What is the preferred surgical approach, laparoscopic vs open, for patients with viral hepatitis (e.g. HBV, HCV) and HIV infections undergoing surgery?

Laparoscopic vs Open Surgical Approach in Patients with Viral Hepatitis and HIV

In patients with viral hepatitis (HBV, HCV) undergoing liver surgery, the laparoscopic approach should be strongly preferred over open surgery, as it significantly reduces morbidity, mortality, blood loss, hospital stay, and postoperative infectious complications while achieving equivalent or superior long-term oncological outcomes. 1 For HIV-infected patients, laparoscopic surgery offers no specific advantage over open techniques and should follow standard surgical principles based on the underlying indication. 2

Laparoscopic Approach for Viral Hepatitis Patients

Strong Evidence Supporting Laparoscopic Liver Resection

The 2025 EASL guidelines provide the most current and authoritative recommendations for patients with viral hepatitis undergoing liver resection:

• Laparoscopic liver resection demonstrates superior early postoperative outcomes including reduced morbidity, blood loss, length of hospital stay, and perioperative mortality compared to open surgery. 1

• Long-term survival outcomes are similar or slightly superior with minimally invasive liver surgery (MILS) versus open surgery, making laparoscopy the preferred approach when technically feasible. 1

• Centers should strive to perform liver resection with a minimally invasive approach, especially for small tumors in favorable locations. 1

Specific Advantages in Cirrhotic Patients with Viral Hepatitis

The benefits of laparoscopy are particularly pronounced in patients with cirrhosis (commonly associated with HBV/HCV):

• Reduced postoperative infectious complications: Laparoscopic hepatectomy is independently associated with lower incidences of overall infection (6.9% vs 14.6%), incisional surgical site infection (1.8% vs 6.3%), organ/space infection (1.8% vs 4.6%), and remote infection (3.8% vs 9.8%) compared to open surgery. 3

• Lower major complication rates: Meta-analysis demonstrates decreased overall complications (OR 0.57), major complications (OR 0.52), and postoperative mortality (OR 0.27) with laparoscopic approach. 4

• Improved liver-specific outcomes: Laparoscopy results in lower rates of postoperative liver failure (OR 0.60) and postoperative ascites (OR 0.44) compared to open surgery. 4

• Preservation of collateral circulation: In cirrhotic patients, laparoscopy avoids interruption of large collateral veins in the abdominal wall, which is particularly important given portal hypertension. 5

• Reduced protein and electrolyte losses: Nonexposure of viscera restricts losses and improves absorption of ascites. 5

Technical Considerations and Limitations

• Minor resections are ideal: Patients with peripherally located, single HCC <2 cm are ideal candidates for minimally invasive liver resection. 1

• Major hepatectomies require expertise: While laparoscopic major hepatectomies show similar benefits, they require longer operative time (particularly in major resections) and should only be performed in trained teams. 1, 4

• Anatomical resections are feasible: Advances in dye-guided techniques and 3D reconstruction have increased anatomical resections using laparoscopy, which appear non-inferior to open anatomical resections. 1

• No definitive advantage of robotic over laparoscopic approach has been established; choice should be based on availability and surgical expertise. 1

When to Consider Open Surgery

• High-risk surgical profile: Patients with poor hepatic function or centrally located tumors may benefit from open approach given that liver resection has higher morbidity than thermal ablation. 1

• Major hepatectomy requirement: When major hepatectomy is needed, ablation should be preferred over resection in compensated cirrhotic patients. 1

• Reduced operative time needed: Open surgery offers shorter operative time, especially in major resections. 1

HIV-Infected Patients: No Specific Laparoscopic Advantage

Evidence-Based Approach

The evidence for HIV-infected patients differs substantially from viral hepatitis:

• Laparoscopic techniques do not have any specific advantage in HIV-infected subjects compared to open surgery. 2

• Anesthetic and surgical procedures should follow common principles based on the underlying indication, not HIV status. 2

• Perioperative morbidity increases with disease stage but is not significantly elevated compared to HIV-negative subjects in similar preoperative health condition. 2

Historical Concerns About Aerosolization

• Theoretical risk of HIV transmission: Early literature (1993) raised concerns about aerosolized HIV-infected blood and peritoneal fluid during pneumoperitoneum evacuation. 6

• Closed evacuation systems recommended: If laparoscopy is performed, evacuation of pneumoperitoneum into a closed system and appropriate precautions during instrument changes should be used. 6

• However, no conclusive evidence exists that laparoscopy promotes HIV transmission, and these concerns have not translated into contraindications in modern practice. 6

Perioperative Management Priorities

• Extended preoperative work-up required: HIV-infected patients need quantification and treatment of opportunistic disorders and chronic organ damage. 2

• Antiretroviral medication management: Drug interactions with perioperative pharmaceuticals must be considered, while "drug holidays" should be avoided to prevent resistance development. 2

• Higher ICU admission rates: HIV-infected patients require more frequent unplanned intensive care and prolonged artificial respiration postoperatively. 2

COVID-19 Era Considerations (Context-Dependent)

While not directly related to viral hepatitis or HIV, the COVID-19 pandemic guidelines provide relevant safety principles:

• Laparoscopy remains preferred despite aerosol concerns: Despite potential aerosol generation, laparoscopic access should remain the preferred approach when elective surgery resumes due to lower mortality and complication rates. 1

• Appropriate PPE is mandatory given increased risk of viral transmission to staff. 1

• Closed-circuit smoke evacuation systems and ultra-low particulate air filtration should be used. 1

Algorithmic Decision-Making

For Viral Hepatitis (HBV/HCV) Patients:

1. First-line approach: Laparoscopic surgery for all eligible patients, particularly those with:

   • Small tumors (<2 cm) in favorable locations 1
   • Minor resections required 4
   • Compensated cirrhosis (Child-Pugh A) 5

2. Consider open approach if:

   • Major hepatectomy required AND surgical team lacks laparoscopic expertise 1
   • Centrally located tumors with poor hepatic function 1
   • Hemodynamic instability or inability to tolerate pneumoperitoneum 7

For HIV-Infected Patients:

1. Base decision on surgical indication, not HIV status 2
2. Use laparoscopy when it offers standard benefits for the specific procedure 2
3. Ensure closed evacuation systems if laparoscopy is chosen 6
4. Optimize antiretroviral therapy and manage comorbidities preoperatively 2

Critical Pitfalls to Avoid

• Do not delay laparoscopic surgery in viral hepatitis patients due to unfounded concerns about technical difficulty—the evidence strongly supports better outcomes. 1, 3, 4

• Do not assume laparoscopy is contraindicated in cirrhotic patients; it is actually preferred due to reduced complications and preservation of collateral circulation. 5

• Do not use HIV status alone as a reason to choose or avoid laparoscopy—the decision should be based on standard surgical principles. 2

• Do not perform laparoscopic major hepatectomies without appropriate expertise and center experience, as operative time is longer and complexity is higher. 1, 4