Emerging trends and outcomes in minimally invasive liver surgery: a population-based study in the Veneto region up to 2024 stratified by hospital case-volume.

In recent years, minimally invasive liver surgery (MILS) has signifi cantly expanded in terms of indications thanks totechnological advances and increased surgeon expertise. MILS is safe and off ers clear advantages over open liversurgery (OLS), particularly in terms of short-term outcomes. However, the distribution of MILS cases according tohospital volume remains poorly investigated in Italy. Among short-term outcomes, perioperative mortality is the mostcritical factor infl uencing the choice of surgical approach and warrants thorough investigation. This retrospective,population-based study included patients who underwent liver resection for liver tumors between 2010 and 2024 inthe Veneto region, Italy. Trends in the use of MILS were analyzed, and outcomes (i.e., length of hospital stay (LOS),ICU admission, readmission rates, and postoperative mortality) were compared between MILS and OLS. Theoutcomes were also evaluated in relation to hospital case volume (high ≥ 50, medium 5-49, low 5 liver resections peryear) and the presence of cirrhosis to identify relevant patterns and insights. A total of 9,249 liver resections for livertumors were performed during the study period, with 31.7% performed using MILS. The proportion of MILSprogressively increased from 6.6% in 2010 to 57.5% in 2024, with the most notable growth observed in resectionsfor benign/undetermined malignant potential (UMP) tumors, followed by primary and secondary malignancies. Themost signifi cant and consistent increase in MILS utilization occurred in high-volume hospitals among patients withbenign/UMP tumors (n = 295, 81.9%) and those with primary or secondary malignancies (n = 2,163, 84.0%),including 89.3% of patients with primary tumors and cirrhosis. Patients undergoing MILS for malignancy had ashorter median LOS (6 days, IQR 4-9 vs. 10 days, IQR 7-15), lower ICU admission rates with shorter stays (no ICU:64.5% vs. 46.0%; 2 days: 25.6% vs. 34.7%; ≥2 days: 9.9% vs. 19.3%), lower 30-day readmission (6.4% vs. 11.7%) and 90-day mortality rates (2.0% vs. 4.2%) compared to patients who underwent OLS (all p 0.001). Similar resultswere observed among cirrhotic patients (all p ≤ 0.032). Overall, the Cochran-Armitage test for trend demonstrated asignifi cant increase in in-hospital, 30-day, and 90-day mortality rates with decreasing hospital case volume (all p ≤ 0.019). The study demonstrated a growing adoption of MILS in a single administrative region of Italy anddocumented its clinical benefi ts. These results were primarily driven by high-volume centers, supporting thecentralization of MILS. The fi ndings highlight the need for a nationwide study and the development of healthcarepolicies aimed at promoting equitable access to high-quality surgical care, ultimately ensuring the best possibleoutcomes for patients.