Minimally invasive surgery for hepatocellular carcinoma: evolving trade-offs of patient selection and recurrence risk

Background: Minimally invasive surgery (MIS) has gained widespread use for hepatocellular carcinoma (HCC) over the past 2 decades. Although MIS reduces surgical stress and shortens recovery, its intermediate-term effect, particularly on recurrence-free survival (RFS), remains uncertain. Given the increasing adoption of MIS, this study aimed to assess the effect of MIS on intermediate-term outcomes after HCC resection. Methods: Patients who underwent curative-intent HCC resection from 2000 to 2023 were identified from an international, multi-institutional database. Short-term outcomes included complications, hospital stay, operative time, blood loss, and surgical margins. Intermediate-term outcomes were 3-year overall survival (OS) and RFS. Kaplan-Meier and log-rank tests were used to compare outcomes by era (2000–2015 [early] vs 2016–2023 [recent]) and surgical approach (MIS vs non-MIS). Results: Among 1630 patients, MIS usage increased from 19.1% (early) to 36.0% (recent). Compared with non-MIS cases, recent MIS cases involved higher-risk patients, with more American Society of Anesthesiologists class > 2 (52.7% [MIS] vs 41.8% [non-MIS]; P <.001) and cirrhosis (54.9% [MIS] vs 45.2% [non-MIS]; P =.004). Major hepatectomy increased in both groups but remained less common in MIS (early: 10.9% [MIS] vs 36.3% [non-MIS]; P <.001; recent: 18.3% [MIS] vs 52.6% [non-MIS]; P <.001). Compared with non-MIS, MIS consistently demonstrated better short-term outcomes, including reduced blood loss (300 mL [IQR, 150–600] vs 150 mL [IQR, 100–350], respectively; P <.001), shorter hospital stays (10 days [IQR, 6–14] vs 5 days [IQR, 4–8], respectively; P <.001), and fewer complications (32.9% vs 23.2%, respectively; P =.002), including severe (Clavien-Dindo ≥ IIIa) complications (recent: 9.8% vs 4.9%, respectively; P =.013). However, the incidence of R1 margin was higher in patients in the MIS group than among individuals in the non-MIS group (12.2% vs 4.8%, respectively; P <.001). Although the 3-year OS was better in the MIS group than in the non-MIS group (85.6% vs 75.4%, respectively; P <.001), the 3-year RFS was worse in the MIS group in the recent era than in the non-MIS group ( P <.001). The subanalysis demonstrated that larger tumors were associated with higher R1 margin rates and increased recurrence/mortality risk in MIS than in non-MIS (both P <.001). Conclusion: MIS was increasingly performed among high-risk patients over the last decade. Despite better perioperative outcomes, there was an increase in the likelihood of an R1 margin and inferior RFS in patients who underwent MIS HCC resection compared with individuals who underwent non-MIS HCC resection.