Laparoscopic Liver Surgery

Recent improvements in cross sectional imaging, chemotherapy and advances in the techniques of liver resection have resulted in rates of 5 year survival approaching 60% for patients with colorectal liver metastasis. Historically liver resection was perceived as a formidable operation but now liver resection is safe and specialist centres should expect low mortality rates in the region of 1-2%1,2. Consequently, many more patients are now referred for liver resection and its indications are continually being revised and expanded. At the same time there have been many advances in minimally invasive laparoscopic surgical techniques so much so that laparoscopic liver resection (LLR) is becoming an increasingly popular option amongst laparoscopic enthusiasts. Indeed the first laparoscopic liver resection was described nearly 20 years ago for focal nodular hyperplasia3. In a recent review by Nguyen and colleagues 4,5 over 3,000 laparoscopic liver resections have now been reported in various series and meta-analyses 6 7 8. Despite this enthusiasm doubts still remain over its more widespread application because of the risks of complications and whether there is any patient benefit 9-11. The latter is still very difficult to demonstrate in the absence of any well designed randomized controlled trials. Like laparoscopic cholecystectomy that came before, it is now very unlikely that any well designed Randomised controlled trials (RCT) will ever be performed. Perhaps the most important RCT that should have been done is outcome after laparoscopic left lateral resection versus open resection. Yet for laparoscopic enthusiasts the advantages are so obvious they would now be very reluctant to offer open resection in a trial setting. The situation is very different for major resections e.g. right hepatectomy where any advantage is still very difficult to demonstrate. In this situation a RCT would be difficult to design as few centres regularly perform this operation and large numbers would be needed because of high rates of conversion and recruiting patients with tumours distributed in such away that they can be resected laparoscopically.