Current status and future perspective of laparoscopic surgery in hepatobiliary disease

Abstract

Recent advances in minimally invasive surgery include laparoscopic and robotic surgery. These surgical techniques have changed the paradigm of surgical treatment for hepatobiliary diseases. Minimally invasive surgery has the advantages of minimal wound extension for cosmetic effect, early postoperative recovery, and few postoperative complications in patients. For laparoscopic liver resection, the indications have been expanded and oncological outcome was proven to be similar with open surgery in the malignant disease. Laparoscopic cholecystectomy is a classical operation for benign gallbladder diseases and the effort to decrease the surgical wound resulted to perform single incision laparoscopic cholecystectomy. For choledochal cyst, laparoscopic surgery is applied gradually despite of the difficulties associated with anastomosis, and robotic surgery for hepatobiliary disease is also performed for more minimally invasive surgery; however, while admitting the advantage of robotic surgery, robotic technology should be improved for development of more convenient and cheaper instrument and continuous efforts to enhance surgical technique to overcome long operation is necessary. In this review, the status and future perspectives of minimally invasive surgery for hepatobiliary diseases are summarized and discussed.

Introduction

Recent advances in minimally invasive surgery have changed the paradigm of abdominal surgery. Since the 1990s, laparoscopic surgery has become the treatment of choice for cholecystectomy [[1], [2], [3]]. Moreover, laparoscopic liver resection has shown satisfactory oncological and surgical outcomes and has witnessed major technical advances such as the use of robotic surgery [[4], [5], [6], [7], [8]]. Single‐incision laparoscopic surgery is considered a type of minimally invasive surgery, given its feasibility and safety [[9], [10], [11]].

Minimally invasive surgery has the advantages of minimal wound extension for cosmetic effect, early postoperative recovery, and few postoperative complications in patients [[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]]. Several studies have reported the superiority of laparoscopic surgery in terms of immunological aspects [[12], [13], [14]].

Although surgical innovations have accomplished formidable change of operation technique during past 2 decades, limitations to be overcome still remain and might be a challenge to surgeons and surgical technology.

The aim of this review is to focus on the current practice of laparoscopic and robotic surgery and predict the future perspective of minimally invasive surgery for hepatobiliary disease. This review is composed of five parts: (1) laparoscopic liver resection; (2) robotic liver resection; (3) laparoscopic and robotic cholecystectomy; (4) laparoscopic and robotic surgery for choledochal cyst; and (5) laparoscopic common bile duct exploration.

Laparoscopic liver resection

Feasibility and indications for laparoscopic liver resection

The scope of laparoscopic liver resection has widened considerably in the past 2 decades [[15], [16]]. Although laparoscopic hepatectomy was initially used for resection of small and superficial lesions, laparoscopic left lateral sectionectomy has become a standard operation [17]. Recently, more complex liver surgery has performed from the segmentectomy, sectionectomy to hemihepatectomy [[5], [18], [19], [20]]. Many laparoscopic liver surgeons have emphasized the merits and feasibility of laparoscopic hepatectomy [[5], [6], [7], [20]].

In the first consensus conference on laparoscopic liver surgery held in Louisville, KY, USA in 2008, the terminology and indications for laparoscopic hepatectomy were described [17]. The following three techniques can be used to perform laparoscopic liver resection: pure laparoscopy, hand‐assisted laparoscopy, and the hybrid technique. In pure laparoscopy, the entire operation is performed through laparoscopic ports. Hand‐assisted laparoscopy includes the elective placement of a hand port for facilitating the operation. In the hybrid technique, a pure laparoscopic or hand‐assisted procedure is used, but resection is performed through a mini‐laparotomy incision. The best indication for laparoscopic liver resection is solitary lesions of ≤ 5 cm located in the peripheral liver segments. Laparoscopic left lateral sectionectomy should be considered as the standard treatment (Figure 1A) [17].

Figure 1.

(A) Laparoscopic and (B) robotic left lateral sectionectomy.

