Progress and controversy in the application of minimally invasive and robotic techniques in hepatobiliary surgery

Artificial intelligence in HPB surgery: a narrative review on technological advances and imperatives for ethical integration.

Abstract Aim During 2024 we successfully piloted a Physiotherapy led prehabilitation service, aiming to increase fitness of patients awaiting hepatobiliary cancer surgery where improvements in strength were demonstrated. Our aim was to therefore explore the impact on length of stay (LOS) and associated cost. Method LOS data was gathered for elective surgical patients having either liver of pancreatic elective surgery for a cancer in 2024. This was then compared for those who had a period of prehabilitation versus those who did not. Upon completion the planning and costing team reviewed the associated costings. The criteria for referral to the prehabilitation service changed during 2024, initially patients with a poor anaerobic threshold on cardiopulmonary exercise testing (10.9 mls/kg/min or less) were eligible. After six months this was opened to any patient having surgery for a cancer. Results No prehabilitation input.SurgeryAverage LOS (days)Average cost/procedure (£)Distal pancreatectomy8.018,141Liver resection8.719,744PPPD17.631,510Total pancreatectomy2539,418Whipple22.624,745Average16.426,724 With Prehabilitation input.SurgeryAverage LOS (days)Average cost/procedure (£)Distal pancreatectomy5.215,748Liver resection8.620,341PPPD30.119,262Total pancreatectomy8.821,158Whipple19.631,456Average14.421,593 Conclusions Reviewing the data, there is an average LOS reduction of 2 days and cost reduction of £5,131, this figure takes in to account the cost of delivery. In the current NHS climate services like these will be crucial in moving forward with both cost improvements and encouraging long term health improvements.

Abstract Background The aberrant right hepatic artery (ARHA) is a significant anatomical variation in hepatic vasculature, found in approximately 10-20% of the population. Laparoscopic Cholecystectomy is one of the indexed procedures required for certification in General Surgery, here we present 4 cases of laparoscopic cholecystectomy where we encountered ARHA to signify the awareness that it is not uncommon to encounter these variations intra operatively. Case There were 4 cases over 3 months operated by ST3 trainees under direct supervision, anomalies were detected intraoperatively after high suspicions of abnormally large, dilated vessel crossing cystic duct were made. Careful dissection of ARHA till liver insertion were done along with clipping of high origin of cystic artery. The rest of surgery and recovery was uneventful. Post-surgery CT Angiogram were organized to delineate anatomy of vessel for future reference. Discussion This arterial anomaly originates from the superior mesenteric artery rather than the common hepatic artery, deviating from the typical arterial supply of the liver. We encountered 2 cases where the artery was having its course medially and 2 cases from inferior aspect of the hilum. Clinically, the presence of an ARHA holds considerable importance, especially in hepatobiliary and pancreatic surgeries, liver transplantations, and interventional radiology procedures, where unrecognized variants can lead to complications such as ischemia, haemorrhage, and postoperative liver dysfunction. Conclusions ARHA represents a vital anatomical variant with implications interventional outcomes. Recognition of ARHA through imaging and meticulous operative planning is essential for minimizing intraoperative complications and ensuring optimal patient outcomes in hepatobiliary care.

Bibliometric analysis of robotic-assisted hepatobiliary and pancreaticosplenic surgery.

