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Mini-invasive Surg 2022;6:36. 10.20517/2574-1225.2022.52 © The Author(s) 2022.
Open Access Editorial

Minimally invasive liver surgery - rise of a new era

Division of Hepatobiliary and Pancreatic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA.

Correspondence to: Dr. David A. Geller, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Pittsburgh Medical Center, MUH 7S, 3459 Fifth Ave Pittsburgh, Pittsburgh, PA 15213, USA. E-mail: gellerda@upmc.edu

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    Academic Editor: Giulio Belli | Copy Editor: Jia-Xin Zhang | Production Editor: Jia-Xin Zhang

    © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, sharing, adaptation, distribution and reproduction in any medium or format, for any purpose, even commercially, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

    Minimally invasive surgery (MIS) has improved the perioperative risk, hospital stay, and patient satisfaction with operations for lung cancer, colon cancer, and prostate cancer. Hepatobiliary surgery has been more cautious in integrating minimally invasive approaches due to concerns for the quality of oncologic resection and safety. Over the last 20 years, considerable advances have been made demonstrating comparable safety and oncologic efficacy in minimally invasive liver surgery. This special edition of MIS seeks to describe the recent advances to improve safety and efficacy in minimally invasive approaches, as well as novel strategies to consider for future procedures.

    Prior clinical studies have demonstrated that laparoscopic liver surgery can provide safe and equitable results when compared with open liver resections[1]. In a meta-analysis reviewing over 9000 MIS liver surgery cases, laparoscopic surgery was associated with fewer complications, less blood loss, fewer transfusions, and shorter hospital stay[2]. This was achieved without significantly increasing the length of operative time, either for minor or major resections. However, laparoscopic liver surgery should not be utilized by low-volume or inexperienced providers. Review of our institution’s experience with laparoscopic liver resection from 2001 to 2017 suggests a significant improvement in operative time, blood transfusions, use of pure laparoscopic approach, and post-operative complications over a 15-year period of implementation and optimization[3]. Further, surgeons should be familiar with practice guidelines for improving operative safety, including anatomic landmarks, strategic approaches for dissection (i.e., Glissonian approach, hepatic vein guided approach), and trouble-shooting when encountering issues with dissection and bleeding[4].

    Robotic surgery has been utilized in multiple centers as an alternative to the laparoscopic approach in MIS[5]. This was further examined in a retrospective, multi-center, international study comparing robotic- and laparoscopic-assisted liver resection for metastatic colorectal cancer[6]. Here, robotic surgery was used largely for single segment or wedge resections in patients who had undergone neoadjuvant systemic therapy prior to liver resection. There was no difference in perioperative morbidity, mortality, length of hospital stay, readmission, or margin status. At 5-year follow-up, there was no difference in disease-free or overall survival[6]. These findings were recapitulated in a meta-analysis evaluating laparoscopic versus robotic liver surgery. No difference in operative time, blood loss, conversion to open procedure, perioperative mortality, and complication rate was noted[7]. This suggests that robotic surgery can provide safe and comparable care for patients when compared with laparoscopic procedures at expert centers.

    The advent of laparoscopic ultrasound has been helpful in facilitating the transition from open to laparoscopic procedures. Newer technologies such as indocyanine green (ICG) localization offer new adjuncts for guiding anatomic minimally invasive liver surgery resections[8]. Recent findings suggest that ICG can be safely integrated into MIS liver procedures without adding significant operative time or safety risk to the patient[9]. A recent meta-analysis suggests that perioperative ICG staining can facilitate laparoscopic anatomical liver resection using either positive or negative staining techniques[9].

    In this special issue of MIS, we discuss topics at the frontier for minimally invasive liver surgery. These include resection of posterior liver segments, laparoscopic ALPPS (associated liver partition and portal vein ligation for staged hepatectomy) procedure, resection for HCC, ultrasound technique, ICG-guided resection, and integrating robotic surgery for major hepatectomy.


    Authors’ contributions

    Made substantial contributions to the conception and design of the study and performed data analysis and interpretation: Lo W, Geller DA

    Performed data acquisition, as well as providing administrative, technical, and material support: Lo W, Geller DA

    Availability of data and materials

    Not applicable.

    Financial support and sponsorship


    Conflicts of interest

    All authors declared that there are no conflicts of interest.

    Ethical approval and consent to participate

    Not applicable.

    Consent for publication

    Not applicable.


    © The Author(s) 2022.


    • 1. Nguyen K, Gamblin TC, Geller DA. World review of laparoscopic liver resection - 2804 patients . Ann Surg 2009;2520:831-41.

    • 2. Ciria R, Cherqui D, Geller DA, Briceno J, Wakabayashi G. Comparative short-term benefits of laparoscopic liver resection: 9000 cases and climbing. Ann Surg 2016;263:761-77.

    • 3. Swaid F, Sucandy I, Tohme S, et al. Changes in performance of more than 1000 minimally invasive liver resections. JAMA Surg 2020;155:986-8.

      DOIPubMed PMC
    • 4. Gotohda N, Cherqui D, Geller DA, et al. Expert consensus guidelines: how to safely perform minimally invasive anatomic liver resection. J Hepatobiliary Pancreat Sci 2022;29:16-32.

    • 5. Tsung A, Geller DA, Sukato DC, et al. Robotic versus laparoscopic hepatectomy: a matched comparison. Ann Surg 2014;259:549-55.

    • 6. Beard RE, Khan S, Troisi RI, et al. Long-term and oncologic outcomes of robotic versus laparoscopic liver resection for metastatic colorectal cancer: a multicenter, propensity score matching analysis. World J Surg 2020;44:887-95.

      DOIPubMed PMC
    • 7. Ziogas IA, Giannis D, Esagian SM, Economopoulos KP, Tohme S, Geller DA. Laparoscopic versus robotic major hepatectomy: a systematic review and meta-analysis. Surg Endosc 2021;35:524-35.

    • 8. Aoki T, Yasuda D, Shimizu Y, et al. Image-guided liver mapping using fluorescence navigation system with indocyanine green for anatomical hepatic resection. World J Surg 2008;32:1763-7.

    • 9. Felli E, Ishizawa T, Cherkaoui Z, et al. Laparoscopic anatomical liver resection for malignancies using positive or negative staining technique with intraoperative indocyanine green-fluorescence imaging. HPB (Oxford) 2021;23:1647-55.


    Cite This Article

    OAE Style

    Lo W, Geller DA. Minimally invasive liver surgery - rise of a new era. Mini-invasive Surg 2022;6:36. http://dx.doi.org/10.20517/2574-1225.2022.52

    AMA Style

    Lo W, Geller DA. Minimally invasive liver surgery - rise of a new era. Mini-invasive Surgery. 2022; 6:36. http://dx.doi.org/10.20517/2574-1225.2022.52

    Chicago/Turabian Style

    Lo, Winifred, David A. Geller. 2022. "Minimally invasive liver surgery - rise of a new era" Mini-invasive Surgery. 6: 36. http://dx.doi.org/10.20517/2574-1225.2022.52

    ACS Style

    Lo, W.; Geller DA. Minimally invasive liver surgery - rise of a new era. Mini-invasive. Surg. 20226, 36. http://dx.doi.org/10.20517/2574-1225.2022.52




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