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Abstract
Background: The implementation of robotics in liver surgery offers several advantages compared to conventional open and laparoscopic techniques. One major advantage is the enhanced degree of freedom at the tip of the robotic tools compared to laparoscopic instruments. This enables excellent vessel control during inflow and outflow dissection of the liver. Parenchymal transection remains the most challenging part during robotic liver resection because currently available robotic instruments for parenchymal transection have several limitations and there is no standardized technique as of yet. We established a new strategy and share our experience. Methods: We present a novel technique for the transection of liver parenchyma during robotic surgery, using three devices (3D) simultaneously: monopolar scissors and bipolar Maryland forceps of the robot and laparoscopic-guided waterjet. We collected the perioperative data of twenty-eight patients who underwent this procedure for minor and major liver resections between February 2019 and December 2020 from the Magdeburg Registry of minimally invasive liver surgery (MD-MILS). Results: Twenty-eight patients underwent robotic-assisted 3D parenchyma dissection within the investigation period. Twelve cases of major and sixteen cases of minor hepatectomy for malignant and non-malignant cases were performed. Operative time for major liver resections (≥ 3 liver segments) was 381.7 (SD 80.6) min vs. 252.0 (70.4) min for minor resections (p < 0.01). Intraoperative measured blood loss was 495.8 (SD 508.8) ml for major and 256.3 (170.2) ml for minor liver resections (p = 0.090). The mean postoperative stay was 13.3 (SD 11.1) days for all cases. Liver surgery-related morbidity was 10.7%, no mortalities occurred. We achieved an R0 resection in all malignant cases. Conclusions: The 3D technique for parenchyma dissection in robotic liver surgery is a safe and feasible procedure. This novel method offers an advanced locally controlled preparation of intrahepatic vessels and bile ducts. The combination of precise extrahepatic vessel handling with the 3D technique of parenchyma dissection is a fundamental step forward to the standardization of robotic liver surgery for teaching purposing and the wider adoption of robotic hepatectomy into routine patient care.
Highlights
With the continued successful implementation of minimally invasive surgery in various surgical specialities including surgical oncology [1–11], notably, robotic surgery has been accepted for increasing indications [9,10,12,13]
From February 2019 until December 2020, 12 major and 16 minor liver resections using the “three-device (3D) technique” for liver parenchyma transection were identified from the Magdeburg Registry of Minimally Invasive Liver Surgery (MD-MILS)
We defined the duration of the postoperative hospitalization as length of stay (LOS)
Summary
With the continued successful implementation of minimally invasive surgery in various surgical specialities including surgical oncology [1–11], notably, robotic surgery has been accepted for increasing indications [9,10,12,13]. Through continuous development of technical and surgical demands, the indication spectrum has been expanded in general surgery and surgical oncology, involving more complex situations such as major hepatic resections These can be performed safely with low blood loss, faster postoperative mobilization and less postoperative pain for patients when compared to open procedures while maintaining similar oncologic outcomes [5–9,12,13]. The access to all liver segments is described and even Associating liver partition and portal vein ligation (ALLPS) procedures have been performed [12,13] It is considered safe and effective with advantages regarding the perioperative measures compared to open operations with similar oncological outcomes [13]. One major advantage is the enhanced degree of freedom at the tip of the robotic tools compared to laparoscopic instruments This enables excellent vessel control during inflow and outflow dissection of the liver. Operative time for major liver resections (≥ 3 liver segments) was 381.7 (SD 80.6)
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