Robotic hepatectomy is a feasible minimally-invasive modality for experienced liver surgeons

Abstract

Presenter: Benjamin Motz MD | Carolinas HealthCare System Background: Modern liver surgery has seen increasing success over the last several decades due to advances in perioperative anesthesia care and surgical technique. One such improvement has been the development of minimally-invasive approaches to hepatectomy, which is associated with lower surgical morbidity, shorter hospital length of stay (LOS) and patient-reported outcomes. Although laparoscopic liver resection continues to be associated with a steep learning curve, more recently, the development of robotic approaches has reduced the technical limitations of these complex procedures. Herein we present outcomes and learning curve experience following the development of a high-volume robotic liver surgery program at a major hepatobiliary surgery center. Methods: A retrospectively maintained registry of robotic hepatectomies performed at a single high-volume tertiary care center was queried for all procedures performed between September 1, 2012 when the robotic hepatobiliary program was started and September 30, 2020. All operations were performed by either of two surgeons with significant experience in hepatobiliary surgery: JBM and DV. DV began his robotic liver surgery practice in the midst of the study period. Patient charts were retrospectively reviewed and data was collected, including patient demographics, preoperative characteristics, intraoperative details, and postoperative outcomes. Once cases were identified, they were then divided into five epochs of equal size (n=53) based on date of surgery in order to identify trends in outcomes related to experience. Statistical comparisons were performed using ANOVA or χ2 test, as appropriate. All data collection and chart review was approved by the Institutional Review Board. Results: During the study period, 265 patients underwent robotic hepatectomy. 152 (57.4%) were female, and average age was 58 years. 101 (38.1%) were major hepatectomies involving ≥3 segments. Case volume has steadily increased over time, before decreasing slightly in 2020 (Figure 1). Intraoperative outcomes remained similar between the five epochs. Average EBL over the study period was 435mL for all hepatectomies, 555 mL for major hepatectomies, 301cc for minor hepatectomies, and there was no significant improvement or decrement over time (p=0.57). Average operative time was 196 minutes, and there was no significant difference in operative time between epochs (p=0.90). Postoperative outcomes also remained similar over time. Median hospital LOS was 3 days and has remained stable between the five epochs (p=0.91). Finally, 54 patients (20.4%) suffered a complication, with the majority being minor and only 12 major complications (Clavien-Dindo Grade ≥3). The highest Clavien-Dindo Complication Grade within 30 days of surgery was not significantly different between epochs (p=0.23). Conclusion: Robotic hepatectomy is a safe and feasible option for most liver resections, including complex major resections. Over the development period of a high-volume robotic liver surgery program, there were no significant changes in major intraoperative and postoperative outcomes over time, despite the fact that one of the surgeons was going through his learning curve during the study period. This supports the hypothesis that robotic techniques may reduce the learning curve for minimally-invasive liver surgery, opening minimally-invasive options for experienced hepatobiliary surgeons who typically perform open liver surgery.