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Current advances in liver surgery

Hepatobiliary surgery has taken a big step forward in recent decades especially in the minimally invasive approach for hepatectomy. From being sceptical at the beginning of the 1990s when laparoscopic surgery had become prevalent, to now, where laparoscopic hepatectomy has been well-established, especially in minor hepatectomies; this new technique has evolved rapidly over the past 20-years demonstrating better short-term outcomes and equivalent oncological outcomes in selected patients and in expert hands. Laparoscopic hepatectomy is indeed, more difficult to master than the open procedure with restrictions in working space, difficulty in haemostasis and the potential risk of gas embolism. However, with better visibility of the operative field around the liver, especially beneath the costal margin, the magnified view and theoretical advantage of pneumoperitoneum acting as haemostatic pressure have made laparoscopic hepatectomy increasingly popular. Another important advancement is the new surgical technique of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS). This procedure induces more rapid liver hypertrophy within a median period of 9-days, allowing resection to be performed in candidates with borderline functional liver remnant and at an earlier date. However, studies have shown that ALPPS is associated with a relatively higher rate of morbidity and mortality. Therefore, it remains a highly controversial treatment option and more studies have to be performed to establish its usefulness and define its role in liver surgery.