Robotic Artery-First Approach During Pancreatoduodenectomy.

BACKGROUND: Surgical resection with adjuvant or neoadjuvant chemotherapy is the only curative modality for treatment of patients with pancreatic and periampullary tumors. With the increasing use of minimally invasive techniques, laparoscopic and robotic pancreatoduodenectomy (PD) has become more common, but laparoscopic artery-first techniques have been described in few studies. The aim of this study is to describe our robotic artery-first technique. METHODS: Video clips were compiled from several robotic PDs to demonstrate the artery-first technique. This technique consists of early retroperitoneal dissection of the superior mesenteric artery from the pancreatic head. RESULTS: Overall, 73 patients underwent robotic PD at our center between March 2018 and August 2020. Of these, 24 patients underwent the robotic artery-first approach. Indication for its use included proximity of the tumor to the portal vein or SMV in six cases. In three cases, partial resection of the portomesenteric axis was necessary, and the artery-first approach allowed for safe venous resection and reconstruction. In three other cases, the tumor was in close contact with the vein, but it could be resected with free margins without venous resection. In the remaining 18 patients, the approach was systematically used regardless of tumor proximity to the portomesenteric axis. CONCLUSIONS: This robotic artery-first approach is feasible and safe for PD. The approach could facilitate robotic PD, and its systematical use could provide some important advantages during the resection phase. The videos could also help oncological surgeons to perform this complex yet important maneuver.

Multiple colorectal liver metastases resection can offer long-term survival: The concept of a chronic neoplastic disease.

BACKGROUND: Resection for colorectal liver metastases has evolved significantly and, currently, there are no limits to the number of resected nodules. This study aimed to evaluate the outcomes and prognostic factors after liver resection for patients with ≥4 colorectal liver metastases, emphasizing long-term survival. METHODS: The study population consisted of 137 patients with ≥4 colorectal liver metastases out of a total of 597 patients with colorectal liver metastases who underwent curative intent liver resection from January 2010 to July 2019 in a single hepatobiliary center. RESULTS: The probability of overall and disease-free survival at 1, 3, and 5 years was 90.8%, 64.5%, 40.6%, and 37.7%, 19.3%, 18.1%, respectively. In a multivariate analysis for overall survival, the size of the largest metastatic nodule was the only unfavorable factor (P = .001). For disease-free survival, complete pathological response was a favorable factor (P = .04), and the following were negative factors: number of nodules ≥7 (P = .034), radiofrequency ablation during surgery (P = .04), positive primary tumor lymph nodes (P = .034), R1 resection (P = .011), and preoperative carcinoembryonic antigen >20 ng/mL (P = .015). After the first and second years of follow-up, 59 patients (45.3%) and 45 patients (34.6%), respectively, were not receiving chemotherapy. After 5 years of follow-up, 21 (16.1%) multimetastatic patients were chemotherapy-free. CONCLUSION: A significant number of patients with multiple colorectal liver metastases will present long-term survival and should not be denied surgery. The long-term survival rates, even in the presence of recurrence, characterize a chronic neoplastic disease.

HEPATOSPLENIC SCHISTOSOMIASIS-ASSOCIATED CHRONIC PORTAL VEIN THROMBOSIS: RISK FACTOR FOR HEPATOCELLULAR CARCINOMA?

BACKGROUND: Hepatosplenic schistosomiasis is an endemic disease prevalent in tropical countries and is associated with a high incidence of portal vein thrombosis. Inflammatory changes caused by both parasitic infection and portal thrombosis can lead to the development of chronic liver disease with potential carcinogenesis. AIMS: To assess the incidence of portal vein thrombosis and hepatocellular carcinoma in patients with schistosomiasis during long-term follow-up. METHODS: A retrospective study was conducted involving patients with schistosomiasis followed up at our institution between 1990 and 2021. RESULTS: A total of 126 patients with schistosomiasis were evaluated in the study. The mean follow-up time was 16 years (range 5-31). Of the total, 73 (57.9%) patients presented portal vein thrombosis during follow-up. Six (8.1%) of them were diagnosed with hepatocellular carcinoma, all with portal vein thrombosis diagnosed more than ten years before. CONCLUSIONS: The incidence of hepatocellular carcinoma in patients with schistosomiasis and chronic portal vein thrombosis highlights the importance of a systematic long-term follow-up in this group of patients.

Two decades of liver resection with a multidisciplinary approach in a single institution: What has changed? Analysis of 1409 cases.