In the second international consensus conference on laparoscopic liver resection held in 2014, expert recommendations were made on the basis of literature reviews and presentations [21]. Major laparoscopic liver resection including three or more segments of liver was defined as an innovative procedure, still in an exploration or learning phase of development of procedure with incomplete defined risk according to the Balliol classification of Innovation, Development, Exploration, Assessment, and Long‐term study (the IDEAL model) [[21], [22]]. Minor liver resection, defined as the resection of one or two liver segments, is regarded as a standard surgical treatment but is still in the assessment phase of development according to the Balliol classification of IDEAL [[21], [22]]. Most studies on laparoscopic liver resection have been observational studies with low‐quality evidence.

In technical aspects, the main conceptual change in laparoscopic liver resection is the caudal approach, which offers improved exposure around the vena cava and facilitates identification of the Glissonian pedicle at the hilar plate [23]. Moreover, the laparoscopic view facilitates the caudal–cranial transection of the hepatic parenchyma, allowing better identification of vascular structures. The anterior approach, which has been described for liver parenchymal transection before right liver mobilization, was described by Belghiti et al. [24].

In the 1990s, laparoscopic liver surgery was performed for left‐sided and right‐peripheral lesions requiring limited resection [4]. Generally, laparoscopic hepatectomy has been limited to patients with tumors (≤ 5 cm) located in the peripheral liver segments (segments, 2–6) [17]. In a review of laparoscopic liver resection in 2804 patients, the most common type of resection was wedge resection or segmentectomy (45%), followed by left lateral sectionectomy (20%), right hepatectomy (9%), and left hepatectomy (7%) [25]. In a study comparing the surgical outcomes of laparoscopic liver resection for posterosuperior and anterolateral segments, the operative time and blood loss, intraoperative accidents, and postoperative outcomes did not significantly differ between the two study groups, thus showing the feasibility of laparoscopic liver resection for tumors located in the posterosuperior segments after appropriate adjustment of surgical techniques and optimal patient positioning [18]. Cho and Han [20] reported their experiences with laparoscopic right posterior sectionectomy and suggested that this procedure was feasible when performed by experienced surgeons and that further efforts are necessary to reduce the operative time, because the mean operative time for this technique was 567 minutes.

Regarding the tumor size, several authors have reported that a laparoscopic approach for hepatocellular tumors > 5 cm produces similar operative and postoperative outcomes to that for tumors < 5 cm [26]. Moreover, a comparison of the surgical outcomes between single and multiple hepatocellular carcinoma groups revealed that use of laparoscopic surgery in the multiple lesion group did not increase the operative time, intraoperative transfusion rate, length of hospital stay, or postoperative complications [27]. Several authors have compared the surgical outcomes of repeat laparoscopic liver resection in patients who had recurrent tumors and had undergone previous laparoscopic surgery and those who had undergone previous open surgery [28]. They found that patients who had undergone previous open liver resection had more blood loss and transfusion requirements. However, the operative time, length of hospital stay, and complication rate did not significantly differ between the two groups, suggesting that laparoscopic repeat hepatectomy can be performed safely with good results [28]. For limitation of age, laparoscopic major hepatectomy for colorectal liver metastasis might be performed safely in elderly patients with similar operative and postoperative surgical outcomes, suggesting that age should not be a contraindication for laparoscopic major hepatectomy [29]. Therefore, the indication and application of laparoscopic liver resection will be expanded by the enhancement of surgical skill, development of innovative technology, better support of anesthesiology and precise preoperative planning and postoperative care.

Immediate postoperative and long‐term outcomes

In a review of 2804 patients from 127 published studies on laparoscopic liver resection, Nguyen et al [25] revealed that in experienced hands, laparoscopic hepatectomy is a safe procedure with acceptable morbidity and mortality rates for both minor and major hepatic resections. In this review, the complication rates ranged from 0% to 50%, and 295 complications (10.5%) and nine postoperative deaths (0.3% mortality) occurred in the 2804 laparoscopic liver resection patients. As shown in Table 1, the mortality rates ranged from 0% to 1.6%, and the complication rates ranged from 0% to 34.8% [[5], [6], [7], [18], [30], [31], [32], [33], [34], [35]]. In a multicenter study performed in 12 medical centers in Korea, postoperative complications occurred in 53 patients (20.0%) and postoperative mortality occurred in two patients (0.75%) among 1009 laparoscopic liver resection patients [36]. In another study, Nomi et al [37] concluded that simultaneous radiofrequency ablation, intraoperative blood transfusion, and bilobar resection were significant risk factors for complications after laparoscopic major hepatectomy.

