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Anatomical liver resections (ALR) in the form of segmentectomy or subsegmentectomy require the clear demarcation of the segment volume of parenchyma to be resected. Indocyanine green (ICG) fluorescence achieved through either the positive or the negative staining technique combined with near-infrared (NIR) imaging technology constitutes a real-time intraoperative navigation tool during segmentectomy. The laparoscopic approach in ALR is continuously expanding rendering accurate segment demarcation even more crucial. Yet, ICG fluorescence imaging in laparoscopic ALR is associated with some specific challenges.

Aim. To report a single-centre experience with the novel Associating Liver Partition and Portal vein ligation for Staged hepatectomy (ALPPS) technique. Methods. Patients with extended primary or secondary liver tumors whose future liver remnant (FLR) was considered too small to allow a standard hepatic resection were prospectively assessed for the ALPPS procedure. Results. From January 2013 until December 2018, 25 patients were considered for the ALPPS procedure at our institution. Five patients were judged intraoperatively not to be suitable for the surgical therapy and two patients underwent the first step of the ALPPS procedure but did not complete the second step. The ALPPS procedure was completed in 18 patients whose median age was 61.9 ± 6.5 years. Indications for surgical resection were metastases from colorectal cancer in 4 cases, perihilar cholangiocarcinoma in 4 cases, intrahepatic cholangiocarcinoma in 4 cases, hepatocellular carcinoma in 4 cases and gallbladder carcinoma in 2 cases. The calculated FLR volume was 302.5 ± 88.9 mL (22.6 ± 5.2% of the total liver volume) before ALPPS-1 and 514.4 ± 130.0 mL (31.9 ± 6.0%) before ALLPS-2 (p < 0.001). After a mean interval of 10.6 ± 2.6 days between the two procedures, the increase in FLR was 76.4 ± 39.6% (p < 0.001). Sixteen (88.9%) out of 18 patients required one or more additional interventions during the first surgical step; these consisted in 7 Roux-en-Y hepaticojejunostomy, 3 wedge resections of a residual tumor in the FLR and 10 cholecystectomies. The median hospital stay was 23 (IQR: 22–27.7) days. In-hospital mortality occurred in 3 (16.7%) patients for postoperative liver failure (2 cases) and multiple organ failure; 10 (55.5%) out of 18 patients experienced a grade III or above surgical complication according to Clavien-Dindo classification. After a median follow-up of 26.6 (IQR: 4.5–40.0) months, the 1- and 3-years overall survival rates were 69.4% and 47.6%, respectively. The 1- and 3-years recurrence-free survival rates were 70.7% and 53.0%, respectively. Conclusion. The ALPPS technique effectively increased the resectability of otherwise inoperable liver tumors, improving survival in these patients. The postoperative morbidity in our series was high in accordance with the data from the international ALPPS registry.

Nowadays, laparoscopic liver resections (LLR) are routinely performed in many centers worldwide for the treatment of benign and malignant liver lesions. Colorectal liver metastases (CRLM) represent the most frequent malignant indication to liver resection in Western countries, and the available evidence supports the advantages of LLR over open liver resections (OLR) in terms of perioperative short-term outcomes. Furthermore, despite initial skepticism, the long-term oncological outcomes appear safe and comparable to OLR. The clinical presentation of CRLM differs from patient to patient in terms of time interval from the diagnosis of the primary tumor (synchronous vs. metachronous) and in terms of location, size, and number of lesions, making the management of patients challenging. Surgical resection is associated with long-term survivals, and laparoscopic approach has been described in each setting with different levels of evidence. Selection criteria should take into account patients’ characteristics and disease presentation as well as learning curve and expertise in order to achieve improvement in postoperative results, maintaining safe oncological outcomes.

