Surgical Resection in HCC | IntechOpen

Surgical resection, or partial hepatectomy (PH), is a potentially curative surgical treatment option for up to 15–20% of patients with HCC. Home>Books>LiverCancerOpenaccesspeer-reviewedchapterSurgicalResectioninHCCWrittenByKevinLabadie,KevinM.SullivanandJamesO.ParkSubmitted:April6th,2018Reviewed:September6th,2018Published:November5th,2018DOI:10.5772/intechopen.81345DOWNLOADFORFREEShareCiteCitethischapterTherearetwowaystocitethischapter:1.ChoosecitationstyleSelectstyleVancouverAPAHarvardIEEEMLAChicagoPlaceholderCopytoclipboard2.ChoosecitationstyleSelectformatBibtexRISDownloadcitationIntechOpenLiverCancerEditedbyAhmedLasfarFromtheEditedVolumeLiverCancerEditedbyAhmedLasfarBookDetailsOrderPrintChaptermetricsoverview1,227ChapterDownloadsViewFullMetricsDOWNLOADFORFREEShareCiteCitethischapterTherearetwowaystocitethischapter:1.ChoosecitationstyleSelectstyleVancouverAPAHarvardIEEEMLAChicagoPlaceholderCopytoclipboard2.ChoosecitationstyleSelectformatBibtexRISDownloadcitationImpactofthischapterIntechOpenDownloads1,227TotalChapterDownloadsonintechopen.comCitationsCitations1CitationsAdvertisementAdvertisementAbstractHepatocellularcarcinoma(HCC)isadeadlydisease.Itsincidenceisrisingworldwidewithoutsignificantimprovementinsurvivalinspiteofimprovingtherapies.AwidearrayoftreatmentoptionsforHCCexistandincludesurgery,catheter-basedtherapies,radiationandsystemictherapy.Thesemodalitiesareoftenusedincombinationforoptimalmanagementinamultidisciplinaryapproach.SurgicalresectionremainsoneoftheonlycurativetherapeuticoptionsforHCC,althoughitisindicatedinselectpatientswithlocalizeddisease.Herein,wecovertheroleofsurgicalresectioninthemanagementofHCC,reviewingtheperioperativeandoperativeconsiderations,inadditiontohighlightingtheadvancesinminimallyinvasivesurgeryandnovelnavigationtechnologies.KeywordshepatocellularcarcinomalivercancersurgeryminimallyinvasivemultidisciplinaryAuthorInformationShow+KevinLabadieUniversityofWashington,Seattle,WA,USAKevinM.SullivanUniversityofWashington,Seattle,WA,USAJamesO.Park*UniversityofWashington,Seattle,WA,USA*Addressallcorrespondenceto:[email protected](HCC)isthesecondmostlethalmalignancyworldwide[1].DespitetheadventofeffectiveantiviraldrugstoeradicatehepatitisCinfection,theprevalenceofHCCisprojectedtoincreasesecondarytoincreasingratesoffattyliverdiseasefromdiabetesandtheobesityepidemic[2].Unfortunately,therehasbeenlittletonochangeinthesurvivabilityofHCCoverthelastthreedecades[3]inspiteoftheincreasingarrayoftherapeuticoptions,leavingmuchroomforimprovement.ThearmamentariumformanagingHCCiswideandincludessurgicalresection,orthotopiclivertransplantation(OLT),ablativetechniquesusingethanol(percutaneousethanolinjection,PEI),microwave(MWA)orradiofrequency(RFA),catheter-directedtransarterialchemoembolization(TACE)orradioembolization(TARE),externalbeamradiationtherapyintheformofstereotacticbodyradiationtherapy(SBRT)orprotonbeamtherapy(PBT),systemictargetedsmallmoleculetyrosinekinaseinhibitors,check-pointinhibitorimmunotherapyandinvestigationalagents.Thesemodalitiesareoftenusedtogetherinamultidisciplinaryapproach.Surgicalresection,orpartialhepatectomy(PH),isapotentiallycurativesurgicaltreatmentoptionforupto15–20%ofpatientswithHCC. TheprimaryobjectiveofPHistoremovetheHCCwithanadequatemargin,whilepreservingasmuchfunctionalliverparenchymatoavoidpost-resectionhepaticfailure.Withimprovementsinpreoperativeassessment,patientselection,surgicalandanesthetictechniques,intraoperativeultrasound,PHforHCCisnowroutineandsafe.Operativemortalityhasbeenreducedtolessthan5%witha5-yearoverallsurvivalof60–75%.Advertisement2.PreoperativeconsiderationsSeveralfactorsareconsideredindeterminingtheeligibilityforPH,includingthepatient’shealthstatus(e.g.age,ECOGPS),tumor-specificfactors(e.g.extentandtumorbiology