Laparoscopic and robot-assisted surgery - a new face of liver surgery in the 21st century

At a later stage of professional development, it is time to perform more extensive procedures on the stomach, intestines, spleen, or the most extensive and most risky liver, biliary and pancreatic surgeries. Performing them using the classic method requires a wider opening of the abdominal cavity, and thus a larger incision. This close link between the extent of surgery and the size of the postoperative wound made it easy to distinguish patients who underwent minor surgery from those who underwent major surgery.

Pain is the main factor limiting the patient's functioning and quick recovery after abdominal surgery. However, its intensity is closely related to the size of the postoperative wound and the trauma of the very well innervated abdominal integuments. Therefore, the patients themselves, based on the pain they experienced, could guess how extensive their surgery was. This face of surgery changed drastically in the first two decades of the 21st century.

Extensive incisions within the abdominal wall provide adequate insight into the operating field and freedom of movement for the surgeon, two factors necessary for the safe conduct of a technically complex procedure. Initially, laparoscopy was associated with the limitations of both of these aspects, but the enormous technological advances allowed to overcome many barriers. The introduction of modern optical systems into clinical practice made it possible to identify the most subtle anatomical elements. And new tools, such as devices replacing traditional surgical suturing with a multi-row system of staples, have provided surgeons with the technical ability to perform advanced procedures using laparoscopic techniques.

In common perception, laparoscopy is associated with aesthetics. Instruments and optics are inserted into the abdominal cavity through a series of small incisions to avoid extensive scarring. Adequate insight into the operating field is obtained by "inflating" the peritoneal cavity with carbon dioxide, which raises the abdominal wall by the generated pressure, producing the so-called "work space". In the case of extensive operations, often performed for oncological reasons, aesthetics is one of the last aspects on the minds of patients and surgeons. The basis for introducing new surgical techniques is their safety and the benefits they bring to patients. Depriving the surgeon of the sense of touch and limiting the range of movements of tools, even in the case of using the latest technological achievements, increases the degree of technical difficulty of the procedure. Thus, a reduction, even a very significant one, of postoperative scars could not be the only reason to impede the already extremely complicated surgical procedures. It does not mean, however, that avoidance of making an extensive wound within the abdominal wall is an irrelevant element in the patient's treatment process.

The use of minimally invasive access, such as laparoscopy, reduces pain, improves the rehabilitation process, accelerates recovery and minimizes the risk of wound complications, especially in terms of infections. All these factors are of key importance for the rapid initiation of adjuvant chemotherapy, thus affecting not aesthetics, but the chances of recovery and long-term survival rate. In the last study on the surgical technique of abdominal wall closure in classical surgery, the risk of postoperative wound infections was 6-18%. The importance of the problem of wound infections is evidenced by the publication of our results in the most prestigious surgical journal in the world - Annals of Surgery (one of only a few Polish papers published in the over 130-year history of the journal).

For minor surgery, such as removal of the appendix or gallbladder, the laparoscopic technique has become the technique of choice over the past two decades. Its application in the case of technically complex and difficult oncological operations was connected with crossing another border. In the Department of General, Transplant and Liver Surgery of the University Clinical Center of the Medical University of Warsaw, we clearly focused on the use of laparoscopy in the case of extensive liver surgery. Since I performed the first right hemihepatectomy in the Clinic (removal of the right segments of the liver, i.e. about 60-70% of its mass), we have started a program of extensive laparoscopic liver resections. To date, we have performed several dozen technically advanced laparoscopic liver surgeries, and by using the technique we joined the group of world's leading centers that use minimally invasive access in liver surgery. These procedures included the most extensive surgery in patients with the highest level of risk, often performed for the first time in our country (https://www.wum.edu.pl/node/15653;  https://bp.wum.edu.pl/node/2515 ). The introduction of the program was an undoubted success, as evidenced by its results just published in the World Journal of Surgical Oncology. We have shown that the laparoscopic technique significantly reduces the overall risk of complications and the length of hospitalization. Most importantly, the risk of any complications was lower with the laparoscopic technique, not only the risk of complications related to the postoperative wound. Preliminary observations also indicate a reduction in intraoperative blood loss and thus a reduction in the need for transfusions, but this requires further confirmation.

The lower incidence of complications after laparoscopic liver surgery seems to be the most important advantage of using a minimally invasive technique. Interestingly, this can only be partially explained by the avoidance of a major incision and surgical wound. Although the laparoscopic technique is associated with technical difficulties, the extremely clear and magnified image of the abdominal organs provided by modern imaging methods allows for more precise preparation of tissues. In addition, almost every bleeding in laparoscopy makes it difficult to see the operative field properly and prompts the surgeon to immediately close even the tiniest of open blood vessels. Given all these advantages of the laparoscopic technique, it is no surprise that the best liver surgery centers in the world are expanding the use of this method. The experience gained by the operating team of the Clinic of General, Transplant and Liver Surgery of the University Clinical Center of the Medical University of Warsaw, involved in the program of extensive laparoscopic liver resections, allowed for crossing new boundaries of medical science. Currently, we use the laparoscopy even in patients undergoing subsequent liver surgeries or excision of a fragment of the liver with a fragment of the diaphragm, with the need to simultaneously close the resection and separate the peritoneal cavity from the right pleural cavity. It is also less common to change the laparoscopic technique to the classic one, i.e. opening the abdominal cavity, due to technical difficulties or intraoperative complications.

Laparoscopy, however, has its limitations. Some tools make it possible to mimic the movements of a surgeon's hand in a laparoscopic procedure, but are far from, for example, the range of motion in a human wrist. A greater range of movements during classic surgery makes it easier to make anastomosis between blood vessels or between the bile ducts and the intestine. For this reason, the classical technique has an advantage over the laparoscopic technique for a small proportion of surgeries that involve complex anastomosis. However, this is where the latest technology, i.e. surgical robots, is used. Their use provides the surgeon with a much greater range of movements, enabling difficult anastomosis, while maintaining all the advantages of minimally invasive access. However, in contrast to introducing laparoscopic access for technically difficult operations, the introduction of robotic operations for surgeons experienced in laparoscopic surgery facilitates their work.

Notwithstanding all the advantages of minimally invasive access in surgery, some  procedures will still be performed using the classical technique. Patient safety is always a priority. However, advances in surgery, supported by advances in medical technology, are moving the frontiers of minimally invasive access towards the most technically complex operations.

 
 
Publications:

1. Grąt M, Morawski M, Krasnodębski M i wsp. Incisional Surgical Site Infections After Mass and Layered Closure of Upper Abdominal Transverse Incisions: First Results of a Randomized Controlled Trial. Ann Surg. 2021;274:690-697.
2.  Morawski M, Grąt M, Krasnodębski M i wsp. Early results of the implementation of laparoscopic major liver resection program. World J Surg Onc 2022 [in print]