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BACKGROUND: Laparoscopic and robotic minimally invasive liver surgery (MILS) is gaining popularity. Recent data and views on the implementation of laparoscopic and robotic MILS throughout Europe are lacking.METHODS: An anonymous survey consisting of 46 questions was sent to all members of the European-African Hepato-Pancreato-Biliary Association.RESULTS: The survey was completed by 120 surgeons from 103 centers in 24 countries. Median annual center volume of liver resection was 100 [IQR 50-140]. The median annual volume of MILS per center was 30 [IQR 16-40]. For minor resections, laparoscopic MILS was used by 80 (67%) surgeons and robotic MILS by 35 (29%) surgeons. For major resections, laparoscopic MILS was used by 74 (62%) surgeons and robotic MILS by 33 (28%) surgeons. The majority of the surgeons stated that minimum annual volume of MILS per center should be around 21-30 procedures/year. Of the surgeons performing robotic surgery, 28 (70%) felt they missed specific equipment, such as a robotic-CUSA. Seventy (66%) surgeons provided a formal MILS training to residents and fellows. In 5 years' time, 106 (88%) surgeons felt that MILS would have superior value as compared to open liver surgery.CONCLUSION: In the participating European liver centers, MILS comprised about one third of all liver resections and is expected to increase further. Laparoscopic MILS is still twice as common as robotic MILS. Development of specific instruments for robotic liver parenchymal transection might further increase its adoption.

Background Loco-regional treatments have improved the survival of patients with early hepatocellular carcinoma (HCC), but tumor relapse is a frequent event and survival rates remain low. Moreover, conflicting evidences address early HCC patients to surgery or radiofrequency ablation (RFA), with the clinical need to find predictive non-invasive biomarkers able to guide treatment choice and define patients survival. Methods Two independent case series of treatment-naive HCC patients treated with local RFA, and a cohort of 30 HCC patients treated with liver surgery were enrolled. On the basis of literature evidence, we customized a panel of 21 miRNAs correlated with relapse and prognosis after local curative treatment of HCC. Results Expression levels of let-7c predict tumor relapse after RFA; we also investigated the same panel in a small cohort of HCC patients undergoing surgery, finding no statistically significance in predicting tumor relapse or survival. Moreover, interaction test indicated that let-7c expression levels are predictive for identifying a subset of patients that should be addressed to surgery. Conclusion Results from this study could predict prognosis of early HCC patients, helping to address early HCC patients to surgery or RFA treatment.

Background Hepatocellular carcinoma (HCC) is the sixth most common form of cancer worldwide. Although surgical treatments have an acceptable cure rate, tumor recurrence is still a challenging issue. In this meta-analysis, we investigated whether statins prevent HCC recurrence following liver surgery. Methods PubMed, Web of Science, EMBASE and Cochrane Central were searched. The Outcome of interest was the HCC recurrence after hepatic surgery. Pooled estimates were represented as hazard ratios (HRs) and odds ratios (ORs) using a random-effects model. Summary effect measures are presented together with their corresponding 95% confidence intervals (CI). The certainty of evidence was evaluated using the Grades of Research, Assessment, Development and Evaluation (GRADE) approach. Results The literature search retrieved 1362 studies excluding duplicates. Nine retrospective studies including 44,219 patients (2243 in the statin group and 41,976 in the non-statin group) were included in the qualitative analysis. Patients who received statins had a lower rate of recurrence after liver surgery (HR: 0.53; 95% CI: 0.44–0.63; p P P P Conclusion Statins increase the disease-free survival of patients with HCC after liver surgery. These drugs seem to have chemoprevention effects that decrease the probability of HCC recurrence after liver transplantation or liver resection.

Only a few decades ago, the opinion that colorectal liver metastases were a palliative diagnosis changed. In fact, previously, the prevailing view was strongly resistant against resecting colorectal liver metastases. Constant technical improvement of liver surgery and, much later, effective chemotherapy allowed for a successful wider application of surgery. The clinical use of portal vein embolization was the starting signal of regenerative liver surgery, where insufficient liver volume can be expanded to an extent where safe resection is possible. Today, a number of these techniques including portal vein ligation, associating liver partition and portal vein ligation for staged hepatectomy, and bi-embolization (portal and hepatic vein) can be successfully used to address an insufficient future liver remnant in staged resections. It turned out that the road to success is embedding surgery in a well-orchestrated oncological concept of controlling systemic disease. This concept was the prerequisite that meant liver transplantation could enter the treatment strategy for colorectal liver metastases, ending up with a 5-year overall survival of 80% in highly selected cases. In particular, techniques combining principles of 2-stage hepatectomy and liver transplantation, such as "resection and partial liver segment 2-3 transplantation with delayed total hepatectomy" (RAPID) are on the rise. These techniques enable the use of partial liver grafts with primarily insufficient liver volume. All this progress also prompted a number of innovative local therapies to address recurrences ultimately transferring colorectal liver metastases from instantly deadly into a chronic disease in some cases.

espanolLa gammagrafia hepatobiliar con 99mTc-mebrofenina con SPECT/TC (HBS-M) se ha convertido en un metodo cuantitativo importante para evaluar la funcion hepatica global y la funcion remanente hepatica futura (FLR) en pacientes candidatos a cirugia hepatica resectiva. El proposito de este trabajo es describir el metodo para predecir la probabilidad de insuficiencia hepatica posquirurgica. La funcion hepatica general y la del futuro remanente hepatico (FLR) se obtienen del analisis de la fase dinamica inicial de la exploracion. El volumen hepatico a conservar se expresa como un porcentaje del volumen hepatico total medido en ambas secciones de TC. La HBS-M es capaz de medir con precision las anomalias regionales de la funcion hepatica que podrian representarse como parenquima normal del tejido hepatico en el estudio de TC. Esta tecnica puede proporcionar informacion pronostica muy valiosa para la estimacion del riesgo postoperatorio de insuficiencia hepatica en todos los pacientes candidatos a cirugia hepatica resectiva. English99mTc-mebrofenin hepatobiliary scintigraphy with SPECT/CT (HBS-M) has become an important quantitative method to evaluate global liver function and future liver remnant function (FLR) in patients candidate for resective liver surgery. The purpose of this work is to describe the method, in the prediction of post-surgical liver failure. The overall liver function and that of the future liver remmant (FLR) are obtained from the analysis of the initial dynamic phase of the scan. Liver volume to be preserved is expressed as a percentage of the total liver volume measured both from the CT sections. HBS-M is able to accurately gauge regional liver function abnormalities that could be represented as normal liver tissue parenchyma in the CT study. This technique can provide very valuable prognostic information for the estimation of the postoperative risk of liver failure in all patients candidates for resective liver surgery.

