Hepatobiliary surgery

The transformation of liver and biliary tract surgery into a full specialit y began with the application of functional anatomy to segmental surgery in the 1950's, reinforced by ultrasound and new imaging techniques. The spectr um of gall-stone disease encountered by the hepatobiliary surgeon has chang ed with the laparoscopic approach to cholecystectomy, There is increased ne ed for conservation techniques to repair the bile duct injuries that arise more often in the laparoscopic approach to cholecystectomy, These and other surgical interventions on the bile ducts should be selected as a function of risk versus benefit in relation to the patient's requirements and the in stitutional expertise. Bile duct cancers, including hilar cholangiocarcinom a, and gallbladder cancers have a dismal reputation, but evidence is accumu lating for better survivals from aggressive approaches performed by special ist hepatobiliary surgeons. Hepatic surgery has increased in safety and eff ectiveness, largely due to the segmental approach, but also to experience w ith techniques for vascular control and exclusion used in liver transplanta tion, Techniques such as portal vein embolisation, which induces hypertroph y of the future remnant liver, percutaneous local tumour destruction using cryotherapy or radiofrequency tumour coagulation and more effective chemoth erapy are beginning to increase the number of patients who can undergo cura tive resection. In liver transplantation, segmental surgery has been applie d to graft reduction and to split liver grafts, and is opening new perspect ives for living donor transplantation, Today the limitation to survival in primary and metastatic liver cancer lies mt in the surgical technique but i n the difficulty of dealing with microscopic and extrahepatic disease. Prog ress in these fields will enable the hepatobiliary surgeon to further exten d the possibilities for proposing curative resections.