ASO Author Reflections: The Integration of Precision Anatomy Concepts into Minimally Invasive Liver Surgery-A New Way to Approach Routine Clinical Practice Complex Situations

Past
Minimally invasive (MI) liver surgery (MILS) has evolved rapidly in the last decade, and a stepwise safe implementation has been adopted by liver surgeons. Slow and steady, from left lateral sectionectomy and minor anterolateral resections, more complex clinical scenarios have been accomplished, including cirrhotic patients, major hepatectomies, posterosuperior locations, and complex anatomical and extended resections. Most of surgical procedures have been successfully performed using the MI approach; however, although meritorious, most of them have been performed according to the same principles and concepts traditionally followed in open surgery.

Present
Laparoscopy offers a magnified and detailed view of the structures. When the scope gets closer to critical structures, and with the new technological systems (3D/4K), laparoscopy may become even better than that obtained in open surgery. The caudal view is considered the main conceptual change in MILS in the last years. This view is a unique perspective that the position of the camera offers of the anatomical structures during liver surgery. These factors, as well as the growth of three-dimensional (3D) reconstruction software, have sparked the interest of surgeons in liver anatomy and the importance of tailoring the procedure to the particular patient´s variants. In parallel, the Laennec´s capsule approach and its application in liver surgery,1 as well as the combination of the Glissonian and vein-guided approaches,2,3 has led to the concept of precision anatomy liver surgery. These concepts were discussed during the "Expert Consensus Meeting on Precision Anatomy for Minimally Invasive HBP Surgery (PAM-HBP Surgery Consensus)" hosted in 2021. This PAM-HBP Surgery Consensus led to the Tokyo 2020 Terminology for Liver Anatomy and Resections,4 with several precision anatomy-based recommendations. All these concepts and definitions together lead to a shift from traditional to renewed approaches. Our recent report entitled “Anatomical Left Hepatectomy Extended to Caudate Lobe Due to Colorectal Metastasis with Intrabiliary Growth: Securing the Optimal Margins with a Laennec´s Capsule Approach and Vein-Guided Resection”5 is a good example of the application of these concepts in daily clinical practice, improving the safety of the procedure and securing the best possible surgical and oncological outcomes.

Future
MILS has reached high levels of precision and perfection that has a real impact on patients’ benefit. However, even though the literature is wide, including expert consensus guidelines,4,5 the application of these techniques and concepts is far from being standard practice and widely adopted. The future of surgery relies mostly on augmented reality and robotic platforms, leading to improvements in the care of our patients. Nonetheless, before that, and undoubtedly much cheaper, precision surgery using an MI approach should become standard practice in hospitals worldwide. An educational effort must be made by scientific and medical societies to achieve a diffusion that benefits the majority of patients undergoing liver surgery.

CITA DEL ARTÍCULO  Ann Surg Oncol. 2024 Apr 13. doi: 10.1245/s10434-024-15287-9