Resection of Liver Tumor With Vascular Contact. A Difficult Liver Surgery With Bleeding Risk. Why Liver Surgery Must be Done By An Expert Surgeon?
Liver surgery is the only curative treatment for many primary and metastatic liver cancers. Many studies had shown clinical advantages of minimally invasive surgery when compared to traditional open method, such as less blood loss, lower postoperative complications, less pain, higher precisions in microanatomical dissection, and less wound-related infection/reoperation. In 2024, the operative technique of choice is via minimally invasive robotic approach to minimize chance of ‘unplanned crash’ conversion often seen in laparoscopic method, while keeping all the benefits of minimally invasive surgery with robotic surgery. With constant development and refinements of robotic surgical systems, the outcomes (including long-term survivals) are expected to further improve. As chemotherapy and immunotherapy continue to improve and become more effective, the cure for cancer is becoming a reality under a comprehensive multidisciplinary team approach.
While difficulty in liver resection is widely variable based on tumor location, size, quality of liver tissue, proximity to major vessels, patient’s body weight, and several other factors, the consumers (patients) often did not spend enough time to research for their surgeons. Tumor resection in caudate lobe with contact with vena cava (the largest vessel in the body) is a technically very complex operation, much more difficult than resection of a 3cm tumor located peripherally in segment 6. In the current era of minimally invasive surgery, more than 90% of surgeons consider this type of resection can only be done via an open approach. Part of the reason of choosing the open approach is concern of massive bleeding from the vena cava during the tumor dissection. Bleeding from the vena cava can quickly become catastrophic and lethal. Emergent control of the vena cava is often technically challenging to obtain due to difficulty in placing vascular clamps while bleeding occurs. Only very selected centers in the United States are experienced enough to safely handle this kind of operation using robotic approach. More than 200 robotic liver resections are needed to overcome learning curve in complex liver tumor resection, otherwise an unsafe operation takes place.
In the recent month, Dr Sucandy and his team in Tampa published their technical approaches for liver resection in cases of tumor contact with the vena cava [1]. This is a continuation of their prior publication on outcomes of liver surgery for tumor in difficult segments (segment 1,7,8,4A) [2]. The current study was published in a very prestigious journal in cancer surgery, called Annals of Surgical Oncology. Dr Sucandy in his multimedia video demonstrated how to dissect a caudate tumor off of the vena cava wall without causing major bleeding. He also showed how to partially resect the vena cava itself using a vascular stapler without having to convert the operation to an open technique. Most surgeons are unable to do this step without converting to open. This video was also invited for an oral podium presentation at the American College of Surgeon’s Annual Clinical Congress in 2024.
It is crucial to see a liver surgeon with extensive experience in liver surgery to be able to also handle difficult cases, not only the simple ones. When robotic surgery is desired as known as the best way of removing liver tumors, the liver surgeon must be experienced in this type of digital surgery for at least five years. In the past 10 years, Dr Sucandy and his team have performed more than 1000 liver surgeries, almost 700 of them were robotic liver resections. This type of team can deliver the safest short and long-term outcomes with the lowest chance of postoperative complications, even though this means that the patient may need to travel by car, train, or planes to come to Tampa Florida. Tumors located in close proximity to major vessels need a seasoned robotic surgeon and this is when ‘experience matters the most’.
