Southampton Difficulty Score

Select Procedure Grade

Select the grade that best describes the planned laparoscopic liver procedure.

Grade 1 — Low Difficulty

Left lateral sectionectomy (S2/S3); anterior segment resections (S4b, S5, S6); single non-anatomical resections in peripheral / anterolateral segments

Grade 2 — Moderate Difficulty

Left hepatectomy (S2–S4); right anterior sectionectomy (S5+S8); non-anatomical resections of ≥2 segments; resections involving S7 (anterosuperior approach); resections of S4a without major vascular proximity

Grade 3 — High Difficulty

Right hepatectomy; right posterior sectionectomy (S6/S7); central hepatectomy (S4/S5/S8); resections involving S1 (caudate lobe); resections involving S7/S8 with proximity to RHV/IVC; re-do hepatectomy; trisectionectomy

Southampton Score — Procedure Classification

Grade	Difficulty	Representative Procedures
1	Low	Left lateral sectionectomy; S4b/S5/S6 resections; peripheral non-anatomical resections
2	Moderate	Left hepatectomy; right anterior sectionectomy (S5/S8); multi-segment non-anatomical resections; S4a resections
3	High	Right hepatectomy; right posterior sectionectomy; central hepatectomy; S1; S7/S8 with IVC proximity; re-hepatectomy; trisectionectomy

Surgical Capability Requirements

Grade	Minimum Surgeon Experience	Centre Requirement
1	Advanced laparoscopic training; >20 laparoscopic liver resections	Any centre offering laparoscopic surgery
2	Dedicated laparoscopic liver fellowship; >50 LHR cases	Specialised hepatic centre
3	Expert laparoscopic hepatic surgeon or robotic platform; >100 LHR cases	High-volume HBP specialist centre

Anatomical Basis of Difficulty

Right hepatectomy: Requires mobilisation of right liver, control of right hepatic vein before division; significant risk of IVC injury during hepatocaval dissection
Posterosuperior segments (S7, S8): Depth from laparoscope, restricted instrument angulation, proximity to major hepatic veins; require positional changes and specific laparoscopic ports
Segment 1 (Caudate lobe): Posterior location; requires mobilisation of both hepatic pedicles; poorest laparoscopic access of all segments
Re-hepatectomy: Adhesions, altered portal anatomy, reduced remnant liver mass — high risk of inadvertent vascular injury

Clinical Application

Southampton Grade 3 resections should be restricted to expert centres performing >100 laparoscopic hepatectomies per year
Laparoscopic right hepatectomy conversion rate: 5–25% depending on centre experience and patient selection
Robotic-assisted hepatectomy may facilitate Grade 2–3 resections by improving dexterity and instrument articulation in restricted spaces
International consensus meeting (Morioka, 2014): endorsed staged progression from Grade 1 to 3 as centres develop expertise — do not skip grades
ORANGE II PLUS RCT: first RCT of laparoscopic vs open right hepatectomy — ongoing; results awaited

References

Abu Hilal M, et al. The Southampton Consensus Guidelines for Laparoscopic Liver Surgery: From Indication to Implementation. Ann Surg. 2018;268(1):11–18.
Wakabayashi G, et al. Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Ann Surg. 2015;261(4):619–629.