Gastrointestinal
Robotic liver resection including the posterosuperior segments: initial experience

https://doi.org/10.1016/j.jss.2016.06.079Get rights and content

Abstract

Background

Robot-assisted laparoscopy has been introduced to overcome the limitations of conventional laparoscopy. This technique has potential advantages over laparoscopy, such as increased dexterity, three-dimensional view, and a magnified view of the operative field. Therefore, improved dexterity may make a robotic system particularly suited for liver resections, which require nonlinear manipulation, such as curved parenchymal transection, hilar dissection, and resection of posterosuperior segments.

Methods

Between August 2014 and March 2016, 16 patients underwent robot-assisted laparoscopic liver resection at University Medical Center Utrecht.

Results

Fifteen robot-assisted laparoscopic liver resections were performed in a minimally invasive manner. One procedure was converted. In eight patients, we performed a resection of a posterosuperior segment (segment 7 or 8). Median operating time was 146 (60-265) min, and median blood loss was 150 (5-600) mL. Four patients had a Clavien–Dindo grade III complication. Median length of stay was 4 (1-8) days. There was no mortality.

Conclusions

This prospective study reporting on our initial experience with robot-assisted laparoscopic liver resection demonstrates that this technique is easily adopted, safe, and feasible for minor hepatectomies in selected patients. Moreover, it shows that the robotic platform also enables fully laparoscopic resections of the posterior segments.

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

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