BACKGROUND: Indications for laparoscopic liver resection (LLR) are continuously expanding. The Japanese Society of Hepato-Biliary-Pancreatic Surgery defines highly difficult hepatectomy as a procedure involving one or more sections (except for left lateral sectionectomy) or anatomical segmentectomy. This study aimed to assess the outcomes of complex LLR procedures and compare their technical difficulties, about which only a little is known to date. METHODS: We performed a retrospective review of the operative outcomes of 118 consecutive patients who underwent pure laparoscopic complex hepatectomy. The surgical outcomes, including operative times, blood loss amounts, and postoperative morbidity rates, were compared among complex LLR procedures. RESULTS: The overall median operative time was 280 minutes, and the median intraoperative blood loss was 86 mL. Two patients required conversion to open laparotomy (1.7%). The postoperative major morbidity rate was 11.0% Posterosuperior segmentectomy, right hemihepatectomy, and anterior sectionectomy required the longest operative times. Anterior and posterior sectionectomy resulted in the highest blood loss, and right hemihepatectomy and anterior sectionectomy resulted in the most complications. CONCLUSIONS: The surgical difficulties associated with complex LLR procedures vary. It is critical to recognize the specific risks and cautionary points to ensure patient safety and provide proper systemic training to surgeons.