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Robotic hepatopancreatic surgery 139
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al. Robot-assisted
140 Chapter 8
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CHAPTER 9
Enhanced recovery after
hepatopancreatobiliary surgery
David Fuks,1Thomas A. Aloia,2and Brice Gayet
1
Department of Digestive Diseases, Institut Mutualiste Montsouris, Paris, France
2
Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, USA
EDITOR COMMENT
In this chapter, the authors provide an overview of the available evidence regarding enhanced recovery after hepatopancreatobiliary
surgery. They remind us that optimal recovery for the major procedures we perform in liver and pancreas surgery begins prior to surgery.
Meticulous patient selection and optimization of medical comorbidities are key contributors to the goals of any fast-track program,
shortening length of stay while lowering perioperative morbidity. During surgery, the surgeon must strive for a transfusion rate of zero,
while communicating clearly with the anesthesia team regarding fluid, pain, and analgesic management. While the results of published
literature on enhanced and fast-track recovery programs can be difficult to interpret because of variations in protocol adherence,
uncontrolled confounders, and nonweighted composite outcome measures, a programmatic approach to optimizing recovery is
important. In addition to programmatic policies of early enteral nutrition, early mobilization, and restrictive transfusion policies, excellent
communication among the patient, family, nursing, anesthesia, and surgery staff is critical for ensuring optimal recovery with faster
discharge. As advanced laparoscopic hepatopancreatobiliary surgeons, we must remind ourselves that low complication rate is the most
important component in earlier discharge.
Keywords: enhanced recovery after hepatic surgery, enhanced recovery after hepatopancreatobiliary surgery, enhanced recovery
after pancreas surgery, fast-track surgery, length of stay
9.1 Introduction
Major abdominal surgical procedures such as hepatic or
pancreatic resections cause a considerable surgical stress
reaction and derangements in metabolic and cardiopulmonary function [1,2]. In past decades, advances in
diagnostic and surgical techniques and improved anesthetic/intensive care management have led to better outcomes after both liver and pancreatic resections. Mortality
for the most common liver and pancreatic resection has
been reported to be consistently below 5% in specialized
centers [3,4]. However, morbidity, especially for pancreatic surgery, remains high at a rate of 40–60% [3,4].
Complications, such as anastomotic leak, hemorrhage,
biliary and pancreatic fistula, delayed gastric emptying
1
(DGE), and intra-abdominal abscess, are the main reasons
for delayed recovery and frequently require additional
percutaneous or surgical interventions.
In the past decade, fast-track surgery protocols
have been used for various types of surgery, to attenuate
the stress response to surgical trauma and improve
recovery, thereby decreasing postoperative complications
and postoperative length of stay (LOS) [5]. The intention
is to prevent complications associated with an exaggerated inflammatory reaction to surgery, such as poor
healing, infections, and organ dysfunction [6]. Fast-track
surgery incorporating intensive optimization of early
patient mobility, intestinal function, and analgesia [7]
contributes to expediting recovery and minimizing
morbidity [8].
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
141
142 Chapter 9
Table 9.1 Elements included in the fast-track programme applicable to both liver and pancreatic surgery.
Evidence-based factors Probably useful factors
No oral bowel preparation Preoperative counseling
Preoperative feeding: carbohydrate loading up to 2 h before surgery Provision of intravenous analgesia
No preanaesthetic medication Stimulation of bowel movement with laxatives
Antithrombotic prophylaxis Early and scheduled mobilization
Single-dose antibiotics Audit
Epidural analgesia
Prevention of postoperative nausea and vomiting
Avoidance of hypothermia
No routine drainage of peritoneal cavity
Preoperative biliary drainage if total bilirubinemia >250 μmol/L
No postoperative nasogastric intubation
Optimized fluid balance
Removal of urinary catheter on day 1
Normal food at will after surgery from day 1
∗
Specific to liver surgery.
∗∗
Specific to pancreas surgery.
