The Value of Fast-track Surgery in Hepatobiliary Surgery
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Colorectal Surgery
Fast track
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Colorectal Surgery
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Background Laparoscopic surgery has become the standard for most visceral surgery procedures in many hospitals. Now, liver resections are also being increasingly carried out laparoscopically. The advantages of the laparoscopic technique have been demonstrated in numerous case series and in a recent randomized controlled trial. Aims The aim of this review article is to present the available techniques for laparoscopic liver surgery (LLS). Methods The technical variations reported in the literature as well as the own experience with LLS are reported. Results Optimal patient and trocar positions are crucial for successful LLS and they are chosen according to the planned type of liver surgery: the literature offers several options in particular for surgery of the cranial and dorsal liver segments. As for open liver surgery, a restrictive volume management and the application of the Pringle maneuver are helpful to reduce intraoperative blood loss in LLS. In addition, several dissection techniques have been adopted from open liver surgery. The Cavitron Ultrasound Surgical Aspirator (CUSA™) is particularly suitable for parenchymal dissection close to major vascular structures, since it guarantees a meticulous parenchymal dissection with minimal vascular injuries. Conclusion The developments of minimally invasive surgery nowadays allow complex liver resections, which can mostly be performed comparable to open liver surgery. Hopefully, minimally invasive liver surgery will further develop in Germany in the near future, since it offers several advantages over open liver surgery.
Open surgery
Invasive surgery
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The d evelopment of surgical techniques and specialization and specifically complication management in pancreatic surgery have improved surgical outcomes as well as oncological results in pancreatic surgery in recent decades. Historical morbidity and especially mortality rates of up to 80% have decreased to below 5% today. This review summarizes the current state of the art in pancreatic cancer surgery.The present literature and clinical experience are summarized to give an overview of the present best practice in pancreatic surgery as one of the most advanced surgical disciplines today.Based on the available literature, three important aspects contribute to best patient care in pancreatic surgery, namely, surgical progress, interdisciplinary complication management, and multimodal oncological treatment in case of pancreatic cancer. In addition, minimally invasive and robotic procedures are currently fields of development and specific topics of research.In experienced hands, pancreatic surgery-despite being one of the most challenging fields of surgery-is a safe domain today. The impact of multimodal, especially adjuvant, therapy for oncological indications is well established and evidence-based. New technologies are evolving and will be evaluated with high-evidence studies in the near future.
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Abstract The worldwide trend in surgery has moved from open surgery to minimally invasive surgery. Likewise, the application of minimally invasive surgery in the hepato‐pancreato‐biliary (HBP) field is also rapidly expanding. The field of HBP surgery can be divided into liver, pancreas and biliary fields. Minimally invasive liver surgery is recently developed. However, laparoscopic liver resection in difficult areas is challenging. However, with the accumulation of experiences, laparoscopic liver resection for difficult areas is performed more than before. With more propagation, more and more liver resection will be performed by laparoscopic approach. In minimally surgery for the pancreas, distal pancreatectomy has become a well‐recommended procedure in benign and borderline malignancy. There have been several systemic reviews that show advantages of laparoscopic distal pancreatectomy. The reports on laparoscopic pancreaticoduodenectomy (PD) are slowly increasing in spite of technical difficulty, with several systemic reviews showing advantages of the procedure. However, more PD will be performed as robotic‐assisted procedures in the future. The laparoscopic surgery for biliary tract malignancy is still in early stages. The laparoscopic surgery for gallbladder cancer has been contraindicated, although there have been encouraging reports from expert centers. The laparoscopic surgery for Klatskin tumor is still an experimental procedure. Robotic‐assisted procedures for the surgery of cholangiocarcinoma will be the future. Robotic‐assisted surgery for the HBP field is still not well‐developed. However, with the necessity of more precise manipulation like intracorporeal suturing, robotic‐assisted surgery will be used more often in the field of HBP surgery.
