GastrointestinalRobotic liver resection including the posterosuperior segments: initial experience
Introduction
Minimally invasive liver surgery has a relatively brief history. Compared to other gastrointestinal procedures, laparoscopy in liver surgery lags behind. In the 1992, the first nonanatomic laparoscopic liver resection was performed, and the first anatomic laparoscopic liver resection was performed in 1996.1, 2 Nowadays, minimally invasive techniques are widely accepted. Over 3000 laparoscopic liver resections have been reported in the literature, ranging from resections for malignant and benign lesions to donor procedures.3, 4 Nonrandomized studies have shown that laparoscopic liver resection is safe and feasible in selected patients. Moreover, when comparing the laparoscopic liver resection with open liver resection, the laparoscopic approach is associated with significantly shorter hospital stay, less blood loss, and similar oncologic outcomes.5, 6, 7, 8, 9
In the last few years, a new minimally invasive technique for liver resection emerged: robot-assisted laparoscopic liver resection. The robotic system has been designed to overcome the shortcomings of conventional laparoscopy. It provides increased dexterity, a three-dimensional, magnified view of the operative field and leads to decreased fatigue for the surgeon. Presumed current cost and lack of randomized evidence for use of robotics have been cited as potential downsides.10 Anyway, robot-assisted laparoscopy is nowadays widely used in gastrointestinal, urological and gynecological surgeries. However, in liver surgery, it is not extensively used. Currently, approximately 400 procedures have been described in the literature.11
The aforementioned advantages of the use of a robotic system lead to increased precision in surgical dissection. Theoretically, the use of a robotic system would especially be advantageous in resections that require nonlinear manipulation such as resections of the posterosuperior segments and in hilar dissection and curved parenchymal transection.12, 13, 14
In this study, we describe our first experiences with minor liver resections using the da Vinci Si robotic system (Intuitive Surgical, Sunnyvale, CA). Sixteen consecutive, selected patients underwent robot-assisted laparoscopic minor liver resections. Among these were eight patients who underwent a resection of a posterosuperior segment.
Section snippets
Methods
The University Medical Center Utrecht has experience on robotic surgery for several years. Since 2000, robot-assisted esophagectomies are performed. In addition, also pancreatic resections and thyroidectomies are performed robotically. This experience was used to help in setting up the program for the robot-assisted laparoscopic liver resections.
Following this, the first 16 patients underwent robot-assisted laparoscopic liver resection at University Medical Center Utrecht using the da Vinci Si
Room setup and port placement for resections of anterior segments (2 or 3, 4B, 5, and 6)
Patients who underwent a resection of an anterior segment were placed in a supine position, 30° anti-Trendelenburg. First, a 12-mm trocar was placed in the umbilicus for camera introduction. Pneumoperitoneum was established to 15 mm Hg. Subsequently, the abdominal cavity was inspected for metastatic disease or other abnormalities. Under camera supervision, two additional 8-mm trocars were placed for robotic arms, and one port was placed for assisting. The robot was then docked over the
Patient demographics and procedures performed
Patient demographics and procedures performed are summarized in Table 1. Median age was 69 (range, 34-75) years. Nine patients were male. Median BMI was 25 (range, 18-33). Eleven patients had previous abdominal surgery, including two patients who had undergone previous liver surgery. Six patients had received chemotherapy preoperatively. In total, 18 resections were performed in 15 patients. Two patients underwent a procedure in which multiple segmentectomies were performed. The majority of the
Discussion
In this study, we present the technique and results of our first 16 consecutive robot-assisted laparoscopic liver resections. Our results show that robot-assisted laparoscopic minor liver resection of all segments is safe and feasible in selected patients. Indications consisted of colorectal liver metastasis, hepatocellular carcinoma, cholangiocarcinoma, adenoma, and hemangioma. In addition, eight of our patients underwent a resection of a posterosuperior segment.
Conventional laparoscopy is
Acknowledgment
Before starting the program, the authors have paid two visits to Dr. Yuman Fong in the United States, who has extensive experience on robotic liver surgery. The authors thank Dr. Y. Fong for his generous advice. The authors also like to thank E.S.M. Hesselink for help during preparation of the manuscript. This work was supported in part by KWF UU 2014-6904 (to J.H.).
