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.

Hepatocellular carcinoma (HCC) is common in China. With the large number of HCC patients, experienced clinicians in managing this disease and the huge amounts of resources by the government to put into researches on HCC, the treatment of HCC in China has reached to the forefront of international standards in many aspects. The treatment of HCC can roughly be divided into three levels: (1) local treatment which includes liver resection, local ablative therapy and liver transplantation. The technical aspect of liver resection has become very matured. A recent study indicated that in HCC patients with microvascular invasion (MVI), anatomic liver resection resulted in significantly better long-term survival than non-anatomic liver resection. However, no significant difference could be found in HCC patients without MVI. As there are now models using preoperative data to predict presence or absence of MVI after surgery, surgeons can now decide on whether to use anatomic resection for a particular patient before surgery. Furthermore, medical evidences are accumulating on the effective and safe use of laparoscopic and robotic liver resection for selected HCC patients, which has less trauma and faster recovery compared with open hepatectomy. As the ability in predicting HCC recurrence improves, HCC patients predicted to have high risks of developing HCC recurrence can now be put into studies to investigate the treatment strategy for reducing recurrence after R 0 liver resection. There are now a lot of high level evidence studies on the use of local ablative therapy in treating HCC. Size of lesion is an important factor in choosing radiofrequency ablation (RFA) treatment alone (for diameter of HCC <2 cm), or RFA combined with transcatheter arterial chemoembolization (TACE) or percutaneous ethanol injection (for diameter of HCC with 3 to 5 cm), or to use surgery instead of RFA (for diameter of HCC >5 cm). Liver transplanta-tion has progressed rapidly in China. To supplement the Milan criteria, other criteria have been reported in China to select suitable candidates for liver transplantation beyond the Milan criteria. Furthermore, a lot of basic and clinical researches have been carried out attempting to improve the clinical outcomes of liver transplantation. (2) Regional therapies. The recent developments in TACE has focused on the use of increasingly highly selective canalization of branches of the hepatic artery to achieve bitter treatment outcomes and to decrease adverse treatment effects. Resin yttrium 90 microsphere has just been approved for clinical use in China. The indications of yttrium 90 microspheres are treatment for patients who are unsuitable to undergo TACE, failure of TACE, bridging therapy for HCC patients waiting for liver transplantation, and tumor downstaging followed by salvage liver resection. Recent developments in yttrium 90 microsphere therapies include radiation hepatectomy and ablative transarterial radioembolization. These two procedures can offer a chance of cure to patients who cannot undergo curative treatment because of poor general status, compromised liver function and unfavorable locations of HCC. (3) Systemic therapy. This is a rapidly advancing field in HCC management, which includes the use of chemotherapy, targeted therapy and immunotherapy. These therapies when used either alone, or in combination, have improved the long-term survival outcomes of patients with intermediate or late stages of HCC. A major hurdle to overcome for systemic therapy is related to the multiple gene mutations in HCC, which even with successful blockade of a tumor signal pathway, can lead to an alternate signal pathway being opened for tumor progression. In conclusions, management of HCC has rapidly improved through the enormous efforts put in by researchers in China and all around the world. It is my sincere hope that in the near future, HCC will become a very healable disease through tireless efforts of researchers.

BACKGROUND: Chemotherapy is a common treatment for advanced hepatocellular carcinoma, but the effect is not satisfactory. The study aimed to retrospectively evaluate the effects of adding all-trans-retinoic acid (ATRA) to infusional fluorouracil, leucovorin, and oxaliplatin (FOLFOX4) for advanced hepatocellular carcinoma (HCC). METHODS: We extracted the data of patients with advanced HCC who underwent systemic chemotherapy using FOLFOX4 or ATRA plus FOLFOX4 at the Eastern Hepatobiliary Surgery Hospital, First Hospital of Jilin University, and Zhejiang Sian International Hospital and retrospectively compared for overall survival. The Cox proportional hazards model was used to calculate the hazard ratios for overall survival and disease progression after controlling for age, sex, and disease stage. RESULTS: From July 2013 to July 2018, 111 patients with HCC were included in this study. The median survival duration was 14.8 months in the ATRA plus FOLFOX4 group and 8.2 months in the FOLFOX4 only group ( P  < 0.001). The ATRA plus FOLFOX4 group had a significantly longer median time to progression compared with the FOLFOX4 group (3.6 months vs. 1.8 months, P  < 0.001). Hazard ratios for overall survival and disease progression were 0.465 (95% confidence interval: 0.298-0.726; P  = 0.001) and 0.474 (0.314-0.717; P  < 0.001) after adjusting for potential confounders, respectively. CONCLUSION ATRA plus FOLFOX4 significantly improves the overall survival and time to disease progression in patients with advanced HCC.
Humans ; Carcinoma, Hepatocellular/drug therapy* ; Retrospective Studies ; Liver Neoplasms/pathology* ; Oxaliplatin/therapeutic use* ; Fluorouracil/adverse effects* ; Disease Progression ; Antineoplastic Combined Chemotherapy Protocols/therapeutic use* ; Leucovorin/adverse effects* ; Colorectal Neoplasms/drug therapy*

