Novel perspectives in liver surgery Embracing innovation to optimize clinical outcomes

The current thesis reports novel evidence on the efficacy of several innovations in liver surgery. Based on the currently available evidence, an additional liver MRI leads to a change in the local treatment plan in nearly one fourth of the patients that have been deemed eligible for local treatment of their colorectal liver metastases based on CT. There is substantial variability in the surgical management of patients with synchronous colorectal liver metastases. In selected patients with limited liver disease, simultaneous resections of the primary colorectal cancer and liver metastases appear safe and can offer benefits. Nevertheless, the currently available evidence mainly consists of low-quality studies, demonstrating a need for randomized controlled trials such as the LIVACOR trial. It was demonstrated that laparoscopic liver surgery offers perioperative benefits over open surgery in elderly and obese patients and patients affected by benign liver tumors, although the textbook outcome rates in the latter patient population did not improve during the implementation phase of laparoscopy. Laparoscopic liver surgery also appears to offer some perioperative benefits, in centres with the appropriate expertise, when adopted for technically complex procedures such as right hemi hepatectomies after portal vein embolization or resections in the posterosuperior segments. Robotic liver surgery, compared to laparoscopic liver surgery, mainly seems to offer benefits intraoperatively, and lowers the need to convert to an open procedure. Concludingly, marked variability was noted in American Society of Anesthesiologists scoring of patients affected by Hepato-Pancreato-Biliary diseases among 1283 surgeons and anesthesiologists from 55 countries.