Johns Hopkins Surgery
April 9, 2015

Not long ago, patients in need of liver resection had one choice: open surgery, with a chevron incision. Extending from the armpit below the ribs on the right side of the abdomen to the opposite armpit, the 24- to 30-inch cut almost guarantees a lengthy hospital stay; significant, lingering discomfort; and increased risk of morbidity. But in recent years, as laparoscopic and robotic techniques for other abdominal surgeries have matured, applications to liver resection offer an attractive alternative for eligible patients, says Timothy Pawlik, director of surgical oncology at Johns Hopkins.

There’s far less morbidity, he says, and hospital stays range from four to five days—instead of seven to 10. Patients generally return to work in two weeks, versus four to six.

Using a minimally invasive approach, Johns Hopkins surgeons begin with a 1-inch incision at the navel, a small incision to the pelvis and about four tiny holes in the abdomen.Through these openings, surgeons can excise up to 60 percent of the liver.The liver segment can be removed through a small pelvic incision that doesn’t involve dividing any muscle.This is similar to a C-section incision that obstetricians use.

“Not only is the recovery quicker as a result,” says Ben Philosophe, liver surgeon and clinical director of Johns Hopkins Medicine’s Division of Transplantation, “but the herniation rate is lower with this approach.”

The newer robotic method takes place remotely, from a corner of the operating room. Two surgeons work in tandem: One sits at the console controlling the robot, and the other stands at the bedside to change the robotic instruments as needed, and in case there’s a major problem with bleeding that requires rapid conversion to an open procedure emergently. In these cases, Philosophe works closely with surgical oncologist Matthew Weiss and hepato-pancreato-biliary surgery director Christopher Wolfgang.

Considering the liver’s location, multiple blood vessels leading to and from the vena cava, and the
organ’s propensity to bleed, liver surgery of any kind poses risks. But, says Philosophe, “We have the best of both worlds here for our patients—an elite class of liver surgeons and specialists across several disciplines working together to advance the field.” These include oncology, pathology, hepatology, gastroenterology, interventional radiology and radiation oncology.

With better chemotherapy, imaging and surgical techniques, a patient’s tumor previously thought not to be removable can sometimes be removed laparoscopically—and with excellent results, says Philosophe. And, as the incidence of liver cancer rises, more patients will likely need liver resection. Knowing that he and his team can sometimes spare these patients the hardships of an open procedure—even as a bridge to transplant—says Philosophe, is heartening.

To refer a patient: 877-548-3799