Open Liver Surgery for Liver Cancer is Cleaner and Better. Is This Really True?

Liver resection is the gold standard treatment for primary and metastatic liver cancers. The type of cancers treated this way include gallbladder cancer, bile duct cancer, Klatskin tumor, metastatic colon cancer to the liver, metastatic neuroendocrine tumor to the liver, and other soft tissue tumors with spread to the liver. Symptomatic benign masses such as large complex hepatic cyst, mucinous cystadenoma, hepatic adenoma, or large hemangioma also require liver resection to prevent further complications. With the advancement in technology, knowledge of liver anatomy, better surgical instrumentation, and better care after major surgery, liver resection has become a safe routine operation in many hospitals. The chance of death even after a major liver resection is now less than 1%. Major liver resection is defined as removal of 3 or more consecutive liver lobes. Liver surgery can be done via open or minimally invasive technique. The traditional liver surgery is done via open incision, utilizing a transverse incision in the upper abdomen. Majority of liver surgery in the United States are performed via the traditional open technique (95%). Even major academic liver surgery centers such as MD Anderson or Memorial Sloan Kettering are still performing open liver surgery in the majority of their patients.

In the early 1990s, minimally invasive technique in liver surgery was developed. This modern technique then gained significant interest by liver surgeons/liver specialists around the world. The reasons for the significant interest are less blood loss, less pain, shorter recovery, and lower postoperative complications such as wound infection and long-term hernia formation. In a randomized clinical trial conducted by Oslo University Hospital team, minimally invasive liver surgery results in lower postoperative complications, shorter length of stay, and quicker recovery without compromising the oncologic outcomes of the operation. Minimally invasive liver surgery does not require elevation or retraction of the ribcage to create exposure of the tumor mass, resulting in minimal pain postoperatively. This is a very common complaint after an open liver surgery, where the pain often persists for several weeks around the area of right ribcage.

Now, minimally invasive liver surgery has become the standard technique for minor liver resections and majority of the major liver resections. While this is clearly the better surgical technique, some patients are not a candidate for minimally invasive liver surgery due to tumor size, tumor location, proximity to major biliary and vascular structures, and the need for biliary or vascular reconstructions. In our Tampa liver surgery center led by Dr. Iswanto Sucandy and his colleagues, approximacalltoy 15-20% of the liver surgery are performed using traditional open approach due to large tumor size (> 15 cm) and the need for vascular reconstruction. In the last 3 years, our team has performed about 300 robotic liver resections for various liver tumors.

A common concern that we hear from patients is whether minimally invasive liver surgery is “as good as” the open liver surgery, since this surgeon does not have his hands “inside the abdomen touching the liver”. Other patients are questioning whether small liver tumors are “missed” during robotic liver surface due to lack of surgeon’s tactile sensation. Other patients are questioning whether the robotic liver ultrasound is “as sensitive as” the open liver ultrasound. We have heard also from discussion forums on the Internet that patients are willing to endure or resist more pain from open liver surgery as a reward of getting “a cleaner” cancer operation. As an expert in liver surgery performing both open and minimally invasive technique 2-3 cases per week, we have an obligation to educate our patients.

None of the three comments above are correct. Minimally invasive liver surgery is just as good as open liver surgery to clean up liver tumors (and even maybe better in several specific circumstances). This has been studied extensively in the surgical literatures in the past 5 years. Minimally invasive liver surgery results in similar rate of negative resection margins, 5 year disease-free survival and overall survival. The liver ultrasound probe of the minimally invasive surgical system is just as sensitive as the open liver ultrasound. The robotic camera is a 3-dimensional camera with a very high definition, high precision, and 20x magnification. In this sense, the robotic visualization is actually better than naked surgeons eyes in finding small liver lesions/tumors and not miss them. The laparoscopic and robotic system is also equipped with ICG fluorescent imaging, which can further enhance tumor detection. Hepatocellular tumor cells and metastatic cancer cells stain differently compared to the background liver parenchyma when ICG fluorescence imaging is used.

Whether a liver operation needs to be performed open or minimally invasively, it is important to find a liver surgeon/liver specialist, who are are familiar with both techniques. In our Tampa liver cancer center, Dr. Iswanto Sucandy and his colleagues are familiar with both open and minimally invasive liver surgery for various types of liver cancer. This way, best surgical outcomes can be expected for every patients.