Abstract
Simple SummaryPrimary liver malignancies are some of the most common and fatal tumors today. Robotic-assisted liver surgery is becoming increasingly interesting for both patients and surgeons alike. Up to date, prospective comparative studies around the topic are scarce. This leads us to an ever existing controversy about the efficacy, safety, and economic benefits of robotic surgery as an extension of traditional minimally invasive surgery over open liver surgery. However, there is evidence that robotic-assisted surgery is, after passing the learning curve, equivalent in terms of feasibility and safety, and in some cases superior to traditional laparoscopic hepatic resection. With this work, we want to provide an overview of the latest and most significant reviews and meta-analyses focusing on robotic hepatectomy in primary liver malignancies. We outline the technical aspects of robotic-assisted surgery and place them into the context of technical, surgical, and oncological outcomes compared with laparoscopic and open resection. When chosen per case individually, any hepatic resection can be performed robotically to overcome limitations of laparoscopic surgery by an experienced team. In this paper, we propose that prospective studies are needed to prove efficacy for robotic-assisted resection in liver malignancy.Hepatocellular and cholangiocellular carcinoma are fatal primary hepatic tumors demanding extensive liver resection. Liver surgery is technically challenging due to the complex liver anatomy, with an intensive and variant vascular and biliary system. Therefore, major hepatectomies in particular are often performed by open resection and minor hepatectomies are often performed minimally invasively. More centers have adopted robotic-assisted surgery, intending to improve the laparoscopic surgical limits, as it offers some technical benefits such as seven degrees of freedom and 3D visualization. The da Vinci® Surgical System has dominated the surgical robot market since 2000 and has shown surgical feasibility, but there is still much controversy about its economic benefits and real benefits for the patient over the gold standard. The currently available retrospective case studies are difficult to compare, and larger, prospective studies and randomized trials are still urgently missing. Therefore, here we summarize the technical, surgical, and economic outcomes of robotic versus open and laparoscopic hepatectomies for primary liver tumors found in the latest literature reviews and meta-analyses. We conclude that complex robotic liver resections (RLR) are safe and feasible after the steep learning curve of the surgical team has plateaued. The financial burden is lower in high volume centers and is expected to decrease soon as new surgical systems will enter the market.
Highlights
Primary hepatobiliary cancer is the seventh most frequent cancer globally, with increasing incidence in recent decades in some areas like India, USA, and Europe and decreasing in other areas such as Asia
Indocyanine green (ICG) fluorescence imaging is supported by the robotic platform
We firstly aim to provide an overview of robotic-assisted liver surgery in primary malignant liver tumors
Summary
Primary hepatobiliary cancer is the seventh most frequent cancer globally, with increasing incidence in recent decades in some areas like India, USA, and Europe and decreasing in other areas such as Asia. More technically complex liver resections are accompanied by difficult accessibility of the vena cava, major hepatic veins, and the hilum, making conventional laparoscopy challenging and risky due to limitations of instrument movement, lack of depth perception, fixed fulcrum at the ports, and difficult suturing, in the presence of hemorrhage. Complicated liver surgeries are still frequently performed with the open approach. In 2000, the United States Food and Drug Administration approved the da Vinci® System (Intuitive Surgical, Inc., Sunnyvale, CA, USA), which is aimed to perform the techniques of open surgery in a minimally invasive approach by overcoming the obstacles of conventional laparoscopy. The robot is operated by the surgeon sitting at a console. The robot provides 3-dimensional imaging, allowing better resolution, depth perception, and magnification and a stable camera platform for improved hand-eye coordination. The ergonomic feature of sitting comfortably reduces the fatigue of the surgeon, which is important in difficult, long procedures [6]
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