The diagnosis and treatment rates for hepatitis C virus (HCV) remain below target levels. This study aims to define and analyze the HCV care cascade for surgical patients in a high-prevalence region, evaluate the impact of a hospital-wide elimination program, and identify barriers and facilitators to completing the diagnostic pathway. This retrospective cohort study analyzed de-identified electronic health records from 114,968 consecutive preoperative patients undergoing routine Hepatitis C virus (HCV) antibody screening at a tertiary academic medical center between January 2021 and December 2024. We evaluated the effectiveness of a multifaceted HCV elimination program initiated in 2022 by assessing patient management through a predefined three-step care cascade: (1) universal anti-HCV antibody screening; (2) HCV RNA testing within 72h for antibody-positive individuals; and (3) prompt hepatology referral within the patient's hospitalization for RNA-positive cases. Data on patient demographics, clinical department, HCV antibody results, HCV RNA testing completion status, and key clinical variables (emergency surgery, transfusion history, dialysis, length of stay, physician practice duration) were extracted from standardized electronic health records. Data accuracy was verified via a manual audit of 200 randomly selected records. Continuous variables were summarized as mean ± standard deviation (SD) and categorical variables as counts (percentages). Group comparisons were performed using Pearson's χ2 or Fisher's exact tests. A multivariable binary logistic regression model with backward stepwise selection was employed to identify independent predictors of HCV RNA testing completion, and the Hosmer-Lemeshow test was used to assess model goodness-of-fit. Results were reported as adjusted odds ratios (aORs) with 95% confidence intervals (CIs). A two-tailed P-value < 0.05 was considered statistically significant. A post-hoc power analysis confirmed the study was sufficiently powered (> 80%) for its primary outcomes. Among 114,968 patients, the overall anti-HCV positivity rate was 2.03% (95% CI: 1.95-2.11; n = 2,334), with significant demographic disparities: males had a 1.48-fold higher positive rate than females (2.45% vs. 1.63%, P < 0.001). The prevalence of hepatitis C antibodies exhibited a nonlinear positive correlation with age distribution, with infection rates rising significantly after the age of 30. The 70-79 age group presented an 11.74-fold greater prevalence than patients aged 40-49 years (3.64% vs. 0.31%, P < 0.001). Significant gaps were observed in the care cascade, with only 33.6% of anti-HCV positive patients completing RNA confirmation. There were notable interdepartmental disparities: Hepatobiliary Surgery had the highest anti-HCV positivity rate (7.90%), whereas Pediatric (0.04%) and Obstetric (0.26%) departments had the lowest. Multivariate logistic regression identified key factors associated with testing completion. A hospital stay of ≤ 7 days was the strongest barrier (aOR = 0.48, 95% CI: 0.39-0.60; P < 0.001). Conversely, receipt of dialysis was the strongest facilitator (aOR = 8.69, 95% CI: 3.83-19.76; P < 0.001), followed by admission to an HCV-related department (aOR = 2.18, 95% CI: 1.75-2.71; P < 0.001) and history of blood transfusion (aOR = 1.82, 95% CI: 1.20-2.76; P = 0.005). Physicians with < 5 years (aOR = 1.60, 95% CI: 1.27-2.01; P < 0.001) or 5-10 years of experience (aOR = 1.71, 95% CI: 1.35-2.18; P < 0.001) were more likely to order testing than those with > 10 years of experience. The model demonstrated good discriminative ability, with an overall correct classification rate of 69.6%. This study identifies a critical breakdown in the hepatitis C virus (HCV) care cascade at our institution, where a substantial "diagnostic gap" resulted in only 33.63% of anti-HCV positive patients receiving confirmatory RNA testing. The high seroprevalence (2.03%) in our pre-operative cohort, particularly among males and the elderly (peaking at 3.64% in the 70-79 age group), underscores the need for targeted screening. The primary barrier was identified as a fundamental incompatibility between the two-step diagnostic process and clinical workflows, with short hospital stays (≤ 7 days) being the strongest negative predictor. This systemic failure, observed across various non-hepatology departments, contrasts sharply with high performance in settings like Nephrology (87.80% testing rate) and mirrors challenges reported globally. Conversely, downstream linkage to care proved successful, with hepatology referral rates rising to 66.67% in 2024, demonstrating the effectiveness of structured, technology-driven interventions like electronic referral systems. These findings advocate for fundamental system-level reforms, including the implementation of reflex RNA testing, intelligent EMR alert systems, and performance-linked quality metrics, to bridge the diagnostic gap and advance progress towards HCV elimination goals.

Major adverse cardiovascular and cerebrovascular events (MACCE) pose significant challenges in hepatobiliary and pancreatic surgeries, contributing to increased morbidity, mortality, and healthcare burdens. Accurate identification of perioperative risk factors remains critical yet underexplored due to limited large-scale data. This study aimed to find intraoperative predictors of MACCE within 30 (MACCE-30) and 90 days (MACCE-90) post-surgery using the INSPIRE database. A retrospective cohort of 6135 patients from Seoul National University Hospital was analyzed. MACCE was defined as angina, myocardial infarction, cardiac arrest, arrhythmia, heart failure, stroke, or in-hospital mortality. Variables including patient characteristics, intraoperative factors (e.g., estimated blood loss [EBL], crystalloid volume), and comorbidities were extracted. Univariate Cox proportional hazards models identified variables (p < 0.2) for multivariate analysis, with Kaplan-Meier plots visualizing survival differences. Of 6135 patients, 179 experienced MACCE-90. Multivariate analysis identified male sex (HR 1.88, 95% CI 1.27-2.78, p < 0.01), EBL (HR 1.19, 95% CI 1.03-1.37, p = 0.02), and crystalloid infusion volume (HR 1.29, 95% CI 1.00-1.65, p = 0.05) as significant predictors of MACCE-90. Mean EBL was 565 mL (MACCE) versus 357 mL (non-MACCE), and crystalloid volume was 498 mL versus 486 mL. We observed no significant difference in early survival based on sex, EBL, or infused crystaollioids. Male sex, higher EBL, and crystalloid volumes predict MACCE-90. Optimized management and refined protocols are needed.

