Surgical Decision-Making in Hepatobiliary and Pancreatic Surgery

Hepato-pancreatic-biliary (HPB) surgery has long been recognized as one of the most challenging fields in general abdominal surgery because of its anatomical complexity, diversity of presentations and historically high morbidity rates. Nonetheless, it is also one of the most dynamic and rapidly evolving surgical areas, regarding minimally invasive surgery and transplantation. Newly discovered systemic therapeutic agents continuously stretch the limits of surgical resectability, further increasing the complexity in the decision-making process. Multidisciplinarity is the key element in the decision-making process for HPB surgical patients. Advancements in diagnostic methods and preoperative optimization of the HPB patient have allowed for substantially better outcomes in the last decades. However, sometimes even in the intraoperative setting, the surgical team can be challenged by unforeseen patient and surgical factors that might have been missed or unknown before surgery. HPB surgeons have sometimes to be faced with complex decisions, usually without the benefit of consulting with the patient, or even with other colleagues. The modern HPB surgeon must therefore possess great cunning, creativity and plasticity to make the best possible decision in a case-to-case approach. In this chapter we will illustrate some general aspects of surgical decision-making, as well as others specific to HPB surgery, showcasing relevant real-world cases.