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Gallbladder carcinoma (GBC) is a rather rare malignancy associated with a rapidly lethal course independent of any kind of treatment. The high mortality rate associated with the disease is due to the early silent growth of the tumor with a late presentation, an early occurrence of lymph node spread, and an anatomic relation to the porta hepatis [ 1 ]. It is considered as the most common biliary tract malignancy and the fifth most common gastrointestinal cancer, pancreatic cancer occurring about five times as frequently [ 2 ]. In general, the incidence of GBC seems to be increasing in the Western World. A recent study from France reported an annual incidence of 0.6 cases per 100,000 men and 1.7 cases per 100,000 women [ 3 ]. In the US it accounts for approximately 7,100 new cases and 3,500 deaths per annum [ 4 ]

Cholangiocarcinoma (CCA) is the primary cancer of the biliary tree. It is broadly divided into intrahepatic, extrahepatic hilar tumors and extrahepatic distal bile duct tumors, according to its anatomic distribution within the biliary tree [ 1 ]. It is an epithelial neoplasm, adenocarcinoma in most cases. Although it comprises about 10%–15% of hepatobiliary neoplasms, its incidence is increasing globally [ 2 , 3 ]. The annual incidence of CCA is approximately 1.0 per 100,000 in the United States, 7.3 per 100,000 in Israel, 6.5 per 100,000 among American Indians, 5.5 per 100,000 in Japan [ 4 ], and 2 per 100,000 in England and Wales [ 5 ]. However, this increase is mainly due to a sharp rise in the incidence of intrahepatic cholangiocarcinoma, whereas the incidence of extrahepatic cholangiocarcinoma seems to have declined the last two decades [ 6 ]. Using the Surveillance Epidemiology and End Results (SEER) database, which represents 10–14% of the total US population, the age adjusted incidence of intrahepatic CCA has increased by 165%, from 0.32 per 100,000 population during 1975–1979 to 0.85 per 100,000 during 1995–1999 [ 2 , 12 ]

The main causes of malignant obstruction of the main biliary duct are ampullary carcinoma, cholangiocarcinoma, adenocarcinoma of the pancreatic head and carcinoma of the gallbladder. During diagnosis, most of these tumors usually have locally advanced disease or distant metastases. Nevertheless, in such cases if an accurate tissue diagnosis is obtained, preferably without the need of laparotomy, it helps us plan further management [1]. Biliary duct lesions are not always readily accessible to biopsy and cytological techniques have therefore become the initial diagnostic modality in many cases. Brush cytology performed at endoscopic retrograde cholangiopancreatography (ERCP) has now become the preferred initial method of pursuing tissue diagnosis in many patients with biliary strictures, providing a diagnostic sensitivity of 59% (range 42–85%) [2]. Percutaneous radiologically guided fine needle aspiration (FNA) is an accurate diagnostic technique but it is operator–dependent and requires a sufficiently distinct mass lesion for targeting

The dramatic improvement in hepatobiliary surgery over the past four decades has been one of the important advances in surgery. Increasing numbers of hepatobiliary operations are being performed by better-trained hepatobiliary surgeons, who have learned the techniques from their predecessors and made further improvements. These procedures are indicated for benign and malignant diseases of the common bile duct, hepatic ducts, liver and pancreas; are performed in the pediatric population; and may be life saving during the course of an emergency laparotomy for injury within the hepatoduodenal ligament or the liver hilum. Moreover, with the evolution of newer endoscopic, radiologic and minimally invasive techniques, the results obtained by the time-honored open approach are constantly challenged and at times improved. Hence, the hepatobiliary surgeon not only needs to be aware of the indications and contraindications, advantages and disadvantages and technical aspects of each single open approach, but he/she also needs to have detailed knowledge of the newer techniques, in order to be better prepared to individualize treatment for each patient

