I read with great interest the consensus and guideline of laparoscopic hepatectomy, which was originated from the experts in China [
1]. This is a significant step forward in minimally invasive liver surgery.
The development of minimally invasive liver surgery over the last 2 decades has a great impact on the surgical practice in China, and the other parts of the world. The potential advantages of laparoscopic hepatectomy are those of minimal access surgery (Table 1). However, there were many heterogeneous ways of performing these procedures. In order to summarize the current role and status of laparoscopic hepatectomy, the first international consensus meeting on laparoscopic hepatectomy was held in Louisville, US, in November 2008, incorporating the opinions of the world’s experts in laparoscopic and open liver surgery [
2]. The organizing committee selected 45 international experts with the extensive experience in both laparoscopic and open liver surgery. Currently accepted indications for laparoscopic hepatectomy are patients with solitary lesion,≤5 cm, located in antero-peripheral liver segments 2 to 6. The laparoscopic left lateral sectionectomy should be considered as a standard practice. They concluded that laparoscopic hepatectomy is a safe and effective approach provided it is performed by trained surgeons with experience in hepatobiliary and laparoscopic surgery. Although most types of hepatectomy can be performed laparoscopically, including major hepatectomy, these should be only reserved to experienced liver surgeons already skilled at more complex laparoscopic resections. Based on the current nonrandomized comparative studies and meta-analyses, laparoscopic hepatectomy for benign and malignant liver pathologies is safe and feasible with significant benefits for well selected patients consisting of fewer complications, less blood loss, less analgesic requirements, and shorter length of hospital stay [
3-
7]. Traditionally, approaches of conventional laparoscopic hepatectomy include total laparoscopic, hand-assisted laparoscopic approach, or hybrid technique. The hybrid technique is defined as a procedure, which is started as a total laparoscopic, or a hand-assisted procedure but the resection is performed through a mini-laparotomy incision. Their advantages and disadvantages are shown in Table 2 (Figs.1 and 2). The recent introduction of robot has offered an alternative option to minimally invasive liver surgery. It was developed to overcome the disadvantages of conventional laparoscopic surgery. Well-known advantages of the robotic surgery such as improved view via three-dimensional vision, visual magnification, tremor suppression, and the flexibility and dexterity of the instruments have allowed precise operating techniques in liver surgery [
8-
10]. These special features allow the surgeons to perform delicate dissection and precise intra-corporeal suturing. The main drawback of robotic surgery is the higher associated cost. Its future application will highly depend on the advantages that it can provide over conventional laparoscopic hepatectomy or open hepatectomy.
With the rapid popularization and development of minimally invasive liver surgery around the world, a consensus and the guidelines suitable to the Chinese population are urgently needed. A working group of National Hepatic Surgery Group, Society of Surgery, Chinese Medical Association was convened to review the consensus and guidelines of minimally invasive liver surgery. This led to the publication of the 2013 consensus and guideline of laparoscopic hepatectomy as Chinese version in Chinese Journal of Digestive Surgery [
1]. Sixty experts in hepatobiliary surgery were invited to participate in a consensus conference convened in Wuhan, China in December 2012. This consensus and the guidelines are based on the best published evidence, their precious experiences, and the agreed opinions of the committee members. The purpose of the guidelines is to provide information for liver surgeons in China in order to promote safe and effective minimally invasive liver surgery. These guidelines set minimum standards and are intended to apply to practice in China. This is a very good starting and provides references for the training and development of minimally invasive liver surgery.
With the evolving of new evidences and development, continuous evaluation and refinements of the guidelines are important to allow their diffusion and usage in daily surgical practice. In addition to the consensus and guidelines, surgery by well-trained surgeons with advanced laparoscopic skills and open liver surgery experience, and the establishment of comprehensive programs of training and credentialing are essential. Without any doubt, these will benefit all clinicians dealing with liver pathologies.
Eric C.H. Lai declares that he has no conflict of interest. This manuscript does not involve a research protocol requiring approval by the relevant institutional review board or ethics committee.
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