Minimally invasive surgery: hepatobiliary-pancreatic and foregut

This review is confined to the liver, biliary tract, pancreas, and foregut (oesophagus and stomach). The issues relating to laparoscopic cholecystectomy mainly concern the bile duct injuries associated with this operation. This review provides some evidence that although the risk for this iatrogenic injury is declining, it continues to be a problem and is accompanied by significant morbidity, mortality, and a huge escalation in care costs. Laparoscopic clearance of ductal stones is undoubtedly safe and effective, and issues have now focused on comparisons between this form of management and orthodox endoscopic clearance. Laparoscopic cardiomyotomy may well replace other forms of treatment of achalasia, including balloon dilation and botulinum toxin injection. As the results of laparoscopic antireflux surgery have been so good in the medium term, the question of medical versus laparoscopic treatment is being addressed by two randomized clinical trials. Gastric resection is established only in respect of excision of mesenchymal tumours. Gastric surgery for advanced gastric cancer must still be regarded as developmental. Laparoscopic liver resections and in situ ablation are still confined to developing centres, but the early results are promising. However, simpler hepatic procedures, such as de-roofing of symptomatic simple hepatic cysts, are well established and in widespread practice. Only a few centres have published their results on laparoscopic pancreatic surgery. The early reported outcome for internal drainage of pancreatic pseudocysts, enucleation of benign insulinomas, and distal pancreatic resections has been good, but the experience is limited.