Background Although laparoscopic liver resection has become the standard for minor resections, evidence is lacking for more complex resections such as the right posterior sectionectomy (RPS). We aimed to compare surgical outcomes between laparoscopic (LRPS) and open right posterior sectionectomy (ORPS). Methods An international multicenter retrospective study comparing patients undergoing LRPS or ORPS (January 2007—December 2018) was performed. Patients were matched based on propensity scores in a 1:1 ratio. Primary endpoint was major complication rate defined as Accordion ≥ 3 grade. Secondary endpoints included blood loss, length of hospital stay (LOS) and resection status. A sensitivity analysis was done excluding the first 10 LRPS patients of each center to correct for the learning curve. Additionally, possible risk factors were explored for operative time, blood loss and LOS. Results Overall, 399 patients were included from 9 centers from 6 European countries of which 150 LRPS could be matched to 150 ORPS. LRPS was associated with a shorter operative time [235 (195–285) vs. 247 min (195–315) p = 0.004], less blood loss [260 (188–400) vs. 400 mL (280–550) p = 0.009] and a shorter LOS [5 (4–7) vs. 8 days (6–10), p = 0.002]. Major complication rate [n = 8 (5.3%) vs. n = 9 (6.0%) p = 1.00] and R0 resection rate [144 (96.0%) vs. 141 (94.0%), p = 0.607] did not differ between LRPS and ORPS, respectively. The sensitivity analysis showed similar findings in the previous mentioned outcomes. In multivariable regression analysis blood loss was significantly associated with the open approach, higher ASA classification and malignancy as diagnosis. For LOS this was the open approach and a malignancy. Conclusion This international multicenter propensity score-matched study showed an advantage in favor of LRPS in selected patients as compared to ORPS in terms of operative time, blood loss and LOS without differences in major complications and R0 resection rate.

Background Data regarding clinical outcomes of patients undergoing hepatic resection for BRAF-mutated colorectal liver metastases (CRLM) are scarce. Most of the studies report an impaired median overall survival (OS) in BRAF-mutated patients, but controversial Results regarding both recurrence-free survival (RFS) and recurrence patterns. The purpose of this updated meta-analysis was to better precise the impact of BRAF mutations on clinical outcomes following liver surgery for CRLM study, especially on recurrence. Methods A systematic literature review was performed to identify articles reporting clinical outcomes including both OS and RFS, recurrence patterns, and clinicopathological details of patients who underwent complete liver resection for CRLM, stratified according to BRAF mutational status. Results Thirteen retrospective studies, including 5192 patients, met the inclusion criteria. The analysis revealed that both OS (OR = 1.981; 95% CI = [1.613–2.432]) and RFS (OR = 1.49; 95% CI [1.01–2.21]) were impaired following liver surgery for CRLM in BRAF-mutated patients. Risks of both hepatic (OR = 0.42; 95% CI [0.18–0.98]) and extrahepatic recurrences (OR = 0.53; 95% CI [0.33–0.83] were significantly higher in BRAF-mutated patients. These patients tended to have higher rates of right-sided colon primary tumors, primary positive lymph nodes, and multiple CRLM. Conclusions This meta-analysis confirms that BRAF mutations impair both OS and RFS following liver surgery. Therefore, BRAF mutational status should probably be included in further prognostic scores for the assessment of the expected clinical outcomes following surgery for CRLM.

Background The Enhanced Recovery Program after surgery is a multimodal, evidence-based protocol of care developed to minimize the response to surgical stress. Data on the influence of ERP on outcomes, particularly according to the complexity of liver surgery, are lacking. Methods A prospective multicenter cohort of patients undergoing liver surgery and exposed to Enhanced Recovery Program from 2016 to 2020 in France was analyzed. High Enhanced Recovery Program compliance was defined as more than 70% of items (15 out of 21). The outcomes were the rate of complications, length of stay, and functional recovery according to Enhanced Recovery Program compliance. Results A total of 297 patients were included in the study, and they had 61.9% overall compliance (median = 13 items, interquartile range 11–15). Complications were observed in 32.2% (n = 95) of cases, and the mean length of hospital stay was 7.28 (±7.15) days overall. A longer duration of liver surgery was associated with an increase in the complication rate, while high compliance was independently associated with a reduced risk of complications in the multivariable analysis. Conclusion High Enhanced Recovery Program compliance was associated with a lower rate of postoperative complications.

Zusammenfassung Zielsetzung Minimalinvasive Eingriffe im Bereich der Leberchirurgie werden aufgrund des intraoperativ geringeren Blutverlustes, der verringerten postoperativen Morbidität sowie der verkürzten Aufenthaltsdauer im Vergleich zur offenen Leberchirurgie immer häufiger durchgeführt. Bei primären Lebertumoren erscheinen exakte Resektionsränder als vorteilhaft, stellen allerdings eine Herausforderung in der minimalinvasiven Technik dar. In diesem Fallbericht zielten wir darauf ab, die chirurgische Präzision durch Kombination des Glissonean Pedicle Approach mit intraoperativer Fluoreszenzfärbung zu erhöhen. Indikation Eine 73-jährige Patientin mit einer CHILD-A-Leberzirrhose durch eine chronische Hepatitis-C-Infektion wurde mit erhöhten Werten des Tumormarkers Alphafetoprotein (792 ng/ml) unserer Klinik vorgestellt. Die Verdachtsdiagnose eines einzelnen hepatozellulären Karzinoms (HCC) mit einer Größe von 2,2 cm in den Segmenten 6/7 wurde mittels Schnittbildgebung bestätigt. Entsprechend der Empfehlung des Tumorboards wurde eine anatomische posterolaterale Resektion entsprechend dem Glissonean Pedicle Approach geplant. Methode Die Patientin wurde in französischer Position gelagert. Nach der Mobilisierung der rechten Leber wurde der posterolaterale Pedikel identifiziert und ligiert. Anschließend wurde Indocyaningrün (ICG) in einer Dosierung von 0,2 mg/kg Körpergewicht intravenös injiziert. Das perfundierte Parenchym der Segmente I–V und VIII färbte sich grün, während die nicht perfundierten posterolateralen Segmente VI und VII ungefärbt blieben. Die Transsektionslinie wurde unter ICG-Bildgebung markiert und zeigte den Übergang des posterolateralen zum anteromedialen Sektor an. Die Dissektion des Parenchyms wurde unter intermittierender ICG-gesteuerter Bildgebung durchgeführt. Die histopathologische Untersuchung des Resektats bestätigte eine R0-Resektion eines gut differenzierten HCC in einer zirrhotischen Leber (Grad 4). Die Patientin konnte am 6. postoperativen Tag nach unkompliziertem Verlauf aus dem Krankenhaus entlassen werden und war in der Verlaufskontrolle nach 6 Monaten nachweislich tumorfrei. Schlussfolgerung Als zusätzliches intraoperatives Hilfsmittel ermöglicht die ICG-Bildgebung die Visualisierung von Segment- und Sektorgrenzen und erlaubt damit eine präzise anatomische Resektion. Weitere prospektive Studien sind nötig, um den Mehrwert dieser Technik zu evaluieren, insbesondere im Hinblick auf die Rate der R0-Resektionen.

