all surgeons from multiple centers in performing traditional open liver surgery as well as laparoscopic surgery.

Laparoscopic liver resection for large HCC: short- and long-term outcomes in relation to tumor size.

OBJECTIVE: In this study, we aim to assess the impact of tumor size on clinical and oncological outcomes in patients undergoing laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC). BACKGROUND: LLR has been shown to be feasible, safe, and oncologically efficient. However, it has been slow to develop in patients with HCC who often suffer from chronic liver disease which represents an additional challenge for the surgeon. The experience with large HCCs is even more limited. METHODS: Between 2003 and 2016, 172 patients from two high-volume liver surgery centers underwent LLR for HCC. Prospectively collected data were analyzed after stratification in 3 groups according to tumor major diameter (group 1: < 3 cm; group 2: between 3 and 5 cm; group 3: ≥ 5 cm). Perioperative and long-term outcomes were compared between the three groups and sub-analyses were carried out on the extent and location of the resections. RESULTS: Groups 1, 2, and 3 consisted of 82, 52, and 38 patients, respectively. Minor and major resections were performed in 98.8% and 1.2% in group 1, in 90.4% and 9.6% in group 2, and in 68.4% and 31.6% in group 3, respectively. Postero-superior "technically major" resections were performed in 15.8% patients in group 1, in 19.2% in group 2, and in 15.8% in group 3, respectively. Group 3 had higher conversion rates (p < 0.001), more frequent (p = 0.056) and more prolonged (p = 0,075) pedicle clamping and longer operative time (p < 0.001), higher blood losses (p = 0.025), and longer total hospital and intensive care unit stays. These differences ceased after removing the major resections from the study population, except for the postoperative length of stay. There were no differences in morbidity, mortality, completeness of resection rates, and long-term outcomes between the three groups. CONCLUSION: LLR for HCC appears to be safe and oncologically efficient when performed in high-volume HPB and laparoscopic centers. Tumor size does not appear to impact negatively on the outcomes except for postoperative hospital stay.

Comparison of Image Quality and Diagnostic Performance of Cone-Beam CT during Drug-Eluting Embolic Transarterial Chemoembolization and Multidetector CT in the Detection of Hepatocellular Carcinoma.

PURPOSE: To compare image quality and diagnostic performance of cone-beam computed tomography (CT) and multidetector CT in the detection of hypervascular hepatocellular carcinoma (HCC) in patients with cirrhosis undergoing transarterial chemoembolization with drug-eluting embolic agents. MATERIALS AND METHODS: Fifty-five consecutive patients referred for chemoembolization of hypervascular HCC were prospectively enrolled. Imaging included preprocedural multidetector CT within 1 month before planned treatment, intraprocedural cone-beam CT, and 1-month follow-up multidetector CT. Analysis of image quality was performed with calculations of lesion-to-liver contrast-to-noise ratio (LLCNR) and lesion-to-liver signal-to-noise-ratio (LLSNR). One-month follow-up multidetector CT was considered the reference standard for the detection of HCC nodules. RESULTS: Median LLCNR values were 3.94 (95% confidence interval [CI], 3.06-5.05) for preprocedural multidetector CT and 6.90 (95% CI, 5.17-7.77) for intraprocedural cone-beam CT (P < .0001). Median LLSNR values were 11.53 (95% CI, 9.51-12.44) for preprocedural multidetector CT and 9.36 (95% CI, 8.12-10.39) for intraprocedural cone-beam CT (P < .0104). Preprocedural multidetector CT detected 115 hypervascular nodules with typical HCC behavior, and cone-beam CT detected 15 additional hypervascular nodules that were also visible on 1-month follow-up multidetector CT. CONCLUSIONS: Cone-beam CT has a significantly higher diagnostic performance compared with preprocedural multidetector CT in the detection of HCCs and can influence management of patients with cirrhosis by identifying particularly aggressive tumors.

Yttrium-90 Radioembolization for Hepatocellular Carcinoma Prior to Liver Transplantation.