Safe liver surgery has been performed for the past three decades. Before the 1980s, the mortality rate associated with liver resections was above 20%, mostly related to massive hemorrhage. Improved anesthesia and postoperative care, in addition to a better understanding of the liver’s anatomy, reduced mortality rates to less than 5% in specialized centers. Laparoscopic liver surgery started in the mid-1990s [1]. The recent advances in laparoscopic devices and the development of liver parenchymal transection equipment led to an increased performance of laparoscopic liver resections in recent years. Although laparoscopy has been shown to be a safe and feasible approach [2–9], major hepatectomies are being performed in few centers [1]. In expert hands, oncologic and clinical outcomes have proven to be equivalent to those of the open technique [10–13], with the benefits of minimally invasive surgery (early recovery, shorter hospitalization, and better cosmetic outcomes) [14]. Limitations of laparoscopic surgery such as the restricted movement of the instruments and two-dimensional view, the complexity of these procedures, and the potential risk of major bleeding during the parenchymal transection are some of the obstacles preventing a wider application of laparoscopy in liver resections [1].

Minimally invasive liver resection has been adopted as the standard of care for peripheral hepatic lesions. While many surgeons are comfortable with left lateral sectionectomies and with laparoscopic wedge resections in peripheral segments, more major resections are less often attempted as minimally invasive (MIS). Recent improvements in robotic instrumentation, such as articulated instruments, sealers, and staplers, are expanding implementation of MIS liver surgery. Robotic surgery is now able to make MIS liver surgery much easier and safer. In this chapter, we will discuss indications for robotic liver resections, and provide an overview of the robotic procedures including preoperative considerations, procedure steps and tips, and postoperative patient care.

Robotic assistance offers several advantages for certain surgical procedures. Its use is being investigated for its application in hepatobiliary surgery. This chapter describes techniques for various robotic-assisted liver resections and biliary surgery.

Post-hepatectomy liver failure (PHLF) is a major source of morbidity and mortality after major liver resections and appears to be related to the quality and volume of the future liver remnant (FLR). Assessment of liver quality and calculation of FLR using 3-D cross-sectional imaging modalities are essential before proceeding with any major live resection. Volume optimization strategies must be considered in all patients at high risk for PHLF. This chapter discusses the indications and details of the commonly used strategies of hepatic volume optimization. A proposed treatment algorithm is also included.

Liver surgery is complex and technically demanding. A teamwork consisting in experienced surgeons and well-trained anaesthesiologists is mandatory to achieve optimal results. Expertise teams have incorporated minimally invasive techniques to their liver surgery armamentarium and now, it is a well-established approach for several indications. Since the first laparoscopic left-lateral sectionectomies in 1996, the progression of laparoscopic liver resections has been exponential and now, complex liver resections, major hepatectomies, sequential procedures and even living donation are being performed laparoscopically. We will provide an overview of indications, advantages and technical considerations of this approach.

With primary and metastatic cancers to the liver, the optimal therapy remains curative surgical resection. Various non-anatomical and anatomical liver resections are common practice, but when tumors are in difficult locations, surgeons may require the use of vascular resection with portal venous or arterial reconstruction to obtain negative resection margins. In situations where tumors involve the inferior vena cava (IVC) or hepatic veins, other techniques may be employed for resection that was developed from liver transplant techniques. Ex vivo resection remains the most dramatic of these complex resection techniques and is used for the most difficult tumors to resect, including malignant disease such as hepatocellular carcinoma, cholangiocarcinoma, colorectal metastasis, benign obstructive disease, or echinococcal cysts. Ex vivo resection carries a 10–15% mortality, with a high chance of surgical complications and postoperative liver failure, but offers a potential for cure in otherwise unresectable patients. This chapter outlines the technique of ex vivo resection and highlights two cases where it was used.

The development of new technological devices, the improvement of surgeon’s skills, and other technical advances were three different factors that allowed the increasing applicability of laparoscopy for the resection of colorectal liver metastasis (CLM). The roles of laparoscopy in CLM surgery are: oncological staging, tumor ablation, and liver resections.