Compliance with ethical standards:
Ethical approval: All procedures performed in studies involving human participants were in
References (24)
- et al.
Laparoscopic liver resection: benefits and controversies
Surg Clin North Am
(2004) - et al.
Clinical comparison of laparoscopic and open liver resection after propensity matching selection
Surgery
(2015) - et al.
Laparoscopic versus open liver resection: a meta-analysis of long-term outcome
HPB (Oxford)
(2014) Robotics: the next step?
Best Pract Res Clin Gastroenterol
(2014)- et al.
Robot-assisted laparoscopic liver resection: a systematic review and pooled analysis of minor and major hepatectomies
HPB (Oxford)
(2016) - et al.
Robotic liver surgery
Surg Clin North Am
(2010) - et al.
Robotic-assisted major pancreatic resection
Adv Surg
(2011) - et al.
Laparoscopic anatomical (hepatic) left lateral segmentectomy-technical aspects
Surg Endosc
(1996) - et al.
World review of laparoscopic liver resection-2,804 patients
Ann Surg
(2009) - et al.
Laparoscopic liver resection
World J Surg
(2011)
Long-term and perioperative outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma with propensity score matching: a multi-institutional Japanese study
J Hepatobiliary Pancreat Sci
Short- and long-term outcomes after laparoscopic and open hepatic resection: systematic review and meta-analysis
HPB (Oxford)
Cited by (24)
Pan-European survey on the implementation of robotic and laparoscopic minimally invasive liver surgery
2022, HPBCitation Excerpt :A systematic review of comparative cohort studies reported reduced morbidity and shorter hospital stay with robotic MILS as compared to open liver surgery.6 It is suggested that robotic MILS may facilitate more difficult liver resections due to freely articulating and angling instruments, such as resections of the postero-superior segments or those requiring extensive hilar dissection.8–11 However, there are concerns regarding the additional costs of MILS.12
Robotic anatomic isolated complete caudate lobectomy: Left-side approach and techniques
2021, Asian Journal of SurgeryCitation Excerpt :There are only a few case reports on laparoscopic anatomical isolated complete caudate lobectomies.2,7–9 Since Giulianotti first reported robotic hepatectomy surgery in 2003, robotic hepatectomy has shown advantages with respect to complex hepatectomy.10–13 Currently, robotic isolated caudate lobectomies reported in the literature are only Spiegel lobectomies.14–16
Robotic isolated partial and complete hepatic caudate lobectomy: A single institution experience
2020, Hepatobiliary and Pancreatic Diseases InternationalCitation Excerpt :As we all know, robotic system provides 3-dimensional visualization, instruments with 7 degrees of freedom and better ergonomics for the operating surgeon. Currently, the Da Vinci robotic system has been widely applied to liver surgery procedure and it has initially shown potential advantages in complex hepatectomy [15,16]. However, recent reports on robotic caudate lobectomy are limited to Spiegel lobectomy [17–19].
Robotic Liver Resection
2020, Surgical Clinics of North AmericaCitation Excerpt :Nota and colleagues20 performed a multinational, retrospective, propensity score–matched study that evaluated 51 robotic and 145 open posterosuperior liver resections performed between 2009 and 2016 by high-volume liver surgeons. The final 1:1 propensity-matched analysis of 31 robotic and 31 open resections of posterosuperior segments showed no differences in median operative time (222 minutes; interquartile ranges [IQRs], 164–505 vs 231 minutes and 190–301 minutes respectively; P = .668), estimated blood loss (200 mL; IQRs, 100–400 vs 300 mL and 125–750 mL respectively; P = .212), major complications rates (3% vs 10% respectively; P = .612), or readmission rates (10% vs 6% respectively; P>.99).21 Although these studies showed feasibility and safety of robotic-assisted liver surgery, the long-term oncologic outcomes have until recently been debated.
Clinical efficacy of robot-assisted versus laparoscopic liver resection: a meta analysis
2019, Asian Journal of SurgeryCitation Excerpt :A boom in the number of robotic liver resections being performed because of these theoretical benefits.9 Although several series of RLR have been published,10–12 there is little evidence that it provides superior outcome when compared with LLR.13 Presently, the use of RLR remains relatively new and indications for its application remain controversial.14