),andthereserveoftheliverremnant.Determinedbythedegreeofliverdysfunctionandthesizeofthepostoperativeliverremnant.Whilethereisnostrictagelimit,onemustconsidertheliver’sregenerativecapabilitiesinelderlypatients,andthepatient’sabilitytotoleratethephysiologicconsequencesofportalpedicleclampingandacutehemorrhageontheircardiopulmonarysystem.Inaddition,patientsundergoingaminimallyinvasiveapproachmustalsobeabletoenduretheeffectsofthepneumoperitoneumandreverseTrendelenburgpositioningontheirphysiology.Severaldifferentclinicalstagingsystemsexisttostratifypatientsaccordingtoprognosticvariables[4].OneofthemostcommonlyusedistheBarcelonaClinicLiverCancer(BCLC)systemwhichincorporatestumorsize,numberofnodulesandhepaticfunctionasclassifiedbytheChild-Pughscore[5].Thesystemclassifiespatientsintoearly,intermediate,advancedandterminalstagesandproposesrecommendedtreatmentstrategy.Accordingtothisstagingsystem,onlystage0orearlystagepatientswithsmalltumorsarerecommendedforsurgicalresectionorlivertransplant.However,manyviewtheBCLCcriterionforresectiontoberestrictive.Forpatientswithlargetumors(beyondanydown-stagingorexpandedOLTcriteria)whoareineligibleforOLT,PHistheonlypotentiallycurativetreatment.Withimprovementsinperioperativemanagement,preoperativemorphologicalassessmentandmanipulationofthefutureliverremnant,PHforlargeHCChasbeensafelyperformedwithgoodoncologicoutcome[6,7].Therefore,largetumorsizealoneisnotacontraindicationtoPH,ratherfactorssuchasmultipleorbilobartumors,extrahepaticmetastasis,involvementofthemainbileduct,portalvenousorothermacroscopicvascularinvasion,andportalhypertensionareallrelativecontraindicationstoPH. Whenclinicallynotevident,portalhypertensioncanbeevaluatedbymeasuringthetransjugularintrahepaticportosystemicgradient(PSG).PSGvaluesgreaterthan10 mmHgareindicativeofsignificantportalhypertensionandthesepatientsmustbeapproachedwithcaution.85–90%ofpatientswithHCChaveconcomitantliverdysfunction.Itiscriticaltoaccountforthedegreeofliverdysfunctioninadditiontothepatient’soverallfunctionalandnutritionalstatus.Patientswithliverdiseaseareoftenmalnourishedwithdiminishedperformancestatusandcomorbidconditions.Tohelpstratifyclinicalliverdysfunction,patientsareclassifiedbytheChild-Turcotte-Pugh(CTP)scoreandtheModelforEnd-StageLiverDisease(MELD)system.Thesetwosystemsclassifypatientsbasedonphysicalexamandlaboratorydata,withincreasingscoresassociatedwithhigheroverallsurgicalrisk.Ingeneral,patientswithCTPscoreuptoB7,MELDscore <9withoutsignificantportalhypertensioncanbeconsideredforPH. PatientswithmoresevereliverdysfunctionandHCCcanbeconsideredforOLTiftheymeetspecificcriteria[8,9].Assessmentofthehepaticfunctionandfutureliverremnant(FLR)isimportantforpatientselectionpriortosurgicalresection[10].ThevolumeoftheFLRandtheregenerativecapacityarekeypredictorsofpostoperativemorbidity.Severallaboratorytestshavebeenusedtoevaluatehepaticreserveincirrhoticpatientsincludingassessmentofclearanceofindocyaninegreen,sorbitoland99mTc-galactosylserumalbuminscintigraphy[11].Preoperativevolumetricanalysiscanbeperformedwith3Dcomputerizedtomographyvolumetry[12].Tominimizethechanceofpost-hepatectomyliverfailure,datasuggestaliverremnanttobeatminimum>20%ofpreoperativelivervolumeinanormalfunctioningliver,>30%forpatientswhohaveundergone>3 monthssystemicchemotherapyand>40%inthosewithadvancedliverdisease[13,14].SeveraltechniquesforpreoperativeoptimizationoftheFLRexistincludingportalveinembolization(PVE)andtheassociatedliverpartitionwithportalveinligationforstagedhepatectomy(ALPPS)[15].Initiallydevelopedin1986,PVEresultsinatrophyoftheembolizedsegmentsandcompensatoryhypertrophyoftheperfusedsegments[16],withinapproximately4–6 