In major hepatectomies, biliary reconstruction may be necessary due to oncological reasons or intraoperative events. Duct-to-duct biliary reconstruction (DDBR) may be an alternative to the classical Roux-en-Y bilioenteric (RYBE) anastomosis in well selected cases. This study aims to evaluate the outcomes of DDBR in our institution. Between 2014 and 2023, 14 patients underwent major hepato-biliary resection with subsequent DDBR. Ten were planned preoperatively and classified as intentional and 4 were dictated by intraoperative events and classified as non-intentional. Bile leak occurred in a single patient (7%), requiring reoperation for biliary peritonitis. Five patients (36%) developed intra-abdominal collections, including three abscesses and two bilomas that required percutaneous drainage. During these procedures, routine cholangiography was performed through the trans-anastomotic drain placed at the initial surgery. In all five patients, no anastomotic leakage was demonstrated, indicating that the collections originated from the transection margin of the liver rather than the anastomosis. Clinically relevant anastomotic stricture occurred in four patients (28.5%): three (75%) were successfully managed endoscopically, while one (25%) required conversion to RYBE. An additional patient was diagnosed with a stricture on follow-up imaging without biochemical or clinical consequences and was managed conservatively. DDBR, when performed under optimal conditions, yields satisfactory functional outcomes and long-term results. The ability to manage complications effectively further supports DDBR as a viable reconstructive technique in major hepatectomy in well selected cases.

OBJECTIVE:Analysis of 6-segmentectomies coded H145678 or H123458 in the New World classification of liver resections using contemporary indicators to improve the shared surgical decision-making. SUMMARY OF BACKGROUND DATA:Specific reports on H145678 and H123458 have lacked granularity or have focused on perihilar cancer. METHODS:We performed a retrospective single-center analysis of consecutive patients who underwent H145678 or H123458 from 1993 to 2024. Surgical futility (90 d mortality), failure-to-rescue, oncological futility (early tumor recurrence), and outcome futility (surgical or oncologic futility) were evaluated. Textbook outcome achievement and the potential role of liver transplantation (LT) were also assessed. RESULTS:The study population included 237 patients with perihilar cholangiocarcinoma (n=117, 49.4%), intrahepatic cholangiocarcinoma (n=39, 16.4%), hepatocellular carcinoma (n=17, 7.2%), colorectal cancer liver metastases (n=38, 16.0%), or miscellaneous tumors (n=26, 11%). H145678 and H123458 were performed in 166 (70.0%) and 71 (30.0%) patients, respectively. Combined vascular and bile duct reconstructions were performed in 46.4% (n=110) and 62.4% (n=148) of patients, respectively. Rates of surgical, failure-to-rescue, oncological, and outcome futility were 15.6% (n=37), 30.3% (n=37), 14.5% (n=29), and 27.8% (n=66), respectively. Textbook outcome was achieved in 30.8% (n=73). With a median follow-up of 26 months, 5-year overall-survival rates and disease-free survival rates were 30.8% and 18.9%. LT criteria were not met in 94.9% (n=225). CONCLUSIONS:H123458 and H145678 offer selected patients a chance for long-term survival. LT is not a therapeutic option for most patients, and targeted rescue strategies may improve failure-to-rescue rates.

BACKGROUND:Curative R0-R1 resection is not always feasible in patients with extensive bilobar colorectal liver metastases (CRLM). When unresectatility is confirmed, the standard of care is palliative chemotherapy or more recently liver transplantation (LT) with very restrictive eligibility criteria. This exploratory study evaluated cytoreductive surgery as an alternative to chemotherapy alone in patients with initially unresectable CRLM responding well to systemic chemotherapy but ineligible to LT. METHODS:This prospective study (January 2017-January 2024) included patients with permanently unresectable CRLM involving >6 segments, with or without limited extrahepatic metastases. Those achieving a sustained partial response on RECIST criteria after ≥3 months of chemotherapy and not amenable to LT, underwent cytoreductive surgery defined as resecting or ablating all visible residual lesions while leaving disappearing liver metastases (DLMs) untreated-The primary endpoint was 5-year overall survival (OS); secondary endpoints included disease-free survival (DFS) and time to surgical failure (TSF). RESULTS:Of 330 patients undergoing CRLM resection, 33 were eligible, and 28 underwent cytoreductive surgery (18 major, 10 limited hepatectomies, frequently with ablation). Grade ≥ III complications at 3 months occurred in 4 patients (14%), including one mortality (3.6%). At 57- month median follow-up, 5-year OS was 47% (whole cohort) and 64% (operated patients), respectively. Liver recurrence occurred in 22 patients (79%), with a 5-year DFS of 17%. Recurrences were frequently managed with repeat hepatectomy and/or ablation, including second (n = 15) and third (n = 7) hepatectomies, resulting in a 5-year TSF rate of 36%. CONCLUSIONS:Cytoreductive surgery combined with chemotherapy is a strategy that may improve long-term survival in selected patients with unresectable CRLM. This favorable outcome is likely driven by highly selected tumor biology, by sustained response to chemotherapy and by the feasibility of repeat surgical resections for recurrences, rather than by the initial surgery alone.