∗
∗∗
Fast-track surgery protocols have gained ground
quickly because of the associated cost efficiency derived
from the reduction in LOS, an important issue in today’s
context of rapidly increasing healthcare costs and the
consequent need for optimization. Studies showing
fast-track surgery protocols that reduce LOS and morbidity rates and improved patient satisfaction have been
published for vascular [9], orthopedic [10], gynecological [11], breast [12], bariatric [13], and prostate
surgery [14], as well as other forms of abdominal (including major) surgery [15]. However, although fast-track
surgery protocols have also been implemented in hepatopancreatobiliary (HPB) surgery, their widespread
acceptance remains limited. A summary of fast-track
protocols applicable to both liver and pancreas surgery
is detailed in Table 9.1.
9.2 Fast-track liver surgery
Liver resection is associated with specific postoperative
changes which need to be recognized when optimizing
outcomes of patients following liver surgery. The surgical
outcomes of liver resection are largely dependent on the
complexity of the procedure and the host liver function.
To maximize the potential benefit of fast-track liver surgery programs, future research needs to aim at establishing perioperative care plans specific to liver surgery. We
have identified a total of 257 relevant articles on fast-track
liver surgery. These include studies investigating outcomes of open hepatic surgery, including two randomized
controlled trials (RCTs) [16,17], two prospective cohort
studies [18,19], one retrospective cohort study [20], and
two case-control studies [21,22].
The two case–control trials compared outcomes of fast-
track surgery protocols with those of conventional care
after laparoscopic surgery [23,24]. As expected, fast-track
surgery programs in those two studies reduced LOS, a
result seen in all studies on fast-track surgery in open liver
resection. However, fast-track programs have the ability to
reduce not only LOS but also complication rates. Similar to
the colorectal literature [5], in hepatic surgery, fast-track
programs reduced complication rates: a meta-analysis of
two published RCTs [16,17] shows a reduction in overall
complication rates. This reduction was not reproduced in
non-RCT studies, though this may be due to selection bias
or to the methodology of those particular protocols. In the
randomized series reported by Ni et al. [17], the selected
population was particularly young and fit, and it is possible
that better general health in the study populations leads to
no difference between fast-track and conventional care
with respect to complication rate [16,17].
Compliance with fast-track protocols is an additional
factor that has been examined in several studies. Compliance with a fast-track program incorporating 19 components was exceptionally high in the series published by
Jones et al. [16]. While only three trials commented on
adherence to the protocol, higher rates of compliance are
Enhanced recovery after hepatopancreatobiliary surgery 143
associated with reduced LOS. Further, low compliance is
associated with higher readmission rates [16,18,22].
Compliance with fast-track programs is clearly an area
which has potential to increase the efficacy of fast-track
liver surgery protocols.
Although the rates of general complications were
reduced in the two RCTs, no difference in liver-specific
surgical complications was observed. Liver resection
offers a unique set of postoperative circumstances as a
result of liver regeneration, the anatomical complexity of
biliary drainage and intraoperative vascular inflow control, and the transient impairment of liver function following resection [25]. It is therefore not surprising that a
fast-track surgery approach does not reduce liver-specific
complications. However, while fast-track surgery protocols focus on general pre- and postoperative considerations, the liver surgeon must not forget to optimize
intraoperative care for best possible outcome. For example, minimizing blood loss is one area that may reduce
liver-specific surgical complications [26–28].
Overload of salt and free water, as well as hypovolemia
in the perioperative period, all increase postoperative
complication rates [29], suggesting that near-zero fluid
balance should be achieved around the time of surgery.
Determining the correct amount required is complicated
by the use of epidural anesthesia as it causes vasodilatation and intravascular depletion with hypotension,
often treated with fluid resuscitation. This may result in
the administration of unnecessary and large volumes of
fluid [30]. Importantly, elevated central venous pressure
(CVP) has been shown to be associated with intraoperative blood loss during liver resection [31]. Six of the nine
trials included a carecomponent based on the reduction of
intraoperative fluid, but only two [21,22] commented on
titration of intravenous fluid according to CVP. Jones et al.
used goal-directed fluid therapy guided by cardiac output
monitoring to prevent fluid overload, although they only
monitored this in the early postoperative period [16].
