Current difficulty scoring systems may underestimate the technical complexity of segment 6 laparoscopic hepatectomy in patients with hepatocellular carcinoma.

INTRODUCTION

Laparoscopic hepatectomy is a standard treatment for selected Hepatocellular carcinoma (HCC) patients. Although segment 6 (S6) is generally classified as a favorable location, its deep transection plane, restricted working angle, and proximity to major vessels may increase operative difficulty. This study reassesses the technical complexity of S6 by comparing perioperative outcomes and established scoring systems across liver segments.

METHODS

We retrospectively analyzed patients undergoing laparoscopic hepatectomy for primary HCC and compared S6, favorable location (FL), and unfavorable location (UFL) groups using the IWATE, Hasegawa, IMM, and SHH scoring systems. Univariable and multivariable analyses were performed to strengthen the robustness of our findings.

RESULTS

Among 153 patients undergoing laparoscopic hepatectomy for HCC, 32 were in the S6 group, 68 in the UFL group, and 53 in the FL group. S6 was consistently classified as low-to-intermediate difficulty with IWATE scores 6 vs. 9 vs. 6, Hasegawa 3 vs. 4 vs. 1, IMM 2 vs. 2 vs. 1, and SHH 4 vs. 6 vs. 4 (S6 vs. UFL vs. FL). However, S6 showed longer operative time (246 vs. 198 vs. 171 min, p = 0.005), prolonged Pringle time (78 vs. 62 vs. 46 min, p = 0.036), greater blood loss (300 vs. 200 vs. 150 mL, p = 0.011), longer hospital stay (6 vs. 7 vs. 6 days, p = 0.022), and comparable major complication rates (3.1% vs. 4.4% vs. 0%, p = 0.314). These findings suggest that current scoring systems may underestimate the true technical complexity of S6 resections.

CONCLUSIONS

Although S6 has conventionally been considered a favorable anterolateral segment, laparoscopic hepatectomy for HCC in this location demonstrated greater operative complexity than predicted by existing difficulty scoring systems. These results suggest that current anatomical classifications may oversimplify segment-specific challenges and support the need for more precise difficulty assessment models that better reflect actual surgical demands.