Efficacy of laparoscopic liver resection for small hepatocellular carcinoma located in the posterosuperior segments: A multi-institutional study using propensity score matching by the Kyushu Study Group of Liver Surgery.

AIM: Laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) located in the posterosuperior segments (PS) have generally been considered more difficult than those for HCC in anterolateral segments (AL), but may be safe and feasible for selected patients with accumulated experience. In the present study, we investigated the effectiveness of LLR for single nodular HCCs ≤3 cm located in PS. METHODS: In total, 473 patients who underwent partial liver resection for single nodular HCCs ≤3 cm at the 18 institutions belonging to the Kyusyu Study Group of Liver Surgery from January 2010 to December 2018 were enrolled. The short-term outcomes of laparoscopic partial liver resection and open liver resection (OLR) for HCCs ≤3 cm, with subgroup analysis of PS and AL, were compared using propensity score-matching analysis. Furthermore, results were also compared between LLR-PS and LLR-AL. RESULTS: The original cohort of patients with HCC ≤3 cm included 328 patients with LLR and 145 with OLR. After matching, 140 patients with LLR and 140 with OLR were analyzed. Significant differences were found between groups in terms of volume of blood loss (median, 55 vs. 287 ml, p < 0.001), postoperative complications (0.71 vs. 8.57%, p = 0.003), and postoperative hospital stay (median, 9 vs. 14 days, p < 0.001). The results of subgroup analysis of PS were similar. Short-term outcomes did not differ significantly between LLR-PS and LLR-AL after matching. CONCLUSIONS: Laparoscopic partial resection could be the preferred option for single nodular HCCs ≤3 cm located in PS.

Risk Factors and Outcome of Portal Vein Thrombosis After Laparoscopic and Open Hepatectomy for Primary Liver Cancer: A Single-Center Experience.

BACKGROUND: Post-hepatectomy portal vein thrombosis (PH-PVT) is a severe complication. The risk factors of PH-PVT after laparoscopic and open hepatectomy have not been clarified yet. We aimed to retrospectively investigate the risk factors and outcome of PH-PVT in patients with primary liver cancer. METHODS: We enrolled 622 consecutive patients who underwent hepatectomy in our hospital between January 2006 and August 2016. RESULTS: Of 21 patients (3.4%) with PH-PVT, 7 had grade I; 13, grade II; and 1, grade III. The patients with PH-PVT were significantly older than those without PH-PVT. Of the 413 patients who underwent open hepatectomy, those who underwent a major right hepatectomy (4.1%) had a slightly higher incidence of PH-PVT. Of the 209 patients who underwent laparoscopic hepatectomy, those who underwent a left lateral sectionectomy (21.2%) and major right hepatectomy (16.7%) had high incidence rates of PH-PVT. The treatment was only observation in five patients, medication with an antithrombotic drug in 15 patients, and reoperation in one patient. PH-PVT diminished in 17 patients. Cavernous transformation and/or stenosis of the portal vein developed in three patients. The patient with grade III PH-PVT after open right hemihepatectomy underwent reoperation but died of hepatic failure. CONCLUSION: This study demonstrated that patient age, left lateral sectionectomy were risk factors of PH-PVT. Laparoscopic left lateral sectionectomy and major right hepatectomy might bring about relatively higher risk of PH-PVT. Major right hepatectomy tends to lead to severe PH-PVT. Careful handling of the PV during hepatectomy and early treatment of PH-PVT are necessary.

Donor-dependent variations in hepatic differentiation from human-induced pluripotent stem cells.

Hepatocytes generated from human induced pluripotent stem cells (hiPSCs) are unprecedented resources for pharmaceuticals and cell therapy. However, the in vitro directed differentiation of human pluripotent stem cells into mature hepatocytes remains challenging. Little attention has so far been paid to variations among hiPSC lines in terms of their hepatic differentiation. In the current study, we developed an improved hepatic differentiation protocol and compared 28 hiPSC lines originated from various somatic cells and derived using retroviruses, Sendai viruses, or episomal plasmids. This comparison indicated that the origins, but not the derivation methods, may be a major determinant of variation in hepatic differentiation. The hiPSC clones derived from peripheral blood cells consistently showed good differentiation efficiency, whereas many hiPSC clones from adult dermal fibroblasts showed poor differentiation. However, when we compared hiPSCs from peripheral blood and dermal fibroblasts from the same individuals, we found that variations in hepatic differentiation were largely attributable to donor differences, rather than to the types of the original cells. These data underscore the importance of donor differences when comparing the differentiation propensities of hiPSC clones.

