Laparoscopic versus open hemihepatectomy: does side matter? A post-hoc analysis of the ORANGE II PLUS randomized controlled trial

Journal article

Background: Laparoscopic liver surgery offers several benefits, yet the adoption of laparoscopic right hemihepatectomy (RH) is slow, owing to its high degree of technical complexity. It is uncertain whether the general benefits of laparoscopy also extend to RH. This study evaluates perioperative outcomes of laparoscopic vs open RH, and illustrates differences in laparoscopic RH and left hemihepatectomy (LH) within the international, multicentre, double-blinded ORANGE-II-PLUS randomized trial. Methods: Patients were randomly assigned to open (n = 166) or laparoscopic hemihepatectomy (n = 166). The present post-hoc subgroup analysis compares perioperative and oncological outcomes of laparoscopic RH (n = 105) vs open RH (n = 108). In addition, interaction between surgical approach (open or laparoscopic) and hemihepatectomy laterality (RH; n = 213 vs LH; n = 119) was assessed. Results: There was a higher proportion of malignancy, including more colorectal liver metastases, and more preoperative portal vein embolization in patients undergoing RH compared to LH, other characteristics were well-balanced. The laparoscopic approach was associated with shorter time to functional recovery compared to open surgery for RH (median 5 vs 5 days, p = .004) and shorter length of hospital stay (median 5 vs 6 days, p = .014). Except for longer operating times in laparoscopy (332 vs 263 min, p < .001), no differences were found in other perioperative and oncological outcomes between laparoscopic and open RH. For all outcomes, interaction testing between surgical approach and laterality did not reach significance, suggesting that approach did not affect RH and LH differently. Though patients requiring laparoscopic RH needed longer operating time (332 vs 225 min) and time to functional recovery (median 5 vs 3 days) than patients requiring laparoscopic LH. Conclusion: Patients undergoing RH showed modest, population-level, benefits from a laparoscopic approach with regard to time to functional recovery and hospital length of stay, despite higher technical complexity and a more pronounced postoperative impact on the patient. Interaction testing between RH and LH did not reach significance, suggesting the effect of the approach on outcomes were consistent regardless of resection laterality. These results support the implementation of the laparoscopic approach for RH if surgeons are experienced. Clinical trial information: NCT01441856.

Authors: Olij, B; Pilz da Cunha, G; Ratti, F; Abu Hilal, M; Troisi, RI

• Publication status: Published
• Peer review status: Peer reviewed
• Publisher: Springer
• Journal: Surgical Endoscopy
• Volume: 40
• Issue: 5
• Pages: 4195-4205
• Publication date: 2026-03-09
• Acceptance date: 2026-01-10
• DOI: 10.1007/s00464-026-12588-w
• EISSN: 1432-2218
• ISSN: 1866-6817, 0930-2794
• Language: English
• Keywords: Minimally invasive liver surgery; Randomized controlled trial; Right hemihepatectomy; Left hemihepatectomy; Laparoscopic hepatectomy