BACKGROUND: Liver transplantation (LT) is a well-established procedure for hepatocellular carcinoma (HCC) within the Milan criteria. Yttrium-90 microspheres radioembolization (Y90-RE) has shown to be an effective and safe treatment of primary liver tumors. We retrospectively evaluate the efficacy of the Y90-RE in patients with HCC prior to LT. METHODS: From January 2002 to December 2015, 365 patients were transplanted at the San Camillo Hospital Center. One hundred forty-three patients were transplanted for HCC, and in 22 cases the patients were treated with Y90-RE before LT. RESULTS: Three patients were treated with Y90-RE within the Milan criteria, and 19 patients were out of criteria before Y90-RE. Four patients had an increasing MELD score between Y90-RE and LT. On the other hand, alpha-fetoprotein decreases after Y90-RE treatment in all cases. No patient death was observed in Y90-RE procedure or at LT. In 78.9 % of cases, a successful downstaging was observed, and in 100 % of cases bridging was achieved. From Y90-RE treatment overall survival was 43.9 months. From LT, overall mean survival was 30.2 months with a free survival of 29.6 months. The overall survival after LT analysis between the patients treated with Y90-RE and patients without was not significant (p = 0.113). Free survival analysis was not significant (p = 0.897) between the two populations. CONCLUSIONS: We successfully performed LT in patients after Y90-RE treatment both as bridging and downstaging for HCC and obtained a similar overall and free survival of LT for HCC within Milan criteria. Y90-RE becomes a real option to provide curative therapy for patients who traditionally are not considered eligible for surgery.

Clinical outcomes of ERCP-related retroperitoneal perforations.

Endoscopic retrograde cholangiopancreatography (ERCP)-related perforations represent rare but often severe conditions. While lesions with intraperitoneal perforation have an almost imperative indication to surgery, whether or not to manage retroperitoneal perforations surgically is still an area of debate. The aim of the present work was to review the available clinical evidence on the operatively and medically treated ERCP-related retroperitoneal perforations. From MEDLINE/PubMed databases 137 patients with retroperitoneal perforation were included from 12 studies that met the selection criteria for data investigation and analysis. Twenty-four patients were treated by prompt surgery; 113 were primarily managed conservatively and about 20% of these patients required surgery subsequently. Overall, the morbidity and mortality were 15.4% and 6.6%, respectively. Although most patients with retroperitoneal perforation may benefit from a non-operative management, a considerable number of patients fail to respond to medical treatment and require surgery afterwards. Identifying those patients who are at highest risk of poor outcome after conservative treatment should be considered a research priority.

Intravascular Leiomyomatosis with Intracardiac Extension.

Intravenous leiomyomatosis (IVL) is a rare nonmalignant tumor defined as a benign smooth muscle cell neoplasia in the veins. Patients with IVL may present with symptoms of a uterine leiomyoma such as pelvic pain and vaginal bleeding, or cardiorespiratory symptoms, including dyspnea and leg swelling. We report the case of a 65-year-old otherwise healthy Caucasian woman. Past medical history consisted of hysterectomy and left salpingo-oophorectomy 15 years before for multiple uterine fibromyomas associated with leiomyoma of vascular origin. A thoracoabdominal computed tomography (CT) scan confirmed the presence of a mass, measuring 76 × 37 × 44 mm, arising from the inferior vena cava (IVC) at the level of the left renal vein extending all the way into the right atrium and right ventricle. At laparotomy, a tumoral mass was excised from the left broad ligament up to the left renal vein and from the IVC up to its retrohepatic tract. Sternotomy was performed and cardiopulmonary bypass (CPB) was established among ascending aorta, upper vena cava, and right common femoral vein. After atriotomy, a voluminous and firm mass was excised from the right atrium, down to the level of the IVC. CPB was maintained for 80 min. Perioperative transfusion included two plasma and two red blood cells units. No adjuvant treatment was administered. Follow-up with annual CT scans was performed. Patient had no signs of recurrence after 3 years.

Mesothelial cyst of the round ligament of the liver.