OBJECTIVES: To evaluate results of patients undergoing liver resection in a single center over the past two decades with a particular look at Colorectal Liver Metastasis (CRLM) and Hepatocellular Carcinoma (HCC). METHOD: Patients were divided into two eras, from 2000 to 2010 (Era 1) and 2011 to 2020 (Era 2). The most frequent diagnosis was CRLM and HCC, with 738 (52.4%) and 227 (16.1%) cases respectively. An evaluation of all liver resection cases and a subgroup analysis of both CRLM and HCC were performed. Preoperative and per operative variables and long-term outcomes were evaluated. RESULTS: 1409 liver resections were performed. In Era 2 the authors observed higher BMI, more: minimally invasive surgeries, Pringle maneuvers, and minor liver resections; and less transfusion, less ICU necessity, and shorter length of hospital stay. Severe complications were observed in 14.7% of patients, and 90-day mortality was 4.2%. Morbidity and mortality between eras were not different. From 738 CRLM resections, in Era 2 there were significantly more patients submitted to neoadjuvant chemotherapy, bilateral metastases, and smaller sizes with significantly less transfusion, the necessity of ICU, and shorter length of hospital stay. More pedicle clamping, minimally invasive surgeries, and minor resections were also observed. From 227 HCC resections, in Era 2 significantly more minimally invasive surgeries, fewer transfusions, less necessity of ICU, and shorter length of hospital stay were observed. OS was not different between eras for CRLM and HCC. CONCLUSIONS: Surgical resection in a multidisciplinary environment remains the cornerstone for the curative treatment of primary and metastatic liver tumors.

Feasibility of Right Upper Transversal Hepatectomy in the Absence of an Inferior Right Hepatic Vein: New Insights regarding This Complex Procedure.

BACKGROUND: Right upper transversal hepatectomy (RUTH) is defined as the removal of liver segments 7, 8, and 4A with ligature of the right and middle hepatic veins and is considered one of the most complex techniques of parenchymal-sparing hepatectomies. This procedure can be performed, without venous reconstruction, if collateral veins are present communicating within remnant liver segments to a large inferior right hepatic vein and/or to the left hepatic vein. This venous network could maintain outflow from the inferior right segments (S5, S6) to the left liver when a RUTH is performed, even in the absence of an inferior right hepatic vein. The aim of this study is to present our experience with RUTH without venous reconstruction in patients with and without the presence of an inferior right hepatic vein (IRHV). METHODS: Patients submitted to RUTH for treatment of liver metastases were selected from our database. The presence of an IRHV, clinical and surgical characteristics of the patients, immediate outcomes, viability of liver segments 5 and 6, and long-term survival were analyzed. RESULTS: RUTH was successfully performed in four patients. In two patients, IRHV was not present, but intrahepatic communicating veins between proximal right and middle hepatic veins and left hepatic vein were present. No venous reconstructions were performed. Mild congestion of the inferior right segments occurred in the patients where there was no IRHV but no immediate, early, or late complications were observed. CONCLUSIONS: RUTH is feasible and can be performed even in the absence of an IRHV, without venous reconstruction. Some degree of congestion of the right inferior liver segments might occur when an IRHV is absent, yet this is not clinically significant when communicating veins are present. Maximum parenchyma preservation might prevent postoperative liver failure and allow repeated resections in case of hepatic recurrence.

A Combined "Hanging Liver Maneuver" and "Intrahepatic Extra-Glissonian Approach" for Anatomical Right Hepatectomy: Technique Standardization, Results, and Correlation With Portal Pedicle Anatomy.

Background: The hanging liver maneuver and intrahepatic extra-Glissonian approach are distinct modalities to facilitate safe anatomical liver resections. This study reports a standardized combination of these techniques focusing on safety, results and correlation with portal pedicle anatomy in oncological patients. Method: Combined hanging liver maneuver and intrahepatic extra-Glissonian approach for anatomic right hepatectomy was described stepwise. Portal pedicle anatomy was correlated with the Glissonian approach failure and complications. Clinical characteristics of patients, perioperative outcomes, short and long-term survival rates were analyzed. Results: Thirty colorectal liver metastases patients submitted to the combined approach were evaluated. Anatomical variations of the right portal pedicle were present in 26.6%. Hanging liver maneuver was feasible in 100%, and Glissonian approach in 96.7% despite portal pedicle variations. Mean operative time was 326 min. Mean blood loss was 507 ml. Mean hospital stay was 8 days. There was no 90-day operative mortality and no significant morbidity. Oncological surgical margins were free. Overall and disease-free 5-year survival were 59 and 37%. Conclusion: Regardless of frequent anatomical variations of the right portal pedicle, the hanging liver maneuver, and intrahepatic extra-Glissonian approach can be combined, being useful for anatomical right hepatectomies in a safe and reproducible way in most patients.