BACKGROUND Laparoscopic liver resection of tumors located in segments 7 and 8 are considered a complex resection. The aim of this study was to compare the intraoperative and early postoperative outcomes of patients operated by pure laparoscopic (PLS) vs hand-assisted laparoscopic surgery (HALS). METHODS From January 2003 to January 2021, we included patients with minimally invasive surgery for lesions located in segments 7 and 8. To overcome selection bias, we performed 1:1 propensity score matching (PSM) between HALS and PLS cohorts, including 30 patients in each of the groups. Of the 60 patients who underwent PSM, we compared the first 30 patients with the following 30 patients. RESULTS A total of 79 LLRs were performed, 46 by HALS and 33 by PLS. After PSM, in the PLS cohort, cirrhosis was more frequent (33.3% vs. 13.3%, p = 0.02). The surgical time, blood loss, Pringle maneuver, clamping time, and morbidity were similar between both groups, but with a lower hospital stay in the PLS group (3 days vs. 4 days, p

Introduction: Colorectal cancer (CRC) is the third most common cancer in the world. The liver is the most common site of metastasis with 15 to 25% of patients presenting with synchronous colorectal liver metastasis (CRLM). This study is aimed at evaluating the long- and short-term outcomes of laparoscopic and robotic CRLM surgery, and directly comparing their respective effectiveness. Methodology: A literature search was performed and all studies that reported on operative characteristics, oncological outcomes for CRLM, morbidity or mortality and cost-effectiveness on robotic or laparoscopic surgery were included. The study design was in keeping with the PRISMA guidelines. Results: From the initial 606 manuscripts identified, 19 studies were included in the final qualitative analysis. A total of 1340 patients with 1194 LLR (Laparoscopic Liver Resection) and 146 RLR (Robotic Liver Resection) cases were analysed. Within the LLR group, the average tumour size excised was 32.1 mm compared to the RLR group of 33.8 mm. The average operative time in the LLR was 193 min, CI of 95% (147.4 min to 238.6 min) compared to RLR 257 min, CI of 95% (201.5 min to 313.8 min) with a p-value < 0.0001. Estimated blood loss was lower in the RLR group (210 mL) compared with the LLR group (246 mL). Conclusion: Despite the higher operative cost, RLRs do not result in statistically better treatment outcomes, with the exception of lower estimated blood loss and excision of larger CRLMs. Operative time and total complication rate are significantly more favourable with LLRs. Our study has shown that robotic liver surgery is safe and feasible in well-selected patients.

Surgical planning software is a key component in the treatment of tumor diseases. However, desktop-based systems provide only limited visualization and interaction opportunities. Moreover, collaborative planning among members of a surgical team is only possible to a limited extent. In this work, a collaborative virtual reality (VR) environment to assist liver surgeons in tumor surgery planning is presented. Our aim is to improve virtual resection planning between surgeons in a remote or co-located environment. The system allows surgeons to define and adjust virtual resections on patient-specific organ 3D surfaces and 2D image slices. Changes on both modalities are synchronized, which will enable surgeons to iterate and refine the resection surfaces quickly. In addition, a real-time risk map visualization is presented that displays safety margins around tumors. An evaluation performed by liver surgeons provides information on potential benefits, such as the possibility to visualize complex cases and assessing the safety-critical areas, applicability, and limitations for further improvement.

Background The aim of this systematic review is to evaluate the current evidence in the context of clinical prediction model for post-hepatectomy liver failure (PHLF). Methods A systematic search of the English literature for a period from December 2005 to September 2020 was conducted. Primary outcome was defined using the three common PHLF criteria (50-50 criteria, peak bilirubin>7 mg/dl criteria, and ≥ grade B PHLF criteria by the International Study Group of Liver Surgery). Studies that reported the value of area under receiver operative characteristic curve (AUC) for the occurrence of PHLF were included. Results Twenty eight of 1327 screened articles were eligible for inclusion. Eighteen studies developed the prediction models. The median AUC was found to be 0.79 (0.65–0.933). The parameters related to the amount of future liver remnant volume were most commonly identified as significant predictors for PHLF in statistical analysis (24 studies) and were most frequently incorporated in the prediction models (18 studies). The parameters associated with portal hypertension were significant for predicting PHLF in 16 studies and were adopted in the prediction models in 14 studies. Conclusion Parameters related to future liver remnant volume and portal hypertension seem to be facilitating in predicting PHLF.

Minimally invasive liver surgery (MILS) was established as last abdominal surgical specialty through the 1990s. With a shift from mainly benign to malignant indications, MILS was shown to be equal to open liver surgery in terms of oncological outcomes, with benefits in intraoperative blood loss, postoperative pain, postoperative complication rates, hospital length of stay and quality of life. With colorectal liver metastases and hepatocellular carcinoma as the most common indications, most liver resection can be performed minimally invasive nowadays, including patients with liver cirrhosis. Initially perceived limitations of laparoscopic liver surgery were weakened by gaining experience, technical progress and pioneering of new resection approaches. Lately robotic liver surgery was adopted to the field of MILS to further push the limits. To simplify first resections, technical variations of the minimally invasive approach can be utilized, and difficulty scores help to select resections suitable to the level of experience. We hereby give an overview of the establishing of a minimally invasive liver surgery program at our center.

Clinical use of augmented reality, mixed reality, three-dimensional-navigation and artificial intelligence in liver surgery

Background and objectives: Both hepatic functional reserve and the underlying histology are important determinants in the preoperative risk evaluation before major hepatectomies. In this project we developed a new approach that implements cutting-edge research in machine learning and nevertheless is cheap and easily applicable in a routine clinical setting is needed. Methods: After splitting the study population into a training and test set we trained a convolutional neural network to predict the liver function as determined by hepatobiliary mebrofenin scintigraphy and single photon emission computer tomography (SPECT) imaging. Results: We developed a workflow for predicting liver function from routine CT imaging data using convolutional neural networks. We also evaluated in how far transfer learning and data augmentation can help to solve remaining manual data pre-processing steps and implemented the developed workflow in a clinical routine setting. Conclusion: We propose a robust semiautomatic end-to-end classification workflow for abdominal CT scans for the prediction of liver function based on a deep convolutional neural network model that shows reliable and accurate results even with limited computational resources.

The occurrence of colorectal liver metastases (CRLM) impairs prognosis, yet long-term survival can be achieved by enabling liver resection. This study aims to describe factors associated with conversion therapy leading to liver surgery and treatment outcome.A retrospective cohort study was conducted including all patients with CRLM discussed at multidisciplinary team conference at Karolinska University Hospital, Stockholm, Sweden, from 2013 to 2018. Factors associated with conversion therapy and outcome following conversion therapy were analysed with logistic regression and survival analyses.Out of 1023 patients with CRLM, 100 patients (10%) received conversion chemotherapy, out of whom 31 patients (31%) subsequently underwent liver resection. Patients in whom conversion chemotherapy resulted in liver resection were younger (median age 61 vs. 66 years, p = .024), less likely to have a KRAS/NRAS-mutated primary tumours (25% vs. 53%, p = .039) and more likely to have received anti-EGFR agents (32% vs. 4%, p = .001) than patients progressing during conversion chemotherapy. The median OS for patients treated with conversion chemotherapy leading to liver resection was 24 months, compared to 14 months for patients progressing during conversion chemotherapy, p .001. The OS for patients progressing during conversion chemotherapy was similar to patients given palliative chemotherapy, approximately 13 months.Conversion therapy offers a survival benefit in selected patients. Despite treatment advances, the majority of patients undergoing conversion chemotherapy never become eligible for curative treatment.