A 34-year-old man was admitted in our department with a 3 months history of epigastric pain, abdominal distension and tenderness. Helical computed tomography scan and magnetic resonance imaging showed a 10 cm low-density fluid-filled polilobate cystic lesion with internal septations and calcifications located between the left lobe of the liver, shorter gastric curvature, pancreas and mesocolon. Laparoscopic exploration was performed. Macroscopically the lesion was a unilocular serous cyst with a thick fibrous wall. Histopathology revealed a thin fibrous wall with a single layer of flattened to cuboidal mesothelial cell lining lacking any cellular atypia. The patient is currently alive without evidence of recurrence at 6 months. Cysts of mesothelial origin are rare lesions seen more frequently in young and middle-aged women, mostly benign and located in the mesenteries or omentum. Diagnosis is usually based on clinical examination and radiographic imaging. Immunohistochemistry is used to differentiate histologic type, with simple mesothelial cysts being positive for cytokeratins and calretinin and negative for CD31. The laparoscopic approach appears safe, feasible and less-invasive without compromising surgical principles and today should be considered the gold standard in most cases.

Extrahepatic portal vein aneurysm.

Portal vein aneurysms (PVAs) are usually incidental on imaging and asymptomatic. If it is symptomatic or associated with a pathologic finding, a treatment is recommended. We report a case of a 75-year-old Caucasian man presenting with symptomatic and size-increasing portosplenomesenteric aneurysms. Interventional radiology was not indicated because of the large size. A surgical approach was chosen for the patient. Surgical technique consists of an aneurysmorrhaphy in the first time and in the second time, a Goretex prosthesis placement involving the vein. Early complication was treated with a radiologic approach. Six months after surgery, patient had no more symptoms. PVA management remains a surgical challenge for surgeon, for timing and type of treatment.

Bilateral ex vivo repair and kidney autotransplantation for complex renal artery aneurysms: a case report and literature review.

We report the surgical management of a bilateral renal artery aneurysm diagnosed in a 41-year-old patient with a history of recurrent abdominal pain. The preoperative contrast-enhanced computed tomography showed a complex saccular aneurysm on both renal arteries within the renal hilum. The characteristics of aneurysms precluded endovascular procedures, and a double-step bilateral ex vivo reconstruction with kidney autotransplantation was planned. The intra- and postoperative period was uneventful. Imaging and laboratory examinations show preservation of renal function, and patient is symptom-free at 10-month follow up.

Laparoscopic left liver lobectomy for hepatocellular carcinoma in a cirrhotic patient: a video report.

We present a video case of a 51-year-old man admitted to our surgical and liver transplantation unit for hepatocellular cancer (HCC). Patient has a HCV cirrhosis with portal hypertension and esophageal varices F1. Child Pugh score was B7 and model of end staged liver disease (MELD) was 11. Body mass index (BMI) was 26.7 and ASA score was 2. No previous abdominal surgery. According with our multidisciplinary group we suggest a laparoscopic left lobectomy for the patient. Pringle manoeuvre was not performed. Operation time was 193 min and blood loss estimation was 100 cc. No transfusion was required. Post-operative course was uneventful, grade I of Clavien-Dindo Classification. Patient was discharged in day 8. In our experience laparoscopic resection in cirrhotic liver should be performed in selected patients and in an experienced team.

Exploring 6 years of colorectal cancer surgery in rural Italy: insights from 648 consecutive patients unveiling successes and challenges.

