Anterior approach with or without liver hanging maneuver versus conventional approach in major liver resections. A systematic review and meta-analysis of randomized controlled trials

Introduction: The anterior approach (AA), whether or not associated with the liver hanging maneuver (LHM), has been advocated to improve survival and postoperative outcomes in HCC patients undergoing major liver resection. This systematic review and meta-analysis of randomized controlled trials aims to explore intra/perioperative and long-term survival outcomes of AA ± LHM compared to CA regardless of tumor histology. Methods: The study was conducted according to the Cochrane recommendations searching the PubMed, Scopus, and EMBASE databases until January 27, 2024 (PROSPERO ID: CRD42024507060). Only English-language RCTs were included. The primary outcome, expressed as hazard ratio (HR) and 95 % confidence intervals (CI), was the overall and disease-free survival. Random effects models were developed to assess heterogeneity. The risk of bias in included studies was assessed with the RoB 2 tool. The certainty of evidence was assessed following GRADE recommendations. Results: Six RCTs, for a total of 736 patients were included. A significant survival benefit was highlighted for patients undergoing AA ± LHM in terms of overall (HR: 0.65; 95 % CI: 0.62–0.68; p < 0.0001) and disease-free survival (HR: 0.65; 95 % CI: 0.63–0.68; p < 0.0001). AA ± LHM was associated with a longer duration of surgery (WMD: 29.5 min; 95 % CI: 17.72–41.27; p = 0.004), and a lower intraoperative blood loss (WMD: 24.3; 95 % CI: 31.1 to −17.5; p = 0.0014). No difference was detected for other postoperative outcomes. The risk of bias was low. Conclusion: AA ± LHM provides better survival outcomes compared to CA. Furthermore, AA ± LHM is related to a modest reduction in intraoperative blood loss, at the price of a slightly longer duration of hepatectomy. Regarding other postoperative outcomes, the two techniques appear comparable.