Valentina Ferraro

Liquid biopsy is an emerging approach for the molecular characterization of hepatopancreatobiliary (HPB) malignancies through the analysis of circulating tumor DNA (ctDNA), circulating tumor cells (CTCs), and extracellular vesicles (EVs). These biomarkers may complement conventional imaging and serum markers by providing additional information on tumor biology and disease evolution. This narrative review examines the available evidence concerning the potential applications of liquid biopsy in HPB surgical practice, with particular emphasis on preoperative prognostic assessment, postoperative molecular residual disease detection, recurrence monitoring, and treatment adaptation. Among the different circulating biomarkers, ctDNA currently has the most developed perioperative evidence base. Studies involving pancreatic ductal adenocarcinoma, hepatocellular carcinoma, and biliary tract cancers have demonstrated associations between ctDNA detection and unfavorable oncological outcomes, particularly postoperative recurrence. Nevertheless, the available evidence remains predominantly observational, with considerable heterogeneity in patient populations, sampling protocols, analytical platforms, and outcome definitions. Although the integration of circulating biomarkers with conventional anatomical criteria has generated interest in the concept of “biological resectability”, this framework remains hypothetical and has not been prospectively validated for surgical treatment selection. Similarly, ctDNA-guided modifications of neoadjuvant therapy, adjuvant treatment, or postoperative surveillance have not yet demonstrated clinical benefit in HPB malignancies. Liquid biopsy should therefore currently be regarded as a promising investigational prognostic tool rather than an established determinant of surgical or oncological management. Standardized methodologies and prospective interventional trials are required before its routine clinical implementation.

Background: The evolution of robotic surgery has widened the indications for minimally invasive hepatopancreatobiliary (HPB) surgery, making possible the execution of more complicated cases. Within this context, the learning curve concept is now an essential factor when assessing surgical training and expertise, as well as patient safety within a robotic HPB program. Nevertheless, existing methodologies often make use of procedure volume and surrogate intraoperative measures, which may be an insufficient way to define surgical competence. Methods: This narrative review examines the learning curve concept in robotic HPB surgery, focusing on existing performance metrics, methodological limitations, procedural complexity, risk adjustment, and the influence of team-related and institutional factors. Results: The time of operation, the estimated blood loss, the rate of conversion, and postoperative morbidity are frequently applied to assess learning curves. Nevertheless, these metrics are affected by the criteria of patient selection, the level of complexity of the procedure, and some other factors like institutional characteristics and experience of the team performing the procedure. As a result, one single value or an inflection point might fail to adequately capture the concept of surgical competence. The concepts of competency, proficiency, and mastery are distinct stages of learning, whereas the speed of learning for such skills as technical proficiency, clinical outcomes, oncological sufficiency, and intraoperative decision-making might be different. Conclusions: The learning curve in robotic HPB surgery should be viewed as a multi-dimensional and complex process and not a straightforward correlation between the number of cases and the results. The future assessment of the learning curve needs to consider different domains, including technical, clinical, oncological, cognitive, and team-related aspects, taking into account the level of complexity and institutional context of each case.

Accurate assessment of hepatic functional reserve is essential in patients with primary or secondary liver malignancies undergoing liver resection, particularly in the presence of chronic liver disease, chemotherapy-associated liver injury, cholestasis, or portal hypertension. Conventional laboratory parameters and clinical scores, including Child-Pugh, MELD, ALBI, and the combined APRI/ALBI score, provide accessible measures of global hepatic status and risk stratification but do not directly quantify regional function or dynamic metabolic capacity. Complementary approaches include indocyanine green clearance, LiMAx testing, liver stiffness measurement, hepatobiliary scintigraphy, gadoxetic acid-enhanced magnetic resonance imaging, and CT/MRI-based future liver remnant volumetry. This narrative review critically examines the strengths, limitations, and clinical applicability of these modalities in the context of contemporary evidence and recommendations. Building on, but extending beyond, the 2023 E-AHPBA-ESSO-ESSR Innsbruck consensus, we incorporate subsequent comparative evidence on blood-based scores and functional imaging and discuss emerging approaches including longitudinal assessment, radiomics, and artificial intelligence. Current evidence supports an individualized, multimodal strategy in which volumetry remains central to surgical planning, while additional functional and portal-hypertension assessment is selected according to the extent of resection, underlying parenchymal disease, previous treatment, and local expertise. No single modality or fixed combination can currently be considered universally superior, highlighting the need for prospective validation of integrated and cost-effective assessment strategies.

