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These prophetic words, written and sung by Bob Dylan almost 50 years ago, may well apply to the (relatively) new field of minimally invasive surgery of the liver (MISL). Nowadays the open approach to liver surgery (OLS) quickly falls behind in comparison with MISL. Older surgeons still have ringing in their ears the repeated warnings concerning risks related to laparoscopic cholecystectomy (LC). Prominent remarks included a possible increased risk of bile duct injuries [1], a prolonged learning curve [2], and the need for young surgeons to have well-established training in OLS before starting to perform LC. None of these alarms has overcome the tide of LC diffusion, and none of them proved to be effectively true. Thanks to many training modalities, such as dry lab, wet lab, simulators, virtual realities, and practice in large animals (pig), young surgeons directly enter into liver surgery using the laparoscopic approach, and open cholecystectomy is almost always and everywhere an embarrassing memory.

Postoperative complications directly due to liver resection are hepatic failure and abdominal fluid collections due to bleeding or biliary leaks from the resection plane. The decrease in complication rates is due to technological advances and the widespread use of anatomically oriented resection techniques that significantly minimize liver-tissue necrosis. Hepatic parenchyma has in fact a complex, high-density framework of vascular and biliary structures, and even the most meticulous and appropriate approach to resection does not exclude the risk of postoperative bleeding and/or biliary leaks.

In 2009, the most comprehensive review of published series of minimally invasive liver resection (MILR) reported nearly 3,000 cases performed worldwide, emphasizing an exponential growth in the application of this technique by surgeons experienced with both hepatic and laparoscopic surgery [1]. The goal of our survey was to provide an overview of the spread of the minimally invasive approach to liver resections in Italy.

Although some liver resections may now be safely performed without vascular clamping, blood saving remains an important concern in hepatobiliary surgery, especially in patients with liver tumors, as blood loss seems to directly affect early and late outcome.

The liver is one of the most frequently injured abdominal organs in trauma (about 35–45% of blunt abdominal trauma, 40% of stab wounds, and 30% of gunshot wounds); about 80% occur in men between 20 and 40 years of age [1]. Liver trauma is classified according to the Liver Injury Scale from the American Association for the Surgery of Trauma (AAST), which lists six grades with progressive severity depending above all on two parameters: depth of parenchyma laceration, and the area of hematoma with or without vascular involvement. The diagnostic and therapeutic approach to abdominal and liver trauma has evolved in recent decades, leading to a reduction in deaths [1, 2].

Shall we see through a camera better than with our eyes? The question, still appropriate at the present time, dates back to the seventeenth century. It seemsthat Vermeer, and then Canaletto some decades later, introduced in their paintings the use of the camera obscura, or optic camera (Figs. 14.1, 14.2). The simplest arrangement, with a lens fastened in the pinhole, projected an inversed and reversed image on a vertical screen opposite the aperture. A variation on this employed a translucent screen, allowing the viewer to see the image from the other side, thereby correcting the left-to-right reversal. These two types of cameras projected the image directly and could be combined in one device. The optical camera obscura ushered in a new approach to optics, opening up new views of the visible world and shaping a new understanding of vision itself.

In 1957, Couinaud published his fundamental paper on the surgical anatomy of the liver [1], describing the eight segments, everyone with its pedicle: artery, portal vein, and bile duct. Since then, every liver surgeon has referred to it as a bible to be followed during routine surgical practice. Only with the experience with liver transplantation in the mid-1990s was splitting segment 1 into two sections suggested, identifying the portion of segment 1 on the right side of the caval vein as segment 9 [2]. This was only a minor modification of the original classification. Since the rapid spread of liver surgery in the 1970s, several authors have suggested technical tricks to remove the entire segment by sectioning the tributary pedicle [3–5].

Portal vein ligation (PVL) is a standard procedure for achieving resectability in patients with an inadequate future remnant liver (FRL) prior to planning subsequent major hepatectomy. Its role in inducing FRL hypertrophy prior to major liver resection is clear [1]. Actually, PVL is the first step in a two-stage hepatectomy for treating initially unresectable liver metastases [1]. As reported in the literature, this procedure can be achieved safely without causing mortality [2]. Capussotti et al. showed how PVL is as effective as PV embolization in inducing hypertrophy of the remnant liver volume [2]. The possibility of using a laparoscopic approach seems to be favorable, even for achieving lower patient morbidity rates, particularly in the case of synchronous colorectal metastasis, avoiding the need to perform a further procedure (laparotomy/portal embolisation) [3,4]. Finally, in a planned two-stage hepatectomy, laparoscopic PVL (LPVL) greatly reduces the presence of adhesions when it is time to perform the second surgical step [5].