Background:The Institut Mutualiste Montsouris (IMM) 3-level complexity classification has been validated for laparoscopic liver resection (LLR) in several studies with small sample size. However, it has not been well-validated in large studies down to the individual procedure type. Hence, in order to address current limitations in the studies validating the IMM complexity classification, we performed an international multicenter study to validate the IMM complexity classification across its three complexity levels and the categorization of the 11 distinct procedure types. Methods:A retrospective cohort study of 22,252 patients undergoing LLR across 64 centers worldwide between 2005 and 2021 was performed. Baseline characteristics and perioperative outcomes were analyzed across the three difficulty levels and 11 procedure types of the IMM complexity classification. Results:A total of 14,765 patients were included in our final analysis. The main indications for LLR in our study was hepatocellular carcinoma or intrahepatic cholangiocarcinoma (n=7,781, 52.7%) followed by liver metastasectomy (n=3,911, 26.5%). In terms of underlying liver pathology, 5,127 (34.7%) cases had cirrhosis, and 1,214 (8.3%) had portal hypertension. Perioperative outcomes including operative time, open conversion rate, intraoperative blood loss, need for intraoperative blood transfusion, need for Pringle's application, length of stay, postoperative morbidity, major postoperative morbidity and 90-day mortality all demonstrated a significant increasing trend with increasing IMM complexity grades (P<0.001). These trends remained significant following adjustment for baseline characteristics (P<0.001). Notably, when examining the 11 LLR procedure types, all procedures within each IMM complexity grade were individually higher than all procedures in the preceding complexity grade for operative time, blood loss, length of stay, postoperative morbidity and major postoperative morbidity. Conclusions:The three IMM complexity grades were well associated with LLR complexity as determined by key surrogate perioperative measures. Our findings also supported the categorization of the 11 distinct LLR procedures into the three complexity levels.

Introduction Adults with congenital heart disease (ACHD) may develop advanced heart failure with associated liver disease from chronic right-sided heart or Fontan failure. Thus, CHD with subsequent irreversible liver dysfunction is an increasing indication for combined heart-liver transplant (CHLT). A systematic liver function assessment is therefore essential prior to listing for heart transplantation (HTx). Objective We aimed to describe clinical characteristics, underlying cardiac defects, surgical history, perioperative issues, and outcomes in a contemporary cohort of ACHD referred for HTx or CHLT. Method We prospectively included all ACHD patients referred to our centre for HTx between August 2021 and February 2025. Liver function and disease were evaluated systematically before listing. Inclusions criteria were 1)CHD; 2)HT/CHLT referral; and 3) age >18years at the time of referral. Results A total of 22 ACHD patients were referred for HT/CHLT to our centre between August 2021 and February 2025. Mean age at referral was 36±24 years. Twelve patients (55%) had univentricular physiology, and all were in New York Heart Association (NYHA) functional class III or IV at the time of referral. Following initial evaluation, 5 patients were listed for CHLT, 7 patients for HTx (including 1 for combined heart-kidney transplantation). The main indications for CHLT were hepatocellular carcinoma and refractory ascites. Three patients died before listing, one of whom received Carmat artificial heart. Prior to transplantation, two patients required inotropic support, two were supported with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) (Fig. 1). The median time from evaluation to listing or death prior to listing was 146 days (IQR 28–598 days). Among listed patients, the median time from listing to transplantation or death was 150 days (IQR 55–210 days). Among the 9 transplanted patients, no one died during the study period. No patients required VA-ECMO after transplantation, and no major post-transplant complications were reported. Conclusion In this contemporary cohort, patients with HF referred for HT/CHLT are heterogeneous also in terms of severity. Results after CHLT in our Centre are encouraging. Times from evaluation to listing and to transplantation are long. This supports the importance of early referral.