Background: Minimally invasive liver surgery has continuously developed with the advent of robotic systems that could present some advantages regarding dexterity and visualization. Single-port robotic devices have been introduced more recently in order to minimize the invasiveness of surgery. Unfortunately, scientific literature on this topic is still poor. This pilot feasibility study aimed to assess the technical applicability and short-term outcomes of single-port robotic liver resection. Methods: The study was designed as a retrospective analysis of 11 consecutive patients treated with single-port robotic liver resection. All interventions were performed in order to treat lesions localized in the anterolateral segments of the liver. All preoperative, intraoperative, and postoperative data were collected retrospectively and considered for the analysis. Cirrhotic patients were graded according to the Child–Pugh score. Results: The median age was 67 years (IQR 41–78), and 63.6% of the patients were women. There was cirrhosis in 27.3% of the cases, and all cases were categorized as Child–Pugh class A. Neoadjuvant chemotherapy was not administered in any of the patients. All procedures were considered Tampa grade II. The median operation time was 190 min (IQR 70–320), and the median blood loss was 50 mL (IQR 0–300). Pedicle clamping was done in 36.4% of the cases. An additional assistant trocar was needed in 45.4% of the procedures. In total, two anatomical and nine non-anatomical resections were done. There were no postoperative complications, reinterventions, and 90-day readmissions. The median length of hospitalization was 2 days (IQR 1–3). The postoperative pain was minimal, with a median VAS and NRS score of 0 on postoperative days 0 and 1. Analgesic treatment was ceased on postoperative day 1, and the median time to first flatus was 1 day in all patients. Conclusions: Single-port robotic liver resection seems to be technically possible in selected patients with intermediate-difficulty lesions in anterolateral segments. Additional research is necessary to establish its role in minimally invasive liver surgery.

Parenchyma-sparing pancreatic surgery (PSPS) is a patient-centered alternative to traditional radical resections for benign and low-grade pancreatic lesions. Unlike pancreaticoduodenectomy and distal pancreatectomy, which tend to cause long-term exocrine and endocrine deficiency, PSPS aims to preserve functional tissue with a guarantee of oncologic safety. Techniques such as enucleation, central pancreatectomy, duodenum-preserving head resection, and uncinectomy are illustrative of this equipoise, with less risk of new-onset diabetes and malabsorption but more short-term morbidity in the form of postoperative pancreatic fistula. Advances in imaging technology, minimally invasive procedures, and robotics technology have extended PSPS indications beyond conventional candidates to thoughtfully selected neuroendocrine tumors, cystic neoplasms, and solid pseudopapillary neoplasms. Results are strongly dependent on patient selection, surgeon experience, and institutional volume, highlighting the importance of centralization and subspecialist training. While oncologic proficiency remains essential in aggressive tumors, evidence is in favor of PSPS being a curative and function-preserving option for properly screened patients with low-grade or benign conditions. Priorities for the future include multicenter prospective trials, optimization of perioperative techniques, and inclusion of patient-reported outcomes. PSPS represents a paradigm shift in pancreatic surgery, where technical innovation is balanced with quality of life in the long term and evolving principles of modern, individualized surgical practice.

Background: Robotic pancreaticoduodenectomy (RPD) is a less invasive alternative to open pancreaticoduodenectomy (OPD) with the potential for perioperative advantage. Concerns remain regarding its technical difficulty, cost, and oncologic adequacy. Methods: Review of PubMed, MEDLINE, Scopus, and Embase databases was conducted (January 2000–October 2025), focusing on systematic reviews, meta-analyses, and significant comparative studies of RPD. Outcomes assessed were perioperative outcomes, oncologic sufficiency, learning curve, model training, cost-effectiveness, and future developments. Results: Several studies report comparable R0 rates and lymph node yield between RPD and OPD, with reduced blood loss, shorter postoperative hospital stay, and faster recovery in high-volume centers. Morbidity (35–50%) and 90-day mortality (<2%) are similar to open or laparoscopic surgery. Competence is usually achieved after 40–60 cases, while optimal outcomes are achieved after 80–100 procedures. Structured mentorship and simulation training improve safety and reproducibility. Novel technologies such as augmented reality, intraoperative fluorescence, and artificial intelligence-based navigation may also enhance accuracy and shorten the learning curve. Conclusions: RPD appears to be a safe and effective minimally invasive option in carefully selected patients if done in specialized, high-volume centers. Future studies need to resolve long-term oncologic results, cost-effectiveness, and the role of next-generation robotic systems.

