In Chinese traditional culture,there are the concepts “Dao” and “Shu”.“Dao” means basic concept,basic principle,rule and regulation.“Shu” on the other hand means the application of “Dao” into daily use.If we apply these concepts of “Dao” and “Shu” into clinical medicine,“Dao” becomes the basic principle and rule that every good clinician should follow.This requires every clinician to have good medical ethics,sound medical knowledge,technical skills and the ability to apply the knowledge and skills into patient management.Furthermore,each clinician should submit himself to life-long continuing medical education and auditing.For a good surgeon,there is the additional requirement that he should have a pair of good hands.In other words,“Shu” is required in a good surgeon so that he can apply his medical knowledge and skills through operating with his hands.A good balance in the development of “Dao” and “Shu” is the basic requirement to become a good surgeon.Thus,a balance in “Dao” and “Shu” forms the launching platform for future development of a good surgeon.Clinical research in surgery is based on good clinical works and results.Without good clinical works and results,there is no good clinical research.On the other hand,good clinical research helps to improve clinical works and results.Thus,the two forms a virtuous cycle.In other words,clinical research and innovation in surgery are the final product of a balanced development of “Dao” and “Shu” in surgery.

Intraoperative ultrasound (IOUS) should be routine in modem liver surgery.It can be divided into open and laparoscopic IOUS.The two types of IOUS differ not only in technique,but also in ultrasound probes.IOUS probes can further be classified as sector and linear probes.IOUS has a wide application in liver surgery.It improves intraoperative diagnosis and staging of tumour.As a consequence,it changes the preoperative surgical plan in 23％ to 51％ of patients.Under IOUS guidance,surgeons can carry out biopsy or treatment of liver nodules.It helps liver surgeons to localize tumours,to determine resection margins,to determine hepatic parenchymal transection planes,to guide and monitor transection planes and to find major vessels in order to protect or to ligate them.Proper IOUS requires special equipments and personnel.IOUS has a very wide application in modem liver surgery.Its widespread use would depend on the establishment of a proper training programme.

There are two international classifications for hepatocellular carcinoma with portal vein tumour thrombosis (HCC with PVTT):the Cheng's Classification and the Liver Cancer Study Group of Japan.These two classifications are quite similar.Personally Ⅰ prefer the Cheng's Classification for 2 reasons:(1) it is not easy to differentiate Vpl and Vp2 in the Japanese Classification;and (2) the Japanese Classification does not have a stage for PVTT that extends to the superior mesenteric vein,i.e.the Cheng's Type Ⅳ.The main defect of these two classifications is that both classifications consider only the extent of PVTT without considering other factors which impact on treatment and prognosis.I apply some important prognostic factors used in the Barcelona Clinic Liver Cancer (BCLC) Classification for liver cancer onto the Cheng's Classification of HCC with PVTT,to come up with a new Lau-Cheng Classification.These factors include:(1) the general condition of the patient,the liver functional status and whether there is any serious associated medical diseases;(2) extrahepatic metastasis;(3) main PVTT;(4) resectability of the primary liver cancer;(5) combination with microvascular invasion (MVI).This new classification divides HCC with PVTT into the very early stage (MVI only),early stage (resectable HCC with PVTT),intermediate stage (not resectable),late stage (wlth extrahepatic metastases),and terminal stage (poor general condition,decompensated liver function,or associated with serious medical diseases).The early,intermediate and late stages can further be divided into A and B according to whether the main portal vein is not involved or is involved by PVTT.All these different stages of HCC with PVTT have their own recommended treatment and prognosis.This new classification needs to be supported by clinical data before it can be used.

Various techniques of liver parenchymal transection have been introduced,including the finger fracture technique,clamp-crush method,Cavitron ultrasonic surgical aspirator,waterjet,TissueLink,Ligasure,harmonic scalpel,vascular stapler,radiofrequency dissection sealer and the Peng's multifunction operative dissector.All these techniques have the common goals of achieving rapid liver parenchymal transection,minimizing blood loss and preventing bile leak or fistula.It is still unclear which technique is the best.The technique of choice for any individual surgeon would depend on the condition of patients,surgeon's experience and the resources available.This article reviewed the current development and role of the various techniques.

