Textbook outcome for laparoscopic liver surgery (TOLLS) is a composite measure including absence of significant intra-operative events, no severe post-operative complications, no readmission within 30 days, no in-hospital mortality, and R0 resection margins.
An extended definition, TOLLS+, incorporates length of hospital stay to further assess quality of care.
Study validates TOLLS in a Western tertiary center and analyzes factors influencing achievement of optimal outcomes.
Guideline-Based Recommendations
Diagnosis
Include assessment of patient demographics, comorbidities (ASA class, Charlson score), liver disease status, and tumor characteristics prior to LLS.
Use Brisbane nomenclature and Southampton guidelines to classify extent of liver resection.
Calculate Iwate difficulty scoring system for operative complexity.
Management
Aim to avoid grade II or III intra-operative events per Oslo classification during LLS.
Strive for R0 resection margins (≥1 mm tumor-free margin).
Minimize severe post-operative complications (Clavien-Dindo grade III or higher).
Prevent 30-day readmissions and in-hospital mortality.
Consider length of hospital stay as an additional quality metric (TOLLS+).
Monitoring & Follow-up
Monitor intra-operative events using Oslo classification.
Track post-operative complications with Clavien-Dindo classification.
Follow patients for at least 90 days post-surgery for readmissions and mortality.
Record length of hospital stay relative to extent of resection.
Risks
Intra-operative incidents leading to significant patient consequences (Oslo grade II or III).
Severe post-operative complications (Clavien-Dindo grade III or higher).
Positive resection margins (R1).
Readmission within 30 days post-discharge.
Prolonged hospital stay beyond 75th percentile for resection category.
Patient & Prescribing Data
Adults undergoing laparoscopic liver resection for benign or malignant liver lesions
Optimal outcomes are associated with absence of significant intra-operative events, no severe complications, negative margins, no readmissions, and shorter hospital stays.
Clinical Best Practices
Use composite outcome measures like TOLLS to assess surgical quality rather than single outcome metrics.
Apply standardized classifications (Oslo, Clavien-Dindo) for consistent reporting of intra- and post-operative events.
Incorporate length of hospital stay into outcome assessments to better reflect recovery and care quality.
Perform thorough preoperative evaluation including comorbidities and tumor characteristics to anticipate surgical difficulty.
Maintain prospective data collection for continuous quality improvement.