Long-term results of esophagogastric devascularization and splenectomy associated with endoscopic treatment in schistosomal portal hypertension.

BACKGROUND: Esophagogastric devascularization and splenectomy (EGDS) is the most performed operation for prophylaxis of esophageal varices bleeding recurrence in hepatosplenic schistosomiasis. Lower rebleeding rates are obtained through the association of postoperative endoscopic treatment; however, there is a dearth of studies showing long-term results. METHODS: Clinical, laboratory, and endoscopic data of 97 patients submitted to EGDS with at least 5 years of follow-up, were analyzed. RESULTS: The mean follow-up was 116.4 months. Bleeding recurrence occurred in 24.7% of patients; however, this percentage was 14.6% when only variceal hemorrhage was considered. Bleeding recurrence occurred in four patients even after endoscopic evaluation demonstrated esophageal varices eradication. In the late follow-up we observed normalization of anemia, leukopenia, thrombocytopenia, hyperbilirubinemia, and a prothrombin activity time increase. No clinical or laboratory hepatic insufficiency was observed. CONCLUSIONS: The EGDS procedure with postoperative endoscopic treatment led to good clinical results and avoided hemorrhagic recurrence in 75.3% of schistosomal patients. There was improvement of laboratory measures of hepatic function, as well as correction of hypersplenism. Variceal hemorrhagic recurrence may occur even when esophageal varices eradication is reached.

Robotic pancreatic resection. Personal experience with 105 cases.

OBJECTIVE: the first robotic pancreatic resection in Brazil was performed by our team in 2008. Since March 2018, a new policy prompted us to systematically employ the robot in all minimally invasive pancreatic surgery. The aim of this paper is to review our experience with robotic pancreatic resection. METHODS: all patients who underwent robotic pancreatic resection from March 2018 through December 2019 were identified. Descriptive data were collected. Preoperative variables included age, sex, and indication for surgery. Intraoperative variables included operative time, bleeding, blood transfusion. RESULTS: 105 patients underwent robotic pancreatectomy. Median age was 60.5 years old. Fifty-five patients were female. 51 patients underwent robotic pancreatoduodenectomies, 34 distal pancreatectomy. Morbidity was 23.8%, mainly related to postoperative pancreatic fistula and one death occurred (mortality of 0.9%). Three patients (2.8%) were converted to open surgery. Four patients had delayed gastric emptying and two presented bleeding. Twenty-four patients had pancreatic fistula that was treated conservatively with late removal of the pancreatic drain. No patient required percutaneous drainage, reintervention or hospital readmission. CONCLUSIONS: the robotic platform is useful for the reconstruction of the alimentary tract after pancreatoduodenectomy or after central pancreatectomy. It may increase the preservation of the spleen during distal pancreatectomies. Pancreas sparing techniques, such as enucleation, resection of uncinate process and central pancreatectomy, should be used to avoid exocrine and/or endocrine insufficiency. Robotic resection of the pancreas is safe and feasible for selected patients. It should be performed in specialized centers by surgeons with experience in both open and minimally invasive pancreatic surgery.

PORTAL PRESSURE DECREASE AFTER ESOPHAGOGASTRIC DEVASCULARIZATION AND SPLENECTOMY IN SCHISTOSOMIASIS: LONG-TERM VARICES BEHAVIOR, REBLEEDING RATE, AND ROLE OF ENDOSCOPIC TREATMENT.

