Preface

 The complicated nature of hepatic anatomy and physiology, as well as the variety of challenging diseases affecting the liver, have all contributed to the field of hepatic surgery being a highly demanding surgical specialty. The training of a liver surgeon consists of achieving technical expertise, a deep understanding of the intricacies of hepatic anatomy and physiology, experience with acute and chronic liver disease ranging from trauma, infections, benign lesions to primary and metastatic malignancies, as well as knowledge of the continuously evolving technologies. This is necessary to be able to choose correctly from a variety of different treatment methods and different hepatectomy techniques that would be best suited to the specific patient and the specific health problem. The multitude of hepatic surgery techniques involve strategies such as ablation, electroporation, resection with several different instruments, and, last but not least, liver transplantation. At the same time, the physician dealing with these complex issues needs to be aware of the right mix of treatments, as well as the proper sequence. Additionally, it is imperative to possess an understanding of the molecular biology of hepatic function and the evolution of the various diseases to be able to provide patient-targeted therapies.

This book provides an overview of all the above with chapters presenting hepatic anatomy, intricacies of liver physiology as seen in the case of hepatic regeneration and the concept of damage control surgery, challenges and current updates on complex hepatic diseases such as cholangiocarcinoma, and, of course, descriptions of the indications and techniques for some of the more demanding hepatic surgeries such as right hepatectomy and liver transplantation. Its value lies in the fact that the authors present us with their distilled wisdom, which is the result of substantial experience and daily involvement in this most difficult field of medicine and surgery.

Overall, this book should be a useful resource for any physician, whether they are in training or in practice, treating patients with hepatic diseases.

> **Georgios Tsoulfas, MD, PhD, FICS, FACS,**  Associate Professor of Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece

Section 1

Introduction

1

Section 1 Introduction

Chapter 1

Surgery

1. Introduction

Georgios Tsoulfas

Introductory Chapter: Hepatic

Hepatic surgery represents one of the more challenging and exciting areas of surgical practice for a variety of reasons. It combines surgical technical expertise with the management of diseases of one of the most vital and elaborate organs of the human organism. Specifically, the liver with its multitude of functions ranging from nutrition, production of energy, clearing and metabolism of a variety of substances and medications, control of the coagulation system, to name a few, represents a human factory with a complex anatomy and physiology. Its various functions make it a central player in a variety of diseases, where irrespective of their benign or malignant nature, can pose significant threats to the whole organism. The main insults faced may include abdominal trauma (with the liver being the second most injured organ), genetic abnormalities, infections, metabolic alterations, and malignancies. The latter can be either primary (hepatocellular carcinoma, cholangiocarcinoma, and hepatoblastoma) or secondary (metastatic hepatic disease from colorectal, neuroendocrine or non-neuroendocrine, and non-colorectal primary). The common feature in all of these diseases is the significant threat that they pose to the human body, as well as the fact that from the multitude of available treatments, surgery is by far the most successful, yet fraught with possible complications and even the possibility of death. This interesting mix allows us to understand the important and challenging nature of hepatic surgery. The liver surgeon needs to possess deep knowledge of hepatic and human physiology, hepatic anatomy, and

This book with chapters covering the whole spectrum of hepatic surgery represents the cumulative effort of a very experienced group of liver specialists who offer us their distilled experience in areas covering hepatic anatomy with all its significant and often critical variations, an overview of some of the more challenging types of hepatic cancers (such as cholangiocarcinoma), a description of some of the more demanding surgical procedures (such as the extended right hepatectomy), the importance of technology as an extension of the surgeon's eyes and hands (intraoperative hepatic ultrasound), the true meaning of damage control hepatic surgery (typifying the union of understanding hepatic physiology and surgical acumen), and a description of the molecular pathways involved in the

The latter carries special weight as we live in the era of precision medicine and patient-targeted treatments. As such, the surgeon should be able to understand the molecular identity of various diseases and how to incorporate that in daily surgical practice. We must learn neither to fear, nor to worship new technology,

but rather to objectively and accurately evaluate it and assess its use, and

surgical skill that is a combination of dexterity and patience.

evolution and management of liver disease.

3

#### Chapter 1

## Introductory Chapter: Hepatic Surgery

Georgios Tsoulfas

#### 1. Introduction

Hepatic surgery represents one of the more challenging and exciting areas of surgical practice for a variety of reasons. It combines surgical technical expertise with the management of diseases of one of the most vital and elaborate organs of the human organism. Specifically, the liver with its multitude of functions ranging from nutrition, production of energy, clearing and metabolism of a variety of substances and medications, control of the coagulation system, to name a few, represents a human factory with a complex anatomy and physiology. Its various functions make it a central player in a variety of diseases, where irrespective of their benign or malignant nature, can pose significant threats to the whole organism. The main insults faced may include abdominal trauma (with the liver being the second most injured organ), genetic abnormalities, infections, metabolic alterations, and malignancies. The latter can be either primary (hepatocellular carcinoma, cholangiocarcinoma, and hepatoblastoma) or secondary (metastatic hepatic disease from colorectal, neuroendocrine or non-neuroendocrine, and non-colorectal primary). The common feature in all of these diseases is the significant threat that they pose to the human body, as well as the fact that from the multitude of available treatments, surgery is by far the most successful, yet fraught with possible complications and even the possibility of death. This interesting mix allows us to understand the important and challenging nature of hepatic surgery. The liver surgeon needs to possess deep knowledge of hepatic and human physiology, hepatic anatomy, and surgical skill that is a combination of dexterity and patience.

This book with chapters covering the whole spectrum of hepatic surgery represents the cumulative effort of a very experienced group of liver specialists who offer us their distilled experience in areas covering hepatic anatomy with all its significant and often critical variations, an overview of some of the more challenging types of hepatic cancers (such as cholangiocarcinoma), a description of some of the more demanding surgical procedures (such as the extended right hepatectomy), the importance of technology as an extension of the surgeon's eyes and hands (intraoperative hepatic ultrasound), the true meaning of damage control hepatic surgery (typifying the union of understanding hepatic physiology and surgical acumen), and a description of the molecular pathways involved in the evolution and management of liver disease.

The latter carries special weight as we live in the era of precision medicine and patient-targeted treatments. As such, the surgeon should be able to understand the molecular identity of various diseases and how to incorporate that in daily surgical practice. We must learn neither to fear, nor to worship new technology, but rather to objectively and accurately evaluate it and assess its use, and

following the appropriate learning curve, incorporate it into our daily practice. The overall goal is to achieve therapy in a safer and more efficient manner for our patients.

Overall, this book represents a true tour de force of a variety of topics having to do with hepatic surgery, as it befits the nature and significance of the subject. It should be stressed that the intended audiences are scientists and physicians and surgeons of different specialties, which all have in common an interest in liver disease and improving the lives of these patients.

#### Author details

Georgios Tsoulfas Aristotle University of Thessaloniki, Thessaloniki, Greece

\*Address all correspondence to: tsoulfasg@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapteris distributed underthe terms oftheCreative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

## Section 2