Table 1.

Clinical outcomes of laparoscopic liver resection.

First author [Ref]	Year	No	Major resection	Minor resection	Operative time (min)	Complication rate (%)	Mortality (%)	Benign disease	Malignant disease	Hospital stay (d)
Abu Hilal [30]	2012	133	42	91	210 (30–480)	13	0.8	0	133	4 (1–15)
Topal [5]	2012	20	17	3	257.5 (75–360)	35	0	0	20	8 (5–51)
Nguyen [6]	2011	314	47	267	196 (53–540)			206	108	3 (1–7)
Kazaryan [18]	2011	75	0	75	127 (50–336)	5.3	0	0	75	2
Chen [7]	2008	116	≥ 2 seg; 19	< 2 seg; 97	Mj: 176 ± 57	Mj; 5.2	0	0	116	6
					Mn: 152±336	Mn; 6.2
Cai [31]	2008	31	3	28	140 (60–380)	0	0	0	31	7.5 (5–15)
Buell [35]	2008	253	≥ 2 seg; 175	< 2 seg; 78	162	16	1.6	147	106	2.9
Koffron [32]	2007	300	119	181	99	9.3	0	197	103	1.9
Dagher [33]	2007	70	19	51	227±109	16	1.4	32	38	5.9
Vibert [34]	2005	89	38	51	Mj: 360 (180–515)	34.8	1.1	24	65	11 (3–47)
					Mn: 180 (85–390)

Data are expressed as mean ± standard deviation or median (range).

Mj = major resection; ≥ 3 segments; Mn = minor resection; < 3 segments; Ref = reference; Seg = segments.

For long‐term survival, oncological outcomes of laparoscopic liver surgery is efficient and safe in the various malignant tumors and similar oncological outcomes compared with open surgery groups [[5], [6], [7], [27], [28], [30], [31], [34]].

Laparoscopic major hepatectomy

Laparoscopic major hepatectomy has become challenging in laparoscopic hepatobiliary surgery [[19], [38], [39], [40]]. Several authors have reported laparoscopic right hepatectomy to be a standard procedure for laparoscopic resection [[19], [39], [40], [41]]. In laparoscopic right hepatectomy, parenchymal transection is usually performed using ultrasonic scalpels, bipolar cautery forceps, and staplers [[19], [39], [41]]. The Cavitron ultrasonic dissector has also been used [39], although not by some authors because of poor visualization caused by the irrigation fluid [41]. The patient is placed supine in mild reverse‐Trendelenburg position, and the operating surgeon stands between the patient's legs [41]. These conditions might facilitate laparoscopic major hepatectomy.

In an international multicenter study on 1184 laparoscopic major liver resections in 18 centers [42], the most common indication for laparoscopic right hemihepatectomy was colorectal liver metastasis (37%). The mean operative time was 291 minutes, and the conversion rate was 10%. The authors concluded that major liver resection remains a challenging procedure requiring substantial experience in both laparoscopy and liver surgery [42]. In a Korean multicenter study [36], mainly left hemihepatectomy (165 patients, 62.3%) and right hemihepatectomy (53 patients, 20.0%) were performed, and the conversion rate of laparoscopic major hepatectomy was 6.4%. The mean operative time was 399.3 ± 169.8 minutes, and the postoperative complication and mortality rates were 20.0% and 0.75%, respectively [36]. Conversion to open surgery is inevitable in some circumstances in major laparoscopic hepatectomy. Conversion in laparoscopic major hepatectomy did not increase morbidity, compared with planned open surgery [43].

To overcome the limitation of laparoscopic liver resection, a three‐dimensional visualization system gives a better depth perception than traditional two‐dimensional systems. This depth perception and hand‐eye coordination were excellent with three‐dimensional imaging system to enable accurate dissection as well as sutures and knotting. Velayutham et al [44] reported that a three‐dimensional visualization system may reduce the operation time compared to high‐definition two‐dimension. For real‐time image guidance in laparoscopic liver resection, several authors attempted an augmented reality guidance system employing intraoperative robotic C‐arm cone‐beam computed tomography (CBCT). After the acquisition of intraoperative CBCT imaging, software produced a real‐time overlay of CBCT data on the fluoroscopy, highlighting important structures in order to navigate the surgeon [45]. This is feasible and could be an option for future liver surgery [45]. A more innovative approach might facilitate the safe and accurate laparoscopic liver resection decreasing the intraoperative complication and improving surgeon's orientation with the real anatomical information.