BACKGROUND: Schistosomiasis is an endemic health problem affecting about four million people. The hepatosplenic form of the disease is characterized by periportal hepatic fibrosis, pre-sinusoidal portal hypertension and splenomegaly. Liver function is preserved, being varices bleeding the main complication of the disease. The surgical treatment used in the majority of centers for the prevention of rebleeding is esophagogastric devascularization and splenectomy. Most authors reported better results with the association of surgical and postoperative endoscopic treatment. OBJECTIVE: The aim of this study was to compare the intra operative portal pressure decrease and esophageal varices behavior and rebleeding rates in patients submitted to surgical and postoperative endoscopic treatment after long-term follow-up. METHODS: A retrospective study of 36 patients with schistosomiasis with, at least, one previous bleeding from esophageal varices rupture submitted to esophagogastric devascularization and splenectomy, added to endoscopic varices postoperative treatment was performed. Patients were stratified according to the intra operative portal pressure decrease in two groups: reduction below and above 30%. Long-term varices presence, size and bleeding recurrence were evaluated. RESULTS: Regarding varices behavior, no significant influence was observed in both groups of portal pressure fall. Regarding bleeding recurrence, despite three times more frequent in the group with lower portal pressure fall, no significant difference was observed. All patients were submitted to postoperative endoscopic treatment. CONCLUSION: Esophageal varices banding, rather than portal pressure decrease, seems to be the main responsible factor for good results after combination of two therapies (surgery and endoscopy) for patients with portal hypertension due to schistosomiasis; further studies are necessary to confirm this hypothesis.

Hepatosplenic schistosomiasis-associated chronic portal vein thrombosis: risk factor for hepatocellular carcinoma? / Esquistossomose hepatosplênica associada à trombose crônica da veia porta: fator de risco para o carcinoma hepatocelular?

ABSTRACT BACKGROUND: Hepatosplenic schistosomiasis is an endemic disease prevalent in tropical countries and is associated with a high incidence of portal vein thrombosis. Inflammatory changes caused by both parasitic infection and portal thrombosis can lead to the development of chronic liver disease with potential carcinogenesis. AIMS: To assess the incidence of portal vein thrombosis and hepatocellular carcinoma in patients with schistosomiasis during long-term follow-up. METHODS: A retrospective study was conducted involving patients with schistosomiasis followed up at our institution between 1990 and 2021. RESULTS: A total of 126 patients with schistosomiasis were evaluated in the study. The mean follow-up time was 16 years (range 5-31). Of the total, 73 (57.9%) patients presented portal vein thrombosis during follow-up. Six (8.1%) of them were diagnosed with hepatocellular carcinoma, all with portal vein thrombosis diagnosed more than ten years before. CONCLUSIONS: The incidence of hepatocellular carcinoma in patients with schistosomiasis and chronic portal vein thrombosis highlights the importance of a systematic long-term follow-up in this group of patients.

RESUMO RACIONAL: A esquistossomose hepatoesplênica é uma doença endêmica prevalente em países tropicais e está associada a uma alta incidência de trombose da veia porta. Alterações inflamatórias causadas tanto pela infecção parasitária quanto pela trombose portal podem levar ao desenvolvimento de doença hepática crônica com potencial carcinogênico. OBJETIVOS: Avaliar a incidência de trombose da veia porta e carcinoma hepatocelular em pacientes com esquistossomose durante um seguimento de longo prazo. MÉTODOS: Foi realizado estudo retrospectivo envolvendo pacientes com esquistossomose acompanhados em nossa instituição entre 1990 e 2021. RESULTADOS: Um total de 126 pacientes com esquistossomose foram avaliados no estudo. O tempo médio de acompanhamento foi de 16 anos (variando de 5 a 31). Do total, 73 (57,9%) pacientes apresentaram trombose da veia porta durante o seguimento e seis (8,1%) deles foram diagnosticados com carcinoma hepatocelular, todos com trombose da veia porta diagnosticada há mais de 10 anos. CONCLUSÕES: A incidência de carcinoma hepatocelular em pacientes com esquistossomose e trombose da veia porta crônica destaca a importância de um acompanhamento sistemático de longo prazo nesse grupo de pacientes.

LAPAROSCOPIC UNCINATECTOMY: A MORE CONSERVATIVE APPROACH TO THE UNCINATE PROCESS OF THE PANCREAS.

BACKGROUND: The isolate resection of the uncinate process of the pancreas is a rarely described procedure but is an adequate surgery to treat benign and low grade malignancies of the uncinate process of the pancreas. AIM: To detail laparoscopic uncinatectomy technique and present the initial results. METHOD: Patient is placed in supine position with the surgeon between legs. Three 5-mm, one 10-mm and one 12-mm trocars were used to perform the isolated resection of the uncinate process of the pancreas. Parenchymal transection is performed with harmonic scalpel. A hemostatic absorbable tissue is deployed over the area previously occupied by the uncinate process. A Waterman drain is placed. RESULT: This procedure was applied to an asymptomatic 62-year-old male with biopsy proven low grade neuroendocrine tumor of the pancreatic uncinate process. A laparoscopic pancreaticoduodenectomy was proposed. During the initial surgical evaluation, intraoperative sonography was performed and disclosed that the lesion was a few millimeters away from the Wirsung. The option was to perform a laparoscopic uncinatectomy. Postoperative period until full recovery was swift and uneventful. CONCLUSION: Laparoscopic uncinatectomy is a safe and efficient procedure when performed by surgical teams with large experience in minimally invasive biliopancreatic procedures.

