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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.

Anatomical liver resections require clear hepatic segment demarcation, that is, delineation of the surface as well as the intersegmental planes of the volume of the liver to be resected. Indocyanine green (ICG) fluorescence is utilized for segmentation mapping and can be visualized by a near-infrared fluorescence (NIR) imaging system. ICG and NIR constitute a novel intraoperative navigation system guiding hepatic transection during both open and laparoscopic liver surgery. In the positive ICG labeling method, either the target portal pedicle is injected with ICG leading to selective fluorescence of the target segment or the portal pedicles feeding the neighboring segments are injected (counter-labeling), resulting in fluorescence marking the target segment. In the negative labeling method, ICG is injected intravenously after selective clamping of the portal pedicle feeding the designated segment exhibiting fluorescence all over the liver except in the segment to be resected. ICG fluorescence-based navigation achieves clear demarcation of the segment boundaries on the liver surface and also allows real-time navigation for intersegmental plane determination during hepatectomy.

Radioembolization with 90Y-microspheres has been reported to induce contralateral liver hypertrophy with simultaneous ipsilateral control of tumor growth. The aim of the present systematic review was to summarize the evidence of contralateral liver hypertrophy and oncological outcome following unilateral treatment with radioembolization. A systematic literature search using the MEDLINE, EMBASE, and Cochrane libraries for studies published between 2008 and 2020 was performed. A total of 16 studies, comprising 602 patients, were included. The median kinetic growth rate per week of the contralateral liver lobe was 0.7% and declined slightly over time. The local tumor control was 84%. Surgical resection after radioembolization was carried out in 109 out of 362 patients (30%). Although the available data suggest that radioembolization prior to major hepatectomy is safe with a promising oncological outcome, the definitive role of radioembolization requires assessment within controlled clinical trials.

Surgical outcomes may be associated with hospital volume and the influence of volume on minimally invasive liver surgery (MILS) is not known.Patients entered into the prospective registry of the Italian Group of MILS from 2014 to 2018 were considered. Only centres with an accrual period of at least 12 months and stable MILS activity during the enrolment period were included. Case volume was defined by the mean number of minimally invasive liver resections performed per month (MILS/month).A total of 2225 MILS operations were undertaken by 46 centres; nine centres performed more than two MILS/month (1376 patients) and 37 centres carried out two or fewer MILS/month (849 patients). The proportion of resections of anterolateral segments decreased with case volume, whereas that of major hepatectomies increased. Left lateral sectionectomies and resections of anterolateral segments had similar outcome in the two groups. Resections of posterosuperior segments and major hepatectomies had higher overall and severe morbidity rates in centres performing two or fewer MILS/month than in those undertaking a larger number (posterosuperior segments resections: overall morbidity 30·4 versus 18·7 per cent respectively, and severe morbidity 9·9 versus 4·0 per cent; left hepatectomy: 46 versus 22 per cent, and 19 versus 5 per cent; right hepatectomy: 42 versus 34 per cent, and 25 versus 15 per cent).A volume-outcome association existed for minimally invasive hepatectomy. Complex and major resections may be best managed in high-volume centres.Los resultados quirúrgicos pueden estar relacionados con el volumen de casos del hospital, pero no se conoce la influencia en la cirugía mínimamente invasiva del hígado (minimally‐invasive liver surgery, MILS). MÉTODOS: Se incluyeron los pacientes registrados en el registro prospectivo del grupo italiano de MILS desde 2014 a 2018. Solo se consideraron centros con extensión de ≥ 12 meses y actividad estable de MILS durante el periodo de reclutamiento. El volumen de casos se definió como el número de MILS efectuado por mes.Se llevaron a cabo un total de 2.225 MILS en 46 centros, 9 de ellos con 2 MILS/mes (n = 1.376 pacientes) y 37 centros con ≤ 2 MILS/mes (n = 849). La proporción de resecciones de segmentos anterolaterales disminuyó con el volumen de casos, mientras que la proporción de hepatectomías mayores aumentó. Los resultados para ambos grupos fueron similares en las seccionectomías lateral izquierda y en las resecciones del segmento anterolateral. Las resecciones del segmento posterosuperior y las hepatectomías mayores presentaron tasas más altas de morbilidad global y morbilidad grave en centros que realizaban ≤ 2 MILS/mes que en los que realizaban 2 MILS/mes (resecciones del segmento posterosuperior, morbilidad global 30,4 versus 18,7%, morbilidad grave 9,9 versus 4,0%; hepatectomía izquierda, 46,2 versus 22,0%, 19,2 versus 5,5%; hepatectomía derecha, 41,7 versus 33,8%, 25,0 versus 14.9%). CONCLUSIÓN: Se observó una asociación volumen‐resultado para la resección hepática mínimamente invasiva. Las resecciones complejas y mayores se pueden manejar mejor en centros de gran volumen.