Robotic liver resection

Laparoscopic liver surgery has inherent limitations including limited degrees of freedom for manipulation, fulcrum effect against the port, tremor amplification, awkward ergonomics, and two‐dimensional imaging adaptation [46]. The da Vinci surgical system allows three‐dimensional visualization by offering a stable camera platform, tremor filtering, EndoWrist instruments providing 7° of freedom for instrument movement, an ergonomically comfortable position for the surgeon, and the possibility of remote site surgery [47]. Previous studies have suggested the safety and feasibility of robotic hepatectomy (Table 2) [[8], [48], [49], [50], [51], [52], [53]]. The complication rate of this procedure is 7.4–43.3%, and the rate of conversion to open surgery is 0–8.6% [[8], [47], [48], [49], [50], [51], [52]]. However, the operation time is long [50]. Giulianotti et al [54] reported the surgical technique and outcomes of total robotic right hepatectomy. Extraparenchymal dissection and hepatocaval dissection were improved by the use of the robotic system. Liver parenchymal transection (Figure 1B) was performed using robotic harmonic shears, bipolar forceps, and endoscopic staplers. Conversion to open surgery occurred in one patient, the mean operation time was 337 minutes (240–480 minutes), and the morbidity rate was 25%. The authors concluded that minimally invasive surgery has a clear role in major liver resection at experienced centers and results in shorter postoperative hospital lengths of stay and minimal need for transfusion, indicating that right hepatectomy is a feasible and safe procedure when performed by an experienced surgeon [54].

Table 2.

Clinical outcomes of robotic liver surgery.

First author [Ref]	Year	No	Major resection	Minor resection	Operative time (min)	Benign disease	Malignant disease	Complication date (%)	Conversion rate (%)	Hospital stay (d)
Tsung [8]	2014	57	21 (≥ 4 seg)	36 (< 4 seg)	253 b	17	40	11 (19.3)	4 (7)	Unavailable
Choi [50]	2012	30	20	10	Mj: 724 (648–812) Mn: 518 (315–763)	9	21	43.3	2 (6.7)	11.7 b (5–46)
Casciola [48]	2011	23		23 a	280 ± 101	2	21	6 (25.8)	2 (8.6)	8.9 b (3–46)
Giulianotti [51]	2011	70	27	43	Mj: 313 (220–480) Mn: 198 (90–459)	28	42	21	4 (5.7)	7 (2–26)
Chan [49]	2011	27	1	26	200 (90–307)	6	21	2 (7.4)	1 (3.7)	5.5 (3–11)
Ji [53]	2011	13	9	4	338 b (150–720)	5	8	1 (7.8)	0	6.7 b
Lai [52]	2011	10	10	0	347.4 ± 85.9	1	9	3 (30)	0	6.7±3.5

Data are expressed as mean ± standard deviation or median (range).

Mj = major resection; ≥ 3 segments; Mn = minor resection; < 3 segments; Ref = reference; Seg = segments.

^aThis study included patients who had lesions located in posterosuperior segments.

^bMean value.

Tsung et al [8] performed a matched comparison of robotic (n = 57) and laparoscopic (n = 114) hepatectomy and concluded that robotic and laparoscopic liver resections show similar safety and feasibility for hepatectomy, with no significant differences in operative and postoperative outcomes. A larger proportion of minor and major hepatectomies were completed in a totally minimally invasive manner by using robotic techniques, than by using laparoscopic techniques (robotic group, 93%; laparoscopic group, 49.1%), without the use of hand‐assist ports or the hybrid technique, suggesting that robotic surgery may offer greater technical ease in accomplishing purely minimally invasive resectional operations [8].

Robotic hepatectomy is limited to tumors located in the posterior and superior segments. Gumbs and Gayet [55] reported the lateral laparoscopic approach to lesions located in the posterior segment. Furthermore, Casciola et al [48] reported their surgical experience and the feasibility of robotic parenchyma‐sparing hepatectomy for lesions located in the posterosuperior segments. Therefore, with increasing surgical experience, tumor location is no longer a contraindication for robotic surgery.