Are Hybrid Liver Resections Truly Minimally Invasive? A Propensity Score Matching Analysis.

BACKGROUND: Hybrid liver resection is considered a modality of minimally invasive surgery; however, there are doubts regarding loss of benefits of laparoscopy due to the use of an auxiliary incision. We compared perioperative results of patients undergoing hybrid × open and hybrid × pure laparoscopic resections. METHODS: Consecutive patients undergoing liver resection between June 2008 and January 2016 were studied. Study groups were compared after propensity score matching (PSM). RESULTS: Six hundred forty-four resections were included in the comparative analysis: 470 open, 120 pure laparoscopic, and 54 hybrids. After PSM, 54 patients were included in each group. Hybrid × open: hybrid technique had shorter operative time (319.5 ± 108.6 × 376.2 ± 155.8 minutes, P = .033), shorter hospital stay (6.0 ± 2.7 × 8.1 ± 5.6 days, P = .001), and lower morbidity (18.5% × 40.7%, P = .003). Hybrid × pure laparoscopic: hybrid group had lower conversion rate (0% × 13%, P = .013). There was no difference regarding estimated blood loss, transfusion rate, hospital stay, complications, or mortality. CONCLUSIONS: Hybrid resection has better perioperative results than the open approach and is similar to pure laparoscopy. The hybrid technique should be considered a minimally invasive approach.

Two decades of liver resection with a multidisciplinary approach in a single institution: What has changed? Analysis of 1409 cases

Abstract Objectives: To evaluate results of patients undergoing liver resection in a single center over the past two decades with a particular look at Colorectal Liver Metastasis (CRLM) and Hepatocellular Carcinoma (HCC). Method: Patients were divided into two eras, from 2000 to 2010 (Era 1) and 2011 to 2020 (Era 2). The most frequent diagnosis was CRLM and HCC, with 738 (52.4%) and 227 (16.1%) cases respectively. An evaluation of all liver resection cases and a subgroup analysis of both CRLM and HCC were performed. Preoperative and per operative variables and long-term outcomes were evaluated. Results: 1409 liver resections were performed. In Era 2 the authors observed higher BMI, more: minimally invasive surgeries, Pringle maneuvers, and minor liver resections; and less transfusion, less ICU necessity, and shorter length of hospital stay. Severe complications were observed in 14.7% of patients, and 90-day mortality was 4.2%. Morbidity and mortality between eras were not different. From 738 CRLM resections, in Era 2 there were significantly more patients submitted to neoadjuvant chemotherapy, bilateral metastases, and smaller sizes with significantly less transfusion, the necessity of ICU, and shorter length of hospital stay. More pedicle clamping, minimally invasive surgeries, and minor resections were also observed. From 227 HCC resections, in Era 2 significantly more minimally invasive surgeries, fewer transfusions, less necessity of ICU, and shorter length of hospital stay were observed. OS was not different between eras for CRLM and HCC. Conclusions: Surgical resection in a multidisciplinary environment remains the cornerstone for the curative treatment of primary and metastatic liver tumors.

Guidelines for the management of neuroendocrine tumours by the Brazilian gastrointestinal tumour group.

Neuroendocrine tumours are a heterogeneous group of diseases with a significant variety of diagnostic tests and treatment modalities. Guidelines were developed by North American and European groups to recommend their best management. However, local particularities and relativisms found worldwide led us to create Brazilian guidelines. Our consensus considered the best feasible strategies in an environment involving more limited resources. We believe that our recommendations may be extended to other countries with similar economic standards.

I BRAZILIAN CONSENSUS ON MULTIMODAL TREATMENT OF COLORECTAL LIVER METASTASES. MODULE 2: APPROACH TO RESECTABLE METASTASES.