Background: Recently, the minimally invasive surgical approach has been available for performing liver resections (LRs) with laparoscopic and robotic techniques. The robotic approach for LRs seems to overcome several laparoscopic limitations, which is a valid alternative when performed in high volume and specialized centers. Laparoscopic difficulty score systems (DSSs) should serve to guide the surgeon's choice in the best surgical approach to adopt for every single patient, giving the possibility to switch to the open approach when needed. To this day, no specific robotic difficulty scores exist. The aim of our study was to verify the feasibility of applying these scores and related updates on robotic LRs performed in our Institute.Materials and Methods: Out of a total of 683 LRs performed from June 2010 to July 2019, 60 were performed through using a mini invasive approach and of these 18 were performed robotically. The Ban DSS and subsequently the modified Iwate DSS were applied to our cases.Results: Based on our findings, applying the DSS we divided our series into two groups: a low difficulty level group (1-3) made up of 5 patients, and an intermediate difficulty level group (4-6) consisting of 13 patients. Average Ban DSS and subsequently updated score system results were 4.6 +/- 1.5 points (range 2-6) for both scores.Conclusions: Difficulties were encountered in applying the score when simultaneous multiple wedge resections were performed. The laparoscopic DSS is applicable to robotic LRs with some limitations due to the peculiarity of the two different minimally invasive approaches. A specific robotic difficulty rating score could be necessary to include these elements.

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.

Robotic surgery has emerged as a promising minimally invasive surgical technique, with the ability to perform complex hepatobiliary surgeries and achieve outcomes similar to open surgery, but with the advantages of a minimally invasive approach. Recent advances in computer-assisted image-guided surgery are proposed to overcome some of the associated limitations of robotic surgery by preoperatively planning the surgical strategy with a patient-specific virtual resection plan, which can be directly transferred to the operating room in an augmented reality setup. Using new technologies, we could theoretically improve the preoperative planning, enhance the surgeon’s skill, and simplify complex procedures. Specifically, using an optical tracking system, calibrated on the patient, we used images-overlay navigation for the location of the lesions during robotic liver resections. Based on our experience, we suggest that robotic image guidance can improve the surgeon’s orientation during the operation, increasing the accuracy of tumor resection. The indications for robotic-assisted liver resection will increase in the coming years. This chapter reviews the recent development of robotic hepatic surgery, discussing its advantages and disadvantages in daily practice. The most common surgical procedures are described and, finally, the evolution of robotic surgery, one of the hottest fields in medical technology, is detailed.

Malnutrition in liver surgery is correlated with higher postoperative complications and longer length of hospital stay (LOHS), the same items that ERAS programs try to optimize. However, to date, standardized dietary protocols have not been defined within ERAS programs. Aim of this study was to evaluate the impact on LOHS and postoperative complications, of a personalized nutritional protocol (NutriCatt) with diet and oral branched-chain amino acid (BCAA) supplementation, adopted within the ERAS program.1960 consecutive liver resections were performed from January 2000 to September 2018.perihilar cholangiocarcinoma, simultaneous colorectal and liver resections. Four groups for analysis: resections before 2009 (1st period); from 2009 to 2016 (2nd period, including laparoscopic resections); between 2016 and September 2017 (ERAS); after September 2017 (ERAS + NutriCatt).LOHS declined (p 0.0001), from a median of 10 days (1st period) to 8, 7 and 6 in 2nd period, ERAS and ERAS + NutriCatt groups, respectively. At multivariable analysis for risk of LOHS 8 days, the 2nd period, ERAS and ERAS + NutriCatt groups showed a protective effect. These results were confirmed for both minor and major resections. LOHS was significantly lower in ERAS + Nutricatt group than in ERAS group, without increasing risk of postoperative complications, although the rate of laparoscopic resections was similar in these two groups and complexity of liver resections was significantly higher in the last period.Adoption of a personalized nutritional protocol with BCAA supplementation within the ERAS program for liver resections was a safe and effective approach that may impact on reducing the LOHS.

Background: In the last decades, there has been an exponential diffusion of minimally invasive liver surgery (MILS) worldwide. The aim of this study was to evaluate our initial experience of 100 patients undergoing MILS resection comparing their outcomes with the standard open procedures. Materials and methods: One hundred consecutive MILS from 2016 to 2019 were included. Clinicopathological data were reviewed to evaluate outcomes. Standard open resections were used as the control group and compared exploiting propensity score matching. Results: In total, 290 patients were included. The rate of MILS has been constantly increasing throughout years, representing the 48% in 2019. Of 100 (34.5%) MILS patients, 85 could be matched. After matching, the MILS conversion rate was 5.8% (n = 5). The post-operative complication rates were higher in the open group (45.9% vs. 31.8%, P = 0.004). Post-operative blood transfusions were less common in the MILS group (4.7% vs. 16.5%, P = 0.021). Biliary leak occurred in 2 (2.4) MILS versus 13 (15.3) open. The median comprehensive complication index was higher in the open group (8.7 [0-28.6] vs. 0 [0-10.4], P = 0.0009). The post-operative length of hospital stay was shorter after MILS (median 6 [5-8] vs 8 [7-13] days, P < 0.0001). Conclusions: The rate of MILS has been significantly increasing throughout the years. The benefits of MILS over the traditional open approach were confirmed. The main advantages include lower rates of post-operative complications, blood transfusions, bile leaks and a significantly decreased hospital stay.