Background and Aims: Liver transplantation (LT) represents a therapeutic option for patients with Wilson’s disease (WD) presenting with acute liver failure (ALF) or end-stage liver disease unresponsive to medical therapy. Data on long-term post-transplant outcomes in this population remain limited. This study evaluates patient (PS) and graft survival (GS) after LT for WD in Europe and identifies prognostic factors influencing outcomes over time.Methods: Data were extracted from the European Liver Transplant Registry (ELTR), including all patients who underwent LT for WD between 1986 and 2019. Baseline demographic and clinical variables were analyzed. Outcomes were compared between two transplant eras (1986–2000 vs. 2001–2019). PS and GS were estimated using Kaplan–Meier analysis and compared with log-rank test. Predictors of PS and GS were identified by multivariable Cox regression. Analyses were repeated after stratifying the cohort by age at LT (pediatric vs. adult). Results. In all, 1,615 patients underwent LT for WD (male 46%; ALF 10.1%; pediatrics 29.4%; mean MELD at LT 25±10). Overall, 1-, 5-, and 10-year PS rates were 88.6%, 85.2%, and 80.0%, respectively, whereas GS rates were 82.5%, 76.9%, and 70.5%. Median follow-up was 60 months, and the re-transplantation rate was 13.1%. Compared with the earlier period, PS significantly improved in the most recent era (2001–2019, p= 0.014), whereas GS showed a trend toward improvement (p=0.052; Figure 1). When stratified by age at LT, PS improved in the recent era among pediatric recipients only (p=0.008 vs. p=0.213 in adults), whereas no statistically significant improvement in GS was observed in either age group (p=0.155 and p=0.181, respectively). In multivariable Cox regression analysis, independent predictors of PS in the whole cohort included recipient age, UNOS status, and the need of reLT (Table 1). Among adults, ALF, UNOS status and recipient age remained independent predictors of PS, whereas in pediatric recipients, tacrolimus therapy and living donor LT remained independent predictors. In the whole cohort, year at LT, donor age, living donor LT, and mycophenolate therapy were independent predictors of GS. Donor age and mycophenolate therapy remained independent predictors of GS among adults, whereas tacrolimus therapy and living donor LT predicted GS in pediatric recipients. Conclusions: LT offers excellent long-term outcomes for patients with WD, both in terms of graft and patient survival. The outcome is influenced by different prognostic factors depending on age at transplantation.

BACKGROUND Liver transplantation (LT) in hyperimmunized recipients with pre-formed donor-specific antibodies (pDSA) or a positive crossmatch (CM) presents a significant immunological graft challenge. AIM To assess whether induction therapy with rabbit anti-T lymphocyte globulin (rATLG) and high-dose intravenous immunoglobulin (IVIG) reduces acute T-cell mediated rejection (TCMR), acute antibody-mediated rejection (aAMR), and graft loss in these patients. METHODS This retrospective case-control study, conducted between 2016 and 2022, compared the outcomes of two groups of LT recipients: Forty-six hyperimmunized patients (high-risk, pDSA and/or CM positive at time of LT) were matched with 46 non-immunized (low-risk) recipients. High-risk patients received anti-T lymphocyte globulin/IVIG induction therapy whereas the low-risk patients did not. Patient and graft survival were compared using Kaplan-Meier survival analysis. RESULTS The incidence of biopsy-proven TCMR was numerically lower in the high-risk group (19.6%) compared to the low-risk group (26.1%), with all cases classified as Banff mild or moderate. Of these, clinically significant rejections requiring treatment occurred in 10.9% of high-risk and 8.7% of low-risk recipients. A subset of the high-risk group (n = 4, 8.7%) developed aAMR vs none in the low-risk group. The one-year (high-risk: 83.6%, low-risk: 95.6%) and three-year (high-risk: 78.0%, low-risk: 91.2%) survival rates were comparable between the two groups (log-rank P = 0.051). Notably, no grafts were lost due to rejection in either group, and no adverse events were linked to the induction therapy used in the high-risk group. CONCLUSION Short course of rATLG and IVIG induction therapy can be a valuable strategy for mitigating early immunological risks in hyperimmunized recipients, leading to comparable outcomes to non-immunized patients.