Since the successful report of the first laparoscopic liver
wedge resection in 1991 [32], laparoscopic liver resection
has progressively gained popularity. For minor liver resections, comparative studies of open and laparoscopic procedures have shown that laparoscopic liver resection resulted
in decreased intraoperative bleeding, fewer complications,
and shorter postoperative hospital stays [33–37]. Over the
last few years, technological and instrumental improvements have resulted in several centers reporting better
hemostasis during laparoscopic liver resection [38–41].
Fast-track surgery protocols in liver surgery should
incorporate preoperative, intraoperative, and postoperative components to maximize their benefits. Interestingly, use of a thoracic epidural was not explored in
any of the studies. Although a thoracic epidural is recommended in fast-track surgery in the context of colorectal
surgery [42], its use has been questioned in liver surgery [43]. There is conflicting evidence regarding the
impact of epidurals on recovery in liver surgery, and
this continues to be an active area of investigation [44,45].
Further evaluation of analgesia in liver surgery within the
context of a fast-track surgery program is required to
establish optimal practice. Indeed, paracetamol (acetaminophen) is routinely utilized as the backbone of
analgesic regimens [46,47], but in major hepatic resections it is often withheld for fear of inducing liver damage,
which increases opiate requirements.
In summary, the level I evidence investigating fasttrack surgery protocols following liver surgery is limited
and only two RCTS have been conducted. Fast track liver
surgery programs seem to reduce complication rates,
although surgical morbidity remains high and is currently
unaffected by fast-track surgery protocols following liver
surgery. Postoperative LOS is reduced in the context of
fast-track surgery in comparison with conventional care
(Table 9.2). Future research should concentrate on perioperative care components specific to liver surgery, such
as optimal analgesic regimens and intraoperative manipulations to reduce blood loss, rather than simply transferring fast-track concepts from colorectal to liver surgery.
9.3 Fast-track pancreas surgery
Most series focusing on fast-track surgery in pancreatic
surgery concern pancreatoduodenectomy (PD). No RCTs
have been conducted in pancreatic surgery. This is probably due to the fact that RCTs are difficult to organize for
multimodal recovery programs under greatly varying
conditions (according to the complexity of liver resection). Problems are likely to be encountered with blinding
when various interventions and professionals are
involved. The incidence of specific complications, such
as DGE and pancreatic fistula, tended to be lower in the
fast-track surgery group, but meta-analysis in patients
undergoing PD did not show statistically significant differences [48,49]. The included studies were either retrospective or prospective case series, or comparative studies
144 Chapter 9
Table 9.2 Postoperative outcomes after implementation of a clinical pathway in liver surgery.
Study Length of stay Morbidity % Mortality % Readmissions %
Study vs control Study vs control Study vs control Study vs control
group group group group
Lin et al. 2011 [21] 7 vs 11 days
Hendry et al. 2010 [62] 3 vs 5 days
Stoot et al. 2009 [24] 5 vs 7 days 15 vs 15% 0 vs 0% 0 vs 0%
Koea et al. 2009 [44] 4 vs 6 days 19 0 4
Van Dam et al. 2008 [22] 6 vs 8 days
MacKay & O ’Dwyer 4 days (2–7) 17 0 0
2008 [63]
∗
Significant difference.
∗
∗
∗
46 vs 43% 1.8 vs 1.6% 7 vs 3%
17 2 5
41 vs 31% 0 vs 2% 13 vs 10%
based on historical controls. Indeed, there seemed to be
little replication of methodology in the studies examined.