Middle Hepatic Vein-Guided Cranial and Hilar Approach Using a Modified Two-Surgeon Technique in Laparoscopic Extended Left Medial Sectionectomy: A Technical Case Report With Videos.

Anatomical liver resection and liver resection close to major blood vessels are quite challenging and require a high level of expertise. In addition, anatomical hepatectomy requires extensive knowledge of the positions of blood vessels and techniques for hemostasis because the resection surface is extensive and operations around blood vessels are required. A hepatic vein-guided cranial and hilar approach using a modified "two-surgeon technique" is effective in resolving these problems. Herein, we present a middle hepatic vein (MHV)-guided cranial and hilar approach using a modified two-surgeon technique in laparoscopic extended left medial sectionectomy to resolve these problems. This procedure is feasible and effective.

The Safety of Laparoscopic Cholecystectomy in Super-elderly Patients: A Propensity Score Matching Analysis.

BACKGROUND: Although reports on the safety of laparoscopic cholecystectomy (LC) exist, few have included patients aged ≥ 85 years. Hence, our study aimed to evaluate surgical outcomes of LC in patients aged ≥ 85 years. METHODS: After excluding patients who underwent other types of surgeries, 583 patients who underwent LC between 2015 and 2022 were included. Patients were classified into two groups based on age: < 85 years (control group, n = 551) and ≥ 85 years (super-elderly group, n = 32). Propensity score matching (PSM) was performed based on preoperative clinical parameters, and intraoperative and postoperative outcomes were compared. RESULTS: After PSM, 28 patients were included in each group. Intraoperative blood loss (1 vs. 5 mL, respectively; P = .052) and frequency of serious postoperative complications (Clavien-Dindo class ≥ 2, 2/28 (7.1%) vs. 6/28 (21.4%), P = .252) were similar between the control and elderly groups. There was no significant difference in the length of postoperative stay (control group: 5 (4-24) days vs. super-elderly group: 7 (3-64) days, P = .236). Unfortunately, one case of pneumonia of unknown cause occurred postoperatively, resulting in the death of one patient in the super-elderly group. CONCLUSIONS: There were no clinically significant differences in the short-term outcomes of LC between super-elderly patients aged ≥ 85 years and patients aged < 85 years. Hence, LC may be relatively safe even in patients aged ≥ 85 years. However, owing to many pre-existing diseases and deterioration of physiological function, careful management during the perioperative period is desirable.

Non-Stick Liver Parenchymal Transection With Saline-Linked Bipolar Clamp-Crush Technique in Robotic Liver Resection.

Background Without satisfactory instruments, liver parenchymal transection during robotic liver resection (RLR) remains challenging. We combined the commonly used bipolar clamp-crush technique with the saline drip, achieving a comfortable liver resection without coagulated liver tissues sticking to the bipolar forceps. Methods Between December 2022 and March 2023, six RLRs were performed using the saline-linked bipolar clamp-crush method for both anatomical and non-anatomical liver resections. We assessed the safety and feasibility of our robotic liver parenchymal transection technique. Results Three of six patients were diagnosed with colorectal liver metastasis, two with hepatocellular carcinoma (HCC), and the other with intrahepatic bile duct stricture. Three of the six patients received anatomical liver resection, and the other three underwent non-anatomical liver resection. There were no conversions to open surgery. The median operative time and estimated blood loss were 406.5 minutes (196-670 minutes) and 5 ml (5-465 ml), respectively. The median length of the postoperative hospital stay was nine days (7-10 days). Postoperative complications (Clavien-Dindo classification grade II or more) or mortality were not encountered in this cohort. Conclusion We presented here our saline-linked bipolar clamp-crush method for liver parenchymal transection in RLR. By simply adding the saline drip to the commonly used bipolar clamp-crush technique, non-stick and comfortable liver parenchymal transection is now possible. This technique may help overcome the limitations of currently available robotic instruments for liver parenchymal resection.

Quick and Easy Application Method of TachoSil®ï¸ During Laparoscopic and Robotic Liver Resections.