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Laparoscopic surgery in hepatobiliary, splenic and pancreatic diseases is being widely used. However, the incidence of postoperative complications is relatively higher due to the complexity of the operative procedures. Surgeons are expected to have familiarity with normal and variant anatomy, as well as a good command of prevention and management of bleeding. Different separation techniques should be used based on the different characteristics of tissues. Moreover, digestive tract reconstruction is the technical bottleneck in laparoscopic hepatobiliary, splenic and pancreatic surgeries, and depending on the team work. Different anastomotic methods should be applied according to patients′ condition. Three-dimensional laparoscopy and Da Vinci robot surgical system have greatly promoted the development of complex laparoscopic surgery in hepatobiliary, splenic and pancreatic surgeries. Comprehensive perioperative management and enhanced recovery after surgery are the guarantee of safe and quick postoperative recovery, which also fully embody the advantages of minimally invasive surgery.
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Hepatobiliary, splenic and pancreatic diseases; Surygical procedures, operative; Enhanced recovery after surgery; Laparoscopy
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Summary Due to the complexity of the procedures and the texture of the organ itself, pancreatic surgery remains a challenge in the field of visceral surgery. During the past decade, a minimally invasive approach to pancreatic surgery has gained distribution in clinical routine, extending from left-sided procedures to pancreatic head resections. While a laparoscopic approach has proven beneficial for many patients with left-sided pancreatic pathologies, the complex reconstruction in pancreas head resections remains worrisome with the laparoscopic approach. The robotic technique was established to overcome such technical constraints while preserving the advantages of the laparoscopic approach. Even though robotic systems are still in development, especially in pancreatoduodenectomy, the current literature demonstrates the feasibility of this approach and stable clinical and oncological outcomes compared to the open technique, albeit only under the condition of such operations being performed by specialist teams in a high-volume setting (>20 robotic pancreaticoduodenectomies per year). The aim of this review is to analyze the current evidence regarding a minimally invasive approach to pancreatic surgery and to review the potential of a robotic approach. Presently, there is still a scarcity of sound evidence and long-term oncological data regarding the role of minimally invasive and robotic pancreatic surgery in the literature, especially in the setting of pancreaticoduodenectomy.
Invasive surgery
Pancreatic head
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Invasive surgery
Minimally invasive procedures
Surgical procedures
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Despite technical advances in surgical resection and postoperative management of the pancreas, surgical procedures of the pancreas are associated with a high rate of complications, resulting in a relevant morbidity and mortality. Early diagnosis and management of complications associated with pancreas surgery is mandatory, favoring a multidisciplinary approach. Interventional radiology offers minimal invasive techniques to manage post-surgical complications. These procedures are highlighted in this review, including percutaneous drainage of fluid collections, percutaneous transhepatic biliary interventions, arterial embolisation and fistula embolisation. Post-surgical complications of pancreatic surgery are effectively managed by radiological procedures, offering a feasible and safe treatment with low morbidity rates. Accurate patient selection is key to an effective management of clinical situations where these interventions represent the first line approach. Radiologic procedures allow for minimal invasive treatment of postoperative complications after pancreatic surgery, reducing the time of hospitalization and the time of recovery.
Interventional radiology
Pancreatic fistula
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In these twenty years, an endoscopic surgery has been widely applied to the patients as the treatment of benign and malignant diseases in the various fields, such as digestive surgery, respiratory surgery, endocrine surgery, urological surgery, and gynecological surgery. It has been generally accepted that the endoscopic surgery is less invasive and more beneficial compared with the conventional surgery in retrospective multicenter studies. In near future, with rapid advances of instruments and techniques, the establishments of EBM by prospective clinical trials, further education and training systems, and technical overcome in NOTES, SPS, and robotics, would be needed to be more widely accepted for the endoscopic surgery as extremely less invasive therapy.
Invasive surgery
Endocrine surgery
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