Is Laparoscopic Hepatectomy Safe for Giant Liver Tumors? Proposal from a Single Institution for Totally Laparoscopic Hemihepatectomy Using an Anterior Approach for Giant Liver Tumors Larger Than 10 cm in Diameter

Round 1

Reviewer 1 Report

1.  Most patients (10 patients in 15 patients with giant tumors) had hospital stay more than 10 days, I did not see any advantages of laparoscopic approach, such as decreasing of hospital stay or short recovery time.

2. Dose TLhH by anterior approach for giant liver tumor have any oncological benefit because of non-touch technique, such as better disease free survival? If so, please describe it.

Author Response

Point 1: Most patients (10 patients in 15 patients with giant tumors) had hospital stay more than 10 days, I did not see any advantages of laparoscopic approach, such as decreasing of hospital stay or short recovery time.

Response 1: At our institution, patients who underwent hemihepatectomy are not encouraged to leave the hospital early, so the postoperative hospital stay tends to be long. The median postoperative hospital stay was 12 days, but there was no longer postoperative hospital stay compared with the nongiant tumors. (L203-206)

Point 2: Dose TLhH by anterior approach for giant liver tumor have any oncological benefit because of non-touch technique, such as better disease free survival? If so, please describe it.

Response 2: I have added the following sentences. “In addition, as a no-touch isolation technique, it can reduce the risk of tumors flowing into the inferior vena cava in cases such as hepatocellular carcinoma and colorectal liver metastasis.” (L192-194)

Reviewer 2 Report

Congratulations for the authors in writing this paper in an interesting area of liver resection, however an effort to describe better the surgical procedures and the differences from  previously described laparoscopic anterior  hepatectomy should be attemped.The manuscript also contains a lot of language and style mistakes so a major review is required

Author Response

Point 1: Congratulations for the authors in writing this paper in an interesting area of liver resection, however an effort to describe better the surgical procedures and the differences from  previously described laparoscopic anterior  hepatectomy should be attemped.The manuscript also contains a lot of language and style mistakes so a major review is required.

Response 1: I have added the following sentences. " Conventional right hemihepatectomy performs hepatic parenchymal transection after liver mobilization. However, in the case of laparoscopic hepatectomy, liver mobilization cannot be performed first for giant liver tumors because of the limited volume of the body cavity."  The English of this manuscript was checked by the editing services. (L182-185)

Reviewer 3 Report

1.L57-58, large and small --> giant and non-giant

2. It is better to add the information about pathological diagnosis; of HCC, metastatic temor and benign patient number(%) in two group.

Author Response

Point 1: L57-58, large and small --> giant and nongiant.

Response 1: Revised large and small to giant and nongiant. (L58-59)

Point 2: It is better to add the information about pathological diagnosis; of HCC, metastatic temor and benign patient number(%) in two group.

Response 2: I have added the following sentences. “There were no cases of intrahepatic cholangiocarcinoma (ICC) or metastatic liver tumor (Meta) in the giant tumor group (Tables 2,3).”

Added disease to Table2 and 3 items. (L131-132)

Round 2

Reviewer 2 Report

An effort to describe better the surgical procedures and the differences from  previously described laparoscopic and non laparoscopic anterior  hepatectomy should be attemped.The discussion about previosly described anterior laparoscopic procedure should be implemented and  literature should be implemented.

Author Response

Response to Reviewer 2 Comments

Point 1: An effort to describe better the surgical procedures and the differences from  previously described laparoscopic and non laparoscopic anterior  hepatectomy should be attemped.The discussion about previosly described anterior laparoscopic procedure should be implemented and  literature should be implemented.

Response 1: I have added the following sentences. " Liver hanging maneuvers in right hemihepatectomy have been reported in both open and laparoscopic procedures for safe anterior parenchymal transection. In particular, Kim reported a modified liver hanging maneuver that involves placing tape between the inferior vena cava and the right adrenal gland. There is no doubt about the usefulness of the hanging technique in right hemihepatectomy, but our method is a simple technique that compresses the liver parenchyma from the dorsal side." (L197-202)

Round 3

Reviewer 2 Report

The  discussion about previosly described anterior laparoscopic procedure and the new approach may be implemented. Complexty or difficulty  using different technical approaches my be addressed

Author Response

Response to Reviewer 2 Comments

In addition to the sentence I added last time (L197-202), I added the following sentence. " In the case of laparoscopic right hemihepatectomy for giant liver tumors, the narrow operating cavity may make the placement and hanging of the tape difficult, and our technique may be more suitable." (L202-205)