Individual studies used different study protocols incorporating a variety of elements, and some protocols may have
included elements that are more conservative than
others. For example, postoperative feeding started from
postoperative days 1–2 in some studies [50,51], whereas
other studies began with liquid intake with a gradual
increase from clear to full liquids and solid food from
days 3–4 [52–57]. Unfortunately, it is still unclear which
elements are important in perioperative care in pancreatic resections, and therefore we cannot draw definitive
conclusions as to the precise benefit of fast-track programs
in pancreas surgery.
Similar to liver fast-track programs, most studies on
pancreatic fast-track surgery do not investigate compliance with the protocol. Therefore, it remains unclear
what the actual measurable difference in perioperative
Table 9.3 Postoperative outcomes after implementation of a clinical pathway in pancreatic surgery.
Study Length of stay Morbidity % Mortality % Readmissions %
Study vs control Study vs control Study vs control Study vs control
group group group group
care between study and control group is. Policies to
improve postoperative protocol adherence, in particular,
should be considered. For instance, reorganization of
surgical wards and continuous education of nurses and
staff [58] may provide helpful information on which
portions of a fast-track program have improved outcomes. A study by Ahmed et al. showed that an overall
protocol compliance of 77% compared with 88% compliance in patients participating in a clinical trial does not
negatively affect outcome [59].
The consistency between criteria defining minor and
major complications after pancreatic surgery in the
included studies is also limited. Only one study reported
complications according to a validated classification
scheme (Clavien–Dindo classification) [60]. Therefore,
comparing morbidity between different centers is difficult, as shown by the variations in leakage rates ranging
from 2% to 62% (Table 9.3). A suggestion would be to use
Robertson et al. 2012 [56] 10 days (8–17) 46% 4% 4%
Di Sebastiano et al. 2011 [51] 10 days (6–69) 39% 2.7% 6%
Kennedy et al. 2009 [57] 7 vs 10 days
Balzano et al. 2008 [54] 13 vs 15 days
Berberat et al. 2007 [52] 10 days (4–115) 25% 2% 3%
Vanounou et al. 2007 [53] 8 vs 8 days 54 vs 62% 1.4 vs 1.6% 9 vs 6%
Kennedy et al. 2007 [55] 7 vs 13 days ∗ 37 vs 44% 1.1 vs 2.3% 8 vs 7%
Porter et al. 2000 [64] 13 vs 16 days
∗
Significant difference.
∗
∗
∗
16 vs 37% 1.1 vs 2.3% 7 vs 25%
47 vs 59%
24 vs 20% 1 vs 3% 9 vs 10%
∗
3.6 vs 2.8% 7 vs 6%
∗
Enhanced recovery after hepatopancreatobiliary surgery 145
a composite endpoint [61], which would reduce the
required sample sizes for studies and improve objectivity
and comparability.
In a meta-analysis of fast-track programs for pancreas
surgery, readmission rates were not significantly higher
in the fast-track surgery group. One s tudy reported a
nonsignificant 1% higher mortality rate in the fasttrack surgery group [54]. Also, in a meta-analysis of
the four studies addressing PDs, mortality was not
significantly different. Additionally, hospital costs
were si gnificantly lower in three of the four studies
that reported a cost-effectiveness analysis. As for liver
surgery, few data on functional recovery or predefined
discharge criteria were available, and accordingly, no
conclusion could be drawn.
In summary, although the available evidence is still
limited, implementation of a fast-track surgery program
in pancreatic resections, particularly PD, is feasible. Such
programs may contribute to a shorter hospital stay and do
not seem to compromise outcome measures, such as
morbidity, mortality, and readmissions. Future studies
should report on predefined discharge criteria and time to
functional recovery to assess whether postoperative
recovery is in fact accelerated.
KEY POINTS
• Recognition of specific postoperative changes is associated with optimal outcomes for patients following liver resection.
Outcomes are largely dependent on complexity of the procedure and the host liver function.