Background: Takotsubo cardiomyopathy (TTC), also known as stress-induced cardiomyopathy, is an acute but reversible form of left ventricular dysfunction, most commonly triggered by physical or emotional stress. Although well documented in cardiology practice, its occurrence following hepatobiliary surgery is rarely reported. Case presentation: We describe the case of a 67-year-old woman with a history of arterial hypertension and prior cholecystectomy who was admitted for elective hepatobiliary surgery due to choledocholithiasis complicated by a liver abscess. She underwent laparotomy with choledocholithotomy, hepaticojejunostomy, and abdominal drainage. The postoperative course was complicated by intra-abdominal bleeding, requiring reoperation, and subsequent intestinal leakage, necessitating a second re-laparotomy. On the tenth postoperative day after the second surgery, she developed chest discomfort and dyspnea upon minimal exertion. Electrocardiography revealed T-wave inversions in leads V3–V6, while echocardiography demonstrated a reduced ejection fraction of 45% with apical akinesis. Plasma levels of N-terminal pro-B-type natriuretic peptide (NT–proBNP) were elevated, whereas troponin remained within normal limits. Coronary angiography excluded obstructive coronary artery disease, and ventriculography confirmed apical ballooning consistent with Takotsubo cardiomyopathy. Conclusions: This case highlights Takotsubo cardiomyopathy as a rare but important postoperative complication of major hepatobiliary surgery. Awareness of this condition in surgical patients presenting with acute chest symptoms is essential, as timely recognition and differentiation from acute coronary syndrome directly influence management and prognosis.

Background Three-dimensional printing (3DP) is increasingly applied in surgical training; however, its effectiveness and reliability in hepatobiliary surgery education remain uncertain. Objectives To systematically review the literature on the application and effectiveness of 3DP in hepatobiliary surgical training and anatomical education. Method PubMed, Embase and the Cochrane Library were searched for publications dated 1 January 1995, to 19 January 2025. Two investigators independently performed the literature search and screened eligible studies that reported the use of 3DP models for surgical training or anatomical education. Study quality was assessed using the Medical Education Research Study Quality Instrument (MERSQI), and levels of evidence were graded using the Oxford Centre for Evidence-Based Medicine (OCEBM) framework. Extracted data included study design, participant numbers, type of surgical training, type of anatomical education, and reported subjective and objective outcomes. Results Twenty-two studies investigated the application of 3DP in clinical surgical training and 12 studies focused on anatomical education. Laparoscopic procedures were the most frequently reported training context (59%). In anatomical education, tumor localization was the most common task (50%). Ten studies reported that 3DP significantly improved operative performance, reducing operation time by 34–54.6% in laparoscopic and choledochoscopic training. In anatomical education, 3DP models improved students’ performance by 57–70% in liver segment memorization. Conclusion 3DP models demonstrated substantial value in both surgical training and anatomical education for hepatobiliary surgery. Although still developing, 3DP has already achieved broad acceptance among surgeons and medical students as an effective adjunct for skill acquisition and anatomical understanding.

Abstract We report an anatomical variant in which an accessory hepatic artery supplying segment 6 arises from the dorsal pancreatic artery, identified during pre-transplant evaluation in a patient with primary sclerosing cholangitis. While a similar variant has been previously reported in a living liver donor, our case represents an independent confirmation in a different clinical context, with clear segmental correlation. Recognition of such rare hepatic arterial configurations is essential for safe planning in hepatobiliary surgery and interventional radiology.

