Navigating the challenges of laparoscopic anatomical SVIII resection: A step forward in hepatobiliary surgery

Abstract

This article comments on the study by Peng et al, published in the World Journal of Gastrointestinal Surgery, representing a notable advancement in hepatobiliary surgery. This article examines laparoscopic anatomical segment VIII resection, a challenging procedure due to the complex liver anatomy and difficulty in accessing deep-seated lesions. Peng and colleagues’ experience with caudal and cranial approaches in 34 patients underscores the feasibility of these techniques while sparking debates about the optimal approach. Their study’s strengths lie in technique standardization and comprehensive analysis, although its limitations highlight the need for further research. As minimally invasive liver surgery progresses, larger, prospective trials and integration of advanced technologies are essential for establishing best practices.

Key Words: Laparoscopic liver resection; Anatomical segmentectomy; Segment VIII; Middle hepatic fissure approach; Surgical techniques

Core Tip: This article critically examines a new study by Peng et al on laparoscopic anatomical segment VIII liver resection using a middle hepatic fissure approach. The authors' comparison of caudal and cranial side techniques contributes valuable insights to the ongoing debate about optimal surgical strategies for this challenging procedure. While demonstrating feasibility and safety, the study also highlights the need for larger, prospective trials to definitively establish best practices. As laparoscopic liver surgery continues to evolve, standardization of techniques, integration of advanced technologies, and focus on long-term oncologic outcomes will be crucial for further progress in the field.

TO THE EDITOR

Laparoscopic liver resection has gained widespread acceptance over the past two decades, offering patients the benefits of minimally invasive surgery without compromising oncologic outcomes[1]. However, anatomical resection of segment VIII remains one of the most technically demanding procedures, even for experienced hepatobiliary surgeons[2]. The deep location under the diaphragm, intimate relationships with major vascular structures, and lack of external anatomical landmarks make this segment particularly challenging to approach laparoscopically[3].

Recent advancements have introduced various approaches to facilitate laparoscopic segment VIII resection, including Glissonean pedicle-first, transparenchymal, and transthoracic approaches[4]. Each method has its proponents, but a standardized approach remains elusive. Peng et al[5] explore the feasibility and safety of laparoscopic anatomical segment VIII resection via the middle hepatic fissure approach, comparing two primary techniques: The caudal and cranial approaches. Based on a cohort of 34 patients, both techniques demonstrated surgical viability. However, their analysis indicates a potential advantage in the caudal approach, notably in terms of shorter operative times and reduced intraoperative blood loss. This suggests that the choice of approach should be individualized, factoring in tumor location, size, and the patient’s hepatic condition.

Critical appraisal of methods

In a recent review by Anselmo et al[4], various surgical techniques for laparoscopic liver segment VIII resection are explored, each with its own advantages and challenges. The review highlights the complexity of SVIII resection due to its anatomical position and the deep-lying Glissonean pedicle. Techniques such as the Glissonean-first approach, cranio-caudal dissection, and the use of intercostal trocars are discussed. The Glissonean-first approach is noted for its anatomical precision, while the cranio-caudal approach is praised for potentially reducing intraoperative bleeding. The use of intercostal trocars is suggested to improve the angle of surgical instruments, particularly in the cranio-caudal approach, which can enhance the safety and feasibility of the procedure.

In contrast, Peng et al[5] focus on the middle hepatic fissure approach, utilizing both caudal and cranial sides. Their study emphasizes the use of 3D reconstruction and intraoperative ultrasound guidance, aligning with best practices for complex liver resections[6]. However, the study's retrospective nature and small sample size limit the robustness of its conclusions. The decision-making process for choosing between caudal and cranial approaches is not randomized, which introduces potential selection bias. Peng et al[5] assign tumors larger than 5 cm or those close to the right anterior pedicle to the caudal approach, but the criteria for technique selection could be more clearly defined. Additionally, the imbalance in the number of patients between the caudal (6) and cranial (28) groups complicates statistical comparisons.

Critical appraisal of results

The study demonstrates the feasibility and safety of laparoscopic segment VIII resection using the described techniques. The reported operative times, blood loss, and complication rates are comparable to other published series on this procedure[7,8]. The authors found shorter operative times with the caudal approach, though this difference should be interpreted cautiously given the small caudal group size.

Interestingly, three patients in the cranial group experienced bile leaks compared to none in the caudal group. While not statistically significant, this trend warrants further investigation in larger studies. The authors' discussion of potential mechanisms for this difference, such as parenchymal congestion, adds value to the paper.

One limitation is the lack of long-term oncologic outcomes. While achieving R0 resection in all cases is promising, data on recurrence rates and survival would strengthen the study's impact. Furthermore, comparison of functional outcomes and quality of life measures between techniques could provide additional insights for surgical decision-making.

Future perspectives

Future perspectives in laparoscopic liver surgery highlight several areas for further research and development. Randomized trials comparing different approaches for laparoscopic segment VIII resection are essential to establish best practices and optimize surgical techniques[9,10]. The integration of novel technologies such as augmented reality, robotics, and fluorescence-guided imaging holds significant promise for enhancing surgical precision and improving patient outcomes[11,12].

In the study by Tao et al[13], the use of augmented reality navigation combined with indocyanine green fluorescence imaging was explored as a method to guide laparoscopic anatomical segment 8 (S8) resection. This approach was found to enhance the accuracy of the resection by providing real-time anatomical information and reducing intraoperative bleeding. However, the study did not specifically address robotic liver resections of segment VIII. While the study focuses on laparoscopic techniques, it is worth noting that robotic surgery has been suggested as a potential innovation to overcome some of the technical challenges associated with laparoscopic segment VIII resections. The robotic platform's endo-wrist features may facilitate the execution of complex resection planes, which are particularly challenging in traditional laparoscopy. However, the current robotic systems lack specific liver-parenchyma transection devices, which limits their application in liver surgery. As of now, the feasibility of robotic isolated segment VIII resections has been demonstrated in a limited number of cases, but larger series are needed to confirm the safety and efficacy of this approach. Therefore, while the study by Tao et al[13] does not provide data on robotic liver resections of segment VIII, it highlights the potential of advanced imaging techniques to improve surgical outcomes in complex liver resections, which could be applicable to robotic approaches as well.

Additionally, developing standardized training programs and credentialing processes for advanced laparoscopic liver resections is crucial to ensure widespread and safe implementation[10]. Furthermore, gathering comprehensive long-term data on oncologic and functional outcomes, including survival rates and recurrence, is vital for thoroughly evaluating the benefits and efficacy of minimally invasive surgical approaches in anatomical liver resections[12].

CONCLUSION

The work by Peng et al[5] represents an important contribution to the evolving field of laparoscopic anatomical liver resection. While questions remain about the optimal approach to segment VIII, their detailed description of middle hepatic fissure techniques provides valuable guidance for surgeons undertaking these challenging procedures. As the surgical community continues to push the boundaries of minimally invasive liver surgery, rigorous evaluation of outcomes and ongoing refinement of techniques will be essential to maximize patient benefit and oncologic efficacy.