BACKGROUND:Intrahepatic cholangiocarcinoma (ICC) is a rare malignancy with rising incidence and poor prognosis. Surgical resection remains the only curative option, with outcomes driven by R0 margins and lymphadenectomy (LND). While open liver resection (OLR) is standard, laparoscopic (LLR) and robotic liver resection (RLR) are increasingly used, with concerns about their oncologic adequacy. OBJECTIVE:To assess the association between composite surgical benchmark attainment (R0 + LND) and short- and long-term outcomes after ICC resection, stratified per surgical approach. METHODS:A retrospective multicenter analysis was conducted including 240 patients treated from 2010 to 2024. The primary endpoint was achievement of both R0 resection and LND. Secondary endpoints included 90-day mortality, overall (OS), and disease-free survival (DFS). RESULTS:Among the 240 included patients 38.8% met surgical benchmarks (R0 + LND), with rates varying by approach: OLR 51.1%, RLR 44.4%, and LLR 14.5% (p < 0.001). 90-day mortality was 5.0% (12/240) overall, with no significant difference between surgical approaches (p = 0.219). One and 3-year overall survival was 79%/30% for OLR, 95%/89% for LLR, and 90%/81% for RLR (p < 0.001). Multivariable analysis identified tumor multiplicity as an independent predictor of mortality (HR = 2.18, p = 0.003), while LLR was independently protective (HR = 0.15, p < 0.001); RLR showed a non-significant protective trend. CONCLUSION:Although OLR and RLR more frequently met oncological benchmark criteria, only LLR was independently associated with improved overall survival, highlighting a potential disconnect between benchmark adherence and long-term outcomes in ICC.

Objective: Analysis of 6-segmentectomies coded H145678 or H123458 in the New World classification of liver resections using contemporary indicators to improve the shared surgical decision-making. Summary of background data: Specific reports on H145678 and H123458 have lacked granularity or have focused on perihilar cancer. Methods: We performed a retrospective single-center analysis of consecutive patients who underwent H145678 or H123458 from 1993 to 2024. Surgical futility (90 d mortality), failure-to-rescue, oncological futility (early tumor recurrence), and outcome futility (surgical or oncologic futility) were evaluated. Textbook outcome achievement and the potential role of liver transplantation (LT) were also assessed. Results: The study population included 237 patients with perihilar cholangiocarcinoma (n=117, 49.4%), intrahepatic cholangiocarcinoma (n=39, 16.4%), hepatocellular carcinoma (n=17, 7.2%), colorectal cancer liver metastases (n=38, 16.0%), or miscellaneous tumors (n=26, 11%). H145678 and H123458 were performed in 166 (70.0%) and 71 (30.0%) patients, respectively. Combined vascular and bile duct reconstructions were performed in 46.4% (n=110) and 62.4% (n=148) of patients, respectively. Rates of surgical, failure-to-rescue, oncological, and outcome futility were 15.6% (n=37), 30.3% (n=37), 14.5% (n=29), and 27.8% (n=66), respectively. Textbook outcome was achieved in 30.8% (n=73). With a median follow-up of 26 months, 5-year overall-survival rates and disease-free survival rates were 30.8% and 18.9%. LT criteria were not met in 94.9% (n=225). Conclusions: H123458 and H145678 offer selected patients a chance for long-term survival. LT is not a therapeutic option for most patients, and targeted rescue strategies may improve failure-to-rescue rates.