In the 2014 international consensus conference for laparoscopic liver resection, the outcomes of robotic liver resection were not confirmed because of the small number of studies reported [21]. The absence of tactile sense and the extremely high cost are the main demerits [56]. During robotic liver surgery, especially major resection, it is mandatory to have an experienced assistant surgeon present who can assist in suctioning and retracting the tissue to obtain optimal exposure [54]. The possible need for two trained surgeons for major liver surgery and much smaller range of instruments available than laparoscopic or open techniques are limitations of robotic liver surgery [21].

Augmented reality in surgery fuses computer‐generated images (3‐dimensional virtual model) obtained from preoperative medical imaging and real‐time patient image in order to visualize unapparent anatomical details [57]. It might facilitate safe surgical resection during robotic liver resection. However, some of the required technology is already available or under development. The goal will be to improve the surgeon's orientation and anatomical knowledge regarding the target vascular structures for more complex and safe operation.

Laparoscopic and robotic cholecystectomy

Laparoscopic cholecystectomy (LC) is a standard treatment procedure for benign gallbladder (GB) disease [[1], [2]]. Figure 2 shows the operative field of (A) three‐port LC, (B) robotic cholecystectomy, and (C) single‐incision LC. Various techniques of minimally invasive surgery for GB have been evolved. Acute cholecystitis was previously considered a relative contraindication for LC [58]. However, with increasing surgical experiences, the indications for LC have expanded in more serious cases such as GB empyema [59], previous surgical history suspecting adhesion [[60], [61]]. In a study in patients with a surgical history of midline incision, subcostal‐approach LC, in which a subcostal incision instead of an umbilical one was used to avoid any adhesions to perform a safe operation, was reported to be effective [62].

Figure 2.

(A) Three‐port laparoscopic cholecystectomy (LC), (B) robotic cholecystectomy, and (C) single‐incision LC. (D) The limited angle of instruments and fulcrum effect in single‐incision LC. Consideration of the angle avoiding the fighting of instrument and use of angulated instrument facilitate safe single‐incision LC.

The proper time to perform LC for acute cholecystitis (early vs. delayed operation) has been widely studied by retrospective observational studies and randomized controlled trials [[3], [59], [63], [64], [65], [66]]. Initial conservative management followed by delayed‐interval LC could not decrease the morbidity and conversion rates of LC for acute cholecystitis [64]. The technical difficulties are associated with repeated inflammation resulting in chronic changes rather than acute inflammatory reactions [67]. In the presence of dense fibrotic adhesions, which are encountered commonly in delayed LC, laparoscopic dissection is often impossible and unsafe [64]. Therefore, delayed surgery did not decrease the conversion rate in previous studies [[3], [63], [64], [65], [68], [69]]. Regarding the clinical outcomes, there was no significant difference in bile duct injury between early and delayed LC patients [[65], [68], [69]]. Moreover, in a large population‐based retrospective cohort study, a lower risk of major bile duct injury was observed in the early cholecystectomy group (0.28%, early group; 0.53%, delayed group) [63]. Furthermore, a shorter hospital stay was reported in the early cholecystectomy group [[3], [63], [65], [68]]. Total hospital cost was significant lower in the early group [[3], [69]] than the delayed group, however, the other randomized trial demonstrated similar cost between the two groups [66]. Early LC for acute cholecystitis is recommended rather than initial conservative treatment followed by delayed LC.

Single‐incision LC

Further efforts towards the development of minimally invasive techniques have led to single‐incision LC, which was reported first in 1996 [70]. Since then, many centers have published their experiences of single‐incision LC [[9], [10], [71], [72]]. The safety and advantages of this technique remain controversial. Some authors have confirmed the feasibility and safety of this procedure [[9], [10]] while others have not [[73], [74]].

In the technical aspect, there exist ergonomic difficulties of crossed instrument movement while using standard instruments in an in‐line view or articulating instruments capable of triangulation, both of which required increased concentration compared with conventional laparoscopic surgery [75]. The use of multiple laparoscopic instruments through a single incision often results in inadequate retractions, loss of triangulation, unintended movement, and hands or trocars fighting for space, which all lead to a prolonged operation time, inadequate exposure of the Calot's triangle, and possibility to develop complications [72]. Therefore much experience and careful decision to conversion to multiport LC is necessary to perform single‐incision LC. Although admitting the limited movements of instrument, consideration of the angle avoid of clashing of instruments and use of angulated instruments will overcome the difficulties (Figure 2D).