weeks,withatleast>10%growthoftheFLRpredictingadequateregenerationpost-PH. PVEhasbeenshowntoreducetherateofpostoperativecomplicationsinselectpatientswithchronicliverdisease[17],andcanalsobeusedsafelyinpatientsundergoingconcurrentchemotherapyforcolorectalmetastases.OnestudydemonstratedimprovedprognosisafterPHinpatientswithimpairedhepaticfunction[18].ALPPSwasdevelopedin2007toinduceliverhypertrophyinpatientsplannedforextendedliverresectionswithmarginalFLR. Atwo-stepoperation,theinitialdatademonstratedittobequiteeffectivewithrapidhypertrophy[15],however,ithasnotgainedwideacceptancesecondarytosignificantmorbidityandmortalityandtheneedforlargerscalestudies[19,20,21].However,therearemorerecentreportsof“mini-ALPPS”wheretheprocedureisperformedminimallyinvasivelyandwithlimitedperipheraldivisionoftheparenchyma.Advertisement3.Surgicalconsiderations3.1.SurgicalanatomyThesurgicalanatomyoftheliverisbasedonClaudeCouinaud’sclassificationsystemandfurtherrefinedintheBrisbane2000TerminologyofLiverAnatomyandResections(Figure 1)[22].Inthisclassification,theliverisdividedintofirst,secondandthirdorderdivisionsbasedoninternalanatomyratherthansurfacelandmarks.FirstorderdivisionsplitstheliverintoarightandlefthemiliveralongCantlie’sline,aplaneextendingfromthemiddleofthegallbladderfossatothecenteroftheinferiorvenacava.Secondorderdivisionssplitthehemiliversintotworespectivesectionsorsectors,themedialandlateralsections/sectorsontheleftandanteriorandposteriorsections/sectorsontheright.Thethirdorderdivisiondivideseachsection/sectorintotwosegments,constitutingthe9individualhepaticsegmentsdefinedbyCouinaud.Ingeneral,eachsegmenthasauniquevascularinflow,outflowandbiliaryductenablingsegmentstoberemovedwithoutdamagetoothersegments.Figure 1.Schematicofliveranatomyseparatingtheparenchymainto9anatomicsegments.Eachsegmenthasuniquebloodsupplyandbiliarydrainage.Source:Cho,Fong.HepaticResection.In:AshleySW,editor.ScientificAmericanSurgery.Hamilton:Decker.7thed;2014.pp. 1094–1114.Theproperhepaticarteryandportalveinbifurcatepriortothehilumoftheliverandformtherightandlefthepaticarteryandportalveinwhichsupplytherightandlefthemiliver.Joinedbythebiliaryduct,theportaltriadgenerallyrunscentrallywithinhepaticsegments.Therighthepaticarteryenterstheparenchymasoonafterbranchingwhilethelefthasalongerextrahepaticcourse.Incontrast,thethreehepaticveinsrunbetweensection/sectorsinthreeportalscissurae.Therighthepaticveindrainsdirectlyintotheinferiorvenacava(IVC)whilethemiddleandlefthepaticveinsoftenformacommontrunkpriortoenteringtheIVC.Theliverisencapsulatedbyafibrouscapsule,knownasGlisson’scapsule.Thecapsuleenvelopstheportaltriadsastheyentertheliverparenchymawhichmakesitidentifiableonintraoperativeultrasound.Furthermore,thedensecapsuleallowsforcontroloftheportaltriadduringdissectionandenablespedicleligation.3.2.AnestheticconsiderationsSomeimportantperioperativeanestheticconsiderationsshouldbeaccountedfortoincreasethesafetyofhepatectomy.Tominimizethepossibilityofmajorintraoperativehemorrhage,thecentralvenouspressureshouldbemaintainedatlessthan5 mmHgtoreducetheintrahepaticvenouspressure.ThisisachievedusingvariousanestheticmaneuversandagentssuchasIVFrestriction,andadministrationofisoflurane,fentanyl,mannitol,andcisatricurium.Foropenhepatectomy,thepatientcanbeplacedinslightreverseTrendelenburgpositionifpressuresallowandswitchedtoTrendelenburgpositionifthereissignificanthemorrhagewithhemodynamicderangementtoincreasecardiacoutputandmaintainend-organperfusion.Forlaparoscopic/robotichepatectomy,thepatientisplacedinreverseTrendelenburgpositionforacaudalapproachwhichimprovesvisualizationofthevasculature,andthepneumoperitoneumcreatesatamponadeeffectonthehepaticveins,whichaidsinlimitinghemorrhage.AdequatevascularaccessshouldbeobtainedusinglargeboreIVs,withappropriateinvasivehemodynamicmonitoringusingA-line.Bloodproductsshouldbereadilyavailableandresuscitationofoperativebloodlossshouldbewithanappropriatecombinationofcrystalloid,albuminandbloodproductasnecessary.End-tidalCO2ismeasuredtomonitorforCO2embolisminthelaparoscopic/roboticapproach.Advertisement4.OperativetechniqueResectionsareeither“anatomic”or“non-anatomic”.AnatomicresectiondefinesaresectionthatobeysBrisbanedivisionsandispreferredformalignantdiseasebecauseithasbeenfoundtolowerrateofpositivemargins,decreaseregionalrecurrencesandimprovesurgicaloutcome.Non-anatomicresectionreferstoparenchymaltransectionthatdoesnotrespectsegmentalplanesandistypicallyusedfordebulkingprocedures,benigntumorsorwhentryingtopreserveremnantparenchyma.Achievingamicroscopicmarginnegative(R0)resectionisparamounttoreducinglocalrecurrence.1 cmsurgicalmarginshavehistoricallybeenconsideredstandard,butnarrowermarginshavebeensafelydemonstrated[23].Therearesixstandard,anatomichepaticresectionsasdefinedbytheBrisbaneclassification(Figure 2).Righthemi-hepatectomyconsistsofsurgicalresectionofsegmentsV-VIIIandlefthepatectomyincludessegmentsII-IVandoccasionallysegmentI. Inanextendedrighthepatectomyorarighttrisectionectomy/trisectorectomy,segmentsIV-VIII,andinanextendedlefthepatectomyoralefttrisectionectomy,segmentsII-IV,VandVIIIareresected.AleftlateralsectorectomyinvolvesresectionofsegmentsII-IIIandarightposteriorsectionectomyincludessegmentsVI-VII. Segmentectomiesdenoteresectionofanyindividualsegment.Figure 2.Schematicillustrationsofthestandardhepaticresectionsaslabeled.Source:Cho,Fong.HepaticResection.In:AshleySW,editor.ScientificAmericanSurgery.Hamilton:Decker.7thed;2014.pp. 1094–1114.Thecommonprincipleofanatomichepatectomiesinvolvesparenchymaltransectionafterbothvascularinflowandoutflowhavebeencontrolled.Giventhateachhepaticsegmenthastheiruniquevascularinflowandoutflow,eachsegmentcanbesafelyexcisedwithoutdamagetosurroundinghepaticsegments.Intraoperativeultrasonographyisusedroutinelyforidentificationofthevascularstructures,evaluationoftumorlocation,extentandrelationshiptothesurroundingvasculature.Afterinitiallaparoscopicinspectionexcludesunresectabledisease(inselectedcases),theincisionismade.Inanopenconventionalapproach,appropriateincisionandexposureiscriticaltosafehepatectomy.Thereareseveralincisionsusedincludingthebilateralsubcostal(Chevron),right/leftsubcostal,J-typeortheinvertedY(Mercedes)incision.Oncetheliverismobilizedbydividingligamentousattachments,carefulinspection,palpationandultrasoundexaminationareperformedtoevaluateforanymissedtumors.Arterialaberranciesareidentifiedandportaltriadinflowiscontrolledwithsuturesandclipsorstapleligation.Thecorrespondinghepaticveinisisolatedandligated.Parenchymaltransectionisperformedalongthelineofdevascularization.Differenttechniquesforparenchymaltransectionexist,varyingfromclamp-crushing,waterjet,monopolar/bipolarcautery,radiofrequencyablativedevices,bipolarvesselsealingdevices,ultrasonicdissectiondevicestostaplers.Theclamp-crushtechniqueisrapidandhasbeenassociatedwithlowerratesofbloodlosscomparedtoothermethods[24].Oncetheresectedsegmentisremoved,hemostasisisobtainedwithsutures,clips,argonbeamcoagulatorandapplicationofvarioushemostaticagents.Biliaryleaksarecontrolledwithclippingandsutureligation.Priortoabdominalclosure,drainsareplacedifthereisaninfectedoperativefieldorifabiliaryreconstructionisperformed[25].Advertisement5.Minimallyinvasivehepatectomy5.1.Laparoscopic-assistedpartialhepatectomyAlthoughestablishedasasafeandbeneficialapproachfornumerousintra-abdominaloperations,laparoscopictechniqueswereslowtobeadoptedforliversurgeryforseveralreasons[26].Concernsovertechnicalfeasibilityofvasculardissectionandcontrol,organmobilization,parenchymaldissectionandmanagementofintraoperativecomplicationswereprohibitive.Furthermore,itwasunknownifport-siteseeding,inadequatemarginsandpooroncologicoutcomeswouldbemorecommonintheminimallyinvasiveapproach.Thebenefitsoflaparoscopicliversurgeryarenumerous.Inadditiontothegeneralizedbenefitsoflaparoscopicsurgeryincludingamorerapidfunctionalrecovery,smallerincisionswhichreducetheincidenceofsurgicalsiteinfectionsandpostoperativepulmonarycomplications,thereareadditionaladvantagesspecifictolaparoscopicliversurgery.SteepTrendelenburgpositioningreducesintrahepaticvenouspressureandthepneumoperitoneumexertstamponadeeffectonvasculatureleadingtoreducedintraoperativebloodloss.Laparoscopycreatesacaudal-cranialsurgicalviewwhichaffordsimprovedvisualizationofmajorvascularstructurescomparedtotheventral-dorsalangleofvisualizationofanopenhepatectomy.Forcirrhoticpatients,smalllaparoscopicincisionsavoiddisruptionofabdominalwallcollateralsandtheconstraintonfluidshiftsinalaparoscopicpartialhepatectomycandecreasetheincidenceofliver-relatedcomplications.Minimallyinvasivehepatectomyalsoresultsinlessadhesionformationwhichfacilitatesadditionalsurgeryinthefuture.Therehavebeennumerousstudiestodatedemonstratingthesafetyandefficacyoflaparoscopicliversurgery.In2009,aworldwideexperienceof127seriesincluding2804casesoflaparoscopicpartialhepatectomydemonstratedcomparable5-yearoverallsurvivalanddiseasefreesurvivalcomparedtoopenhepatectomy[27].Halfofthesecasesweredoneformalignantdiseasewithgreaterthan80%ofresectionsboastingnegativesurgicalmargins.In2015,arandomizedcontroltrialwaspublisheddemonstratingsafetyandfeasibilityoflaparoscopicliverresectionwithreductioninlengthofstayandintraoperativebloodlosscomparedtoopenhepatectomy[28].Numeroussystematicanalyseshavesubstantiatedthesedata,demonstratingthatthelaparoscopicpartialhepatectomyisassociatedwithdecreasedintraoperativebloodloss,shorterlengthofhospitalstay,anddecreasednumberofpositiveresectionmargins.Overall,therewereconsistentlyfewercomplicationsfoundinthelaparoscopicgroupinthesereviews[29].Acase–controlpropensitymatchedstudiesalsofoundnodifferencein1-,3-,and5-yearoverallsurvivalanddisease-freesurvival[30].TheNationalSurgicalQualityImprovementProgramdatabasewasevaluatedtocompareshort-termoutcomesamongpatientsundergoingminimallyinvasivepartialhepatectomy.Over3000patientswereincludeinthestudyanditdemonstratedlowerpostoperativemorbidityandshorterlengthofstaycomparedwithpatientsundergoingopenliverresection[31].SpecifictothetreatmentofHCC,thesafetyandefficacyofthelaparoscopicapproachhasbeenevaluatedinseveralmeta-analysesandpropensityscoreanalyses.Thesestudiesdemonstratedtheequivalentorsuperiorperioperativeoutcomesoflaparoscopiccomparedtoopenresection[32,33].Inapropensityscoreanalysis,theoverallanddisease-freesurvivalweresimilarandforthesecondaryoutcomes,thelaparoscopicgrouphadshorterhospitalstay,lowermorbidity,withfewertransientliverfailureandwoundcomplications,andalargertumormargin[34].Multiplemeta-analysesandcasecontrolserieswerereviewedandanalyzedatthesecondinternationalconferenceforlaparoscopicliverresectioninMoriokain2014.Minorresectionswerevalidatedasstandardpracticeintheassessmentstage,whilemajororcomplexresectionswereconsideredtobeintheexplorationstage,withincompletelydefinedrisks.TheJuryatMoriokamadestrongrecommendationsforhigherqualitystudiesincludingregistriestodefinetheroleandbenefitsoflaparoscopicmajorhepatectomy.Patientselectioniscriticaltoensuringsafelaparoscopicpartialhepatectomy.Althoughistechnicallyfeasible,resectionoflesionsinrightposteriorsectionsorthehepaticdomecanbechallengingandshouldbeapproachedwithcaution.Thepatientisplacedinthesupinepositionandsecurelyfastenedtothetabletoallowforsafeintraoperativerepositioning.Generally,fiveportsarerequiredforlaparoscopicresectionincludingtwo12 mmandthree5 mmports.PortplacementisdependentuponlateralityofthelesionasshowninFigure 3.Somesurgeonsadvocateusingahandaccessporttoassistwithintraoperativemanipulation,intra-corporealsuturingaswellasserveasthespecimenremovalsite.Figure 