From virtual surgical planning, to image-guided surgery, to minimally invasive surgery, we continue to develop technologies with an eye toward the ultimate goal of precision therapy for hepatic and pancreatic tumors.
Virtual Organ Volumetry for Surgical Planning
Full recovery from major hepatic resection requires a healthy, well-perfused liver remnant that is capable of regenerating to its pre-resection volume. Several studies have shown that the percentage of functional liver parenchyma remaining after major hepatic resection is one of the few reliable predictors of postoperative hepatic dysfunction and morbidity (1,2). Having demonstrated that liver volumetry based on preoperative scans can be performed accurately (3), we then developed patient-specific virtual models that provide the surgeon with three-dimensional measurements of parenchyma, tumor, and delicate vasculature in relation to resection lines. Today, we routinely perform detailed virtual planning for individual patients undergoing major liver resection.
As an example, the image in Figure 1a is from virtual surgical planning software for a patient with a potentially small liver remnant (dark orange), and includes the remnant volume projection at 34 percent of the original liver volume. To stimulate growth of the liver remnant prior to resection, the patient underwent portal vein embolization. Figure 1b shows the same patient with increased remnant liver volume (dark orange) at 6 weeks after embolization, including the remnant volume projection at 43 percent of original liver volume. Because growth rate after portal vein embolization is a good predictor of hepatic resection outcome (4), this patient proceeded to resection.
Minimally Invasive Liver Surgery
Over the past two decades, minimally invasive techniques have been increasingly adopted in multiple surgical specialties including colorectal, gynecologic, urologic, and thoracic (5–9). Minimally invasive techniques provide patients with significant benefits, including reduced postoperative pain, reduced morbidity, decreased length of hospital stay, improved cosmesis, and improved overall cost-effectiveness, all without compromising oncologic outcomes.
The initial application of minimally invasive techniques to liver surgery proved challenging given the complex vascular and biliary anatomy, difficult exposure of the liver, risk of bleeding from the liver parenchyma, and limitations of the early minimally invasive technology. We have performed more than 4000 liver resections for malignancies over the past 19 years, and we continue to develop and expand our ability to perform complex hepatopancreatobiliary surgery using minimally invasive techniques.
Laparoscopic Liver Surgery
Laparoscopic liver resections were initially reserved for single, small, peripherally located tumors. Now, we utilize laparoscopy in all aspects of liver surgery and have performed a total of 170 laparoscopic liver resections at MSK.
In a case-control study of 65 laparoscopic liver resections individually paired to comparable cases performed by open surgery, our team, led by Michael I. D’Angelica, MD, found that laparoscopy was associated with significantly reduced estimated blood loss, transfusion frequency, frequency of Pringle maneuver, postoperative morbidity, recovery time, length of hospital stay, and incidence of incisional hernia (10). Furthermore, we found no positive surgical margins and no local recurrence in either group, and the overall pattern of recurrence was similar. Overall, laparoscopic liver surgery was shown to have similar oncologic outcomes yet decreased postoperative morbidity in well-selected patients.
Robotic Liver Surgery
We recently expanded our application of minimally invasive techniques to include robotic liver surgery. Robotic technology offers enhanced instrumentation due to the wristed motion of the robotic instruments and superior 3-dimensional visualization, enabling more natural movements of the surgeon’s hands than with conventional laparoscopy. Our group, led by T. Peter Kingham, MD, has performed a total of 65 robotic liver resections to date (Figure 2). In a case-matched comparison of these operations with 65 open liver resections, we found shorter operative time, decreased blood loss, and shorter hospital stay (unpublished results). Therefore, robotic surgery appears safe.
The future of minimally invasive liver surgery is exciting. With rapid technological advances, our ability to apply minimally invasive techniques to liver surgery continues to grow. With over 300 hepatic resections performed annually by the Hepatopancreatobiliary Service at MSK, we are optimally poised to apply these new techniques to perform safe and effective surgery on this complex anatomical organ, with concurrent preservation of oncologic outcomes.
MSK liver surgeons are assessing an image guidance system to guide minimally invasive liver surgery. Using data from a patient’s CT scans, the system creates a 3-D model—a virtual roadmap through a patient’s anatomy, much like a global positioning system—which can be updated in real-time to guide the surgeon during a procedure. Computational scientist Amber L. Simpson, PhD, of the Hepatopancreatobiliary Service, notes that this system may be very valuable for patients with small, deeply placed tumors—especially those remaining after extended chemotherapy, when liver tissue can become fatty or scarred. Figure 3 shows the image displayed by one such guidance system when the tumor is successfully located on CT, after the tumor was not found using standard ultrasound alone.
- Shoup M, Gonen M, D’Angelica M, Jarnagin WR, DeMatteo RP, Schwartz LH, et al. Volumetric analysis predicts hepatic dysfunction in patients undergoing major liver resection. J Gastrointest Surg. 2003;7(3):325–30.
- Schindl MJ, Redhead DN, Fearon KCH, Garden OJ, Wigmore SJ. The value of residual liver volume as a predictor of hepatic dysfunction and infection after major liver resection. Gut. 2005;54(2):289–96.
- Simpson AL, Geller DA, Hemming AW, Jarnagin WR, Clements LW, D’Angelica MI, et al. Liver planning software accurately predicts postoperative liver volume and measures early regeneration. J Am Coll Surg. 2014;219(2):199–207.
- Leung U, Simpson AL, Araujo RLC, Gönen M, McAuliffe C, Miga MI, et al. Remnant Growth Rate after Portal Vein Embolization Is a Good Early Predictor of Post-Hepatectomy Liver Failure. J Am Coll Surg. 2014 Oct;219(4):620–30.
- The Clinical Outcomes of Surgical Therapy Study Group. A Comparison of Laparoscopically Assisted and Open Colectomy for Colon Cancer. N Engl J Med. 2004;350:2050–9.
- Guillou PJ, Quirke P, Thorpe H, Walker J, Jayne DG, Smith AMH, et al. Short-term endpoints of conventional versus laparoscopic- assisted surgery in patients with colorectal cancer ( MRC CLASICC trial ): multicentre , randomised controlled trial. Methods. 2005;365.
- Ghezzi F, Cromi A, Ditto A, Vizza E, Malzoni M, Raspagliesi F, et al. Laparoscopic versus open radical hysterectomy for stage IB2-IIB cervical cancer in the setting of neoadjuvant chemotherapy: a multi-institutional cohort study. Ann Surg Oncol. 2013;20(6):2007–15.
- Trabulsi EJ, Hassen WA, Touijer AK, Saranchuk JW, Guillonneau B. Laparoscopic radical prostatectomy: a review of techniques and results worldwide. Minerva Urol Nefrol. Italy; 2003 Dec;55(4):239–50.
- Luketich JD, Pennathur A, Awais O, Levy RM, Keeley S, Shende M, et al. Outcomes After Minimally Invasive Esophagectomy. Ann Surg. 2012;256(1):95–103.
- Ito K, Ito H, Are C, Allen PJ, Fong Y, DeMatteo RP, et al. Laparoscopic versus open liver resection: A matched-pair case control study. J Gastrointest Surg. 2009;13(12):2276–83.