Can Operative Time Be a Surrogate Marker for Postoperative Complications in Liver Surgery? A Procedure and Approach-specific International Multicentre Cohort

Purpose: A procedure- and approach-stratified analysis of the impact of operative time on postoperative complications in liver surgery is still lacking. The aim of this study is to assess the impact of operative time on the development of postoperative complications in patients who underwent minimally invasive or open liver resections of various anatomical extent and technical difficulty levels. Method: To perform this retrospective cohort study, patients who underwent a laparoscopic or open right hemihepatectomy (RH), technically major resection (anatomically minor resection in segment 1, 4a, 7 or 8; TMR) or left lateral sectionectomy (LLS) between 2000 and 2020 in 18 centres were identified in an international multicentre database. To ensure homogeneity in comparison, we selected those 3 standardized liver resections. Cases during the learning curve were omitted. Logistic regression models, stratified for the procedure group and allocated surgical approach, were used to assess the association of the fourth quartile of operative time with postoperative complications. Results: Overall, 4463 patients were included. 1378 underwent RH (1138 open & 240 laparoscopic), 2161 TMR (1268 open and 893 laparoscopic) and 924 LLS (335 open & 589 laparoscopic). Patients with complications generally had longer operative times, except for laparoscopic RH. After adjusting for potential confounders, the fourth quartile of operative time was associated with an increased risk of postoperative complications after laparoscopic TMR (aOR 1.91, p=0.001) and LLS (aOR 2.57, p<0.001), but not after open TMR (aOR 1.49, p=0.079), open LLS (aOR 2.19, p=0.096) and both open and laparoscopic RH (aOR 1.12, p=0.587 and aOR 1.26, p=0.475, respectively). Conclusion: A prolonged operative time, as a surrogate of complex resection, is associated with an increased occurrence of postoperative complications after laparoscopic minor liver resections, but not after all open procedures and laparoscopic major liver resections.