BACKGROUND The potential benefit related to laparoscopic liver surgery (LLS) for colorectal liver metastases outcomes is not well known. MATERIALS AND METHODS Serum cytokines associated with Th1 (tumor necrosis factor-α) and Th2 [interleukin (IL)-10 and IL-6] phenotypes were measured in 36 patients operated on for colorectal liver metastases by open liver surgery (OLS) and LLS. Measurements were performed at 3 time points: 1 day before surgery, day 3 postoperative, and 1 month postoperative. We compared the postoperative inflammatory response influence between LLS and OLS on long-term outcomes. RESULTS In both groups, only IL-6 levels on day 3 postoperative were higher than those measured preoperatively and at 1 month. Comparing the tumor necrosis factor-α levels between the LLS and OLS groups, preoperative (7.28 vs. 2.36), day 3 (7.99 vs. 4.08) and 1 month (7.39 vs. 1.99) postoperative levels were higher in the OLS group (P

Thromboprophylaxis protocols in liver surgery vary greatly worldwide. Due to limited research, there is no consensus whether the administration of thromboprophylaxis should be initiated pre- or postoperatively.Patients undergoing liver resection in Helsinki University Hospital between 2014 and 2017 were reviewed retrospectively. Initiation of thromboprophylaxis was changed in the institution in the beginning of 2016 from postoperative to preoperative. Patients were classified into two groups for analyses: thromboprophylaxis initiated preoperatively (Preop-group) or postoperatively (Postop-group). The incidences of VTE and haemorrhage within 30 days of surgery were compared between these groups. Patients with permanent anticoagulation were excluded.A total of 512 patients were included to the study (Preop, n = 253, Postop, n = 259). The incidence of VTE was significantly lower in the Preop-group compared to the Postop-group (3 (1.2%) vs. 25 (9.7%), P =.0001), mainly due to a lower incidence of pulmonary embolisms in the Preop-group (3 (1.2%) vs. 24 (9.3%), P .0001). The rates of posthepatectomy haemorrhage within 30 days of surgery were similar (Preop 38 (15.0%) vs. Postop 36 (13.9%), p = .719).Initiating thromboprophylaxis preoperatively may reduce the incidence of postoperative VTE without affecting the incidence of posthepatectomy haemorrhage in patients undergoing liver resection.

This study aims to evaluate the predictive value of the prognostic nutritional index (PNI) and albumin-bilirubin grade (ALBI) for the postoperative prognosis of hepatitis B virus-associated hepatocellular carcinoma (HBV-HCC) patients undergoing radical hepatectomy (RH). Besides, we seek to identify novel prognosis indicators for HBV-HCC patients. Between April 2009 and March 2015, this work enrolled 868 patients diagnosed with HBV-HCC and undergoing RH in the Liver Surgery Department, West China Hospital, Sichuan University (WCHSU). The basic information, laboratory examination indicators, pathological reports, and follow-up data of patients were included. SPSS 22.0 statistical software was used for statistical data analyses. Platelet (PLT), alpha-fetoprotein (AFP), maximum diameter (max-D), number of tumors (Number), degree of differentiation (DD), Microvascular invasion situation (MVI), satellite focus situation (SF), PNI, and ALBI were the independent risk factors for both overall survival (OS) and disease-free survival (DFS) of HBV-HCC patients undergoing RH. Taking PNI = 46 and ALBI = − 2.80 as cut-off values, the OS and DFS of the PNI-high group were significantly higher than those of the PNI-low group. Meanwhile, the OS and DFS of the ALBI-low group were significantly higher than those of the ALBI-high group; the OS and DFS of the PNI-high + ALBI-low group were significantly higher than those of the PNI-low + ALBI-high group. Xie prognostic index (XPI) was the independent risk factor for both OS and DFS of HBV-HCC patients undergoing RH. The OS and DFS of the XPI-high group were significantly higher than those of the XPI-low group. This paper reveals that preoperative PNI and ALBI can predict the OS and DFS of HBV-HCC patients undergoing RH. Their impact on the prognosis of HBV-HCC patients is insignificant, however, it cannot be ignored. XPI can precisely predict the prognosis of HBV-HCC patients undergoing RH, nonetheless, its effect requires additional research for validation.

Tranexamic acid (TXA) significantly reduces blood loss in a wide range of surgical procedures and improves survival rates in obstetric and trauma patients with severe bleeding. Although it mainly acts as a fibrinolysis inhibitor, it also has an anti-inflammatory effect, and may help attenuate the systemic inflammatory response syndrome found in some cardiac surgery patients. However, the administration of high doses of TXA has been associated with seizures and other adverse effects that increase the cost of care, and the administration of TXA to reduce perioperative bleeding needs to be standardized. Tranexamic acid is generally well tolerated, and most adverse reactions are considered mild or moderate. Severe events are rare in clinical trials, and literature reviews have shown tranexamic acid to be safe in several different surgical procedures. However, after many years of experience with TXA in various fields, such as orthopedic surgery, clinicians are now querying whether the dosage, route and interval of administration currently used and the methods used to control and analyze the antifibrinolytic mechanism of TXA are really optimal. These issues need to be evaluated and reviewed using the latest evidence to improve the safety and effectiveness of TXA in treating intracranial hemorrhage and bleeding in procedures such as liver transplantation, and cardiac, trauma and obstetric surgery.

Background/aim Operative bleeding is one of the major determinants of outcome in liver surgery. This study aimed to describe the impact of intraoperative blood loss on the postoperative course of liver resection (LR). Materials and methods The data of 257 patients who were treated with LR between January 2007 and October 2018 were retrospectively analyzed. LRs were performed via intermittent portal triad clamping (PTC) under low central venous pressure. Results LRs were performed for 67.7% of patients with a malignant disease and 32.3% of patients with a benign disease. Major LR was performed in 89 patients (34.6%). The mean PTC period was 20.32 min (±13.7). The median intraoperative bleeding amount was 200 mL (5–3500 mL), the 30-day mortality rate was 4.3%, and the morbidity rate was 31.9%. The hospital stay (p = 0.002), morbidity (p = 0.009), and 30-day mortality (p = 0.041) of patients with a bleeding amount of more than 500 mL significantly increased. Conclusion Surgeons should consider the adverse effects of intraoperative bleeding during liver resection on patients’ outcome. Favorable outcomes would be obtained with diligent postoperative care.