In a systematic review and meta‐analysis of randomized controlled trials on single‐incision LC and conventional multiport LC, single‐incision LC demonstrated a higher procedure failure rate with more blood loss and a longer operative time, with similar rates of conversion to open surgery, lengths of hospital stay, postoperative pain, and adverse events. Better cosmetic outcomes were also achieved with single‐incision LC [76]. However, another systematic review concluded that in selected patients, single‐incision LC, compared with conventional LC, presented similar overall morbidity, better cosmetic satisfaction, and reduced postoperative pain despite a longer operative time [77]. The selection criteria for patients eligible for single‐incision LC included a relatively low body mass index and less severe inflammation, especially in the earlier experience of single‐incision LC. The 1‐year results of a prospective randomized multicenter trial of single‐incision LC and conventional LC patients showed that the incisional hernia rate was significantly higher in single‐incision LC patients (8.4%) than in conventional LC patients (1.2%, p < 0.0001), and cosmesis scores and patient preference at the 1‐year assessment were higher for single‐incision LC [71]. However, in a matched cohort study based on prospective data from the Danish cholecystectomy database, the authors reported that no differences in the long‐term incidence of port‐site hernia or chronic pain were observed after single‐incision LC compared with conventional LC [78].

A meta‐analysis of randomized controlled trials showed that the incidence of bile duct injury was not higher in the single‐incision LC group than in the conventional LC group [77]. A review of 2626 patients in 45 observational studies reporting the surgical experiences of single‐incision LC showed that most single‐incision LCs were performed in the absence of acute cholecystitis (90.6%), and the aggregate complication rate was 4.2%. Nineteen bile duct injuries were identified, with a single‐incision LC‐associated bile duct injury rate of 0.72% [79]. The bile duct injury rate in the laparoscopic era has been reported to be 0.4–0.5% [80], and thus, the bile duct injury rate of 0.7% in single‐incision LC patients was high, considering that most of the single‐incision LCs were performed in optimal conditions, such as a lack of inflammation [79]. To avoid bile duct injury during single‐incision LC, adherence to traditional principles and the critical view of safety techniques described by Strasberg et al [81] should be emphasized.

To guarantee patient safety, a low threshold of conversion to multiport LC with additional trocar insertion in the epigastric or subcostal areas is necessary before conversion to open surgery is elected [72]. Although most studies have reported longer operative times for single‐incision LC [[76], [77]], development of instruments such as articulating instruments with a high‐degree of effectiveness and thin instruments might be an alternative to overcome ergonomic problems of surgeons, improve patient safety, and decrease operative site pain and port‐site hernia.

Robotic cholecystectomy

Robotic cholecystectomy was introduced in 1998 [82] and single‐incision robotic cholecystectomy was introduced in 2011 [83]. So far, the robotic cholecystectomy is more expensive than LC without demonstrating any definite evidence of benefit to patients [84]. For the development of robotic instrument and increased familiarity of robotic surgery of the surgeons, single‐incision robotic cholecystectomy was performed providing to overcome many of the technical limitations of single‐incision LC such as ergonomics, internal and external instrument clashing, image instability [[83], [85]]. Therefore single‐incision robotic cholecystectomy has revolutionized single incision surgery. In the peritoneal cavity, single‐incision robotic cholecystectomy is more similar to the standard multiport LC than to single‐incision LC [83]. Single‐incision robotic cholecystectomy allows the quick overcoming of the learning curve and may potentially increase the safety [85]. In one study to compare single‐incision robotic cholecystectomy with single‐incision LC, single‐incision robotic cholecystectomy group demonstrates shorter operative time (83.2 minutes vs. 62.7 minutes) and no wound complication, concluding that single‐incision robotic cholecystectomy is safe and feasible and can easily be learned [86]. The robotic system is evolving continuously to overcome the problem of cost and to get more technical advantages by the development of technology.

