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. 2017 Apr 25;1(1):33–43. doi: 10.1002/ags3.12000

Table 1.

Summary of recommendations of Morioka Consensus Conference

Jury Recommendations

  1. MINOR LLR is confirmed to be a standard practice in surgery but is still in the assessment phase (IDEAL 3) as it is adopted by more surgeons.

    1. Some outcomes, such as certain postoperative complications and duration of stay, were superior to those of open procedures; no outcomes were inferior.

    2. The quality of studies is generally LOW.

    3. Additional higher‐quality studies are needed in order to define the role and benefits of minor LLR in relation to open surgery.

  2. MAJOR LLR is an innovative procedure. It is still in the exploratory, learning phase (IDEAL 2b) and has incompletely defined risks.

    1. It should continue to be introduced cautiously.

    2. Duration of stay was shorter than that of open procedures; other outcomes were non‐inferior.

    3. The quality of studies is generally LOW.

    4. There is an urgent need for additional higher‐quality studies and registries, to define the role and benefits of major LLR in relation to open surgery.

  3. LAPAROSCOPIC DONOR SURGERY

    1. Pediatric donor surgery is classified as stage IDEAL 2b, as is major laparoscopic liver surgery.

    2. Adult‐to‐adult donor surgery is an innovative procedure still in the development phase (IDEAL 2a).

    3. The recommendation is that laparoscopic donor surgery be carried out under institutional ethical approval and with registry reporting.

  4. EDUCATION

    1. MAJOR laparoscopic liver surgery requires considerable technical skill and has a steep learning curve.

    2. Skill acquisition by trainees and practicing surgeons should be the subject of an urgent, focused effort by leaders in this field.

    3. The future of laparoscopic liver surgery depends on education initiatives.

  5. DIFFICULTY SCORING SYSTEM

    1. A scoring system is being developed to grade the technical difficulty of laparoscopic liver surgery and safely guide development of expertise.

    2. Validation and application of this process is STRONGLY recommended.

Expert Technical Recommendations

  1. There is GENERAL AGREEMENT that experience in both open liver surgery and advanced laparoscopy is mandatory and that surgeons must begin with minor laparoscopic resections.

  2. HALS AND HYBRID TECHNIQUE can help overcome certain difficulties associated with pure LLR and may be useful in minimizing conversions.

  3. CONCEPTUAL CHANGES include:

    1. A caudal approach that optimizes hilar dissection and transection of the liver parenchyma for major and/or anterior resections.

    2. A lateral approach (left lateral decubitus position) that optimizes access to posterior segments.

  4. CO2 PNEUMOPERITONEUM of 10–14 mmHg is generally used along with low central venous pressure.

    1. This provides satisfactory control of back bleeding during liver transection.

    2. Selective control of inflow during laparoscopy may be more efficient than during open surgery (a possible effect of pneumoperitoneum).

    3. Careful inspection should be routinely carried out after decreasing pneumoperitoneum pressure.

  5. LAPAROSCOPIC PARENCHYMAL TRANSECTION requires specific instruments.

    1. This provides for satisfactory control of back bleeding during liver transection.

    2. Surgeons must have a concrete understanding of the advantages and limitations of available instruments to ensure safe and effective LLR.

    3. Deeper transection should be carried out meticulously by exposing intraparenchymal structures with an ultrasonic aspirator (Cavitron ultrasonic surgical aspirator or equivalent), clamp‐crushing technique, or similar parenchymal dissection technique.

  6. ENERGY DEVICES are efficient and reliable.

    1. Despite their benefits, energy devices cannot replace acquisition of basic skills of hepatic surgery such as meticulous dissection, direct visualization, and sealing of vascular structures.

    2. The argon beam coagulator is not generally recommended because of the risk of gas embolism.

  7. The HILAR APPROACH includes individual hilar dissection and the Glissonian approach.

    1. Hilar dissection cannot be carried out distal to the first bifurcation of the portal branch (i.e. the right anterior and posterior sectional branches).

    2. The Glissonian approach is an important alternative when used appropriately.

  8. ANATOMICAL RESECTION for HCC and margin‐negative parenchyma‐sparing resection for colorectal cancer liver metastases are standard‐of‐care procedures.

    1. The laparoscopic versions of these techniques need to be standardized to increase uptake.

    2. Use of intraoperative ultrasound is recommended for determining the accuracy of clear margins and avoiding injury to major pedicles during LLR.

HALS, hand‐assisted laparoscopic surgery; LLR, laparoscopic liver resection.