Objective To investigate the causes of peripheral cytopenia in patients with posthepatitic cirrhosis and portal hypertensive splenomegaly.Methods The clinical data of 183 patients with hepatitic cirrhosis and portal hypertensive splenomegaly complicated by peripheral cytopenia who were operated in our hospital in the past 17 years were retrospectively studied.Results All these patients underwent splenectomy.Before operation,all these patients had one or more types of peripheral cytopenia (cumulative cytopenia:390 patient-times).After splenectomy,blood counts in 79.2％ returned to normal;in 15.9％ increased but failed to reach normal levels;and in 4.9％ became lower than before operation.5 patients died soon after operation.Conclusion Hypersplenism is the main cause for the peripheral cytopenia most cirrhotic portal hypertension patients.Splenectormy is an effective method to treat hypersplenism.

Modern surgery started at around the 19th century when our pioneers started to solve the problems brought in by surgery:pain,infection and excessive blood loss.Since then,surgery has advanced rapidly,and it gradually develops towards two extremes:ultra-major operations and minimally invasive/non-invasive surgery.The ability for surgeons to carry out ultra-major operations which was previously considered to be impossible would depend on major advances in better understanding of anatomy,physiology and pathology,advances in other fields of medicine to provide improved perioperative care to patients,and advances in surgical equipment and technologies.Hepatic surgery,like any other fields in surgery,has developed rapidly,and is also developing towards these two extremes.In the 2000s,when different types of liver allogenic transplantation techniques have been invented,a lot of liver surgeons thought that this extreme end of liver surgery has probably come to an end.The next advancement would probably be xenotrans-plantation which requires major advances in immunosuppression and molecular medicine to make it happen,but not major advances in surgical techniques.Then came ex vivo liver resection and autotransplantation and their further developments.Another extreme development is towards minimally invasive surgery,which includes interventional,laparoscopic and robotic surgery;and from using multiple ports to single-port or through natural orifice surgery.Techniques using non-invasive surgery to treat patients with liver diseases are just emerging with a lot of space to further develop.All these advances in surgery have only one goal,and the goal is to achieve the best surgical treatment results for patients with the minimal adverse side-effects.

Digital medical technology is a powerful tool which has forcefully promoted the development of general surgery in China. In this article, we reviews the application status of three-dimensional visualization and three-dimensional printing technology in general surgery, introduces the development situation of surgical navigation guided by optical and electromagnetic technology and preliminary attempt to combined with mixed reality applied to complicated hepatectomy, looks ahead the development direction of digital medicine in the era of artificial intelligence and big data on behalf of surgical robot and radiomics. Surgeons should proactively master these advanced techniques and accelerate the innovative development of general surgery in China.

There have been a lot of debates on whether medicine is art or science.Some consider medicine as a discipline of science,others consider as a discipline of science and art,while some others consider as application of art on science.Surgery is a specialty in medicine in which clinicians use their hands to heal patients.It is not surprising that whether surgery is art or science is even more controversial.Modern medicine began in the 1880s when the three major problems in surgery were overcome:pain,infection and blood loss.Since then surgery has developed very fast.Modern surgery is established on the basis of science:from the basic knowledge of anatomy,physiology,pathology and diagnostic radiology,modern surgery evolves to treat diseases.There is little doubt that in the ideal world even surgical decision-making should be based on science and evidence-based medicine.Unfortunately,science cannot solve all of problems encountered by surgeons in their clinical practice.With the rapid development of evidencebased medicine in the past few decades,there are still a lot of areas in surgery where there is no good evidence to guide clinical decision-making.Under these situations,clinicians can only rely on their knowledge and experience to make a judgement-the application of art on science to make a medical decision.Moreover,accurate,appropriate and timely clinical judgement is also a combination of art and science.Similarly,the development of surgical skills is based on science.However,the merging of science and art produces application of technique and surgical innovation.Modern surgery is developed based on science.The application of art on science is sometimes required to make clinical judgement,especially intraoperative judgement.Surgical innovation,which combines science and art,helps to improve the standard of surgery.