The multidisciplinary management of patients suffering from colorectal cancer (CRC) has significantly increased survival over the decades and surgery remains the only potentially curative option for it. However, despite the implementation of minimally invasive surgery and ERAS pathway, the overall morbidity and mortality remain quite high, especially in rural populations because of urban - rural disparities. The aim of the study is to analyze the characteristics and the surgical outcomes of a series of unselected CRC patients residing in two similar rural areas in Italy. A total of 648 consecutive patients of a median age of 73 years (IQR 64-81) was enrolled between 2017 and 2022 in a prospective database. Emergency admission (EA) was recorded in 221 patients (34.1%), and emergency surgery (ES) was required in 11.4% of the patients. Tumor resection and laparoscopic resection rates were 95.0% and 63.2%, respectively. The median length of stay was 8 days. The overall morbidity and mortality rates were 23.5% and 3.2%, respectively. EA was associated with increased median age (77.5 vs. 71 ys, p < 0.001), increased mean ASA Score (2.84 vs. 2.59; p = 0.002) and increased IV stage disease rate (25.3% vs. 11.5%, p < 0.001). EA was also associated with lower tumor resection rate (87.3% vs. 99.1%, p < 0.001), restorative resection rate (71.5 vs. 89.7%, p < 0.001), and laparoscopic resection rate (36.2 vs. 72.6%, p < 0.001). Increased mortality rates were associated with EA (7.2% vs. 1.2%, p < 0.001), ES (11.1% vs. 2.0%, p < 0.001) and age more than 80 years (5.8% vs. 1.9%, p < 0.001). In rural areas, high quality oncologic care can be delivered in CRC patients. However, the surgical outcomes are adversely affected by a still too high proportion of emergency presentation of elderly and frail patients that need additional intensive care supports beyond the surgical skill and alternative strategies for earlier detection of the disease.

Complications and adverse events in lymphadenectomy of the inguinal area: worldwide expert consensus.

BACKGROUND: Inguinal lymph node dissection plays an important role in the management of melanoma, penile and vulval cancer. Inguinal lymph node dissection is associated with various intraoperative and postoperative complications with significant heterogeneity in classification and reporting. This lack of standardization challenges efforts to study and report inguinal lymph node dissection outcomes. The aim of this study was to devise a system to standardize the classification and reporting of inguinal lymph node dissection perioperative complications by creating a worldwide collaborative, the complications and adverse events in lymphadenectomy of the inguinal area (CALI) group. METHODS: A modified 3-round Delphi consensus approach surveyed a worldwide group of experts in inguinal lymph node dissection for melanoma, penile and vulval cancer. The group of experts included general surgeons, urologists and oncologists (gynaecological and surgical). The survey assessed expert agreement on inguinal lymph node dissection perioperative complications. Panel interrater agreement and consistency were assessed as the overall percentage agreement and Cronbach's α. RESULTS: Forty-seven experienced consultants were enrolled: 26 (55.3%) urologists, 11 (23.4%) surgical oncologists, 6 (12.8%) general surgeons and 4 (8.5%) gynaecology oncologists. Based on their expertise, 31 (66%), 10 (21.3%) and 22 (46.8%) of the participants treat penile cancer, vulval cancer and melanoma using inguinal lymph node dissection respectively; 89.4% (42 of 47) agreed with the definitions and inclusion as part of the inguinal lymph node dissection intraoperative complication group, while 93.6% (44 of 47) agreed that postoperative complications should be subclassified into five macrocategories. Unanimous agreement (100%, 37 of 37) was achieved with the final standardized classification system for reporting inguinal lymph node dissection complications in melanoma, vulval cancer and penile cancer. CONCLUSION: The complications and adverse events in lymphadenectomy of the inguinal area classification system has been developed as a tool to standardize the assessment and reporting of complications during inguinal lymph node dissection for the treatment of melanoma, vulval and penile cancer.

Use of albumin infusion for cirrhosis-related complications: An international position statement.

Background & Aims: Numerous studies have evaluated the role of human albumin (HA) in managing various liver cirrhosis-related complications. However, their conclusions remain partially controversial, probably because HA was evaluated in different settings, including indications, patient characteristics, and dosage and duration of therapy. Methods: Thirty-three investigators from 19 countries with expertise in the management of liver cirrhosis-related complications were invited to organise an International Special Interest Group. A three-round Delphi consensus process was conducted to complete the international position statement on the use of HA for treatment of liver cirrhosis-related complications. Results: Twelve clinically significant position statements were proposed. Short-term infusion of HA should be recommended for the management of hepatorenal syndrome, large volume paracentesis, and spontaneous bacterial peritonitis in liver cirrhosis. Its effects on the prevention or treatment of other liver cirrhosis-related complications should be further elucidated. Long-term HA administration can be considered in specific settings. Pulmonary oedema should be closely monitored as a potential adverse effect in cirrhotic patients receiving HA infusion. Conclusions: Based on the currently available evidence, the international position statement suggests the potential benefits of HA for the management of multiple liver cirrhosis-related complications and summarises its safety profile. However, its optimal timing and infusion strategy remain to be further elucidated. Impact and implications: Thirty-three investigators from 19 countries proposed 12 position statements on the use of human albumin (HA) infusion in liver cirrhosis-related complications. Based on current evidence, short-term HA infusion should be recommended for the management of HRS, LVP, and SBP; whereas, long-term HA administration can be considered in the setting where budget and logistical issues can be resolved. However, pulmonary oedema should be closely monitored in cirrhotic patients who receive HA infusion.