BACKGROUND: The laparoscopic approach to liver resection has experienced exponential growth in recent years; however, its application is still under debate and objective, evidence-based guidelines for its safe future progression are needed. OBJECTIVE: The aim of this study was to perform a systematic review and meta-analysis comparing the short- and long-term outcomes of laparoscopic and open liver resections for hepatocellular carcinoma (HCC). METHODS: To identify all the comparative manuscripts reporting on laparoscopic and open liver resection for HCC, all published English-language studies with more than 10 cases were screened. In addition to the primary meta-analysis, four specific subgroup analyses were performed on patients with Child-Pugh A cirrhosis, resections for solitary tumors, and those undergoing minor and major resections. The quality of the studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) methodology and the Newcastle-Ottawa Scale. RESULTS: From the initial 361 manuscripts, 28 were included in the meta-analysis. Five of these 28 manuscripts were specific to patients with Child-Pugh A cirrhosis (321 cases), 11 focused on solitary tumors (1003 cases), 16 focused on minor resections (1286 cases), and 3 focused on major resections (164 cases). Three manuscripts compared 1079 cases but could not be assigned to any of the above subanalyses. In general terms, short-term outcomes were favorable when using a laparoscopic approach, especially in minor resections. The only advantage seen with an open approach was reduced operative time during major liver resections. No differences in long-term outcomes were observed between the approaches. CONCLUSIONS: Laparoscopic liver resection for HCC is feasible and offers improved short-term outcomes, with comparable long-term outcomes as the open approach.

Background: About 15 to 25% of colorectal cancer patients have synchronous liver metastasis at diagnosis. In the recent years, the strategy of simultaneous removal of colorectal cancer and liver metastases has been preferred. Development of minimally invasive technologies in abdominal and hepatopancreatobiliary surgery allows for active advance to fully laparoscopic approach to these types of interventions.Aim: Comparative analysis of simultaneous and isolated laparoscopic liver resections performed in the Department of Surgery, Russian Research Center of Roentgenoradiology (Moscow).Materials and methods: We have analyzed intra- and postoperative results of 29 laparoscopic procedures for metastatic liver disease. Group 1 included 14 patients who had undergone simultaneous laparoscopic primary tumor resection and laparoscopic liver resection for metastatic disease. Group 2 included 15 patients who had undergone isolated laparoscopic liver resection for metastatic lesions.Results: Mean (± SD) blood loss in the simultaneous and isolated procedures groups was 469 ± 176 and 408 ± 124 mL, respectively (p = 0.2), whereas the duration of surgeries was 296 ± 107 and 204 ± 82 min, respectively (p = 0.01). Conversion rate in the isolated resection group was higher (26% vs. 14%). This difference is to be explained by the learning curve in laparoscopic liver surgery. All liver resections in both groups were carried out in R0 mode. No deaths and significant complications were seen in any of the groups.Conclusion: The study demonstrated feasibility and safety of simultaneous, fully laparoscopic liver resections, including those for difficult localization of primary tumors and metastatic lesions.

BACKGROUND: Minor liver resections of posterosuperior segments (1, 4A, 7, 8) are challenging to perform laparoscopically and are mainly performed using an open approach. We determined the feasibility of robotic resections of posterosuperior segments and compared short-term outcomes with the open approach. METHODS: Data on open and robotic minor (≤ 3 segments) liver resections including the posterosuperior segments, performed between 2009 and 2016, were collected retrospectively from four hospitals. Robotic and open liver resections were compared, before and after propensity score matching. RESULTS: In total, 51 robotic and 145 open resections were included. After matching, 31 robotic resections were compared with 31 open resections. Median hospital stay was 4 days (interquartile range [IQR] 3-7) for the robotic group, versus 8 days (IQR 6-10) for the open group (p 0.99). There was no mortality in either group. CONCLUSION: Minor robotic liver resections of the posterosuperior segments are safe and feasible and display a shorter length of stay than open resections in selected patients at expert centers.

Background Parenchymal transection(PT) still remains a challenge in liver resection. The outcomes of the first experience of a novel vessel-sealer for hepatic transection were assessed. Methods A bipolar articulating vessel-sealer (Caiman®, Aesculap Inc., Center Valley, PA) was used in 100 liver resections through both open (OLR) and laparoscopic (LLR) approaches. All data were prospectively collected into an IRB-approved department database, and clinical, surgical and perioperative parameters were analyzed. Results Fifty patients underwent OLR and 50 patients underwent LLR. Eighty hepatectomies were performed for malignancy. Median number of tumors was 1, with the largest focus measuring an average of 5.1 cm. Forty-nine of the procedures were major liver resections. Parenchymal transection time was 29.9 ± 3.1 min in OLR and 29.9 ± 3.6 min in LLR. Median estimated blood loss was 300 cc (Inter-quartile range (IQR) 100–575 cc). Median hospital stay was 6 days for open and 3 days for laparoscopic procedures. Ninety-day complication rate was 8% without any mortality. Bile leak rate was 4%. Staplers were used for parenchymal transection in 16 cases. Conclusion This study introduces a new multifunctional device into the armamentarium of the liver surgeon. In our experience, this device facilitated the parenchymal transection by adding speed and consolidating the amount of instrumentation used in liver resection without increasing complications.

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.