Thirty years ago, the imaging investigation of the liver and the biliary tree began with the plain x-ray. Nowadays it is considered less valuable since the ultrasound has become the modality of choice for their initial examination. The liver casts an appreciable shadow on a simple X-ray film. The hepatic shadow appears homogenous and is mostly formed by the right lobe. It is delineated at the right quadrant of the abdomen, though modified by individual variations of shape and orientation. Its outline is deduced due to contrast differences between the right lobe and the right hemidiaphragm and lung above, the preperitoneal fat line laterally, and the extraperitoneal fat and the kidney below. The liver lies approximately at the level of fifth intercostal space at the midclavicular line. The lower border extends to or slightly below the costal margin and should not cross the right psoas margin. The lower anterior edge of the liver that is the one clinically palpated is not directly seen on a plain film, but the gas in the right colon usually indicates its position

Advancement in radiological imaging technique has been crucial in the development of most of the surgical fields. Planning for operations needs good visualization of the organ and localization of the lesion within it, which was possible by Computed Tomography (CT) & Magnetic Resonance Imaging (MRI). However, without knowledge of major blood vessels or other important structures related to the lesion, surgery cannot be performed curatively and safely at the same time. In neurosurgery, this fact has been early recognized and three-dimensional (3D) imaging technique widely adopted to increase accuracy of the procedures. Similarly, reconstructed 3D images have been very useful in orthopaedic and maxillofacial surgery as well [ 1 ]

Hepatic failure following hepatectomy carries a dismal prognosis. Inadequate reserve compromises liver function, the ability of the liver to regenerate and results in liver failure. Jarnagin et al defined postoperative hepatic insufficiency and failure as “prolonged hyper-bilirubinemia unrelated to biliary obstruction or leak, clinically apparent ascites, prolonged coagulopathy requiring fresh frozen plasma and/or hepatic encephalopathy” [ 1 ]

Over the past twenty-five years, hepatic resection has evolved from a high risk, resource intensive procedure with limited application to a safe and commonly performed operation, with broad indications. This period has seen dramatic improvement in perioperative outcome, including reductions in mortality, blood loss, transfusion rates, and hospital stay [ 1 ]–[ 2 ]. These improved perioperative results are largely responsible for the emergence of hepatic resection as a viable and effective treatment option for selected patients with 1 and 2 hepatobiliary malignancy. Continued advances in imaging technology, along with a heightened awareness of the clinical and tumour-related variables that dictate outcome, have allowed better preoperative assessment of disease extent and improved patient selection. Advances in other areas, such as minimally invasive and ablative techniques, have increased the treatment options and have had some impact on the approach to patients with malignant hepatobiliary disease. However, resection remains the most effective therapy

The role of liver resection for benign and malignant hepatobiliary diseases is expanding, because of the markedly reduced operative mortality in recent years, as the result of better patient selection, improved surgical techniques and better perioperative management. The major technical challenge of liver resection is control of bleeding during transection of the parenchyma. Liver resection can be performed by different transection devices with or without inflow occlusion (Pringle manoeuvre). Only limited data is available on the best transection technique. The most popular devices facilitating bloodless transection include the ultrasonic dessicator (e.g: Cavitron Ultarsonic Surgical Aspirator (CUSA), Tyco Healthcare, Mansfield, MA), water jet dissector [ 1 ] (e.g: Hydro-jet, Erbe, Tubingen, Germany), harmonic scalpel, mono and bipolar cautery devices, and the dissecting sealer (e.g: Tissuelink, Dover, NH0) [ 2 ]. Parenchymal dissection has been performed under routine inflow occlusion with finger fracture technique (digitoclasy), where liver parenchyma is crushed between finger and thumb, isolating vessels and bile ducts, which then can be ligated and divided

Liver surgery remains the gold standard for the treatment of liver tumours. To aid with hepatic resection, several devices have been developed in an attempt to stem significant blood loss and reduce the necessity for vascular exclusion. Of note are the Harmonic scalpel, bipolar scissors, hydrodissectors, Ligasure diathermy, Cavitron ultrasonic aspirator (CUSA) and Monopolar floating ball. However, most of these devices still require some degree of vascular inflow occlusion or are time consuming and none, except radiofrequency, can also be used to successfully ablate tumours. Furthermore, vascular occlusion- whether it is intermittent, continuous, partial or total- affects postoperative function of the hepatic remnant, especially in those patients treated with neo-adjuvant chemotherapy or in those patients with underlying chronic liver disease. Of all the new techniques now being applied to liver surgery the most successful and versatile is radiofrequency, which, until recently, was used only for in situ ablation of unresectable tumours