Reporting guidelines for surgical technique could be improved: a scoping review and a call for action.

OBJECTIVES: To identify reporting guidelines related to surgical technique and propose recommendations for areas that require improvement. STUDY DESIGN AND SETTING: A protocol-guided scoping review was conducted. A literature search of MEDLINE, the EQUATOR Network Library, Google Scholar, and Networked Digital Library of Theses and Dissertations was conducted to identify surgical technique reporting guidelines published up to December 31, 2021. RESULTS: We finally included 55 surgical technique reporting guidelines, vascular surgery (n = 18, 32.7%) was the most common among the clinical specialties covered. The included guidelines generally showed a low degree of international and multidisciplinary cooperation. Few guidelines provided a detailed development process (n = 14, 25.5%), conducted a systematic literature review (n = 13, 23.6%), used the Delphi method (n = 4, 7.3%), or described post-publication strategy (n = 6, 10.9%). The vast majority guidelines focused on the reporting of intraoperative period (n = 50, 90.9%). However, of the guidelines requiring detailed descriptions of surgical technique methodology (n = 43, 78.2%), most failed to provide guidance on what constitutes an adequate description. CONCLUSION: Our study demonstrates significant deficiencies in the development methodology and practicality of reporting guidelines for surgical technique. A standardized reporting guideline that is developed rigorously and focuses on details of surgical technique may serve as a necessary impetus for change.

Impact of tumor size on the difficulty of laparoscopic left lateral sectionectomies.

BACKGROUND: Tumor size (TS) represents a critical parameter in the risk assessment of laparoscopic liver resections (LLR). Moreover, TS has been rarely related to the extent of liver resection. The aim of this study was to study the relationship between tumor size and difficulty of laparoscopic left lateral sectionectomy (L-LLS). METHODS: The impact of TS cutoffs was investigated by stratifying tumor size at each 10 mm-interval. The optimal cutoffs were chosen taking into consideration the number of endpoints which show a statistically significant split around the cut-points of interest and the magnitude of relative risk after correction for multiple risk factors. RESULTS: A total of 1910 L-LLS were included. Overall, open conversion and intraoperative blood transfusion were 3.1 and 3.3%, respectively. The major morbidity rate was 2.7% and 90-days mortality 0.6%. Three optimal TS cutoffs were identified: 40-, 70-, and 100-mm. All the selected cutoffs showed a significant discriminative power for the prediction of open conversion, operative time, blood transfusion and need of Pringle maneuver. Moreover, 70- and 100-mm cutoffs were both discriminative for estimated blood loss and major complications. A stepwise increase in rates of open conversion rate (Z = 3.90, P < .001), operative time (Z = 3.84, P < .001), blood loss (Z = 6.50, P < .001), intraoperative blood transfusion rate (Z = 5.15, P < .001), Pringle maneuver use (Z = 6.48, P < .001), major morbidity(Z = 2.17, P = .030) and 30-days readmission (Z = 1.99, P = .047) was registered as the size increased. CONCLUSION: L-LLS for tumors of increasing size was associated with poorer intraoperative and early postoperative outcomes suggesting increasing difficulty of the procedure. We determined three optimal TS cutoffs (40-, 70- and 100-mm) to accurately stratify surgical difficulty after L-LLS.