Liver surgery for metastatic colorectal cancer has become one of the most sophisticated and specialized areas in modern visceral surgery. Exact knowledge of the normal liver anatomy and its variants is necessary in order to carefully plan one- or two-staged liver resections and to perform the correct techniques of parenchymal transections and vascular control for each individual case. Although vascular control and/or vascular reconstruction is not required for every liver resection, a profound knowledge of vascular control is required for the modern liver surgeon. Intraoperative blood loss remains one of the major risk factors for postoperative morbidity and mortality, and therefore vascular control plays a major role in performing safe liver resection for colorectal liver metastases.

Resection is the established gold-standard treatment of colorectal liver metastases. The surgical management of colorectal liver metastases has changed dramatically during the past three decades with the diffusion of the parenchymal-sparing liver resection. This approach involves preserving healthy functional liver parenchyma by performing a wide range of liver resections, ranging from small non-anatomical wedge resections to complex atypical non-anatomical resections, to segmentectomies or subsegmentectomies. Site and relationships of the tumor with glissonian pedicles or hepatic veins have to be exactly identified, in order to perform the appropriate type of resection. Therefore, it is clear that only the intensive use of intraoperative liver ultrasound makes it possible to perform parenchymal-sparing liver resections. The same strategy can be applied with the laparoscopic approach. The parenchymal-sparing liver resection is supported by pathological, oncological, and technical reasons. This approach reduces postoperative mortality and morbidity rates, better preserves postoperative liver function, thus decreasing the risk of liver dysfunction, offers similar survival results, and increases the opportunity of re-resection in case of recurrence.

Couinaud’s usual representation of liver anatomy, with a right liver composed of two sectors and four segments; a left liver, composed of two sectors and three segments; and a dorsal, retroportal segment 1; separated by the main hepatic veins and the portal bifurcation, offers a consensual ideal description that is very useful to localize liver lesion and the main types of liver resections. Alternative representations, and in particular customized radiological reconstructions and intraoperative ultrasound, allow the experienced liver surgeon to adapt the surgical procedures to the real individual anatomy, and to perform anatomically based, radical yet conservative resections (territorial liver resections). The principles of these different anatomical representations will be illustrated, together with the surgical anatomy of some important liver structures that permit the anatomical surgery that is required in this expanding specialty.

The current trend in surgical treatment of benign liver masses is headed toward parenchyma preservation and null morbidity. Nevertheless, laparoscopic surgery is still far from reproducing results of open liver surgery. Liver resections in the anterior segments are the most diffuse procedures in minimally invasive surgery of the liver. Contrarily, laparoscopic liver resections in the posterolateral segments are still considered a challenging task. Contact with a main vascular structure and the deep location are also limiting factors for a laparoscopic parenchyma-preserving resection. Robotics, coupled to intraoperative ultrasonography, could be the appropriate tool to overcome limitations of traditional laparoscopy to carry out safe liver resections even in challenging conditions.

Robotic assistance offers several advantages for certain surgical procedures. Its use is being investigated for its application in gallbladder and liver surgery. This chapter describes techniques for various robotic-assisted liver resections and gallbladder surgery.

Liver surgery is one of the last areas where the minimally invasive technique spread, in view of the considerable technical difficulties associated. The feasibility and efficacy of laparoscopic liver resections have gradually been demonstrated, along with the benefits that this procedure provides to postoperative outcome as compared to the open technique, in particular by reducing the length of hospital stay. Therefore, these results have encouraged the use of the single-site approach for liver resections, in an attempt to reduce the invasiveness and biological stress associated with the procedure, to further improve the outcome after surgery. Several reports have demonstrated the feasibility and safety in selected cases of liver resections, and technical dissertations have already been processed. The possible postoperative benefits of the procedure have already been highlighted, in particular in terms of reduced postoperative pain, even if the real benefits have yet to be confirmed, as well as its oncological adequacy. Single-site liver resections remain a highly challenging procedures to be performed by experienced surgeons in both hepatic and laparoscopic surgery.