Introduction Surgical treatment for hepatic cystic ehinococcosis (CE) is not standardized in Kashi Prefecture. Previous evidence identified effectiveness of a clinical pathway in the field of liver surgery. However, proof of a clinical pathway program, especially for CE patients, is lacking. This study aimed to assess the validity of a clinical pathway for hepatic CE surgery performed on patients from Kashi Prefecture. Methods A clinical pathway was developed and implemented by a multidisciplinary team for patients undergoing hepatic CE surgery. Two groups were formed from patients undergoing hepatic CE surgery during a defined period before and after implementing a clinical pathway. Additionally, a propensity score matching analysis was performed. Results In the overall analysis (n = 258) as well as the matched analysis (n = 166), after implementing the clinical pathway, hospital stay was significantly reduced from 13 to 10 days and from 14 to 10 days, respectively (P

The rising evidence of the tumor microenvironment (TME) and its role in cancer have made this an area of increased research efforts. The focus is both on the primary tumor but also on the metastatic setting. The TME though, does not only consist of the non-malignant cells of a tumor, but also of the acellular compartment: The Extracellular Matrix (ECM). The liver is a common organ for metastasis of many cancers and for some of these cancers' liver surgery is a standard treatment with long-term cure, whereas for other cancers not considered meaningful. Blood supply and anatomical reasons plays one part for the establishment of liver metastasis. It is however a well-known fact that the "soil" of a metastatic organ is of utter importance in the process of metastasis. The "soil" consists of the TME where the ECM is a critical and active part. This review focuses what is known about the normal ECM of the human liver, what is known about ECM proteins in human liver metastasis, challenges of studying the ECM in liver metastases and lastly, potential applications of this field of knowledge.

Background: Despite a lack of high-level evidence, current guidelines recommend laparoscopic left lateral sectionectomy (LLLS) as the routine approach over open LLS (OLLS). Randomized studies and propensity score matched studies on LLLS vs OLLS for all indications, including malignancy, are lacking.Methods: This international multicenter propensity score matched retrospective cohort study included consecutive patients undergoing LLLS or OLLS in six centers from three European countries (January 2000-December 2016). Propensity scores were calculated based on nine preoperative variables and LLLS and OLLS were matched in a 1:1 ratio. Short-term operative outcomes were compared using paired tests.Results: A total of 560 patients were included. Out of 200 LLLS, 139 could be matched to 139 OLLS. After matching, baseline characteristics were well balanced. LLLS was associated with shorter operative time (144 (110-200) vs 199 (138-283) minutes, P < 0.001), less blood loss (100 (50-300) vs 350 (100-750) mL, P = 0.005) and a 3-day shorter postoperative hospital stay (4 (3-7) vs 7 (5-9) days, P < 0.001).Conclusion: This international multicenter propensity score matched study confirms the superiority of LLLS over OLLS based on shorter postoperative hospital stay, operative time, and less blood loss thus validating current guideline advice.

Background The advantages of robotic liver surgery are strongest for minor resections, where incision size drives recovery time, but cost remains a concern. We hypothesized that patients who underwent robotic minor liver resections would have superior peri-operative outcomes resulting in decreased cost. Methods We queried the medical record and cost data for patients who underwent open or robotic minor (1–2 segment) liver resection from 1/2016–8/2019. Financial data were normalized to Medicare reimbursements. Results There were 87 patients who underwent minor liver resections (robotic n = 46, open n = 41). Specimen size (173 ± 203 vs 257 ± 481 cm3), surgical duration (233 ± 87 vs 227 ± 83 min), estimated blood loss (187 ± 236 vs 194 ± 165 mL), and margin status (89% vs 93% R0) were similar for robotic and open resections respectively, yet complications (3/46, 7% vs 10/41, 24%, p = 0.02) and length of stay (2.2 ± 2.2 vs 6.2 ± 2.9, p Conclusion Patients undergoing robotic minor hepatectomy had superior peri-operative outcomes resulting in lower total cost of care when compared to open minor hepatectomy. Financial considerations should not adversely influence selection of a robotic approach for minor hepatectomy.

Background Repeat hepatectomy has been recognized as an effective treatment for hepatic malignancies, and a sheet type adhesion barrier, Seprafilm® has increasingly been used during hepatectomy to ease future relaparotomy. However, there is not yet sufficient evidence to support the safety of use of Seprafilm in liver surgery. Methods Data of 151 patients who had undergone open hepatectomy were retrospectively reviewed and the incidence of major abdominal morbidity was compared between patients in whom Seprafilm had and had not been used. Results Seprafilm was used in 108 patients (Seprafilm group) and no adhesion barrier was used in 43 patients (comparison group). There was no significant difference in the rate of major abdominal morbidities between the two groups (Seprafilm vs. comparison: 10% vs. 16%, P = 0.403). Although the Seprafilm group showed a tendency toward increased incidence of bile leakage (7% vs. 2%), and placement of Seprafilm on the hepatoduodenal ligament or on the visceral surface of the liver seemed to be associated with an increased incidence of major morbidity, multivariate analysis showed no significant correlation between the use of Seprafilm and postoperative major abdominal morbidity. Conclusion Use of Seprafilm may not increase the risk of major abdominal morbidity in liver surgery.

Die minimal-invasive Leberchirurgie ist sicher und kann mit nahezu gleichwertigen Ergebnissen wie die offene Chirurgie durchgefuhrt werden. Es stehen verschiedene Techniken der Parenchymdissektion und Blutstillung fur die sichere Durchfuhrung sowohl laparoskopisch als auch roboterbasiert zur Verfugung. Die roboterbasierte Chirurgie stellt durch ihre technischen Optionen die Weiterentwicklung der Laparoskopie dar. Eine Expertise in der minimal-invasiven und in der Leberchirurgie sind fur den Operateur unabdingbare Voraussetzungen.

Background The objective of the current study was to summarize and evaluate all published evidence regarding viscoelastic testing in the field of liver surgery. Methods A systematic search of the literature was performed using Medline/PubMed, Scopus, Cochrane Library Central, Google Scholar, and clinicaltrials.gov databases. The following keywords were used:“Thromboelastography”, “Thromboelastometry”, “Viscoelastic tests OR testing”, “Sonoclot Devices”, “Point-of-care tests OR testing”, “Coagulation OR Haemostasis OR Hemostasis”, “Liver OR Hepatic Surgery”, “Cirrhosis.” Results A total of 12 studies analyzing 348 patients who underwent viscoelastic testing of coagulation during liver surgery for benign or malignant diseases were included; 7 (58.3%) studies reported on the use of thromboelastography (TEG), and 5 (41.7%) reported on rotational thromboelastometry (ROTEM). Viscoelastic testing (TEG and ROTEM) identified normo-, hyper- and hypo-coagulable status in 77% (n = 268/348), 18.4% (n = 64/348), and 4.6% (n = 16/348) of patients, respectively. In contrast, conventional coagulation tests indicated normo-coagulability in 111 patients (34.2% out of 325) and hypo-coagulability in 214 (65.8% out of 325) patients following liver resection. No patient (0% out of 291) experienced postoperative hemorrhage, whereas 5.8% (n = 17/291) experienced postoperative thromboembolic events. Conclusions Global viscoelastic testing may be a reasonable adjunct to conventional coagulation testing to provide a more robust assessment of the coagulation status of patients undergoing liver surgery.