BACKGROUND: Laparoscopic liver resection (LLR) is increasingly common worldwide but its suitability in patients with cirrhosis is not clearly defined. There are minimal data in the western literature on this topic and previous work has compared LLR to open hepatectomy rather than to LLR in non-cirrhotic patients. This study compared short-term outcomes of LLR in cirrhotic patients to LLR in non-cirrhotic patients. METHODS: Retrospective review of minor LLR at the Royal Infirmary of Edinburgh from January 2006 to January 2018 was conducted. Patients were stratified by whether they had cirrhosis - defined as per radiological appearances and liver function tests. Variables of interest included baseline clinicopathological information with short-term outcomes (length of stay and complications) regarded as the primary outcome of interest. RESULTS: Out of 1207 liver resections in the study period, there were 120 LLR with 30 patients having cirrhosis. Patients with cirrhosis were more likely to be male and have higher median American Society of Anesthesiologists scores (3 versus 2; P

Aim. To determine the indications for staged treatment in planning of advanced liver resections using SPECT. Material and methods. There were 26 patients for the period 2007–2016 who required advanced liver resections at the surgical clinic of the Botkin Hospital. Anatomic FLR (aFLR) was less than 30% in all cases that is an indication for right portal branch embolization. Two-stage treatment has been applied in 15 patients (group 1) for the period 2007–2014. Preoperative examination has included SPECT since 2015. Indication for two-stage treatment was functioning FLR (fFLR) less than 30% (group 2). The second group included 11 patients. Results. In the first group (n = 15), all patients underwent right portal branch embolization. Nine of them underwent surgery including advanced right-sided hemihepatectomy in 5 cases and right-sided hemihepatectomy in 4 cases.Acute postoperative liver failure occurred in 1 (11.1%) patient (ISGLS class A). In the second group (n = 11) need for portal embolization was determined after SPECT. In 5 patients fFLR was over 30%. Thus, advanced right-sided hemihepatectomy and conventional right-sided hemihepatectomy were carried out in 2 and 3 cases, respectively. Six patients had fFLR less than 30% and two-stage approach was indicated. Five patients underwent radical surgery: advanced right-sided hemihepatectomy and conventional right-sided hemihepatectomy were carried out in 2 and 3 cases, respectively. There were no cases of acute postoperative liver failure and mortality in this group. Conclusion. Preoperative SPECT is able to predict high risk of acute postoperative liver failure after advanced liver resection. Therefore, certain measures for prevention of this complication may be considered.

Background Laparoscopic surgery has become the standard for most visceral surgery procedures in many hospitals. Now, liver resections are also being increasingly carried out laparoscopically. The advantages of the laparoscopic technique have been demonstrated in numerous case series and in a recent randomized controlled trial. Aims The aim of this review article is to present the available techniques for laparoscopic liver surgery (LLS). Methods The technical variations reported in the literature as well as the own experience with LLS are reported. Results Optimal patient and trocar positions are crucial for successful LLS and they are chosen according to the planned type of liver surgery: the literature offers several options in particular for surgery of the cranial and dorsal liver segments. As for open liver surgery, a restrictive volume management and the application of the Pringle maneuver are helpful to reduce intraoperative blood loss in LLS. In addition, several dissection techniques have been adopted from open liver surgery. The Cavitron Ultrasound Surgical Aspirator (CUSA™) is particularly suitable for parenchymal dissection close to major vascular structures, since it guarantees a meticulous parenchymal dissection with minimal vascular injuries. Conclusion The developments of minimally invasive surgery nowadays allow complex liver resections, which can mostly be performed comparable to open liver surgery. Hopefully, minimally invasive liver surgery will further develop in Germany in the near future, since it offers several advantages over open liver surgery.

BACKGROUND: Surgery remains the gold standard both for delimited hepatocellular carcinoma by selective anatomic liver segentectomy and for colorectal liver metastases by parenchymal sparing liver resection. Right anterior sector (RAS) (segments V-VIII; Couinaud) is the largest and most difficult sector to operate on. A better knowledge of its segmentation could prevent postoperative remnant liver ischemia and its impacts on patient's survival. METHODS: A literature search was conducted in PubMed for papers on anatomy and surgery of the right anterior sector. RESULTS: Segmentation of the RAS depended of the anatomic variations of the third-order portal branches. Cranio-caudal segmentation was the most commonly found (50-53%), followed by ventro-dorsal (23-26%), trifurcation (13-20%), and quadrifurcation types (5-11%). Ventral and dorsal partial or total subsegmentectomy seemed accessible in 47 to 50% of patients, including bifurcation, trifurcation, and quadrifurcation types, and could spare up to 22% of the total liver volume. The RAS hepatic vein was present in 85-100% of the patients and could be used as a landmark between RAS dorsal and ventral part in 63% of patients. Reported overall morbidity rate of RAS subsegmentectomy ranged from 33 to 59% among studies with a postoperative major complication rate (Clavien-Dindo ??III) ranging around 18% and a biliary leakage rate from 16 to 21%. In-hospital reported mortality rate was low (0-3%), and results were comparable to "classic" liver resections. RAS subsegmentectomy remains a complex procedure; median operating time ranged from 253 to 520 min and median intraoperative blood loss reached 1255 ml. CONCLUSION: Better knowledge of RAS anatomy could allow for parenchymal preservation by using subsegmentectomy of the RAS, selective or as a part of a major hepatectomy.