Digital medicine has played a vital role in promoting the development of hepatobiliary and pancreatic surgery of China.The multidisciplinary integration of medical science and technology innovates research and development,and practice in clinical diagnosis and treatment.Digital medicine has enabled within 20 years,development from digital virtual human,three-dimensional visualization,molecular fluorescence imaging to artificial intelligence.There are four important stages of the development in China′s digital medical technology:digital medicine 1.0 (2002 to 2004,digital virtual human) on digital human anatomy, digital medicine 2.0(2004 to 2014,three-dimensional(3D) visualization and 3D printing) on 3D diagnosis and treatment of complex hepatobiliary and pancreatic diseases, digital medicine 3.0(2014 to 2019,molecular fluorescence imaging) on precision navigation of tumor boundaries and micro tumors using indocyanine green molecular imaging, and digital medicine 4.0(2019 to present,digital artificial intelligence) on augmented reality-based and mixed reality-based 3D abdominal navigation hepatectomy and photoacoustic imaging of tumors.Over the past 20 years′ course of development,Chinese researchers have made countless and remarkable achievements in digital medicine through continuous efforts and innovation. In the future,cutting-edge technologies such as artificial intelligence on deep machine learning,multi-mode image real-time fusion navigation surgery,photoacoustic imaging and targeted molecular probe technology will promote the development of digital medicine 4.0 in a coordinated manner,leading to the advent of digital medicine 5.0.

Digital medicine has played a vital role in promoting the development of hepatobiliary and pancreatic surgery of China.The multidisciplinary integration of medical science and technology innovates research and development,and practice in clinical diagnosis and treatment.Digital medicine has enabled within 20 years,development from digital virtual human,three-dimensional visualization,molecular fluorescence imaging to artificial intelligence.There are four important stages of the development in China′s digital medical technology:digital medicine 1.0 (2002 to 2004,digital virtual human) on digital human anatomy, digital medicine 2.0(2004 to 2014,three-dimensional(3D) visualization and 3D printing) on 3D diagnosis and treatment of complex hepatobiliary and pancreatic diseases, digital medicine 3.0(2014 to 2019,molecular fluorescence imaging) on precision navigation of tumor boundaries and micro tumors using indocyanine green molecular imaging, and digital medicine 4.0(2019 to present,digital artificial intelligence) on augmented reality-based and mixed reality-based 3D abdominal navigation hepatectomy and photoacoustic imaging of tumors.Over the past 20 years′ course of development,Chinese researchers have made countless and remarkable achievements in digital medicine through continuous efforts and innovation. In the future,cutting-edge technologies such as artificial intelligence on deep machine learning,multi-mode image real-time fusion navigation surgery,photoacoustic imaging and targeted molecular probe technology will promote the development of digital medicine 4.0 in a coordinated manner,leading to the advent of digital medicine 5.0.

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.

Introduction: Carpal tunnel syndrome (CTS) is the commonest median nerve entrapment neuropathy of the hand, up to 90% of all nerve compression syndromes. The disease is often treated with conservative measures or surgery. The senior author initially intended to treat his own neurosurgical patients concurrently diagnosed with carpal tunnel syndrome in 2014, subsequently, he began to pick up more referrals from the primary healthcare group over the years. This has led to the setup of a peripheral and spine clinic to act as a hub of referrals. Objective: Department of Neurosurgery Sarawak aimed to evaluate the surgical outcome of carpal tunnel release done over five years. Methods: The carpal tunnel surgeries were done under local anaesthesia (LA) given by neurosurgeons (Bupivacaine 0.5% or Lignocaine 2%). Monitored anaesthesia care (MAC) was later introduced by our hospital neuroanaesthetist in the beginning of 2018 (Target-controlled infusion propofol and boluses of fentanyl). We looked into our first 17 cases and compared these to the two anaesthesia techniques (LA versus MAC + LA) in terms of patient’s pain score based on visual analogue scale (VAS). Results: Result showed MAC provided excellent pain control during and immediately after the surgery. None experienced anaesthesia complications. There was no difference in pain control at post-operation one month. Both techniques had equal good clinical outcome during patients’ clinic follow up. Conclusion: Neurosurgeons provide alternative route for CTS patients to receive surgical treatment. Being a designated pain free hospital, anaesthetist collaboration in carpal tunnel surgery is an added value and improves patients overall experience and satisfaction.

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.

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.