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Evolution of liver surgery

Dr Joslyn Ngu
28 Aug 2017
The earliest liver surgeries were performed in the 17th century primarily to manage trauma injury, says a specialist.

Liver surgery has been continuously evolving since then, said consultant surgeon Datuk Mr Harjit Singh at the12th Liver Update 2017 in Kuala Lumpur recently.

In the 1950s, Claude Couinaud published a landmark book on the segmental anatomy of the liver, which is still relevant today. Better understanding of the liver anatomy and physiology, plus advancements in the field of anaesthesia and surgical techniques ushered in an era of safe liver surgery. In the 1960s, mortality rate for liver surgery decreased significantly, he said.

In the 1970s, 1-out-of-5 patients died in the operating theatre because of exsanguinating haemorrhage during liver surgery, said Harjit. Others died post-operatively due to haemorrhage during the operation or liver failure caused by technical factors other than haemostasis, such as bile duct injuries. There were scepticism surrounding liver surgery for metastatic liver disease, he noted. Nevertheless, despite scepticism, surgery provided the best outcomes for patients with metastatic liver disease. [Ann Surg 1984;199(5):502–508, Br J Surg 1990;77(11):1241–1246.] Patients with untreated metastatic liver disease have a poor survival rate; median survival was less than 2 years, he explained.
The safety of liver surgery improved and risk of haemorrhage continue to decrease as technology, haemostatic techniques and surgical equipment become more refined. Today, minimally invasive laparoscopic and robotic techniques are widely available.

Liver surgery in Malaysia
Locally, Datuk Dr Manickavasagar Balasegaram laid the framework for liver surgery in the 1960s. As there were limited equipment available for liver surgery, he created his own, such as the Balasegaram liver clamp and Balasegaram liver retractor. In 1969, Manickavasagar set up the hepatobiliary centre in Kuala Lumpur Hospital, which became the referral centre for the nation. The referral centre was relocated to Selayang Hospital in 1999.
At the moment, there are 18 liver surgeons in the country, said Harjit. Besides the public healthcare system, there are also tertiary liver surgery units at the University Malaya Medical Centre and Universiti Kebangsaan Malaysia Medical Centre. 

Short history of liver transplantation
A major achievement in liver surgery is liver transplantation, said Harjit. The first human liver transplantation in humans was attempted by Dr Thomas Starzl in 1963; none of the patients survived longer than 23 days. He continued to research procedures and principles for liver transplantation and later in 1967, performed several successful liver transplantations. 
Liver transplantation started as an experimental treatment and today, it is an established and definitive treatment for end-stage liver disease. Advancements in liver transplantation was aided by the discovery of cyclosporine and immunosuppressive agents. The first successful live donor liver transplantation was performed by Professor Russell Strong and his team in 1989. Unfortunately, liver transplantation is currently limited by the lack of organ donors, said Harjit.
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