Liver regeneration is a complex and unique process. When two-thirds of a mouse liver is removed, the remaining liver recovers its initial weight in approximately 10 days. The understanding of the mechanisms responsible for liver regeneration may help patients needing large liver resections or transplantation and may be applied to the field of regenerative medicine. All differentiated hepatocytes are capable of self-renewal, but different subpopulations of hepatocytes seem to have distinct proliferative abilities. In the setting of chronic liver diseases, a ductular reaction ensues in which liver progenitor cells (LPCs) proliferate in the periportal region. Although these LPCs have the capacity to differentiate into hepatocytes and biliary cells in vitro, their ability to participate in liver regeneration is far from clear. Their expansion has even been associated with increased fibrosis and poorer prognosis in chronic liver diseases. Controversies also remain on their origin: lineage studies in experimental mouse models of chronic injury have recently suggested that these LPCs originate from hepatocyte dedifferentiation, whereas in other situations, they seem to come from cholangiocytes. This review summarizes data published in the past 5 years in the liver regeneration field, discusses the mechanisms leading to regeneration disruption in chronic liver disorders, and addresses the potential use of novel approaches for regenerative medicine.

Introduction To evaluate the hepatic arterial, bile duct and portal venous anatomy as applicable to major liver resections. Methods The study was conducted on 100 formalin fixed adult cadaveric livers. The hepatic arterial, bile ductal and portal venous anatomy of the liver was dissected from their origin up to their segmental branching. Left and right hemilivers were compared with regard to the single and multiple vascular or biliary pedicles entering their respective hemilivers. Results The anatomy of all the three structures, ie., hepatic artery, bile duct and portal vein were conventional in 39% and variant, i.e., “triple” anomaly in 4% of liver specimens. In 57% liver specimens, the anatomy of one or two structures was variant and individual variation of hepatic artery, bile duct and portal vein anatomy was observed in 34%, 42% and 14% of livers respectively. The anatomy of hepatic artery was classified according to the Michels classification. In 9% of livers, rare variations not included in Michels classification was found. The drainage pattern of bile ducts was grouped according to Blumgart’s classification. In 11% of livers, rare variations not included in Blumgart’s classification were found. The branching pattern of main portal vein was classified according to the Akgul’s classification. In 1% of livers, rare variations in the right portal vein were found. Discussion In the present study, the vasculobiliary anatomies of liver were highly complex with the existence of many anatomic variations. The increasing complexity of hepatic surgical procedures necessitates appropriate knowledge of these anatomic variations.

Aim . To compare early and long-term outcomes of laparoscopic and robot-assisted liver resections with open procedures. Material and Methods. Retrospective case-control study was performed. Pseudo-randomization was used to compare homogeneous data. We have assessed survival in patients with various forms of cholangiocellular carcinoma and colorectal cancer metastases after minimally invasive liver resections. Results. For the period 2013–2017 two hundred and fifteen minimally invasive liver resections were performed including 49 robot-assisted and 166 laparoscopic ones. Malignant tumors were in 45% of cases, benign tumors – in 42%, parasitic neoplasms – in 13%. Early results of minimally invasive resections and 70 comparable open liver resections were compared. All procedures were carried out within the same period at one institution. Immediate results were significantly better after minimally invasive liver resections both before pseudo-randomization and after that. There were 60 pairs of patients after pseudo-randomization. In groups of minimally invasive and open resections blood loss was 396 (0–3400) and 853 (20–6000) ml respectively, time of surgery – 319 (85–580) and 376 (180–775) min, incidence of severe (Clavien–Dindo II and over) complications – 10% (n = 6) and 23% (n = 14), length of postoperative hospital-stay – 9 (3–90) and 12 (2–39) days, respectively. 3-year survival after mini-invasive liver resections for colorectal cancer metastases was 70%, various forms of cholangiocellular carcinoma – 40%. Conclusion. Conventional liver resections can be successfully performed in laparoscopic or robot-assisted fashion in certain patients at specialized center of surgical hepatology with sufficient experience in open and laparoscopic liver surgery.

The robotic system has emerged as a new minimally invasive technology with promising results. We sought to systematically review the available literature on the safety and the oncologic outcomes of robotic liver surgery. A systematic review was conducted using Medline (PubMed), Embase and Cochrane library through November 12th, 2017. A robotic approach may be a safe and feasible surgical option for minor and major liver resections.

It is presented a review of current and the most relevant materials including evidence-based researches, guidelines, devoted to anesthesia during extended liver resections. Present algorithms of anesthesia were analyzed based on these data. It was noted significant differences in anesthetic approaches which are mainly explained by the problem of massive intraoperative blood loss. Expanding practice of liver transplantation is making significant adjustments to the carrying out of anesthesia during surgical intervention. Optimal algorithm of anestesia is determined based on the experience of extended liver resections and transplantations.