BACKGROUND: Liver metastases of colorectal cancer are frequent and potentially fatal event in the evolution of patients. AIM: In the second module of this consensus, management of resectable liver metastases was discussed. METHOD: Concept of synchronous and metachronous metastases was determined, and both scenarius were discussed separately according its prognostic and therapeutic peculiarities. RESULTS: Special attention was given to the missing metastases due to systemic preoperative treatment response, with emphasis in strategies to avoid its reccurrence and how to manage disappeared lesions. CONCLUSION: Were presented validated ressectional strategies, to be taken into account in clinical practice.

Anatomical basis for the intrahepatic glissonian approach during hepatectomies.

BACKGROUND: Anatomical liver resections are based on some basic technical principles such as vascular control, ischemic area delineation to be resected and maximum parenchymal preservation. These aspects are achieved by the intrahepatic glissonian approach, which consists in accessing the pedicles of hepatic segments within the hepatic parenchyma. Small incisions on well-defined anatomical landmarks are performed to approach the pedicles, making dissection of the hilar plate unnecessary. AIM: Analyze parameters in liver anatomy related to intrahepatic surgical technique to glissonians pedicles, to set the normal anatomy related to the procedure and thereby facilitate the attainment of this technique. METHODS: Anatomical parameters related to the intrahepatic glissonian approach were studied in 37 cadavers. Measurements were performed with precision instruments. Data were expressed as mean±standard deviation. The subjects were divided into groups according to gender and liver weight and groups were compared statistically. RESULTS: Twenty-five cadavers were male and 12 female. No statistically significant difference was observed in virtually all parameters when groups were compared. This demonstrates the consistency of the anatomical parameters related to the intrahepatic glissonian approach. CONCLUSION: The results obtained in this study made possible major technical advances in the realization of open and laparoscopic hepatectomies with intrahepatic glissonian approach, and can help surgeons to perform liver resections by this method.

Laparoscopic Distal Pancreatectomy Using Single-Port Platform: Technique, Safety, and Feasibility in a Clinical Case Series.

BACKGROUND: A novel technique using a single-incision laparoscopic approach has been described for several laparoscopic procedures. The aim of this article is to describe our experience with an alternative technique for laparoscopic distal pancreatectomies using a single-port platform. MATERIALS AND METHODS: We have performed this procedure on 20 patients with pancreatic tumors in the pancreatic body or tail. A transumbilical incision is performed, and a single-incision platform is introduced. The stomach is sutured to the abdominal wall to expose the pancreas. This technique uses an additional 5-mm trocar in the left quadrant, ultimately used for drainage after the end of the procedure. RESULTS: The median operative time was 176 minutes, and the hospital stay was 2 days. Mortality was 0%, and morbidity was 20%; 4 patients developed grade A pancreatic fistula. During follow-up (median, 11 months), no patient developed an incisional hernia. The cosmetic appearance of the incision was excellent in all cases. CONCLUSIONS: Laparoscopic distal pancreatectomy using a single-port platform is feasible and can be successfully performed by surgeons with experience in pancreatic and advanced laparoscopic surgery.

Video assisted resections. Increasing access to minimally invasive liver surgery?

OBJECTIVE: To evaluate perioperative outcomes, safety and feasibility of video-assisted resection for primary and secondary liver lesions. METHODS: From a prospective database, we analyzed the perioperative results (up to 90 days) of 25 consecutive patients undergoing video-assisted resections in the period between June 2007 and June 2013. RESULTS: The mean age was 53.4 years (23-73) and 16 (64%) patients were female. Of the total, 84% were suffering from malignant diseases. We performed 33 resections (1 to 4 nodules per patient). The procedures performed were non-anatomical resections (n = 26), segmentectomy (n = 1), 2/3 bisegmentectomy (n = 1), 6/7 bisegmentectomy (n = 1), left hepatectomy (n = 2) and right hepatectomy (n = 2). The procedures contemplated postero-superior segments in 66.7%, requiring multiple or larger resections. The average operating time was 226 minutes (80-420), and anesthesia time, 360 minutes (200-630). The average size of resected nodes was 3.2 cm (0.8 to 10) and the surgical margins were free in all the analyzed specimens. Eight percent of patients needed blood transfusion and no case was converted to open surgery. The length of stay was 6.5 days (3-16). Postoperative complications occurred in 20% of patients, with no perioperative mortality. CONCLUSION: The video-assisted liver resection is feasible and safe and should be part of the liver surgeon armamentarium for resection of primary and secondary liver lesions.