3.Suggestedportplacementsforlaparoscopicleftlateralsectionectomy(a)andhand-assistedlaparoscopicrighthepatectomy(b).Source:Cho,Fong.HepaticResection.In:AshleySW,editor.ScientificAmericanSurgery.Hamilton:Decker.7thed;2014.pp. 1094–1114.5.2.Robotic-assistedpartialhepatectomyFurtheradvancesinsurgicaltechnologyhascreatednewopportunitiesinminimallyinvasiveliversurgery.Roboticsurgicalsystemsofferuniqueadvantagestotheliversurgeonthatenhancestheminimallyinvasiveapproach.Thereareseveralkeyimprovementsontheroboticsurgicalsystemincludingacamerawithopticsprovidinga3-dimensionalstereotacticvisualfield.Inaddition,theinstrumentsallowforsevendegreesoffreedomintheirmotion,providingeasiersuturingforhemorrhagecontrol.Thereisnofulcrumeffectonthebodywallofthepatientasinlaparoscopicsurgery,andithasbeenassociatedwithreductioninsurgeonfatiguecomparedtothelaparoscopicapproach.Similartolaparoscopicpartialhepatectomy,thepatientisplacedinthesupinepositionandinsteepreverseTrendelenburgposition.Thetableistiltedwithrightsideupapproximately25degreesforright-sidedresections.Fiveportsareplacedincludingfourrobot-controlledportsandoneassistantport(Figure 4).Theportsareplacedbasedonthelateralityoftheresection.Ingeneral,foraright-sidedhepatectomy,thecameraportisplacedtotheright-sideofmidline.Oncetheportshavebeenplaced,therobotisdockedfromthecephaladposition(Figure 5).Intraoperativeultrasoundiscriticaltoestablishingvascularanatomyanddefiningoncologicplanesofresection.Aftervascularcontrolandestablishingthelineoftransection,parenchymaltransectionisperformedusingoneofmanypublishedtechniques[35].Figure 4.Imageofportplacementforarobot-assistedsurgeriesleftlateralsectionectomy.BluedotsdenotedaVinci8-mmreusablecannulas(3).Greendotdenotes12-mmcameraport.PurpledotdenotesAirSeal®assistantport.Costalmarginandmidlinemarkedindottedpen.Figure 5.Standardoperatingroomsetupforrobotic-assistedliversurgery.Headofbedisonleftsideofimage,anesthesiaequipmentandpersonnelonrightsideofimage.Severallargecaseserieshavebeenpublisheddemonstratingthesuccessofroboticliverresection[36,37].Thefirstlargecaseseriesof70patientsincluded38.5%majorliverresectionswithoutanymortalities[36].Anearlysystematicreviewoftheliteraturedemonstratedsafetyandfeasibilityoftherobotictechnique,withconversiontoopenrateof4.6%andcomplicationrateof20.3%[38].In2018,aninternational,multicenterretrospectivereviewofroboticliversurgerywaspublishedspecificallyevaluatinglong-termoncologicoutcomesinpatientswithprimaryhepatobiliarymalignanciesafteramedianfollowupof75 months[39].Thisstudydemonstratedcomparableoutcomesbetweenrobotic,openandlaparoscopicliversurgerywith3-yearoverallsurvivalof90%forHCC. Themajorityofthecaseswerenon-anatomicresectionswithanR0resectionachievedin95%ofHCCresections,68%incholangiocarcinomaand82%ingallbladdercancer.Minimallyinvasiveapproachtoliversurgery,bothlaparoscopicandrobotic-assisted,havetheirshareoflimitations.Animportantpotentialcomplicationassociatedwiththeestablishmentofpneumoperitoneumandlaparoscopicliversurgeryiscarbondioxidegasembolism.Reportshavedemonstratedthatthiseventrateislow,particularlyifthepneumoperitonealpressureismaintainedbelow12 mmHg[40].Studieshavepublishedandeventrateofaslowasat0.5~1.5%[41].Thereisalearningcurvewithgainingproficiencyinthelaparoscopictechniqueofliverresectionwithexpertcentersestimatingthelearningcurveforlaparoscopicliverresectionatapproximately45~70caseswithseniorpartnerproctoring[42].Otherlimitationsincludetheneedforaskilledbedsideassistant,andthediminishedtactilesensewhendealingwithfriabletissuesuchassteatoticliverparenchymaorthinvenuleswithinacirrhoticlivercanmakethecasechallenging.Andintherareeventwhenmassivevenousbleedingensues,itcanbedifficulttocontrol.Costisonemajorbarriertothewideadoptionoftheroboticapproach.Thereisasignificantinitialcapitalinvestmentinadditiontomaintenancefeesandcostsofstafftraining.However,onestudydemonstratedthatwhileperioperativecostsarehigherwiththerobot,theoveralltotaldirecthospitalcostsareloweratleastinpartduetothedecreaselengthofstaywithroboticminimallyinvasiveresection[43].Thereareseveralgenerationsoftherobotwitholdergenerationunitsbestsuitedforanoperationinasingleworkfield,withcumbersomeredockingstepstoperformmulti-quadrantoperations.Themajorityofstudiesindicatealongeroperatingtimesecondarytorobotsetupanddraping.Technicallyspeaking,therobotdoesnotprovidehapticfeedbackchallengingthesurgeonto“feelwiththeireyes”andoccasionallyresultinginexcessivetissuedamageininexperiencedhands.Furtherstudiesareneededtoexaminethecomparativeeffectivenessofroboticversuslaparoscopicminimallyinvasivehepatectomy.Advertisement6.PostoperativecomplicationsThemainpostoperativecomplicationsincludepostoperativehemorrhage,liverdysfunction,biliaryleakandfluidcollections.Postoperativehemorrhageisuncommonafterliverresectionifmeticulousattentionisgiventoconfirmationofhemostasisattheconclusionofthecase.Bleedingmayoccasionallyoccurfromretroperitonealstructures,suchastheadrenalgland,ordiaphragmaticmusculature.Argonbeamcoagulatorandavarietyoftopicalhemostaticapplicationsareutilizedtoreduceliversurfacerelatedbleeding.Posthepatectomyliverfailure(PHLF)isamajorpostoperativecomplicationwithmortalityofapproximately30%.Thedefinitionofpost-hepatectomyliveristheimpairedabilityofthelivertomaintainitssynthetic,excretoryanddetoxifyingfunctions,characterizedbyanincreaseininternationalnormalizedratioandbilirubinonorafterpostoperativeday5[44].ThemosteffectivetreatmentofPHLFislivertransplantationbutthatisreservedforthemostseverecases.Initialcareissupportiveandoftenincludesmechanicalventilation,hemodynamicsupportandhemodialysis.Administrationofcolloidproductsandnutritionalsupplementationisalsoadvocated.Thebestwaytotreatpost-hepatectomyliverfailureistopreventit.Preoperativeweightloss,nutritionalsupplementation,carefulpreoperativeselectionandriskstratificationareimportanttominimizetheriskofPHLF[10].Intra-operatively,minimizingbloodlossandbloodtransfusion,closeattentiontohemostasisandminimizingskeletonizationofthehepatoduodenalligamentwilllowerriskofPHLF. Inthepostoperativeperiod,recognizingandaggressivelytreatingpostoperativehemorrhage,biliaryobstructionsorleaksandintra-abdominalinfectionswillreducethehepaticstressandlikelihoodofdevelopinghepaticfailure.Postoperativefluidcollectionscollectintheresectedliverbed.Thesecollectionsarevariedinetiologybutcanincludehematoma,seromaorbiloma.Theyoftentonotresultinsymptoms,butoccasionallytheycancausepainorfullnessrequiringdrainage.Thesecollectionsalsoareatriskforinfectionandabscessformation.Biliaryleakagefromtherawsurfaceoftheresectedlivercanoccurinupto8%ofpatientsafterliverresection[45].Advertisement7.Emergingtechnologies7.1.Near-infraredfluorescentimaginginhepaticsurgeryNewtechnologiescontinuetobedevelopedtoenhanceminimallyinvasiveliversurgery.Oneexampleisintra-operativenear-infraredfluorescence(NIF)imaging.NIFimaginghasbecomecommonplaceinmanylaparoscopicandroboticcamerasystemsenablingtheidentificationofvariousdyes,suchasindocyaninegreen,injectedpreoperatively.Indocyaninegreenisagreendyethatispreferentiallymetabolizedbyhepatocytesandexcretedinthebiliarytree.Itlightsupthebiliarytreeandhasbeenutilizedforroboticandlaparoscopicassistedcholecystectomy.Ithasbeenmorerecentlyutilizedtoguideparenchymaldissectionaftervascularcontrolbyidentifyingperfusedfrompoorlyperfusedhepaticparenchyma.7.2.Intelligentimaginginrobotic-assistedsurgeryFuturedirectionswithintherealmofroboticliversurgeryincludetheapplicationofpreoperativeplanningwithvirtualreality(VR)modelsandreal-timeaugmentedreality(AR)intraoperativeendoscopicoverlaystoaidwithsurgicalnavigationondaVinci®surgicalsystems.Thecurrentpracticestandardforoperativeplanninginvolvespreoperativecross-sectionalimagingusingcontrast-enhanced,multiphaseliverprotocolcomputedtomography(CT)ormagneticresonanceimaging(MRI)scanstoevaluatethetumor’sextent(sizeandnumber)andlocationwithrespecttocriticalstructuresincludingthemajorvasculatureandbiliaryarchitecture.Surgeonsrelyonyearsoftrainingtodeveloptheabilitytomentallyreconstruct2Dimagesintoamental3Dmodelinordertopreoperativelyplanforasurgerywhilereferencingthe2Dimagesintraoperatively.Computer-basedthree-dimensional(3D)reconstructionsoflivertumorshavebeenshowntoincreaseaccuracyoftumorlocalizationandprecisionofoperativeplanningforliversurgery[46].Whileusefulforoperativeplanning,intraoperativereviewof2DimagesonatraditionalPACSsystemrequiresdiversionofattentionawayfromtheoperativefield.Intraoperativeultrasoundisroutinelyusedforreal-timelocalizationoflivertumorsandidentificationofvesselsandbiliarystructures.However,itsuseislimitedinminimallyinvasiveliversurgeryduetotheneedforanadditionalportsiteandtheneedtointerpretthe2Dultrasoundimagesandmentallyreconstructthe3Danatomybeingprojectedbasedontheorientationoftheultrasoundprobe.PreoperativeplanningwithaVRmodel(Figure 6)andtheapplicationofARendoscopicoverlay(Figure 7)ofpatient-specificanatomyintotheroboticsurgicalsystemcouldpotentiallyimprovesurgicalefficiencyinreal-timewithintelligentsurgicalnavigation.Figure 6.Virtual3Dmodeloftheliver.Porcineexperimentalmodelwithimplantedradiopaquetumorwithintheliverparenchyma.Preoperatively,CTimageswereobtainedoftheporcineliverwith3DsegmentedreconstructionscreatedfromtheDICOMimages.The3DreconstructionscanbeviewedforpreoperativeplanningwithintuitiveSurgical’sdaVinci®SurgicalSystem.Figure 7.Real-timeendoscopicoverlayof3DreconstructionoverthesurgicalfieldonthedaVinci®XiSurgicalSystem.Therelationshipbetweenthetumor(lightpink)andadjacentvasculatureincludingthehepaticveins(lightblue),hepaticarteries(red)andportalveins(blue)ispresentontheoverlay.Afterinitialregistration,theoverlayismappedontothepatient-specificanatomychanginginreal-timewithcameramovement.ARmaybedevelopedtooverlayaccurate3Dreconstructiondataontotheoperativefielditself,therebyeliminatingtheneedtodiverttheattentionfromtheoperativefieldandtotranslatethe2Dimagesintoa3Dconstruct.Theseadvancementswithplanningandguidancecanpotentiallyreducethecognitiveloadburdenonthesurgeon.Augmentedrealityforspatialrecognitionhasbeenshowntoimprovelocalizationaccuracyinanexperimentalmodelofuterinemyomectomy[47],andourrecentexperiencehasshownpromiseandfeasibilityinanexperimentalporcinelivermodel(Figures 1and2).NextstepsintheapplicationofVRandARtohepatobiliarysurgeryincludeovercomingtechnicalobstaclesofcontinuousco-registrationtoamobileliverwithtissuedeformationwhilecontinuingtodefinetheutilityofthetechnologywithpatienteducation,tumorboardevaluations,preoperativeplanningandintraoperativenavigation.Advertisement8.ConclusionHepatocellularcarcinoma(HCC)isadeadlydiseasethatrepresentsmajorchallengesforpatientsandhealthcareprovidersalike.NumeroustherapeuticoptionsexistforthetreatmentofHCCthatareoftenusedincombinationforlocalandregionalcontrol.Surgicalresectionremainsanimportantinterventionthatcanbecurative.Minimallyinvasivesurgicaltechnologiescontinuetoimproveincreasingitssafetyandapplicabilityforoncologicliversurgery.AdvertisementAcknowledgmentsWewouldliketoacknowledgeDrs.KyleMillerandJonathanSorgerofIntuitiveSurgicalInc.fortheircollaborationontheemergingroboticsurgicaltechnologies.AdvertisementConflictofinterestTheauthorshavenoconflictofinteresttoreport.References1.FerlayJ,SoerjomataramI,DikshitR,et al.Cancerincidenceandmortalityworldwide:Sources,methodsandmajorpatternsinGLOBOCAN2012.InternationalJournalofCancer.2015;136(5):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