The first report of a laparoscopic liver resection for a benign lesion was published in 1991. But it was in 1992 following the report of laparoscopic resection of a liver tumor by Dr. Michel Gagner, that minimally invasive surgery enthusiasm started to grow throughout the world. Dr. Michel Gagner is a well-known general surgeon in the field of minimally invasive surgery. He is responsible for the first laparoscopic adrenalectomy in 1992, first laparoscopic pancreatectomy in 1992-1993, first endoscopic neck surgery in 1995, first cholecystectomy by NOTES, first duodenal switch in 1999 and the first laparoscopic sleeve gastrectomy in 2000. Such different pathologies with such different surgeries all treated and performed by the same general surgeon. Since his innovations from a diversity of surgical fields, minimally invasive surgery has gained major importance in modern surgery.
Minimally invasive liver surgery has better results than open.
Minimally invasive surgery is good for lesions affecting the right anterolateral segments and left lateral sectionectomy due to their peripheric location. According to Dr. Iswanto Sucandy et al. from Florida, USA, although laparoscopic liver resection has proven to have less complications than open surgery and the same free margin resection rates, many surgeons are still facing technical challenges due to the lack of experience in the field of minimally invasive surgery. Additionally, hepatic lesions in the posterior-superior-lateral locations (mostly segments VII and VIII) are difficult to access by laparoscopy, and that is why many patients with lesions within those segments are still treated by laparotomy. Liver resection surgery has the main objective of parenchyma sparing, that is why there is no justification to perform a major hepatectomy to resect a tumor affecting only segment VII, the authors say.
Dr. Iswanto Sucandy et al in their editorial comment about a report of a novel liver resection technique/approach, state there have been several ideas to access the posterosuperior locations: left lateral decubitus, hand-assisted, laparoscope with a flexible tip, transthoracic approach. None has proven good results. However, the use of posterior retroperitoneoscopic approach to manage right posterior hepatic segments have been described and presented by a group of general surgeons with a great experience in adrenal surgery by the same approach. Dr. Alesina et al from Essen, Germany, reported two patients with right posterior liver tumors resected using a posterior retroperitoneoscopic approach with trocars placed as for the posterior retroperitoneoscopic adrenalectomy with the patient in the prone position. During the posterior retroperitoneoscopic liver resection the adrenal was mobilized to expose the retrohepatic inferior vena cava, an ultrasound was used to locate and mark the tumor, and the liver resection was conducted using bipolar, LigaSure and clips. No Pringle maneuver was performed. Mean operation time was 150 min, with minimum blood loss. R0 resection was achieved in both patients and they were discharged home at third and fifth postoperative days. Great results I would say. Incredible operation with minimal aggression resecting lesions difficult to access using both open and laparoscopic approaches. Who will be able to perform this operation? Who will have the necessary surgical background and skills to use this approach? Will it be feasible?
Retroperitoneoscopic approach maybe suitable for difficult liver locations.
Like all techniques there are advantages and disadvantages. The major disadvantage is the difficulty to change the patient to the supine position in the presence of a major bleeding complication during surgery which theoretically indicates the need for laparotomy. How can a Pringle maneuver be performed by retroperitoneoscopy? But, is Pringle maneuver always necessary during liver surgery? Many will say no. Additionally, some will say even an inferior vena cava bleeding can be managed by retroperitoneoscopy. Well, I had one and it was not easy to control… In modern liver surgery there are patients submitted to several liver resections (for instance in cases of colorectal liver metastases), reason why they will have dense liver adhesions to abdominal wall and diaphragm. In these cases, posterior retroperitoneoscopy will have a great advantage by avoiding transperitoneal approach, reducing the probability of abdominal organ injury and diaphragm lesions, which are common when previous liver mobilization has been performed. In my opinion, postoperative pain will be also decreased after posterior retroperitoneoscopic resection, which is also an important advantage for a faster recovery.
The authors also point other drawbacks of this approach, which I believe are connected to the surgeons’ (lack of) knowledge and diversity of skills and not with technique itself. Dr Iswanto et al say that majority of surgeons are not familiarized with the retroperitoneal space and anatomic landmarks, and the so-called hepatobiliary surgeon do not know how to perform posterior retroperitoneoscopy. The authors go even further and say that hepatobiliary fellowships no not teach this approach. But… How could they? “That technique is for adrenal surgery which I do not perform, that is for endocrine surgeons.” They would say… The two surgeons from Essen, Germany, who presented that report of posterior retroperitoneoscopic approach for right posterior liver tumors have a great experience in this technique for adrenal disease. Dr Iswanto et al pointed out this fact as the reason why they did perform that surgery with such good outcomes. However, it was the fact that the same surgeons perform both liver surgery (open and laparoscopic) and adrenal surgery, adding experience in advanced gastrointestinal laparoscopic surgery, that gave them the opportunity, the idea and the skills to combine knowledges from such different areas. Will this new technique have a future? Only time will say.
The experience in several surgical areas by the same surgeons was what made possible this new approach. Will it prevail?
Evolution came from the diversity of knowledge and from the diversity of skills acquired by performing different surgical techniques by those surgeons. New ideas grow from open minds feed with knowledge from diverse fields, medical and non-medical. With the nowadays surgical education it will be hard to find a general surgeon able to do so, I think.
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Dr. Carlos Eduardo Costa Almeida
General Surgeon