Laparoscopic and robotic surgery for choledochal cyst

Farello et al [87] reported the first case of laparoscopic surgery for a choledochal cyst in 1995. Although choledochal cysts are a rare disease, they occur more commonly in young women and pediatric patients, and the advantage of the cosmetic effect in laparoscopic surgery is maximized in these patient groups. A literature review showed that most clinical experiences of minimally invasive surgery for choledochal cysts were reported in pediatric patients [88]. Several centers have attempted laparoscopic excision of choledochal cysts and have reported the surgical outcomes in adult patients [[89], [90], [91]]. Differences in the operative times might exist among centers, suggesting that the operative time might decrease with increasing surgical experience overcoming the learning curve. Therefore, most studies have recommended the feasibility and safety of the laparoscopic procedure for choledochal cysts and have suggested that laparoscopic surgery would be advantageous and the treatment of choice for choledochal cysts, replacing open surgery in the future [[89], [90], [91]].

Several difficulties are associated with hepaticojejunostomy and jejunojejunostomy, which are considered to be time‐consuming procedures (Figure 3A and 3B). In one study, intracorporeal hepaticojejunostomy was performed using a premade surgical knot, which was completed using a knot pusher [90]. It is necessary to decrease the operative time and effort by development of surgical equipment, especially in anastomosis.

Figure 3.

Laparosopic excision of (A) choledochal cyst and (B) hepaticojejunostomy. Robotic‐assisted excision of (C) choledochal cyst and (D) hepaticojejunostomy.

A particular advantage of robotic surgery is that hepaticojejunostomy anastomosis is far easier and more precise with robotic techniques than with conventional laparoscopic techniques [92] (Figures 3C and 3D). Choledochal cysts can be dissected easily, precisely, and safely using a three‐dimensional operative field, and the surgeon could reproduce the same procedures of hepaticojejunostomy as are performed in open surgery [93]. However, despite the advantages of robotic surgery including a three‐dimensional view, tremor filtering, and an ergonomically designed console, the disadvantages include a prolonged operative time, high cost, and need for specially trained tableside assistants [[93], [94]]. In the future, most of the problems will be solved by accumulation of surgical experiences, and development of robotic technology including more convenient and cheaper instruments.

Laparoscopic common bile duct exploration

Clinical outcome and feasibility of laparoscopic common bile duct (CBD) exploration via transcystic or transductal have been reported with high efficiency and minimal morbidity [[95], [96]]. In the laparoscopic CBD exploration, CBD stones were removed by choledochoscopy. Surgeons should be familiar with endoscopic as well as laparoscopic skills [96]. Several strategies are available for the treatment of CBD stones nowadays; endoscopic, laparoscopic, and open surgical approaches. Mostly, endoscopic retrograde cholangiopancreatography sphincterotomy followed by LC (2‐stage) or concomitant laparoscopic CBD exploration and cholecystectomy (single‐stage) could be an option. A meta‐analysis to compare these two methods demonstrated equivalence in stone clearance from the CBD, postoperative morbidity, length of hospital stay, and total operative time; however, laparoscopic CBD exploration (single‐stage) required fewer procedures than two‐stage group [97]. In a nonseptic patient with intraoperative diagnosis of CBD stone, laparoscopic CBD exploration was appropriate regardless of comorbidity; however, in a septic patient with high morbidity and nondilated bile ducts, laparoscopic CBD exploration is not indicated [98]. The appropriate management of patients with CBD stones should be determined according to the condition of the patient, expertise of operators, and local resources [97]. With advancing technology and minimally invasive surgery, laparoscopic CBD exploration has the potential to become more efficient and cost effective.

Conclusion

Laparoscopic and robotic liver surgery require a great deal of experience. The continuous effort of surgeons has achieved the expansion of indication of laparoscopic liver surgery. It offered similar oncological outcome and better shorter outcome such as shorter hospital stay and less postoperative pain compared with open surgery. However, it is still challenging to perform major hepatectomy, which requires a learning curve and accumulation of experience. For biliary disease, LC is a treatment of choice for benign GB disease and single incision LC is widely performed. However, these minimally invasive surgical approaches proceed towards patient safety without increased fatal complication such as bile duct injury. Laparoscopic or robotic surgery for choledochal cyst is also challenging due to difficulties associated with anastomosis. Laparoscopic CBD exploration has been performed effectively. Continuous effort to overcome the limitation of minimally invasive surgery by surgeon's endeavor and development of innovative technology is necessary.