The Textbook Outcome (TO) is a composite outcome measure that integrates commonly utilized independent outcome measures to comprehensively reflect the optimal post-surgical treatment result. It is used to assess the quality of surgeries and has been widely employed in hepatobiliary and pancreatic surgeries. However, its utility in splenic surgery remains unknown. Patients with cirrhosis and portal hypertension are often managed with splenectomy. The objective of this study was to investigate the perioperative textbook outcomes of splenectomy and identify the risk factors associated with achieving textbook outcomes after undergoing splenectomy. The clinical data of 263 patients with portal hypertension and hypersplenism who underwent splenectomy at our hospital were retrospectively analyzed. Perioperative clinical data were statistically analyzed using t-test, Wilcoxon test, χ2 test, or Fisher exact test. The 10-year survival and the incidence of postoperative hepatocellular carcinoma (HCC) were assessed using the Kaplan-Meier method and compared using the Log-Rank test. Among the 263 enrolled patients, 139 (52.85%) achieved textbook outcomes. Multivariate analysis revealed that preoperative prothrombin time and splenic vein diameter were independent risk factors for attaining textbook outcomes in patients undergoing splenectomy. The success rate of minimally invasive surgery was comparable to that of open surgery. Patients with high prognostic nutritional index and low Child-Pugh scores exhibited higher success rates. At 10-years of follow-up, there was no significant differences observed in terms of overall survival or hepatocellular carcinoma (HCC) incidence. However, patients who achieved TO demonstrated a higher long-term survival rate and a lower HCC incidence. Textbook outcomes serve as a comprehensive tool for assessing the quality of splenectomy. This study offers valuable insights guiding surgical treatment decisions for splenic diseases.

BACKGROUNDPancreatic cancer has an extremely poor prognosis. Although surgery is the first-line treatment for pancreatic cancer, its role is ultimately limited because patients often present too late for resection. Thus, multidisciplinary treatment approaches are needed. In particular, chemotherapy, targeted therapy, and immunotherapy can be ineffective for locally advanced pancreatic cancer (LAPC) because of its resistance to these modalities, but cryoablation has shown significant promise for treating this entity and prolonging survival.AIMTo investigate the safety and efficacy of cryoablation for LAPC.METHODSClinical and laboratory data, including surgical procedure, postoperative complications, immunobiochemical markers (e.g., carbohydrate antigen 19-9), and follow-up visits, of 24 LAPC patients treated with cryoablation at the department of hepatobiliary and pancreatic surgery of our hospital from January 2023 to December 2024 were retrospectively analyzed.RESULTSSurgery was smooth in all patients, with no perioperative deaths. Postoperative pancreatic fistulas occurred in 18 patients (75.0%), including biochemical leak in 14 cases and grade B (fistula) in 4 cases. Three patients (12.5%) had delayed gastric emptying. The carbohydrate antigen 19-9 level remained low on postoperative day 30 (P < 0.05). Immune markers (natural killer cells and tumor necrosis factor-alpha) significantly increased on days 7 and 30 (P < 0.01 or P < 0.05), whereas cluster of differentiation CD4+ T cells levels on day 30 significantly differed from baseline. Day 30 pain scores were significantly lower than preoperative ones (P < 0.01). Tumor volume was reduced on postoperative computed tomography. Survival was prolonged. The overall survival time of LAPC patients treated with cryoablation was 16.8 months.CONCLUSIONCryoablation can directly inactivate LAPC and boost immunity, thus delaying tumor progression, alleviating pain, improving quality of life, and prolonging survivals. Therefore, it is a safe and effective treatment option for LAPC.

Minimally invasive techniques are increasingly used in hepatobiliary and pancreatic surgeries, but robotic single-port (SP) splenectomy remains uncommon due to the rarity of splenic diseases. We present a case of a 57-year-old woman with left upper quadrant pain and a 4.3-cm splenic mass suggestive of hamartoma. Due to persistent symptoms and cosmetic concerns, robotic SP splenectomy was performed using the da Vinci SP system (Intuitive Surgical, Inc.) via a transumbilical incision, with an additional assist port in the left abdomen. The procedure lasted 264 minutes with minimal blood loss, and the patient was discharged without complications on postoperative day 9. Histopathology confirmed a splenic hamartoma. This case highlights the feasibility and safety of robotic SP splenectomy in adults, suggesting potential for wider application with further experience and refinement.