Hepatocellular carcinoma (HCC) is a common malignancy worldwide, recognized as the fourth most common cause of cancer related death. Many risk factors, leading to liver cirrhosis and associated HCC, have been recognized, among them viral hepatitis infections play an important role worldwide. Patients suffering from chronic kidney disease (CKD), especially those on maintenance dialysis, show a higher prevalence of viral hepatitis than the general population what increases the risk of HCC onset. In addition, renal dysfunction may have a negative prognostic impact on both immediate and long-term outcomes after malignancy treatment. Several interventional procedures for the treatment of HCC are currently available: thermal ablation, transcatheter arterial chemoembolization, liver surgery or even liver transplantation. The Barcelona Clinic Liver Cancer system provides an evidence-based treatment algorithm to address different categories of patients to the most-effective treatment in consideration of the extension of disease, liver function and performance status. Liver resection and transplantation are usually reserved to patients with early stage HCC and acceptable performance status, while the other treatments are more indicated in case of impaired liver function or locally advanced or unresectable tumors. However, there is no validated treatment algorithm for HCC in CKD patients, mainly due to the rarity of reports in this cohort of patients. Hereby we discuss the available evidences on interventional HCC treatments in CKD patients, and briefly report up-to-date pharmacological therapy for HCC patients affected by viral hepatitis.

Background Liver surgery and transplantation currently represent the only curative treatment options for primary and secondary hepatic malignancies. Despite the ability of the liver to regenerate after tissue loss, 25–30% future liver remnant is considered the minimum requirement to prevent serious risk for post-hepatectomy liver failure. Purpose The aim of this review is to depict the various interventions for liver parenchyma augmentation–assisting surgery enabling extended liver resections. The article summarizes one- and two-stage procedures with a focus on hypertrophy- and corresponding resection rates. Conclusions To induce liver parenchymal augmentation prior to hepatectomy, most techniques rely on portal vein occlusion, but more recently inclusion of parenchymal splitting, hepatic vein occlusion, and partial liver transplantation has extended the technical armamentarium. Safely accomplishing major and ultimately total hepatectomy by these techniques requires integration into a meaningful oncological concept. The advent of highly effective chemotherapeutic regimen in the neo-adjuvant, interstage, and adjuvant setting has underlined an aggressive surgical approach in the given setting to convert formerly “palliative” disease into a curative and sometimes in a “chronic” disease.

Purpose In this systematic review, we aimed to clarify the useful anatomic structures and assess available surgical techniques and strategies required to safely perform minimally invasive anatomic liver resection (MIALR), with a particular focus on the hepatic veins (HVs). Methods A systematic review was conducted using MEDLINE/PubMed for English articles and Ichushi databases for Japanese articles through September 2020. The quality assessment of the articles was performed in accordance with the Scottish Intercollegiate Guidelines Network (SIGN). Results A total of 3,372 studies were obtained, and 59 were selected and reviewed. Due to the limited number of published comparative studies and case series, the degree of evidence from our review was low. Thirty-two articles examined the anatomic landmarks and crucial structures for approaching HVs. Regarding the direction of HV exposure, 32 articles focused on the techniques and advantages of exposing HVs from either the root or the periphery. Ten articles focused on the techniques to perform a segmentectomy 8 in particularly difficult cases of MIALR. In seven articles, bleeding control from HVs was also discussed. Conclusions This review may help experts reach a consensus regarding the best approach to the management of hepatic veins during MIALR.

The resection of colorectal liver metastases (CRLM) within the framework of a multimodal treatment concept is a generally accepted and potentially curative treatment approach. Despite the fact that liver surgery represents a survival extension for patients with a good quality of life, this treatment option is offered to nowhere near all patients. This article summarizes the results of liver resection for CRLM patients and discusses the reasons for the different estimations of resectability even by experienced liver surgeons. The complexity of the treatment is exemplarily shown based on a case report.

Background Cardiopulmonary exercise-testing (CPET) and the (Portsmouth) Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity ((P)-POSSUM) are used as pre-operative risk stratification and audit tools in general surgery, however, both have been demonstrated to have limitations in major hepatopancreatobiliary (HPB) surgery. Materials and methods The aim of this review is to determine if CPET and (P)-POSSUM scoring systems accurately predict morbidity and mortality. Eligible articles were identified with an electronic database search. Analysis according to surgery type and tool used was performed. Results Twenty-five studies were included in the final review. POSSUM predicted morbidity demonstrated weighted O/E ratios of 0.75(95%CI0.57–0.97) in hepatic surgery and 0.85(95%CI0.8–0.9) in pancreatic surgery. P-POSSUM predicted mortality in pancreatic surgery demonstrated an O/E ratio of 0.75(95%CI0.27–2.13) and 0.94(95%CI0.57–1.55) in hepatic surgery. In both pancreatic and hepatic surgery an anaerobic threshold(AT) of between 9 0.5–11.5 ml/kg/min was predictive of post-operative complications, and in pancreatic surgery ventilatory equivalence of carbon dioxide(˙VE/˙VCO2) was predictive of 30-day mortality. Conclusion POSSUM demonstrates an overall lack of predictive fit for morbidity, whilst CPET variables provide some predictive power for post-operative outcomes. Development of a new HPB specific risk prediction tool would be beneficial; the combination of parameters from POSSUM and CPET, alongside HPB specific markers could overcome current limitations., Highlights • Current pre-operative scoring for pancreatic and liver surgery is inaccurate. • In pancreatic and liver surgery anaerobic threshold scores were predictive of complications. • In pancreatic surgery ventilatory equivalence of carbon dioxide was predictive of mortality. • P-POSSUM is inaccurate for predicting mortality and morbidity in pancreatic surgery.

IMPORTANCE: Indication for liver resection (LR) for localized hepatic metastases from breast cancer (BC) is still a matter of debate. OBJECTIVE: A literature review of recent scientific papers pertaining to hepatectomies for BC liver metastases (LM). EVIDENCE REVIEW: We based our systematic review on case series on literature reviews, comparative studies and cost-utility analysis which have been selected based on criteria regarding surgery, possible prognostic factors and evaluation of long-term survival. FINDINGS: There is a strong inhomogeneity in the reported data, with 5-year survivals ranging from 21% to 58%. There is no agreement in the evaluation of prognostic variables predicting good survival, with the only exception of the time of treatment of the primary BC until the diagnosis of metastases. Three out of the four comparative studies report better survivals for patients who underwent a hepatectomy in comparison to those treated with chemotherapy alone, but their strength in terms of scientific evidence is weak. The only cost-utility analysis revealed that 2 out of the 3 scenarios considered were in favor of the treatment with surgery followed by conventional chemotherapy. CONCLUSIONS: There is no definitive proof on the effectiveness of LRs for BC LM. Surgery can be proposed when it is possible to perform radical surgery, with R0 margins and saving at least 30% of the liver with its vascular and biliary connections. Stable skeletal metastases are not a contraindication. The interval between treatment of the primary location and diagnosis of hepatic metastases is the only prognosis criteria available.