TachoSil®ï¸, a fibrin sealant patch, is a sheet-type hemostatic agent. Therefore, it is technically demanding to put it on the target place especially in laparoscopic surgeries due to the motion restriction of straight-fixed instruments. This article describes a quick and easy technique of TachoSil application during laparoscopic liver surgeries, by sewing it to the laparoscopic gauze in advance. This method allows for one-handed operation and stress-free application even in the situation of active bleeding.

Application of Extended Reality (Virtual Reality and Mixed Reality) Technology in Laparoscopic Liver Resections.

Background and purpose Laparoscopic liver resection (LLR) has recently gained popularity owing to advances in surgical techniques. Difficulties in LLR may be influenced by anatomical factors. This study presents a comprehensive overview of LLR performed using extended reality (XR) technology. Methods Six patients underwent LLR performed wearing HoloLens2® XR (Microsoft Corporation, Redmond, Washington, United States) technology. We performed dynamic contrast-enhanced CT scans before surgery and used the data to construct three-dimensional images. Results Of the six patients, two were diagnosed with colorectal liver metastases, two with hepatocellular carcinoma, and one with intrahepatic cholangiocarcinoma. The median maximum tumor diameter was 31 mm (range, 23-80 mm). One patient had liver cirrhosis, with Child-Pugh classification grade B. Anatomical resection was performed in three patients (60%), with a median difficulty score of 7 (intermediate). No conversions to open surgery were necessary. The median operative time and estimated blood loss were 444 minutes (range, 337-597 minutes) and 200 mL (range, 100-1000 mL), respectively. Postoperative complications (Clavien-Dindo classification grade II) were observed in one patient. All six cases achieved negative surgical margins. Conclusions LLR using XR technology enhances surgical visualization and anatomical recognition. The incorporation of XR technology into LLR offers advantages over traditional two-dimensional imaging.

Risk Factors of Complications from Central Bisectionectomy (H458) for Hepatocellular Carcinoma: A Multi-Institutional Single-Arm Analysis.

BACKGROUND: This study aims to clarify the perioperative risk factors and short-term prognosis of central bisectionectomy (CB) for hepatocellular carcinoma (HCC). METHODS: Surgical data from 142 selected patients out of 171 HCC patients who underwent anatomical CB (H458) between 2005 and 2020 were collected from 17 expert institutions in a single-arm retrospective study. RESULTS: Morbidities recorded by the International Study Group of Liver Surgery (ISGLS) from grade BC post-hepatectomy liver failure (PHLF) and bile leakage (PHBL), or complications requiring intervention were observed in 37% of patients. A multivariate analysis showed that increased blood loss (iBL) > 1500 mL from PHLF (risk ratio [RR]: 2.79), albumin level < 4 g/dL for PHBL (RR, 2.99), involvement of segment 1, a large size > 6 cm, or compression of the hepatic venous confluence or cava by HCC for all severe complications (RR: 5.67, 3.75, 6.51, and 8.95, respectively) (p < 0.05) were significant parameters. Four patients (3%) died from PHLF. HCC recurred in 50% of 138 surviving patients. The three-year recurrence-free and overall survival rates were 48% and 81%, respectively. CONCLUSIONS: Large tumor size and surrounding tumor involvement, or compression of major vasculatures and the related iBL > 1500 mL were independent risk factors for severe morbidities in patients with HCC undergoing CB.

High predictive ability of apparent diffusion coefficient value for wall-invasion pattern of advanced gallbladder carcinoma.

PURPOSE: The wall-invasion pattern classification of advanced gallbladder carcinoma (GBC) has been reported. However, its association with clinical findings remains unclear. We aimed to clarify relationships between clinicopathological characteristics, prognosis, and apparent diffusion coefficient (ADC) values of advanced GBC based on the wall-invasion pattern. METHODS: We reviewed the data of 37 patients who had undergone advanced GBC cholecystectomy at our institution between 2009 and 2021. Clinicopathological findings, prognosis, and ADC values were retrospectively analyzed. RESULTS: Based on the wall-invasion pattern, patients were classified into infiltrative growth (IG) type (n = 22) and destructive growth (DG) type (n = 15). In the DG-type, the incidence of venous invasion (P = 0.027), neural invasion (P = 0.008), and lymph node metastasis (P = 0.047) was significantly higher than in the IG-type, and recurrent-free survival (RFS) was significantly shorter (P = 0.015); the median RFS was 11.4 months (95% confidence interval, 6.3-16.5 months) in the DG-type and not reached in the IG-type. The ADC value in the DG-type was significantly lower than in the IG-type (median, 1.19 × 10-3 mm2/s vs. 1.86 × 10-3 mm2/s, P < 0.001). The area under the receiver operating characteristic curve for the ADC values to differentiate wall-invasion patterns was 0.95 (95% confidence interval, 0.87-1.00). The optimal cutoff ADC value was 1.45 × 10-3 mm2/s (sensitivity, 92.9%; specificity, 90.9%). CONCLUSIONS: The wall-invasion pattern of advanced GBC is associated with its aggressiveness and prognosis, and can be predicted by ADC values with high accuracy.