Abstract Extrahepatic cholangiocarcinoma (EC) represents a challenging malignancy, usually requiring extensive surgical resection as concurrent treatment with chemotherapy. Right hepatectomy with ductoplasty and hepaticojejunostomy is an often-used procedure to achieve negative margins. Nonetheless, extensive reconstruction of the gastrointestinal anatomy predisposes to postoperative complications, such as afferent loop syndrome (ALS). ALS occurs when the afferent limb created for biliary drainage becomes obstructed, causing accumulation of bilious material. This report presents a young patient with EC who developed ALS following complex hepatobiliary reconstruction. A 35-year-old woman with EC arising within a choledochal cyst, who underwent right lobe hepatectomy and Roux-en-Y hepaticojejunostomy, was referred to the emergency department due to elevated bilirubin levels (total 8.3, direct 6.7, indirect 1.6, all mg/dL) and generalized jaundice that began two weeks before presentation. Additionally, the patient had increasing abdominal fullness accompanied by fevers, nausea, non-bilious vomiting, and decreased oral intake. Of note, she had received only one cycle of gemcitabine, cisplatin, and durvalumab without adverse events one month prior. CT abdomen and pelvis performed on admission demonstrated extensive intrahepatic biliary ductal dilation with pneumobilia, with markedly dilated proximal loops of small bowel causing short segment bowel obstruction, likely due to tumor infiltration and adhesions. Broad-spectrum intravenous antibiotics were initiated, and a nasogastric tube (NGT) was placed for assistance with decompression. Upon an initial gastroenterology (GI) consult, there was no role for endoscopic retrograde cholangiopancreatography (ERCP) given the extensive pneumobilia; surgical oncology also indicated no intervention due to diffuse biliary dilation and multifocal obstruction sites. Additionally, interventional radiology determined that urgent percutaneous biliary drainage was not indicated, supporting the impression that the clinical picture was most consistent with ALS. Nonetheless, GI performed an upper endoscopic ultrasound which visualized the multiple dilated loops of small bowel, corresponding to the obstructed afferent (biliopancreatic) limb. A 15x10mm metal gastro-jejunal stent was successfully placed from the anterior wall of the gastric body to the target loop of small bowel, with subsequent large amounts of dark bile and sludge seen flowing through the stent. The previously placed NGT was removed, and there were no post-procedure complications. After stent placement, bilirubin levels steadily declined (total 1.3, direct 0.8, indirect 0.5, all mg/dL) and the patient experienced improved oral intake. This case highlights ALS as an inherent risk of extensive hepatobiliary surgery performed for EC, in which an altered anatomy predisposes to a condition that may not be immediately apparent. Anticipating ALS as a possible complication and implementing timely intervention are key to protect long-term biliary function. Citation Format: Humberto R. Nieves-Jiménez, Mohamad Ali Ibrahim, Chase V. West, Mitchell C. Boshkos, Sergio U. Villegas-De León, Daniel J. Leal-Alviárez. Afferent loop syndrome in a young patient with extrahepatic cholangiocarcinoma: A challenging postoperative anatomy after complex hepatobiliary surgery [abstract]. In: Proceedings of the AACR Special Conference in Cancer Research: The Rise in Early-Onset Cancers—Knowledge Gaps and Research Opportunities; 2025 Dec 10-13; Montreal, QC, Canada. Philadelphia (PA): AACR; Clin Cancer Res 2025;31(23_Suppl):Abstract nr A036.

Surgical management of perihilar cholangiocarcinoma (pCCA) is one of the most challenging procedures within hepatobiliary surgery. Robotic platform, with its intrinsic advantages, is emerging as a promising tool for these complex procedures. The aim of the study was to compare perioperative outcomes of robotic and open resections of pCCA. Retrospective, single-referral center, observational study comparing preoperative, intraoperative, and postoperative outcomes between the first 10 consecutive robotic resections and the last 20 consecutive open resections of histologically confirmed pCCA. All cases were potentially candidates for both approaches. Exclusion criteria were palliative resections, unresectable/metastatic disease, associated vascular resections, concomitant malignancies or prior major hepatectomy. Baseline characteristics were similar between the open and robotic groups, with a median age of 69years, a predominance of male (73%) and a homogeneous representation of Bismuth type (I-23%; II-13%; IIIa-13%; IIIb-27%; IV-23%). The only preoperative difference was the use of bilateral biliary drains exclusively in the open group (p = 0.029). Intraoperatively, robotic approach required less blood transfusions (p = 0.038) and allowed more extended lymphadenectomies (p = 0.001), with a consequently higher number of retrieved nodes (median 9 [6-16] vs. 4 [2-8], p = 0.022), at cost of longer operative time (660 vs 345min, p < 0.001). Postoperative complications, 90-days mortality rates and hospital stay were comparable (p = 0.175, p > 0.99 and p = 0.055). Robotic-assisted resection for pCCA appears to be a feasible and safe approach in selected patients and experienced hands, offering potential advantages over open surgery.