Aim. To study the opportunities, immediate and long-term results of surgical treatment of locally advanced hepatic alveococcosis with invasion into great vessels. Material and Methods. The study included 63 patients. There were 19 liver transplantations, 12 normothermal liver autotransplantations (ante situm), 1 hypothermic liver autotransplantation (ex situ ex vivo) and 31 extended liver resections with resection and repair of great vessels. Results. Overall morbidity after liver transplantation was 31.6%, after normothermic liver autotransplantations — 38.5%, after extended liver resections with resection and repair of great vessels — 25.8%. Mortality after liver transplantation was 5.3% (1 patient). There was no in-hospital mortality after liver autotransplantations and after extended liver resections with resection and repair of great vessels. Maximal follow-up after liver transplantation was 54 months, after liver autotransplantations — 38 months, after extended liver resections with resection and repair of great vessels — 40 months. Long-term mortality was absent. Median survival was 21 months. Conclusion. Transplantation techniques in liver surgery can be recognized as an important and new surgical strategy in the treatment of unresectable hepatic alveolar echinococcosis. Excellent immediate and long-term results of radical surgery for locally advanced hepatic alveolar echinococcosis using transplantation technologies emphasize justification to concentrate these patients in highly specialized centers.

Aim. To analyze the results of treatment of patients with pancreatic malignant neuroendocrine tumors. Materials and Methods . Since 2005 to 2014 period 49 patients with malignant neuroendocrine tumors were examined and treated. 76.6% patients (n = 38) were treated within 2010–2014 years. In 59.2% of cases liver metastatic lesion occured. Comprehensive specific treatment with surgical resection of primary tumor site was used in 73.5% of cases (n = 36). Some patients received perioperative intraarterial chemoembolization and surgical tumor removal was supplemented by radiofrequency or microvave ablation of metastatic liver sites, anatomical liver resections. Results. Postoperative mortality was observed only after extended surgical resection (8.3%, (n = 3)). All patients with low differentiated tumors had histological signs of perineural invasion, abcence of therapeutical effect of specific treatment even after surgical resection of primary tumor site. In view of this long-term survival was low. At present time most of surgically treated patients (85.2%, (n = 32)) with low and moderately differentiated neuroendocrine tumors live without signs of progression. Follow-up varies within 5–119 months. Conclusion. Combined treatment including aggressive surgical approach and perioperative intraarterial chemoembolization is associated with good remote results in case of highly and moderately differentiated neuroendocrine tumors.

We propose an objective and practical classification system to predict difficulty of different laparoscopic liver resections (LLRs).Surgical difficulty is highly subjective and is not influenced only by surgical factors. Consequently, few series have described the degree of difficulty of LLR or attempted to objectively assess the surgical difficulty.From a prospectively maintained database between 1995 and 2015, patients undergoing LLR without simultaneous procedures were selected, and LLR procedures were divided into 3 groups according to scores based on operative time (or ≥190 minutes), blood loss (or ≥100 mL), and conversion rate (or ≥4.2%).Altogether, 452 LLRs were divided into 3 groups based on their scores. Group I (0 point) included wedge resection and left lateral sectionectomy. Group II (2 points) included anterolateral segmentectomy and left hepatectomy. Group III (3 points) included posterosuperior segmentectomy, right posterior sectionectomy, right hepatectomy, central hepatectomy, and extended left/right hepatectomy. The rates of overall morbidity (groups I, II, and III: 8.4%, 17.3% and 45.7%, respectively, P0.001) and major complications (1.1%, 4.0%, and 20.4%, respectively, P0.001) increased significantly with a stepwise increase of groups from I to III (P0.001).This objective and practical classification system allows the stratification of LLR comprising the low (group I), the intermediate (group II), and the high (group III) grades.

A gold standard for the treatment of metastases of colorectal cancer in the liver is combined treatment with postoperative or perioperative chemotherapy. Despite the improvement of antitumor drugs, the main condition for the successful treatment of patients with metastatic colorectal cancer is the operation in a radical volume, implying a macroscopic and microscopic absence of a residual tumor. The main contraindications to anatomic resections of the liver include a marked decrease in liver function, insufficient volume of the remaining parenchyma of the liver, and for a long time, bilobar liver damage was considered, which excludes the possibility of simultaneous removal of all foci. The traditional variant of the surgical solution of the problem of bilobar metastatic liver injury is the implementation of two-stage anatomical resections. It has been proved that the reduction of liver and FLR functional reserves of less than 20% at normal and 40% in the case of compromised liver parenchyma, the implementation of surgical interventions is associated with a high risk of hepatic insufficiency. One of the promising ways to overcome this obstacle is to perform various modifications of ALPPS liver resections. In the present work, we present a clinical case of performing a two-stage liver resection according to the type of ALPPS in a patient with metastatic colorectal liver cancer who had previously undergone PVL with unrealized vicar hypertrophy. The described observation testifies to the justification of performing repeated liver resections in patients with metastatic colorectal cancer and demonstrates the possibilities of ALPPS technique.

