The history of liver surgery: Achievements over the past 50 years

Abstract

We reviewed the progress made in the field of liver surgery over the past 50 years. The widespread use and improved outcomes of the hepatectomy were, primarily, due to pioneer surgeons who were responsible for technological advances and rapid improvements in the safety of the procedure in the last century. These advances included the hepatic functional evaluation used to determine the safety limit of liver resections, the introduction of intraoperative ultrasonography, and the development of innovative techniques such as portal vein embolization to increase the remnant liver volume. Cadaveric liver transplantation has been attempted since 1963. However, the clinical outcomes only began improving and becoming acceptable in the 1970s-1980s due to refinements in technology and the development of new immunosuppressants. Partial liver transplantation from living donors, which was first attempted in 1988, required further technological innovation and sophisticated perioperative management plans. Moreover, these developments allowed for further overall improvements to take place in the field of liver surgery. Since the turn of the century, advances in computation and imaging technology have made it possible for safer and more elaborate surgeries to be performed. In Japan, preoperative 3-dimensional simulation technology has been covered by health insurance since 2012 and is now widely used. An urgent need for real-time navigation tools will develop in the future. Indocyanine green (ICG) fluorescence imaging was first used in 2007 and has led to the creation of a new surgical concept known as fluorescence navigation surgery. Laparoscopic surgery and robotic surgery have solved the issue of large incisions, which used to be a major drawback of open liver surgery; however, further improvements are required in order to achieve the level of safety and accuracy observed during open liver resection when performing all minimally invasive procedures. In the near future, liver surgery will become more precise and less invasive due to substantial progress including the development of navigation surgery, cancer imaging, and minimally invasive surgery. This overview of the history of liver surgery over the past 50 years may provide useful insights for further innovation in the next 50 years.

Figure 1

Variations in hepatectomy‐related mortality, according to data from a nationwide follow‐up study conducted by the Liver Cancer Study Group of Japan. In Japan, surgery‐related mortality after liver cancer resection exceeded 15% in the 1970s, but decreased rapidly in the 1980s and reached a level as low as approximately 1% in the late 1990s13

Figure 2

The Makuuchi Criteria for the safety limit of liver resection (cited from Ref. 14 with modification)

Figure 3

Safe hepatic lobectomy using portal vein embolization for the treatment of multiple liver metastases

Figure 4

Typical case of liver navigation. In this patient, the treatment plan consisted of anatomic resection of the dorsal and ventral parts of S8 for the treatment of a small HCC

Figure 5

Typical case of ICG‐positive hepatocellular carcinoma. The fluorescence camera (B: black‐and‐white mode, C: green overlay mode) reveals the presence of a small HCC lesion directly under the surface of the liver, which is impossible to recognize with the naked eye (A)

Figure 6

ICG staining of hepatic segments. In this case, trace amounts of ICG is injected intraoperatively with ultrasound guidance into the portal vein branch, which perfuses the hepatic segment next to the one containing the tumor. The stained area is displayed with green fluorescence, and the boundaries between the hepatic segments are clearly visible