Background: Artificial intelligence (AI) and robotic technologies are reshaping modern surgery, evolving from mechanical aids into cognitive collaborators. Their impact on outcomes, workflow and surgical autonomy remains debated. This review synthesises the highest-level evidence from the past decade examining AI-assisted surgery in humans. Methods: A comprehensive PubMed and Embase search (January 2015–October 2025) identified peer-reviewed human studies using combinations of “artificial intelligence”, “machine learning”, “deep learning”, “computer vision” and “robotic surgery”. Eligible publications included systematic reviews, meta-analyses and large observational cohorts. Thirty-eight studies were narratively appraised and grouped into seven domains: foundational frameworks, comparative outcomes, predictive analytics, intra-operative computer vision, specialty exemplars, training and ergonomics and ethics and safety. Results: Across high-quality meta-analyses and multicentre cohorts, AI-assisted or robotic surgery consistently reduced blood loss (20-35%), shortened hospital stay (by 1-2 days), and lowered conversion rates (up to 40%) without compromising oncological margins or increasing complications. Machine-learning models outperformed conventional risk scores for morbidity, mortality and postoperative delirium prediction. Computer-vision and augmented-reality systems enhanced anatomical recognition, navigation and instrument precision. Specialty-specific studies demonstrated reproducible advantages in hepatobiliary, colorectal, urological, thoracic and paediatric surgery. Training platforms incorporating AI shortened learning curves and reduced ergonomic strain, while ethical analyses emphasised the necessity of transparency, data security and sustained human oversight. Conclusions: Evidence from 38 studies shows that AI augments rather than replaces surgical expertise. When ethically implemented, it enhances precision, safety and efficiency across disciplines. The future of operative care rests on a partnership between human judgement and algorithmic insight.

Awareness and Perceptions of Flexibility in Surgical Training: Insights From a National Survey of Surgical Fellowship Program Directors.

Academic career development in surgical oncology in Germany faces multiple challenges. Young surgeons are confronted not only with high clinical workloads but also with a lack of structured support, funding opportunities, and transparent career pathways. At the same time, there is a strong interest in academic work and specialized training programs such as fellowships. The aim of this study was to assess the current state of training opportunities, interests, and needs of early-career surgeons in surgical oncology in order to derive targeted strategies to support their clinical and academic career development.An online survey covering career planning, research interests, structural support, and training needs was developed and distributed via surgical societies and networks for young surgeons across Germany. The results were analyzed quantitatively.A total of 191 individuals participated, with most working at university hospitals (45.1%) or tertiary care centers (28.0%). The main challenges reported were high clinical workload (82.4%) and lack of time for research (66.0%). A strong interest in specialized fellowships was expressed by 85.4% of respondents, particularly in colorectal, hepatobiliary, or pancreatic surgery. Mentorship (90.9%) and protected research time (77.6%) were deemed essential. Research interests primarily focused on clinical (81.5%) and surgical-technical research (62.3%). The establishment of topic-specific subgroups within a future Early Career Group (ECG)-such as clinical trials, robotics, or mentoring-was considered helpful by the majority.The findings highlight a clear interest in academic engagement among young surgeons and the urgent need for structured support. However, current clinical working conditions often hinder active scientific involvement. The gap between motivation and structural limitations underlines the necessity for targeted measures in training, mentoring, and research support. Despite high motivation, young surgeons in Germany frequently lack sufficient support for pursuing an academic career.

Race and ethnicity data missingness in hepatobiliary and pancreatic surgery: prevalence and outcomes.

Assessment of surgical invasiveness in hepatobiliary and pancreatic surgeries by quantifying intraoperative energy expenditure: A comparison between laparoscopic and open surgery.