Introduction: Pancreatico-duodenectomy (PD) remains one of the most complex abdominal surgeries, and pancreatico-jejunostomy (PJ) fistula is its most critical postoperative complication. In efforts to reduce the incidence of postoperative pancreatic fistula (POPF), several PJ techniques and adjuncts, including stents, have been recommended. This article presents data from an international survey regarding PJ methods, the use of pancreatic stents, and their correlation with POPF rates from surgical centers worldwide. Methods: A nine-item online questionnaire was sent globally through social networks, individual mailing lists, and the ASHBPS mailing list. Data were analyzed through the Student’s t-test (two-tailed, unequal variance). A p-value < 0.05 was considered to be statistically significant. Results: A total of 122 units of pancreatic surgery from 26 countries distributed across five continents responded to the survey. Most centers performed less than 50 PDs a year, preferred a duct-to-mucosa PJ, and employed a stent routinely. Mean POPF grade B and C incidences were lower in high-volume (15.24% ± 7.29 and 3.95% ± 2.39) and in PJ stent-using centers (16.25% ± 8.7 and 5.37% ± 7.49). Conclusions: Institutional case volume and stent usage are more crucial determinants of POPF incidence than the PJ technique itself. Centralization and standardization of PD procedures are related to reductions in major fistula rates.

Introduction: The da Vinci Single-Port (SP) robotic system represents a newer minimally invasive surgical development with greater articulation and reduced surgical footprint through the use of a single incision. While originally applied in urology and otolaryngology, its application in general surgery is on the rise. This review aims to delineate the current applications, outcomes, and limitations of the SP platform in general surgical procedures. Methods: A descriptive literature search of PubMed, Scopus, and Embase databases was conducted to identify relevant peer-reviewed studies up to September 2025. The included studies reported SP robotic surgeries in various fields of general surgery. Results: A growing body of literature was found that reports the safety and feasibility of SP robotic surgery within general surgery. Advantages reported include improved cosmesis, decreased postoperative pain, and shorter recovery time. The present evidence is largely made up of small case series and initial feasibility studies. Technical drawbacks, such as crowding of instruments and a learning curve, remain issues. Conclusions: The da Vinci SP system shows promising potential for application in general surgery, particularly for certain procedures. Additional prospective studies and larger case series need to outline its long-term results, cost-effectiveness, and optimal indications.

Background: The associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a surgical strategy for patients with advanced liver tumors and inadequate future liver remnants (FLR). This study compares post-operative outcomes between open (oALPPS) and robotic (rALPPS) ALPPS in our institution. Methods: This retrospective monocentric study includes eleven patients who underwent ALPPS procedure between January 2023 and February 2024. Demographics, tumor characteristics, and intra- and post-operative outcomes were collected and analyzed. Results: In the first-stage ALPPS, the frequency of intermittent hilum clamp and the estimated blood loss were higher in the oALPPS group, while operative time and complications were similar, and total hospital stay was higher in the rALPPS group. In the second-stage ALPPS, the data regarding intraoperative and post-operative data were similar. In rALPPS, there were no post-discharge complications, readmissions, or deaths within 30 days. Conclusion: This single-center study has an exploratory setting given the small cohort, but if confirmed in larger studies, rALPPS could be a viable alternative to oALPPS.

Intrahepatic cholangiocarcinoma (iCCA) is the second most common primary liver cancer with a poor prognosis. Negative-margin resection is presently the only potentially curative treatment option. Emerging trends with direct applicability to surgical strategy include margin thickness, lymphadenectomy, optimization of future liver remnant (FLR), minimally invasive techniques, incorporation of systemic therapy, and reconsideration of liver transplantation. This review emphasizes areas of consensus and ongoing debate. Margins ≥5–10 mm are associated with improved results, but biology generally takes precedence over prognosis. Regional lymphadenectomy enhances staging accuracy, although its therapeutic benefit remains unsettled. PVE is standard for FLR enlargement, LVD provides faster hypertrophy, and ALPPS remains reserved for highly selective cases. Minimally invasive and robotic hepatectomy share oncologic results in skilled institutions. Systemic therapies, including immunotherapy and biomarker-directed targeted therapy, are increasingly being incorporated perioperatively. Liver transplant may be of potential value in early-stage disease or on strict indications after neoadjuvant treatment. The modern surgical management of iCCA encompasses a blend of oncologic considerations, FLR optimization, minimally invasive surgery, and systemic therapy according to tumor biology. Multidisciplinary planning and participation in clinical trials are necessary to align surgical innovation with advancements in molecular and systemic treatments, ultimately leading to improved long-term outcomes.