• Fast-track programs have the ability to reduce LOS and complication rates. Future research in establishing perioperative care
plans specific to liver surgery can help maximize the potential benefit of fast-track programs.
• Fast-track surgery protocols in liver surgery should incorporate preoperative, intraoperative, and postoperative components.
• Most studies on pancreatic fast-track surgery have not investigated compliance with protocol. Policies to improve postoperative
protocol adherence should be considered.
• Although available evidence is limited, a fast-track surgery program in pancreatic resections, particularly PD, is feasible. It may
contribute to shorter hospital stay without compromising morbidity, mortality, and readmissions.
• Future studies should report predefined discharge criteria and time to functional recovery to assess whether postoperative
recovery is in fact accelerated.
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SECTION 2 Advanced laparoscopic hepatobiliary surgery
CHAPTER 10
Relevant hepatobiliary anatomy
Tadatoshi Takayama,1Masatoshi Makuuchi,2and Kimitaka Kogure
1
Department of Digestive Surgery, Nihon University School of Medicine, Tokyo, Japan
2
Department of Hepato-Biliary-Pancreatic Surgery, Japanese Red Cross Medical Center, Tokyo, Japan
3
Institute for Molecular and Cellular Regulation, Gunma University, Maebashi, Japan
EDITOR COMMENT
This chapter, by world-renowned and pioneering liver surgeons, allows the reader to obtain an important in-depth understanding of liver
anatomy. This level of understanding of liver anatomy is the basis for performing advanced laparoscopic liver surgery as shown in the
video atlas portion. The chapter details anatomical classifications by Couinaud, Healey, and Schroy and the results of the Brisbane
consensus conference on anatomical classification. The authors further detail the anatomy of each liver segment, including a thorough
historical and in-depth account of the special anatomy of segment I. This chapter summarizes essential surgical landmarks that should be
used in anatomical liver resection. Beautiful anatomical sketches and intraoperative pictures will allow in-depth comprehension of liver
anatomy as we know it today.
Keywords: anatomical liver resection, bile duct anatomy, Brisbane classification, Couinaud classification, Healey classification, hepatic
artery anatomy, hepatic vein anatomy, liver segmental resection, caudate lobe (segment I), portal vein anatomy
10.1 Introduction
sound devices. This allowed any of Couinaud’sseg-
3
ments to be removed anatomically [3,4]. The technical
Since the 1950s, our developing understanding of the
surgical anatomy of the liver has enabled safe resection
of hepatic malignancy [1]. A major breakthrough was
the segmental anatomy proposed by Couinaud (1954),
who divided the liver into eight segments based on the
map of the portal vein [2]. The modern era of liver
resection bl ossomed from this anatomical revolution,
shifting from an inabi lity to refer ence vasculature during surgery to maj or resection following anatomical
planes. The credit for the first anatomical right hepatectomy with preliminary hilar ligation belongs to Lortat-Jacob (1952) in France [1]. In 1985, Makuuchi
developed a systematic approach to segmentectomy
through the implementation of intraoperative ultra-
revolution of intraoperative ultrasound has allowed
liver resection to become a potential cure for malig-
nancies; it is now performed at high-volume centers
worldwide, with low morbidity and mortality [5–7]. It
is also the basis for a more recent development, lapa-
roscopic liver resection, which in skillful hands is an
alternative to open surgery in selected cases [8,9].
In this chapter, we outline the relevant hepatobiliary
anatomy that forms the basis for advanced laparoscopic
liver resections, which requires precise knowledge of
hepatic division, vascular structures, and surgical landmarks. A clear understanding of these aspects of liver
anatomy enables advanced laparoscopic and open liver
resections to be performed safely.
Laparoscopic Liver, Pancreas, and Biliary Surgery: Textbook and Illustrated Video Atlas, First Edition.
Edited by Claudius Conrad and Brice Gayet.
© 2017 John Wiley & Sons, Ltd. Published 2017 by John Wiley & Sons, Ltd.
148
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