A historic perspective of liver surgery for tumors at the end of the millennium

Abstract

Liver surgery has evolved in one “surgical lifetime” from being almost nonexistent to a repertoire of operations that can safely remove nearly any amount of liver tissue. These operations are now performed at numerous hospitals and medical centers throughout the world. Such phenomenal achievement did not come easily, but with the “blood, sweat, and tears” of patients and their families and of courageous surgeons who were enabled by extraordinary developments in anesthesiology, infectious disease, and radiologic imaging. At the beginning of this extraordinary era, the major concerns were how to remove a tumor in the liver without major, often fatal, bleeding and the uncertainty about the amount of liver that could be removed safely. Mortality and morbidity rates were unacceptably high initially and cure rates were unknown. Total hepatectomy and replacement by liver transplantation were dreams. Step by step, these problems were addressed. Initial limited excisions were followed by major ablative operations, including total hepatectomy, by less invasive procedures with laparoscopy, and then by increasing popularity for more limited segmental excisions of tumors, representing a cycle of achievements. Today, a new revolution looms: the possibility of computer-directed operations using the techniques of robotics and virtual reality. We hope that these technologic advances will be followed by the discovery of effective adjuvant therapy. The evolution of treatment in this century might be expected to result in surgery’s becoming irrelevant to liver neoplasms. It is well to remember that, in the 19th century, surgery was thought to have reached its apogee—but the best was yet to come. Key features of the liver that allow major resection were known in ancient times. Its structural arrangement into lobes was apparent to those preparing animals for food, ceremony, or human mummification. Clay models of the liver were made around 2000 BC by the Babylonians, who gave names to various areas and made prognostications from their appearances. Similar concepts were followed in later civilizations. Two other properties of the liver, namely functional reserve and rapid regeneration, were recorded in the early Greek myth of Prometheus, in which Prometheus’s liver regrew nightly after the eagle’s daily and apparently bloodless “surgical resections.” This oft-cited fantasy does not necessarily mean that the ancient Greeks knew about liver regeneration. But war wounds and animal sacrifice provided dramatic evidence of the liver’s power for massive hemorrhage, causing the Babylonians to consider it the seat of the soul. Knowledge of the liver’s lobar and segmental structures, functional reserve, capacity to regenerate, and prevention of hemorrhage is essential for successful major surgical resection. It is also of relevance to transplantation, particularly of split-liver homografts and the use of living related donors. The historic development from ancient times of knowledge about these key characteristics is a vast body of work and beyond the scope of this review. The purpose of this article is to present our admittedly imperfect views of the contributions that were seminal to the development of liver surgery for tumors. We have placed particular emphasis on the last 50 years of the second millennium, when progress was most rapid and we were participants.