Laparoscopic versus open resection for hepatocellular carcinoma according to the procedure's complexity: real-world weighted data from a national register

Background: Minimal access liver surgery (MALS) is considered superior to open liver resection (OLR) in reducing the perioperative risk in patients affected by hepatocellular carcinoma (HCC). No national-level comparisons exist based on procedure complexity. This study aims to compare postoperative complications, postoperative ascites (POA), and major complications (MC) between MALS and OLR. Methods: Data were retrieved from the Italian HE. RC.O.LE.S. registry. Patients were categorized into OLR or MALS groups and stratified by complexity grade (CP1, CP2, CP3). An inverse probability weighting (IPW) was performed to ensure balanced comparisons. Results: From 2008 to 2021, 4738 patients were included: 1596 (33.7 %) underwent MALS, and 3142 (66.3 %) underwent OLR. CP1 procedures were conducted in 2522 cases (53.2 %), CP2 in 974 cases (20.5 %), and CP3 in 1242 cases (26.2 %). For CP1, MALS was associated with reduced POA (OR 0.356, 95%CI:0.29–0.43, p < 0.001), and MC (OR 0.738, 95%CI:0.59–0.91, p: 0.006). In CP2, MALS showed association with MC (OR 0.557, 95%CI:0.37–0.82, p:0.004), but not with POA. For CP3, MALS was associated with increased MC risk (OR 1.441, 95%CI:1.10–1.88, p:0.008). Low-volume centers had significantly higher MC risks after CP2 and CP3 procedures than medium or high-volume centers. Conclusion: In CP1 and CP2 procedures, MALS was proven advantageous in reducing POA and MC. Among CP3, MALS increased the risk of MC, but not among high-volume centres.