Anatomically unfavorable segments: laparoscopic and robotic liver resection in posterosuperior segments and the caudate lobe, a narrative review

Objective: Laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) has grown since the early minimally invasive liver surgery (MILS) reports. The advantages of this approach in the treatment of HCC are well known today. However, the indication for LLR for HCC is not yet well defined. Background: The resection of tumors located in the posterosuperior segments and the caudate lobe is still debated. Many techniques have been described, focusing on the trocar introduction and the patient’s position. Methods: A literature search was performed using the PubMed database. Thirty-seven publications, including 331 patients, were relevant to laparoscopic or robotic resection for HCC in unfavorable liver segments. All the articles with no clear indications about the histology of the tumor or the precise posterosuperior or caudate localization were excluded. The present review aims to report the experience of laparoscopic and robotic resection for HCC in unfavorable segments. Based on technical approaches, the resections of tumors located in the segments IVa, VII, VIII, and the caudate lobe have been discussed analyzing preoperative and intraoperative features; in a separate section, the resections performed through robotic approach have been discussed. Conclusions: According to the current literature, LLR for HCC is feasible and safe in unfavorable segments. It is necessary to gradually increase the skills of laparoscopic or robotic surgery according to the experience level before performing technically demanding procedures.