Expert Consensus Guidelines: How to safely perform minimally invasive anatomic liver resection

Abstract

Background The concept of minimally invasive anatomic liver resection (MIALR) is gaining popularity. However, specific technical skills need to be acquired to safely perform MIALR. The “Expert Consensus Meeting: Precision Anatomy for Minimally Invasive HBP Surgery (PAM‐HBP Surgery Consensus)” was developed as a special program during the 32nd meeting of the Japanese Society of Hepato‐Biliary‐Pancreatic Surgery (JSHBPS). Methods Thirty‐four international experts gathered online for the consensus. A Research Committee performed a comprehensive literature review, classifying studies according to the Scottish Intercollegiate Guidelines Network method. Based on the literature review and experts’ opinions, tentative recommendations were drafted and circulated among experts using online Delphi Rounds. Finally, formulated recommendations were presented online in the Expert Consensus Meeting of the JSHBPS on February 23rd, 2021. The final recommendations were validated and finalized by the 2nd Delphi Round in May 2021. Results Seven clinical questions were selected, and 22 recommendations were formulated. All recommendations reached more than 85% consensus among experts at the final Delphi Round. Conclusions The Expert Consensus Meeting for safely performing MIALR has presented a set of clinical guidelines based on available literature and experts’ opinions. We expect these guidelines to have a favorable effect on the safe implementation and development of MIALR.

Current status of minimally invasive liver surgery for cancers

“…For HCC for which anatomical resection is recommended, there are several reports of LLR that can lead to new developments, such as landmark (hepatic veins, etc. )-guided small anatomical resection[ 38 ], indocyanine green (ICG)-guided anatomical resection and tumor identification[ 39 ], and LLR with a Glissonian approach to more peripheral smaller branches from the hilum (cone unit resection)[ 40 ]. Robot-assisted LLR is an important emerging tool under discussion[ 25 , 41 ].…”

“…Simulation and navigation from pre- and intraoperative imaging studies to assure tumors in the resected area with enough surgical margin are important. Landmark (such as hepatic veins)-oriented small anatomical resection[ 38 ], ICG-guided anatomical resection and tumor identification[ 39 ], and LLR with a Glissonian approach to more peripheral smaller branches from the hilum[ 40 , 42 ] are also applied to CRCLM. However, because the liver does not have CLD and the need for anatomical resection is low, LR for CRCLM with a large number of tumors is often planned as a combination of large anatomical resection plus partial resections or multiple partial resections.…”

Current trends in liver surgery (literature review)

“…Были разработаны клинические рекомендации (КР) по безопасной МИАРП. Эти КР были опубликованы недавно [2]. В них сформулированы 7 клинических вопросов и рекомендации.…”

“…Благодаря этим форумам лапароскопическая хирургия печени интенсивно развивается. Однако совсем недавно в свет вышла статья "Expert Consensus Guidelines: How to safely perform minimally invasive anatomic liver resection" [2], в которой выдающиеся эксперты со всего мира дают ответы на вопросы и разрешают противоречия, возникающие при лапароскопических и роботических резекциях печени.…”

Minimally invasive liver surgery - rise of a new era

“…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] .…”