Background Virtual reality (VR) with head-mounted displays (HMD) may improve medical training and patient care by improving display and integration of different types of information. The aim of this study was to evaluate among different healthcare professions the potential of an interactive and immersive VR environment for liver surgery that integrates all relevant patient data from different sources needed for planning and training of procedures. Methods 3D-models of the liver, other abdominal organs, vessels, and tumors of a sample patient with multiple hepatic masses were created. 3D-models, clinical patient data, and other imaging data were visualized in a dedicated VR environment with an HMD (IMHOTEP). Users could interact with the data using head movements and a computer mouse. Structures of interest could be selected and viewed individually or grouped. IMHOTEP was evaluated in the context of preoperative planning and training of liver surgery and for the potential of broader surgical application. A standardized questionnaire was voluntarily answered by four groups (students, nurses, resident and attending surgeons). Results In the evaluation by 158 participants (57 medical students, 35 resident surgeons, 13 attending surgeons and 53 nurses), 89.9% found the VR system agreeable to work with. Participants generally agreed that complex cases in particular could be assessed better (94.3%) and faster (84.8%) with VR than with traditional 2D display methods. The highest potential was seen in student training (87.3%), resident training (84.6%), and clinical routine use (80.3%). Least potential was seen in nursing training (54.8%). Conclusions The present study demonstrates that using VR with HMD to integrate all available patient data for the preoperative planning of hepatic resections is a viable concept. VR with HMD promises great potential to improve medical training and operation planning and thereby to achieve improvement in patient care.

While inflow control can be easily applied by Pringle maneuver, outflow control of the left liver has not been formally described. We report here a safe and reproductible technique of middle and left hepatic veinous trunk control (MLHVC) before parenchymal transection during laparoscopic left hepatectomy. A retrospective review of laparoscopic liver resection was conducted from January 2013 to March 2018 from our prospective database. All cases of laparoscopic left hepatectomy (LLH) were included, and intra- and postoperative outcomes data collected. We collected cases where the middle and left hepatic vein trunk control has been attempted and clamping used, and we analyzed outcomes associated with this maneuver. MLHVC was attempted in 28 cases (77.8) of the 36 LLH identify in a monocentric study. It was technically not feasible only in 3 cases (8.3%) and clamping applied in 15 cases (41.7%). No significant intraoperative unexpected event occurred. We present here a technique for left liver outflow control that can be safely added to the armamentarium of laparoscopic liver surgery.

Objective The Expert Consensus Guidelines initiative on MIDH for LDLT was organized with the goal of safe implementation and development of these complex techniques with donor safety as the main priority. Background Following the development of minimally invasive liver surgery, techniques of MIDH were developed with the aim of reducing the short- and long-term consequences of the procedure on liver donors. These techniques, although increasingly performed, lack clinical guidelines. Methods A group of 12 international MIDH experts, 1 research coordinator, and 8 junior faculty was assembled. Comprehensive literature search was made and studies classified using the SIGN method. Based on literature review and experts opinions, tentative recommendations were made by experts subgroups and submitted to the whole experts group using on-line Delphi Rounds with the goal of obtaining >90% Consensus. Pre-conference meeting formulated final recommendations that were presented during the plenary conference held in Seoul on September 7, 2019 in front of a Validation Committee composed of LDLT experts not practicing MIDH and an international audience. Results Eighteen Clinical Questions were addressed resulting in 44 recommendations. All recommendations reached at least a 90% consensus among experts and were afterward endorsed by the validation committee. Conclusions The Expert Consensus on MIDH has produced a set of clinical guidelines based on available evidence and clinical expertise. These guidelines are presented for a safe implementation and development of MIDH in LDLT Centers with the goal of optimizing donor safety, donor care, and recipient outcomes.

Robotic liver surgery is emerging as the future of minimal invasive surgery. The robotic surgical system offers a stable camera platform, elimination of physiologic tremor, augmented surgical dexterity as well as improved ergonomics because of a seated operating position. Due to the theoretical advantages of the robotic assisted system, complex liver surgery might be an especially interesting indication for a robotic approach since it demands delicate tissue dissection, precise intracorporeal suturing as well as difficult parenchymal transection with subsequent need for meticulous hemostasis and biliostasis. An analysis of English and German literature on open, laparoscopic and robotic liver surgery was performed and this review provides a general overview of the existing literature along with current standards and aims to specifically point out future directions of robotic liver surgery. Robotic liver surgery is safe and feasible compared to open and laparoscopic surgery, with improved short-term postoperative outcomes and at least non-inferior oncological outcomes. In complex cases including major hepatectomies, extended hepatectomies with biliary reconstruction and difficult segmentectomies of the posterior-superior segments, robotic surgery appears to emerge as a reasonable alternative to open surgery rather than being an alternative to laparoscopic procedures. Die robotische Leberchirurgie entwickelt sich zur Zukunft der minimalinvasiven Chirurgie. Das robotische Operationssystem bietet eine stabile Kameraplattform, Elimination des physiologischen Tremors, verbesserte chirurgische Geschicklichkeit sowie eine entspannte Ergonomie durch sitzende Position. Aufgrund theoretischer Vorteile des robotergestützten Systems erscheint die Leberchirurgie ein besonders geeignetes Feld für den Einsatz des OP Roboters zu sein, da es hohe technische Anforderung (delikate vaskuläre und parenchymatöse Präparation, intrakoroprale Anastomosen, Blutstillung) an den Chirurgen stellt. Durch die Auswertung bestehender englisch- und deutschsprachigen Literatur zur offenen, laparoskopischen sowie robotischen Leberchirurgie bietet diese Übersichtsarbeit einen Überblick über aktuelle Literatur sowie Standards und zielt darauf ab, zukünftige Entwicklungen der robotischen Leberchirurgie aufzuzeigen. Die robotische Leberchirurgie ist ein sicheres und technisch durchführbares Operationsverfahren. Im Vergleich zu offener und laparoskopischer Chirurgie zeigen sich verbesserte intra- und postoperative Outcome Daten, bei gleichwertigen onkologischen Ergebnissen. In komplexen Fällen, einschließlich größerer Hepatektomien, erweiterter Gallenrekonstruktionen und Segmentektomien der hinteren Segmente, stellt sich robotische Chirurgie mehr als Alternative zur offenen als zur laparoskopischen Chirurgie auf. Damit erweitert sich das Spektrum minimalinvasiver Leberchirurgie.

Over the past decade, enhanced preoperative imaging and visualization, improved delineation of the complex anatomical structures of the liver and pancreas, and intra-operative technological advances have helped deliver the liver and pancreatic surgery with increased safety and better postoperative outcomes. Artificial intelligence (AI) has a major role to play in 3D visualization, virtual simulation, augmented reality that helps in the training of surgeons and the future delivery of conventional, laparoscopic, and robotic hepatobiliary and pancreatic (HPB) surgery; artificial neural networks and machine learning has the potential to revolutionize individualized patient care during the preoperative imaging, and postoperative surveillance. In this paper, we reviewed the existing evidence and outlined the potential for applying AI in the perioperative care of patients undergoing HPB surgery.

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ZusammenfassungSeit der Einführung der roboterassistierten Chirurgie können immer kompliziertere Operationen in dieser Technik durchgeführt werden. Auch in der hepatobiliären Chirurgie gewinnt die roboterassistierte Operation zunehmend an Bedeutung. Artikulierte und skalierte Bewegungen in einem 3-dimensionalen Operationsfeld ermöglichen eine präzise Präparation, notwendig für Majorresektionen an der Leber. Dieses Video demonstriert die Machbarkeit und Präzision der vollständig roboterassistierten Technik in der Durchführung einer Hemihepatektomie rechts bei einem hepatozellulären Karzinom (HCC) der Segmente V – VIII bei nicht alkoholischer Steatohepatitis (NASH). Der Patient ist bei Operation 72 Jahre und begleiterkrankt mit einem ausgeprägten metabolischen Syndrom.

