Indications to Surgery: Laparoscopic or Robotic Approach

Abstract

Minimally invasive liver surgery is growing worldwide. To date, more than 3,000 cases of laparoscopic liver resections (LLR) have been published, and the interest in robot-assisted resections (RAR) is rising [1–9]. Indications for LLR are similar to those of open liver resections, as recently stated in the Louisville Statement Consensus Conference [2]. LLR was initially indicated for benign and peripherally located lesions, suggesting a concern about the safety and oncologic effectiveness of these procedures. In the last few years, the number of laparoscopic complex liver resections has increased, and even major hepatectomies and segmentectomies of the posterosuperior (PS) segments have been successfully performed [10, 11]. Recently, robotics was introduced into general surgery with the aim of overcoming some of the limitations associated with traditional laparoscopy, thus providing greater manueverability with a set of articulated instruments and a tridimensional vision [12, 13]. The first application of robotics in liver surgery dates back to 2008, when Choi et al. published their first series of four left lateral sectionectomies [14]. After this report, a few case series were published showing the feasibility of robot-assisted minor and major liver resections [5–8, 15–17] and — to date — there is only one prospective comparative study [17]: Berber at al. compared nine patients undergoing RAR matched with 23 patients undergoing LLR. However, the study has some limitations, including small sample size. One inclusion criteria was tumor location in the peripheral liver segments, precluding arriving at definitive conclusions on possible advantages of RAR in situations considered demanding with a laparoscopic approach. Some technical aspects preclude investigating the real role of the da Vinci robotic system in liver resection. The on-table assistant carried out parenchymal division using the Harmonic Scalpel, making it impossible to analyze differences related to the use of the robotic endowristed instruments. Therefore, as of yet, we have no high level of evidence in favor of RAR over LLR, and the associated considerations of the authors regarding this issue come from published case series and their personal experiences.