The incidences of hepatocellular carcinoma (HCC) and ruptured HCC differ significantly in different countries and regions of the world. Ruptured HCC has a very high mortality rate, although the underlying mechanisms why it occurs remain controversial. The diagnosis of ruptured HCC is made based on clinical and imaging examinations. Management of ruptured HCC can be divided into 3 phases. Phase 1: the emergency phase. The treatment aims are to stabilize the patient and stop bleeding by resuscitation.Methodswhich can be used to stop bleeding include correction of coagulopathies, interventional therapy (transarterial embolization) and surgery (including perihepatic packing, hepatic artery ligation, application of energy source or direct injection of ethanol, or even emergency partial hepatectomy). Phase 2: the assessment phase. After the bleeding has been stopped, the next phase is assessment, which includes assessing the general condition of patients, liver function, tumor staging, resectability of tumor, volume of future liver remnant, comorbidity and association with cirrhosis and/or portal hypertension. Phase 3: definitive treatment phase. The definitive treatment can be divided into curative and non-curative treatments. As ruptured HCC is a contraindication to liver transplantation, the only available curative treatment is partial hepatectomy. There is evidence to show that peritoneal irrigation with water or 5-FU during partial hepatectomy for ruptured HCC can reduce the rate of tumor implantation. The timing of partial hepatectomy can be emergency (during the rupture time), early delayed (within 8 days of HCC rupture) or late delayed (>8 days of HCC rupture). Evidence is emerging that partial hepatectomy carried out in the emergency or early delayed period has a lower incidence of peritoneal tumor implantation and metastasis compared with the late delayed period to carry out partial hepatectomy. After the bleeding stopped in patients with ruptured HCC, the treatment of patients with unresectable HCC would be similar to those with non-ruptured HCC. In patients with resectable HCC, high level evidences are emerging to show that partial hepatectomy can result in better long-term survival compared with any form of non-surgical treatments, including transcatheter arterial chemoembolization and transarterial radioembolization.

The terms "Surgery 1.0" to "Surgery 4.0" came from the term "Industry 4.0" . In 2011, the German Government at the Hannover Messe introduced the term "Industry 4.0" to describe the four stages of industrial developments: Industrial revolution, which happened in England in the 18th century, was considered as "Industry 1.0" . The beginning of "Industry 1.0" and the subsequent developments into "Industry 2.0" , "Industry 3.0" and "Industry 4.0" were all based on important scientific discoveries at those material time periods. In 2018, Hooshair A first introduced the concept of similar developments from "surgery 1.0" to "surgery 4.0" . Similar to industrial developments, these stages of surgical developments were based on important scientific discoveries, although the time periods of developments of these surgical stages were slightly different from those of the industrial developmental stages. "Surgery 4.0" started at the beginning of the 21st century. Its development is based on the scientific advances in big data, artificial intelligence, automation, modern robots and 5G technology. Within a short period of 20 years, each of these scientific discoveries has rapidly progressed. As each of these developments leads to increase in demand of another one, this leads to a virtuous cycle with rapid developments in all these individual scientific discoveries. Is there any room for further development of "Surgery 4.0" ? The authors predict that there will be a rapid development into "Surgery 5.0" by integrating these discoveries. Instead of individual and rapid development of each of the scientific advances, these advances will integrate into a single system with further fast and rapid growth. It is ambitions for the authors to make such a prediction when "Surgery 4.0" is still at an developmental stage. However the authors are confident that "surgery 5.0" will not only come, but it will come within a reasonably short time, as this is the natural development of science.