Hybrid liver resection is considered a modality of minimally invasive surgery; however, there are doubts regarding loss of benefits of laparoscopy due to the use of an auxiliary incision. We compared perioperative results of patients undergoing hybrid × open and hybrid × pure laparoscopic resections.Consecutive patients undergoing liver resection between June 2008 and January 2016 were studied. Study groups were compared after propensity score matching (PSM).Six hundred forty-four resections were included in the comparative analysis: 470 open, 120 pure laparoscopic, and 54 hybrids. After PSM, 54 patients were included in each group. Hybrid × open: hybrid technique had shorter operative time (319.5 ± 108.6 × 376.2 ± 155.8 minutes, P = .033), shorter hospital stay (6.0 ± 2.7 × 8.1 ± 5.6 days, P = .001), and lower morbidity (18.5% × 40.7%, P = .003). Hybrid × pure laparoscopic: hybrid group had lower conversion rate (0% × 13%, P = .013). There was no difference regarding estimated blood loss, transfusion rate, hospital stay, complications, or mortality.Hybrid resection has better perioperative results than the open approach and is similar to pure laparoscopy. The hybrid technique should be considered a minimally invasive approach.

Background Central bisegmentectomy of the liver implies excising Couinaud's segments IV, V and VIII (Couinaud and Le Foie, 1957) [ 1 ]. In a recent classification of laparoscopic liver resections, it belongs to the highly advanced level procedure group (Kawaguchi and et al., 2018 Jan) [ 2 ]. Improvement in laparoscopic devices should lead to a wider accessibility of such indications that are currently expert prerogatives. In order to illustrate the assets of robotic-assistance in the management of highly difficult mini-invasive hepatic resections, we present the case of a robotic central hepatectomy. Methods This video illustrates robotic central hepatectomy in a 70-year-old male. A liver tumor involving segments IV, V and VIII was incidentally detected during abdominal ultrasonography. CT scan and MRI suggested the diagnosis of a seventy-millimeter centrally located hepatocellular carcinoma and surgical resection was decided. Results The patient was placed supine in anti-Trendelenburg position. Four robotic trocars were placed and the da Vinci X robotic system was docked. Two laparoscopic ports were placed for the second surgeon (ultrasonic dissector and suction/irrigation set). Central hepatectomy was performed with a glissonean approach. Robotic irrigated bipolar coagulation and laparoscopic ultrasonic dissector was used for parenchymal transection. Postoperative course was uneventful. The patient was discharged on postoperative day eight. Conclusion The recent publication of an International consensus statement demonstrates the growing involvement of robotics in liver surgery (Liu and et al., 2019 March 28) [ 3 ]. Robotic advantages (flexibility, absence of fulcrum effect and visual field stability) could improve accessibility to minimal invasive approach for difficult liver resection.

Laparoscopic liver resections have gained widespread popularity among hepatobiliary surgeons and is nowadays performed for both standard and more complex hepatectomies. Given the increased technical challenges, preoperative planning and intraoperative guidance is pivotal in laparoscopic surgery to safely carry out complex and oncologically safe hepatectomies. Modern tools can help both preoperatively and intraoperatively and allow surgeons to perform more precise hepatectomies. Preoperative 3D reconstructions and printing as well as augmented reality can increase the knowledge of the specific anatomy of the case and therefore plan the surgery accordingly and tailor the procedure on the patient. Furthermore, the indocyanine green retention dye is an increasingly used tool that can nowadays improve the precision during laparoscopic hepatectomies, especially when considering anatomical resection. The use of preoperative modern imaging and intraoperative indocyanine green dye are key to successfully perform complex hepatectomies such as laparoscopic parenchymal sparing liver resections. In this narrative review, we discuss the aspects of preoperative and intraoperative tools that are nowadays increasingly used in experienced hepatobiliary centers.

Introduction The aim of this study was to estimate the immediate and long-term results of laparoscopic and robotic radical surgery for liver alveolar echinococcosis (AE). Methods From 2013 to 2019 6 patients with AE were undergone radically surgery using minimally invasive technologies. In 5 cases, a laparoscopic liver resection was performed, and in one case a Da'Vinci robotic complex was used. The average lesion size was 60 ± 20 mm. Results In three cases (50%) patients with P2 stage of the disease were operated on, in 3 cases with P1. In two cases, in patients with stage P2, a right hemihepatectomy was performed, in 2 cases a segmentectomy 8 with atypical resection segment 4 was performed, in one case a posterior sectionectomy was performed, in one case the intervention was performed with atypical resection of 6 segments. The average age of the patients was 55 years (27-79), three women and three men (1:1). The average size of the lesion was 60 ± 20 cm. The mean operation time and blood loss was 344 ± 141 minutes and 350 ± 333 mL. Complications were observed in one case (16.7%), type II according to Clavien-Dindo, represented by dynamic intestinal obstruction, which developed on the 6th day of the postoperative period and was resolved conservatively. Mean hospital stay was 9 ± 3. Conclusions Laparoscopic and robotic liver resections in the radical treatment of alveococcosis can be safe and feasible in the early stages of alveococcosis (P1-2H0M0), provided they are performed in a specialized hospital with sufficient technical equipment and an experienced surgeon.

