Current status and future perspectives of minimally-invasive redo liver surgery - what can we add with technologies of simulation/navigation and robot?

Abstract

Minimally invasive liver resection (MILR) has been developed and disseminated widely. Almost all styles of liver resection can currently be performed in the way at many high-volume centers. Decreases in blood loss and morbidity and shorter hospital stays have been reported without deteriorating long-term outcomes. The “Caudal approach”, our presented concept, is responsible for these benefits. Its minimal manipulation (damage) on the residual liver and surrounding structures can lead to less operative morbidity and postoperative deterioration of liver function. Also, total adhesiolysis of the whole area is not required in redo liver surgeries under the approach. Preoperative computed tomography simulation and intraoperative ultrasound/indocyanine green (ICG) navigation are working well in conquering the specific disadvantages of MILR, including intraoperative disorientation. In redo surgery, adhesions, scar-formation and deformity of the liver from previous operations could exacerbate this issue, highlighting the increased importance of simulation/navigation. Robot-assisted applications are now expanding rapidly. Their articulated forceps that eliminate tremors make them promising for precise operation. In redo surgery, dissection of major vessels among the scars and procedures in the limited area between adhesions may be facilitated by hands. However, a wider access route into the surgical space should be needed for current bulky robotic systems, and some of the advantages of conventional laparoscopic procedures may be difficult to apply. Current robotic systems are still less equipped and require substantial support from patient-side surgeons. However, advancements such as single-port robot systems and other technological developments could address these challenges in the future.