Minimally invasive techniques in hepatobiliary surgery

  Minimally invasive techniques as a mature technology in modern surgery have been widely practiced in the field of surgery. One of the distinctive features of lumpectomy is that it is minimally invasive and reduces surgical trauma to a great extent, especially in the surgical approach. The lumpectomy technique is based on the use of an endoscope to visualize the internal structures of the body and to perform surgical operations with “extended” instruments. In general, the lumpectomy is a more detailed and more delicate operation than the conventional one. However, because of the difficulty in performing more difficult operations with instruments, laparoscopic surgery tends to be more “simple” or simplified.  Laparoscopic cholecystectomy is the most used procedure in hepatobiliary surgery, and it is widely accepted and considered as the “gold standard” for gallbladder removal, and there is no objection to laparoscopic cholecystectomy for the surgical treatment of gallbladder stones in non-special cases.  In patients with gallbladder stones combined with common bile duct stones, there are two options: one is to treat both gallbladder stones and bile duct stones together through a single laparoscopy; the other is to do ERCP bile duct extraction before laparoscopic cholecystectomy. These two methods have their advantages and disadvantages. The benefits of using laparoscopic choledochotomy for stone extraction can combine two surgeries into one, which largely reduces the patient’s pain.  The laparoscopic choledochotomy requires a T-tube as well as conventional choledochotomy, and the patient needs to be discharged with a T-tube after the operation, and the T-tube needs to be removed again with a long interval, which is inconvenient for the patient. For the method of preoperative ERCP and sphincterotomy for stone extraction and later laparoscopic cholecystectomy, the patient can be discharged soon after surgery to shorten the hospital stay, and there is no need to discharge with T-tube, which has fast recovery and short hospital stay, and there is no risk of T-tube dislodgement, common bile duct stricture, cholangitis, etc. after discharge with T-tube, which reduces the chance of recurrence of gallstone. However, the general trend nowadays tends to favor the treatment of common bile duct stones by minimally invasive ERCP before laparoscopic cholecystectomy.  Laparoscopic surgery on the liver mainly refers to laparoscopic partial hepatectomy and radiofrequency ablation treatment of tumors. Radiofrequency thermal ablation is a minimally invasive tumor in situ treatment technique, which generates high temperature in local tissues of lesions through radiofrequency energy, drying and eventually coagulating and inactivating soft tissues and tumors. The principle is that when the electron generator generates radiofrequency current, it generates high speed ionic vibration and friction in the surrounding tissues through the electrode needle, which is then converted into heat energy and transmitted outward with time, thus causing local tissue thermal coagulation necrosis and denaturation. The present technique of radiofrequency ablation using a single electrode needle can produce coagulated necrotic foci up to 5 cm in diameter.  In clinical observation there are excellent results in treating liver tumors with radiofrequency ablation, and the survival rates at 1, 2, 3 and 5 years after treatment have been reported to be 94%, 86%, 68% and 40% respectively in treating liver malignancies, and this effect approximates the effect of radical surgical resection. Nowadays, radiofrequency thermal ablation is a very promising tumor treatment method, and better results will be obtained if the liver tumors around the liver are directly ablated by radiofrequency thermal ablation under television surveillance using minimally invasive laparoscopic techniques.  In conclusion, the variety of minimally invasive procedures in the field of hepatobiliary surgery will continue to increase, and as the technology continues to improve, more complex procedures can be accomplished through minimally invasive techniques.