Modified Two-Surgeon Technique for Laparoscopic Liver Resection.

While minimizing intraoperative blood loss during liver resection is one of the most important tasks, it is more difficult to control the refractory bleeding during laparoscopic liver resection than with an open approach. We herein provide a modification of the two-surgeon technique that enables laparoscopic liver parenchymal transection to be performed as quickly and securely as open liver resection. To achieve proper "role sharing," the "transection mode" and the "hemostatic mode" are independent sets in place in this procedure, and these modes are switched rigidly according to the surgical field condition. By thoroughly sharing the roles, rapid laparoscopic liver parenchymal transection comparable to open liver resection can be accomplished. The present modified approach achieves satisfactory transection and hemostasis of the liver parenchyma and is also advantageous for teaching young surgeons and the entire surgical team.

Long-Term Survival of a Patient With Peritoneal Carcinomatosis From Pancreatic Cancer Maintained by Nanoliposomal Irinotecan as Third-Line Chemotherapy.

Pancreatic cancer is still one of the most fatal neoplastic diseases, and the recurrence occurs in more than 80% of the patients even though radical resection is performed. We experienced a long-term survival case of a patient with peritoneal carcinomatosis from pancreatic cancer maintained by nanoliposomal irinotecan (nal-IRI) in combination with fluorouracil and folinic acid (FF) as third-line chemotherapy. Nal-IRI + FF combination chemotherapy is one of the promising options for the management of intractable recurrent pancreatic cancer.

Novel Liver Parenchymal Transection Technique Using Saline-linked Monopolar Cautery Scissors (SLiC-Scissors) in Robotic Liver Resection.

Introduction Although there are a number of benefits to using robotics in liver surgery over conventional open and laparoscopic approaches, liver parenchymal transection is still the most difficult aspect of robotic liver resection (RLR) due to the limitations of the currently available robotic instruments and the lack of a standardized method. Methods We present a novel method for transecting the liver parenchyma during RLR employing saline-linked monopolar cautery (SLiC) scissors (SLiC-Scissors method). Between September 2021 and April 2022, 10 RLRs were performed utilizing the SLiC-Scissors method for both anatomical and non-anatomical liver resections. We assessed the short-term results, as well as the safety and practicality of our robotic liver parenchymal transection technique. Results Six of the 10 patients had malignant liver tumors, and four of them had liver metastases from colorectal cancer. Except for S1, the target lesions were present everywhere, and their median size was 25 mm (14-43 mm). The median amount of intraoperative bleeding was 5 mL (5-30 mL), and the median operative and console times were 223 and 134 min, respectively. There were no conversions to open liver resections. The median length of the postoperative stay was seven (4-13) days, and there were no serious postoperative complications or mortality. Conclusions The SLiC-Scissors method is a safe and practical procedure for liver parenchymal transection in RLR. In order to standardize and broadly implement RLR into normal patient treatment, this unique approach enables an advanced, locally controlled preparation of intrahepatic vessels and bile ducts.

Tissue pad degradation of ultrasonic device may enhance thermal injury and impair its sealing performance in liver surgery.