Background Robotic liver resection has not yet been widely implemented. We aimed to evaluate the feasibility and safety of robotic major liver resection by performing a prospective multicenter study. Methods From July 2017 to December 2018, five surgeons from five tertiary hospitals who were novices in robotic liver resection but experienced in open and laparoscopic liver resection performed 46 cases of robotic major anatomical liver resections. Perioperative clinical data and surgical data, including detailed procedure times were prospectively collected. All operations were performed according to a protocol for unify surgical techniques and instruments. Results Twenty-two cases of left hemihepatectomy, one case of extended left hemihepatectomy, 14 cases of right hemihepatectomy, two cases of right anterior sectionectomy, six cases of right posterior sectionectomy, and one case of central bisectionectomy were performed. The most common indications were hepatocellular carcinoma (21 cases) followed by intrahepatic duct stones (10 cases), intrahepatic cholangiocellular carcinoma (7 cases), liver metastases (3 cases), intraductal papillary neoplasms (2 cases), sarcoma (1 case), mucinous cystic neoplasm (1 case), and hemangioma (1 case). Surgical resection margins for all tumor cases were negative. The mean operation time was 378.58 ± 124.31 (190–696) minutes and the estimated intraoperative blood loss was 276.67 ± 397.41 mL (range, 10–2600 mL). Overall complications developed in 16 cases (34.8%). There were three cases of severe surgical complications (Clavien-Dindo classification of III or more). Only one of 46 cases was converted to conventional open left hemihepatectomy because of bleeding. The mean hospital stay was 7.3 ± 2.5 (4–18) days. Conclusions The results of this study indicate that robotic anatomic major liver resection can be safely performed by robotic beginners who are advanced open and laparoscopic liver surgeons.

Hepatocellular carcinoma (HCC) accounts for the vast majority of primary hepatic malignancies. The overall incidence of this disease has always been significant, but in recent years it has continued to rise, now making HCC one of the leading causes of cancer deaths worldwide. Fortunately, research into the mechanisms of carcinogenesis and treatment options for this disease has also been progressing rapidly. Although the future for new insights and therapies appears more promising than ever, it also remains important to understand both the nature of HCC and the current state-of-the-art for treating affected patients. Although surgery is often considered to be a first choice, many patients present with extensive disease and are therefore not operative candidates. Fortunately, significant clinical advances over the last decade have contributed a number of new or improved treatment options. Many of these treatments require expertise from a variety of different clinical subspecialties. Indeed, managing patients with HCC has rapidly become a multi-modality, multi-disciplinary endeavor in which the details of each individual’s circumstance can greatly impact outcomes, and strategies can be quite nuanced. The purpose of this review is to provide a perspective on the disease itself, the patients who become afflicted, the spectrum of currently available treatment options, and the strategies for their optimal implementation. Such knowledge can be critically important as new data become available on the research front.

Although the number of robotic hepatectomy (RH) performed is increasing, few studies have reported its efficacy in comparison with the conventional surgical modalities. The aim of this meta-analysis was to evaluate the perioperative results of RH vs. open hepatectomy (OH) and RH vs. laparoscopic hepatectomy (LH). We systematically searched for English papers published in PubMed (Medline), Embase, and Cochrane library before March 1, 2020. A total of 39 papers and 2999 patients were eventually included. Among the included patients, 1249, 1010, and 740 underwent RH, LH, and OH, respectively. Compared with OH, the operation time was significantly increased but the intraoperative blood loss, blood transfusion rate, incidence of severe complications, and length of postoperative hospitalization were significantly reduced in patients with RH. However, there was no significant difference in the use of Pringle maneuver and overall incidence of complications. Compared with LH, the operation time was significantly increased, and the intraoperative blood loss was also more in RH. However, there were no differences in blood transfusion rate, use of Pringle maneuver, incidence of complications, incidence of severe complications, and length of postoperative hospitalization between the two groups. A longer operation time remains the main shortcoming of RH. However, based on the perioperative clinical efficacy, we conclude that RH is comparable to LH but is better than OH for selected patients.

Objective. To estimate immediate results of surgical treatment of peripheral cholangiocarcinoma in elderly and senile patients. Materials and methods. In 2004-2018 yrs period in the Department of Transplantation and Surgery of the Liver of the Shalimov National Institute of Surgery and Transplantology 84 patients, suffering peripheral cholangiocarcinoma, were radically operated: 31 (36.9%) patients older than 60 yrs (the main Group), and 53 (63.1%) patients, younger than 60 yrs (control Group). Results. Postoperative clinically significant (IIIa-IV degree in accordance to classification of Clavien-Dindo) complications during 90-days of postoperative period were noted in 29.1% patients of the main Group and in 32.1% patients of a control Group (p=0.262), postoperative hepatic insufficiency, in accordance to The International Study Group of Liver Surgery criteria, - in 16.1 and 22.6% accordingly (p=0.473); reoperation was performed in 9.6 and 9.4% patients, accordingly (p=0.973). The causes of postoperative lethality in 2 patients of the main Group were an acute myocardial infarction (1) and an acute pulmonary thromboembolism (1). Conclusion. Hepatic resection is characterized by satisfactory immediate results of treatment of peripheral cholangiocarcinoma in elderly and senile patients, if performed in highly-specialized multidisciplinary centre and thorough selection of patients.

Die minimal-invasive Leberchirurgie stellt an erfahrenen Zentren heute das Standardvorgehen dar, wobei sich Techniken und Strategien standig weiterentwickeln. Es erfolgte eine Analyse englischsprachiger Literatur zur minimal-invasiven und robotisch assistierten Leberchirurgie. Der aktuelle wissenschaftliche Stand wurde zusammengefasst und anhand eigener Zentrumserfahrungen bewertet. Vorteile der minimal-invasiven gegenuber der konventionell-offenen Technik zeigen sich bei leberchirurgischen Eingriffen in verbesserten perioperativen Ergebnissen. Bedenken im Hinblick auf intraoperative Komplikationen und mogliche Kompromisse bei der onkologischen Radikalitat konnten inzwischen durch eine Vielzahl von Publikationen ausgeraumt werden. Erste Berichte uber die robotisch assistierte Technik scheinen bekannte Vorteile der laparoskopischen Leberchirurgie zu bestatigen. Die Datenlage zur robotisch assistierten Leberchirurgie ist entsprechend dem kurzen Erfahrungszeitraum einiger weniger Zentren aber begrenzt und erlaubt noch keine abschliesenden Schlusse. Eine Steigerung der intraoperativen Sicherheit und eine Erweiterung des operativen Spektrums hin zu hoch komplexen Leberresektionen sind aber wahrscheinlich. Schon wahrend der Lernkurve scheinen sich bekannte Vorteile der laparoskopischen Leberchirurgie auch fur die robotisch assistierte Leberchirurgie zu bestatigen. Entsprechend eigenen Zentrumserfahrungen wird die minimal-invasive Leberchirurgie durch die robotisch assistierte Technik zukunftig sinnvoll erganzt werden. Insbesondere werden technisch hoch komplexe Resektionen mit Rekonstruktion ermoglicht.