Robotic Liver Resection for Colorectal Cancer Metastases: A Feasible and Safe Procedure

Abstract

Introduction: This study employs a video on surgical techniques to present the author's experience in the use of the Da Vinci Surgical System in robotic hepatic resections.1 Description of the Video: 00:50—The patient is placed in a supine, reversed Trendelenburg position. A pneumoperitoneum is then created by introducing a Veress needle into the right hypochondrium. A 12-mm trocar, for the robotic camera, is positioned in the right paraumbilical region. The three 8-mm robotic ports are inserted, respectively, into the epigastrium, right hypochondrium, and left subcostal region. A 12-mm extra-port for accessory surgical instruments controlled by the assistant surgeon is placed at the umbilicus. 1:38—The exploration of the hepatic parenchyma reveals a repetitive hepatic lesion, approximately 40 mm in diameter, at segment VII protruding from the Glissonian. 2:40—The right lobe of the liver is mobilized by a section of the right coronary ligament. 3:05—The resection of hepatic segment VII can proceed, using ultrasonic scalpels, along the ischemic demarcation line, beginning at the anterior border of the liver. The exposure of the portion of parenchyma to be resectioned is obtained using polypropylene stitches placed at the left resection margins and used for traction by the instrument's fourth arm. 4:24—Hemostasis of any minor bleeding can be carried out using bipolar cautery, while major bleeds are dealt with using selective stitches of polypropylene 4/0. 6:12—A check is then carried out on the hemostasis and biliostasis. 6:30—Having completed the procedure, the operated section is extracted by means of an endocatch by slightly increasing the widening of the operational trocar access. 6:42—The Jackson drain will be positioned close to the slice of hepatic section. The disconnection of the robotic arms and deflation now take place. Finally, the mini-incisions are sutured. Materials and Methods: A 68-year-old man had previously undergone anterior rectal resection for cancer. During the oncology follow-up, computed tomography scan revealed the onset of a repetitive lesion in segment VII of the liver. A hepatic resection with the aid of the Da Vinci robotic surgical system was performed. The Da Vinci Surgical System is a telerobotic device controlled from a surgeon at remote console, while the surgical team is close to the operating table and follows the procedure through a service screen.2 Results and Conclusion: Estimated intraoperative bleeding was 90 mL, and no blood transfusions were necessary in the perioperative period. The operative time was 150 minutes. There was no postoperative morbidity, and the hospital stay was 3 days. The hystopathological examination of the portion of parenchyma removed (90 × 60 × 45 mm), perfectly contained the nodule measuring 45 × 31 mm with ample-free resection margins. This confirmed the radical solution of the robotic approach adopted. The follow-up was 18 months with disease-free survival. Even if comparative studies are necessary to demonstrate real advantages of the robotic approach with respect to classic laparoscopy, the Da Vinci Surgical System allows a large tridimensional field of view, a steady traction, tremor suppression, flexibility of the instruments, and offers improved dexterity with an internal articulated EndoWrist that permits seven degrees of freedom and therefore execution of precise and safe dissection of tissue and sutures.3,4 The authors state that none of the authors involved in the manuscript preparation has any conflicts of interest toward the manuscript itself, neither financial nor moral conflicts. Besides, none of the authors received support in the form of grants, equipment, and/or pharmaceutical items. Runtime of video: 7 mins