Introduction Laparoscopic minor liver resections (LLR) of the posterosuperior (PS) segments have been increasingly performed at our institution. The aim of this study was to compare the surgical outcomes of LLR and open minor liver resection (OLR) of hepatocellular carcinoma (HCC) located in the PS segments. Methods We included 113 patients: 55 who underwent LLR, and 58 OLR for HCC in the PS segments from January 2008 to August 2019. Propensity score matching in a 1:1 ratio was conducted. The perioperative and long-term outcomes of 37 matched patients were retrospectively analyzed. Results There was no intra-operative mortality or reoperation in either group. One conversion to open surgery was necessary due to severe post-operative adhesions. The LLR group compared to OLR had statistically significantly shorter operative time (215.16 vs. 251.41 min, p = 0.025), lesser blood loss (218.11 vs. 358.92 mL, p = 0.046), lower complication rate (8.1% vs. 29.7%, p = 0.018), and shorter hospital stay (7.03 vs. 11.78 days, p = 0.001). Intraoperative transfusion, R0 resection, resection margin, 5-year disease-free survival and 5-year overall survival were comparable. Conclusions Our standardized LLR for HCC in the PS segments provided improved short-term outcomes and similar long-term outcomes compared with OLR.

Introduction There was no report for comparing long-term survival group with short-term survival group in patients who underwent liver resection for colorectal cancer with liver metastasis. Here, we compared the difference between the short-term and long-term survivors and analyzed the factors that influence the prognosis. Methods From January 2016 to December 2018, liver resections were performed for 478 patients of liver metastasis at the Yonsei University Severance Hospital. Except 111 patients due to lack of data, total 367 patients were analyzed retrospectively. Patients were divided into two groups: those who survived less than 24 months (short-term survival group, n = 87) and those who survived more than 24 months (long-term survival group, n = 280). Results In the short-term survival group, there were more patients with tumor size of 2 cm or more than the long-term survival group (p = 0.017). And the short-term survival group had more patients with margin positive than the long-term survival group (p < 0.05). The long-term survival group had more patients with single lesion than the short-term survival group (p = 0.028). In cox regression analysis, tumor size, tumor number, and resection margin were the prognostic factors effect survival. Conclusions For long-term survival of patients with liver metastasis of colorectal cancer, when deciding whether to undergo liver resection, whether a tumor smaller than 2 cm or a single lesion or curative resection is possible should be considered.

Lecture ENDOEYE 3-D (OLYMPUS, Tokyo, Japan) flexible camera system has been gradually adopted for laparoscopic liver resection because it can allow for the access to the posterior side of the liver and provide a clear discrimination of the intrahepatic vascular structures. However, it requires some learning curve to use it efficiently. The new version of ENDOEYE FLEX 3D has several advantages over the previous model. Angulation of the scope is operated by joystick, which can make it easier to intuitively understand the angulation and to hold the scope from multi-directions. The new design with the joystick angulation allows various ways to hold the scope according to surgeon's preference. In addition, it has the capability of deflecting even while in hold and renewed hold design increases working space of the scope. In this lecture, the advantages of the new version of ENODEYE FLEX 3D will be addressed and advanced laparoscopic liver resections such as right hepatectomy, central bisectionectomy and living donor right hepatectomy using this system will be presented.

Introduction Improved perioperative care combined with proper training has helped in achieving excellent outcomes following liver surgery even in low volume centers. Extended resections require additional surgical skills as well as perioperative care and when done in proper has equally good results. Here, we present the outcome of extended liver resections performed in developing HPB unit of low volume center. Methods Retrospective review of the medical records of all the patients undergoing extended hepatectomies were analyzed. Results Total 86 liver resections were performed, out of which 61 were major liver resections (three or more segments) performed over 6 years period. Out of them, total 11(18% of major liver resections) extended hepatectomies have been performed. All were right extended hepatectomies only. For liver augmentation, 2 underwent successful right side and segment 4b portal vein embolization, 2 patients had open right side portal vein ligation and one had ALPPS procedure. Rest of the patients didn't require any augmentation procedures. Postoperatively, 1 patient had grade 3 PHLF, 2 grade 2 PHLF and resolved, 2 bile leaks and resolved. Patient with ALPPS procedure had grade 3 PHLF has died on 3rd postoperativ week. Rest 10 patients were discharged on average of 12 hospital days. Conclusions Better patient selection combined with proper training and improved perioperative care, extended hepatectomies can also be safely performed with acceptable outcomes even in low volume centers of developing nations.

Background: The aim of the present study was to analyze the long-term outcomes of laparoscopic and open surgery for intrahepatic cholangiocarcinoma (iCCA) in a series, collected in a tertiary referral center with a high annual volume of laparoscopic activity. Methods: Between January 2004 and June 2020, 446 liver resections (LR) were performed for iCCA: of these, 179 were performed by laparoscopic surgery (LS) and 267 with the open approach. The two groups were matched through a 1:1 propensity score using covariates representative of patient and disease characteristics. The study and control groups were compared, with specific attention given to oncological outcomes (rate of R0, depth of resection margins, overall and disease-free survival, rate, and site of recurrence). Results: The number of retrieved nodes, rate, and depth of negative resection margins were comparable between the two groups. The interval time between surgery and subsequent adjuvant treatments was significantly shorter in LS patients. No differences were shown even in the comparison between the LS and the open group in terms of median disease-free and overall survival. Moreover, the disease recurrence rate was comparable between the LS and the open groups (45.2% versus 56.7%), and the recurrence pattern was similar. Conclusions: The minimally invasive approach for iCCA was once again confirmed to be associated with advantages in terms of intraoperative and short-term outcomes, but was also proven to be oncologically non-inferior to the open counterpart. In the present study, overall and disease-free survival were found to be similar between the two approaches.