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Invited Critique
November 15, 2010

The Maximally Invasive Hepatobiliary Surgeon: A Dying Breed?Comment on “Laparoscopic vs Open Hepatectomy for Benign and Malignant Tumors”

Author Affiliations

Author Affiliations: Department of Surgery, University of Minnesota Medical Center, Minneapolis.

Arch Surg. 2010;145(11):1118. doi:10.1001/archsurg.2010.234

Croome and Yamashita present a comprehensive analysis of the rapidly growing field of minimally invasive hepatopancreatobiliary surgery. They have shown that the benefits of laparoscopic surgery, including lower estimated blood loss, shorter hospital stay, reduced narcotic dependence, and reduced overall complication rates, also apply to laparoscopic liver resection.

Perhaps cautious optimism is most appropriate because the rate of margin less than 1 cm was significantly higher in the laparoscopic group, and given the selective nature of these data, the reduction in all-cause mortality, hospital stay, and complications may be partially attributable to healthier patients undergoing laparoscopic resection. In the case of malignant tumors, several factors, including tumor size, location, and severity of cirrhosis, were unexamined. These factors affect patient selection; therefore, it may appear that the laparoscopic group benefited from lower complication rates, when in fact they may have had a less complex disease process. In the absence of a multicenter randomized trial, the most notable finding of this large meta-analysis may be that laparoscopic liver resection provides a safe alternative to open resection, and its use should be supported as a growing part of the surgeon's armamentarium. The ability to perform laparoscopic liver resection is based on an increasing cast of well-established and refined technological advances and skill sets, which include laparoscopic ultrasonography, hepatic vascular management, ablation devices, and permissive hypovolemia. As we broaden minimally invasive techniques into more complex oncologic procedures, investigation into long-term outcomes will be paramount. It is likely that the use of laparoscopic techniques will continue to expand as a primary modality and an adjunct to open surgical resection. Although laparoscopic resection will not replace open surgery, this article supports the idea that surgeons must be facile with both approaches to optimize outcomes while minimizing morbidity for their patients.

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