BACKGROUND: Ultrasonic devices are widely used in many surgical fields, including hepatectomy; however, the negative effects of tissue pad degradation of ultrasonic devices, including those in liver surgery, remain unknown. The Harmonic® 1100 (H-1100) scalpel has advanced heat control technology than previous models, such as the Harmonic® HD1000i (H-HD1000i). We hypothesized that, because of its advanced temperature-control technology, the H-1100 scalpel would show less tissue pad degradation, resulting in superior sealing performance, compared to that with the H-HD1000i scalpel. AIM: To elucidate ultrasonic device tissue pad degradation effects on instrument temperature and sealing performance using ex vivo porcine liver/vessel models. METHODS: Two different harmonic scalpels were used and compared: A newer model, the H-1100 scalpel, and an older model, the H-HD1000i scalpel. Using ex vivo porcine livers, each instrument was activated until the liver parenchyma was dissected. The device temperature (passive jaw temperature) was measured after every 10 consecutive activations, until 300 transections of the porcine liver were performed. Tissue pad degradation was evaluated after 300 activations. Sealing performance was evaluated using excised porcine carotid vessels; vessel sealing speed and frequency of vessel burst pressure below 700 mmHg were determined after 300 transections of porcine liver parenchyma. RESULTS: The temperature of the H-HD1000i scalpel was approximately 10°C higher than that of the H-1100 scalpel, and gradually increased as the number of activations increased. The median passive jaw temperature of the H-HD1000i scalpel was significantly higher than that of the H-1100 scalpel (73.4°C vs 65.1°C; P < 0.001). After 300 transections of porcine liver parenchyma, less tissue pad degradation was observed with the H-1100 scalpel than with the H-HD1000i scalpel (0.08 mm vs 0.51 mm). The H-1100 scalpel demonstrated faster vessel-sealing speed (4.9 sec. vs 5.1 sec.) and less frequent vessel burst pressure < 700 mmHg (0% vs 40%) after 300 activations than the H-HD1000i scalpel; however, the difference did not reach statistical significance (P = 0.21 and P = 0.09, respectively). CONCLUSION: In an ex vivo porcine hepatectomy model, the H-1100 scalpel shows lower passive jaw temperature and maintains its sealing performance by avoiding tissue pad degradation compared to that with the H-HD1000i.

Impact of AirSeal® insufflation system on respiratory and circulatory dynamics during laparoscopic abdominal surgery.

The effect of the AirSeal® insufflation system on hemodynamic parameters, especially end-tidal carbon dioxide (EtCO2), during laparoscopic abdominal surgery remains unclear. This retrospective single-center study included 333 consecutive patients who underwent laparoscopic hepatectomy (n = 43), gastrectomy (n = 69), colectomy (n = 137), or proctectomy (n = 84) using the AirSeal®. Patient demographics and intraoperative hemodynamic parameters, such as EtCO2, peripheral capillary oxygen saturation (SpO2), and arterial systolic blood pressure (ABP), were collected and analyzed. EtCO2 was evaluated during the entire operative period (whole period) as well as the pneumoperitoneum period until specimen removal (pneumoperitoneum period). We defined "positive respiratory and circulatory responses" (positive responses) as a decrease in EtCO2 ≥ 3 mmHg in addition to decreases in SpO2 ≥ 3% and ABP ≥ 10 mmHg simultaneously, which suggest possible carbon dioxide (CO2) embolism. The median EtCO2 values of hepatectomy, gastrectomy, colectomy, and proctectomy in the whole period/pneumoperitoneum period were 37.3/37.4, 37.1/37.3, 37.4/37.9, and 38.2/38.4 mmHg, respectively. The EtCO2 of proctectomy was significantly higher than that of gastrectomy during the whole and pneumoperitoneum periods (P < 0.05). In contrast, the EtCO2 of hepatectomy was comparable to that of the other three surgeries in the whole and pneumoperitoneum periods. Meanwhile, nine (2.7%; eight hepatectomies and one proctectomy) patients showed positive responses, and one who underwent a partial hepatectomy developed a clinically manifested CO2 embolism. Positive responses occurred during venous exposure or bleeding in all nine cases. Although the EtCO2 of hepatectomy was comparable to that of the other surgeries using the AirSeal®, laparoscopic hepatectomy showed a tendency of CO2 embolism. Thus, a secure and careful surgical approach is mandatory for laparoscopic hepatectomy using the AirSeal® insufflation system.

Novel Hemostatic Technique During Laparoscopic Liver Parenchymal Transection: Saline-Linked Electrocautery Combined With Wet Oxidized Cellulose (SLiC-WOC) Method.