e16282 Background: Circadian rhythms moderate cancer biology by regulating cell cycle progression, DNA activity, immune surveillance, and metastatic potential. We aim to assess the relevance of circadian rhythms for the prognosis of patients (pts) undergoing liver transplantation (LT) for hepatocellular carcinoma (HCC). Methods: This retrospective study included pts with curative-intent liver transplantation for HCC. The time of day (ToD) of each graft reperfusion was recorded, and its impact on disease-free survival (DFS) and overall survival (OS) was analysed using time-slot stratification and restricted cubic spline Cox modelling. Baseline characteristics were compared to assess group comparability. Results: From 2015 to 2020, 200 consecutive patients, including 79% males with a median age of 61.4 ± 7.1 yrs underwent liver transplant for HCC at a single centre. Mean (±SD) of waiting time on list, MELD score, and alpha-fetoprotein level (AFP) were 267 ± 293 days, 14.7 ± 7.5 UI and 18.9 ± 59.1 ng/mL, respectively. Pts were allocated to four 6-hour time slots according to graft reperfusion ToD, namely 01:00-07:00 (Night, N = 20), 07:00-13:00 (Morning, N = 49), 13:00-19:00 (Afternoon, N = 69), 19:00-01:00 (Evening, N = 62). Pts characteristics were similar for MELD Score, AFP, tumour numbers, largest tumour diameter, and time elapsed between last treatment and liver transplant in the 4 ToD slots. Median follow-up was 5years [IQR 3.3-5.0]. Recurrence occurred in 33 patients (Night N = 7, 21.2%; Morning N = 2, 6%; Afternoon N = 14, 42.4%; Evening N = 10; 30.3%). DFS differed across reperfusion ToD slots (log-rank p = 0.041), with the most favourable outcomes in the Morning slot, whose pts had improved DFS compared with the three other ToD slots (log-rank p = 0.048). Morning reperfusion was associated with a markedly lower recurrence risk compared to Night reperfusion (HR 0.17, [95% CI, 0.04–0.64]), with consistent trends for afternoon and evening reperfusion. Restricted cubic spline modelling confirmed a circadian pattern, with a nadir of recurrence risk in the early-to-mid afternoon (13:00-15:00) and higher risk estimates toward nighttime reperfusion. Finally, OS differed across reperfusion ToD slots (log-rank p = 0.043), with the most favourable outcomes in the Morning ToD slot. Conclusions: Pts with liver transplant for HCC reperfused in the morning hours had a longer DFS and OS compared to those reperfused at other ToDs. Thus, ToDs could account for significant changes in the recipient’s susceptibility to post-transplant HCC recurrence, possibly resulting from changes in immune responses and/or tumour cell seeding and implantation. These clinically relevant findings warrant further validation in retrospective and prospective pt cohorts and may impact surgical oncology practice.

Objective Veno-occlusive disease (VOD) after liver transplantation mostly described through case reports has uncertain prognostic significance. We aim to determine factors that influence graft survival, and explore the presence of antibody-mediated rejection (AMR) recently reported in this pathological condition. Methods This single-center study included liver transplant recipients with histologically-confirmed VOD between 2014 and 2021. Retrospective analysis of clinicopathological data was primarily focused on their impact on prognosis then compared between AMR/VOD and non-AMR/VOD patients. Results VOD identified in 39/1471 (2.6%) recipients occurred at a median time of 12.6 months (range: 0.3-328.3 months), most cases (79.5%) within the first 5 years and 20.5% beyond 15 years post-transplant. The probability of graft loss was 50% at 4.5 years post-diagnosis. Donor and recipient age, symptoms at presentation, history of rejection, and treatment provided had no impact on graft survival. Late-onset VOD (> 5 years post-transplant) was associated with a higher risk of graft loss (P=0.002). AMR preceded VOD in three patients and developed afterward in two. Patients with AMR were younger age at liver transplantation (P=0.013) and at time of VOD diagnosis (P=0.006), had higher DSA positivity, were of later-onset VOD (P=0.001) and more often underwent retransplantation (P=0.001). There were no significant differences in the sinusoid/centrilobular vein C4d positivity between AMR/VOD and non-AMR/VOD cases. Conclusion We introduced a novel classification of post-transplant VOD cases into early-onset and late-onset, the latter having a poorer prognosis and being more often associated with AMR. The relationship between VOD and AMR requires further investigation.

BACKGROUND:The present study analyzes the complications requiring unplanned abdominal reoperation (Early Unplanned Reoperation [EUReop]) following liver transplantation (LT), its impact on short- and long-term outcomes, and identifies its predictors. METHODS:A single-center retrospective analysis including all consecutive adult LT performed from 2007 to 2018. The impact of EUReop on 90-d mortality was assessed using multivariate analysis, and the failure to rescue (FTR) after EUReop was evaluated. Long-term outcomes were assessed using Kaplan-Meier curves. Predictors of EUReop were identified through multivariate logistic regression. RESULTS:Among 1213 LT, 203 patients (17%) required EUReop within a median of 6 d. The leading causes were bleeding (n = 114, 56%), arterial (n = 24, 12%), wound disruption or collection (n = 14, 7%), and biliary complications (n = 12, 6%). Independent predictors of EUReop included intensive care unit admission at LT (adjusted odds ratio: 3.0 [95% confidence interval, 1.7-5.7]), portal vein thrombosis (2.6 [1.5-4.2]), partial liver graft (1.8 [1.0-3.2]), hospitalization at LT (1.7 [1.1-2.7]), inferior vena cava replacement (1.7 [1.1-2.7]), elective re-LT (1.7 [1.0-2.8]), transfusion ≥4 units of red blood cells (1.7 [1.1-2.6]). FTR rate following EUReop was 12%, associated with Balance of Risk score and higher transfusion requirements during LT. The FTR rate significantly decreased over the study period. EUReop was an independent predictor of 90-d mortality (adjusted odds ratios 2.6 [1.4-4.6]). Patients with EUReop exhibited significantly decreased 1-, 3-, and 5-y patient and graft survival rates. CONCLUSIONS:EUReop following LT remains frequent. It is associated with increased 90-d mortality and compromised long-term survival. Patients at risk for EUReop exhibit higher pre-LT acuity and surgical complexity.

Background: Presently, evidence on the volume-outcome relationship for minimally-invasive liver resections (MILR) remains heterogeneous. This study aimed to investigate the volume-outcome relationships in expert centers which had already mounted the initial learning curve of MILR and had a case volume of >20 MILR/annum. Methods: This was an international multicenter retrospective analysis of 22,210 patients undergoing MILR between 2015 and 2022 at 64 centers. Centers were stratified into medium volume (MV), high volume (HV) and very high volume (VHV) defined as 20-50/51-80 and >80 MLR/annum. Difficulty of resections was graded according to the Iwate score and Institute Mutualiste Montsouris (IMM) system. Results: A total of 19,691 MILR met study criteria and were included. Of the 19,961 patients, 4,747 (2 5.6%), 4,222 (23.8%) and 10,243 (50.7%) were performed in 28 MV, 15 HV and 17 VHV centers, respectively. In the overall IMM I and IMM III cohorts, open conversion rates were consistently significantly higher in MV centers. Significantly, in the subgroup analysis of IMM 3 MILR, the VHV cohort had less blood loss [>500 mL: 443.7 (19.6%) vs. 221.6 (22.1%) (MV) vs. 296.9 (26.0%) (HV), P=0.001], shorter operative times [292 vs. 362.7 (MV) vs. 372.9 (HV) min, P<0.001] and shorter postoperative stay [7.8 vs. 8.3 (MV) and 10 (HV) days, P<0.001]. However, the HV cohort had the lower rates of open conversion [79.4 (7.0%) vs. 174.3(7.7%) (VHV) vs. 103.2 (10.3%) (MV); P=0.03]. Conclusions: Center volume-outcome relationship beyond 20 MILR/annum was not clear and results were heterogenous suggesting that factors other than center volume alone had a more significant impact on perioperative outcomes of MILR in these expert centers.

BACKGROUND:Laparoscopic right hepatectomy (L-RH) is a technically complex procedure, characterized by diverse tumor presentations and anatomical variations. While the Iwate Difficulty Scoring System (I-DSS) is widely utilized to assess technical difficulty in laparoscopic liver resections, its predictive value for surgical outcomes in L-RH remains unclear. This study aimed to evaluate the clinical utility of the I-DSS specifically in the context of L-RH. METHODS:This international, multicenter study included 1732 patients who underwent L-RH at 78 centers between 2005 and 2023. Baseline clinicopathological characteristics and surgical outcomes were collected and analyzed based on I-DSS grades. Multivariable analyses were performed to adjust for potential confounders. RESULTS:Patients were categorized into three I-DSS grades: intermediate (n = 13), advanced (n = 355), and expert (n = 1364). Unadjusted analysis showed that higher I-DSS grades were associated with shorter operation time and increased morbidity. However, after adjustment for baseline factors, no significant differences were observed across I-DSS grades in terms of intra- and postoperative outcomes, including operation time, blood loss, transfusion, morbidity, mortality, and surgical margin positivity. CONCLUSIONS:The I-DSS has limited ability to stratify technical difficulty in L-RH. Future studies should be undertaken to develop a new difficulty classification system tailored specifically to specific procedures such as L-RH.