INTRODUCTION: Although laparoscopic hepatectomy has the potential advantage of reducing intraoperative blood loss, it is more difficult to control bleeding laparoscopically compared to an open approach. We introduced a novel hemostatic technique, the saline-linked electrocautery combined with wet oxidized cellulose (SLiC-WOC) method, during laparoscopic hepatectomy where a combination of saline-linked electrocautery (SLiC) and wet oxidized cellulose (WOC) is used. This study aimed to investigate the feasibility of employing the SLiC-WOC method for laparoscopic hepatectomy. METHODS: Thirteen patients who underwent laparoscopic liver resection with the SLiC-WOC method between 2019 and 2020 were included in this study. The number of bleeding episodes in which the SLiC-WOC method was applied was counted, and the time required to achieve complete hemostasis was measured. RESULTS: Among the bleeding events that were difficult to achieve hemostasis by SLiC alone, 94% were safely and efficiently controlled. Additionally, 69% of hemostasis was achieved within 60 seconds and 91% within 120 seconds. Postoperatively, most patients experienced no complications and no operative mortality was observed. CONCLUSIONS: The SLiC-WOC method can provide safe and time-efficient hemostasis during laparoscopic hepatectomy. This is especially crucial for bleeding, which is difficult to control using electrocautery alone.

Gallbladder Intramucosal Carcinoma Arising in a Cholesterol Polyp: A Case Report.

Cholesterol polyp is the most common benign disease of gallbladder polyps, and is considered not to be the origin of malignancy. Herein, we report a rare case of a well-differentiated adenocarcinoma arising in a gallbladder cholesterol polyp. A pedunculated mulberry-like gallbladder polyp diagnosed with a cholesterol polyp preoperatively consisted of two distinct components macroscopically: a yellow-whitish lobulated lesion and a brownish irregular lesion. Microscopically, the former revealed to be a cholesterol polyp, but the latter demonstrated a well-differentiated adenocarcinoma. Even if imaging findings suggest a gallbladder cholesterol polyp, it is important to keep in mind that carcinoma can coexist like our case.

Dissection Around the Superior Mesenteric Artery (SMA) Using LigaSure Maryland During Left Posterior Approach for Pancreaticoduodenectomy.

R0 resection for pancreatic head cancer without exposing the tumor demands complete resection of "mesopancreas". In other words, dividing the proximal jejunal artery and vein at their roots of the superior mesenteric artery (SMA) and superior mesenteric vein (SMV) respectively during pancreaticoduodenectomy (PD) is absolutely essential. We present here our standardized dissection procedures around the SMA during the left posterior approach for PD. This procedure is safe and reproducible owing to the secure sealing performance of LigaSureTM Maryland.

Crucial Roles of the Assistant Surgeon During Laparoscopic Left Hemihepatectomy.

Background Although left hemihepatectomy has been widely performed via the laparoscopic approach, the roles of the assistant surgeon have not been well-documented so far. We herein present our standardized procedures of laparoscopic left hemihepatectomy without Spiegel's lobe resection, focusing on the crucial roles of the assistant surgeon. Methods During laparoscopic left hemihepatectomy without Spiegel's lobe resection, countertraction by the assistant surgeon is quite important especially during isolating the left Glissonean pedicle and transecting liver parenchyma. When securing the left hepatic pedicle using the Glissonean approach, the assistant surgeon pushes Segment 4 of the liver cranially and pulls the tape encircling the hepatoduodenal ligament caudally in the opposite way, orthogonal to the direction of the laparoscopic forceps toward the left portal triad. During liver parenchymal transection, the assistant surgeon pulls the hanging tape across the left lobe of the liver in order to provide a wide and stable liver transection plane. With this standardized technique, nine cases of laparoscopic left hemihepatectomy were performed over the last two years in our department, and the perioperative data were retrospectively analyzed. Results The median age of the nine patients was 70 years (range: 58 - 84 years). Most of the patients were males (77.8%). Five of nine patients were diagnosed with colorectal liver metastasis, two with hepatocellular carcinoma (HCC), one with inflammatory pseudotumor, and the other one with hepaticolithiasis. There were no conversions to open surgery. The median operative time and estimated blood loss were 337 minutes (range: 219 - 478 minutes) and 100 ml (range: 41 - 375 ml), respectively. The median length of postoperative hospital stay was nine days (range: 7 - 16 days). Major complications (Clavien-Dindo classification grade III or more) were not encountered in our cohort postoperatively. Conclusion We presented here our standardized assistant roles during laparoscopic left hemihepatectomy without Spiegel's lobe resection, which was revealed to be safe and feasible in our cohort.