Robotic Liver Resection Research Articles

Robotic Left Hepatectomy for Hemorrhagic Hepatocellular Adenoma: The Role of Robotic Surgery in a Semi-Acute Setting.

Hepatocellular adenomas are benign liver tumors, more frequently seen in young women with a history of long-standing use of estrogenic hormonal contraception. An acute rupture of these adenomas can be the first sign of symptoms; however, they can be life-threatening. The definitive management of hepatic adenoma is liver resection for those larger than 4cm as this cutoff size is known to be associated with an exponential risk of harboring malignancy and an increased risk for intratumor bleeding. Once intratumor hemorrhage occurs however, the management of hepatic adenoma becomes much more timely critical. In this study, we describe the use of robotic liver resection for the management of hemorrhagic hepatocellular adenoma in a semi-acute setting. We also include a series of robotic hepatic adenoma resection completed in our hepatobiliary program since 2016, which demonstrated the safety, feasibility, and reproducibility of robotic technique in treating hepatic adenoma.

Robotic liver resection of segment I with 3-D rendering and intraoperative ICG-fluorescence for giant hemangioma

Robotic liver resection of segment I with 3-D rendering and intraoperative ICG-fluorescence for giant hemangioma

Analysis of Clinical Outcomes After Robotic Hepatectomy Applying the Western-Model Southampton Laparoscopic Difficulty Scoring System. An Experience From a Tertiary US Hepatobiliary Center.

Identification of resections with high risk of intraoperative complications is critical in guiding case selection for minimally invasive liver surgery. Several Japanese and European difficulty scoring systems have been proposed for laparoscopic liver surgery. However, the applicability of these systems for robotic liver resections has not been fully investigated. This study considers the Southampton system and examines its validity when applied to robotic hepatectomies. We undertook a retrospective review of 372 patients who underwent robotic hepatectomies for various indications between 2013 and 2022. Of these patients, 63 operations were classified as low risk, 91 as moderate risk, 198 as high risk and 20 as extremely high risk based on Southampton criteria. Patient outcomes were compared by utilizing an ANOVA of repeated measures. Data are presented as median (mean ± SD). The Southampton difficulty scoring system was a strong predictor of intraoperative variables including tumor size, operative duration, estimated blood loss (EBL), and incidence of major vs minor resection (all P < .0001). In contrast, the Southampton system was a weaker predictor of postoperative outcomes including 30-day mortality (P = .15), length of stay (P = .13), and readmissions within 30days (P = .38). The Southampton difficulty scoring system is a valid system for classifying robotic liver resections and is a strong predictor of intraoperative outcomes. However, the system was found to be a weaker predictor of postoperative outcomes. This finding may suggest the need for proposal of a new difficulty scoring system for robotic hepatectomies.

The Impact of Smoking History on Outcomes and Morbidity After Robotic Hepatectomy.

The detrimental effects that smoking has on patient health and postoperative morbidity are well documented. However, literature on the impact that smoking history has on robotic surgery, specifically robotic hepatectomy, is scarce. This study was undertaken to determine whether smoking history impacts the postoperative course of patients undergoing robotic hepatectomy. We prospectively followed 353 patients that underwent robotic hepatectomy. 125 patients had an apposite history of smoking (ie, smokers) and 228 patients were classified as non-smokers. Data were presented as median (mean ± SD). Patients were then propensity-score matched based on patient and tumor characteristics. Prior to the matching, the MELD score and cirrhosis status in patients who smoke were found to be significantly higher when compared to those who do not (mean MELD score 9 vs 8 and cirrhosis in 25% vs 13% of patients, respectively). Both smokers and non-smokers have similar BMIs, number of previous abdominal operations, ASA physical status classifications, and Child-Pugh scores. Six percent smokers vs one percent non-smokers experienced pulmonary complications (pneumonia, pneumothorax, and COPD exacerbation) (P = .02). No differences were found for postoperative complications of Clavien-Dindo score ≥ III, 30-day mortality, or 30-day readmissions. After the matching, no differences were found between the smokers and the non-smokers. After a propensity-score match analysis, smoking did not appear to negatively affect the intra- and postoperative outcomes after robotic liver resections. We believe that the robotic approach as the most modern minimally invasive technique in liver resection may have the potential to mitigate the known adverse effects of smoking.

Robotic emergency liver resection of ruptured hepatocellular carcinoma.

The spontaneous rupture of hepatocellular carcinoma (HCC) is a rare complication. The management of this complication needs a stepwise, multidisciplinary approach which considers first of all clinical conditions of the patient and also the possibility of the best curative treatment. We report our experience of an emergency robotic liver resection for a ruptured HCC in an elderly patient. Minimally invasive liver resection is currently recognised as a safe and feasible approach to the treatment of HCC in elderly patients. Our patient presented haemodynamic stability, which allows us to perform a robotic resection of segment 3. To our knowledge, this is the first report of the application of a robotic platform in an emergency setting for liver resection. Rupture of HCC is an uncommon complication, burdened by a high rate of mortality. Its management still remains controversial. Treatment should be individualised taking into consideration the clinical status of the patient, tumour features and possibility of centre therapeutic strategy.

An Efficient Method of Hepatoduodenal Ligament Taping for Pringle's Maneuver During Robotic Liver Resection.

Background and objective Pringle's maneuver is often applied to reduce bleeding during liver resection (LR), although the taping of the hepatoduodenal ligament (HL) is challenging and dangerous due to the lack of tactile perception in robotic liver resection (RLR). In this study, we describe a secureand easy HL taping method in RLR. Methods Twenty-seven cases that underwent RLR at our institution from April to November 2022 were examined. For the HL taping, a taping tool was prepared with a flexible catheter and 3 mm-thick silicon tape. The lesser omentum was opened, the taping tool was inserted behind the HL, and the HL was encircled by silicon tape. The length of time required for taping and the number of attempts were measured. Intraoperative blood loss, the occurrence of post-hepatectomy liver failure (PHLF), and complications were examined. Results A total of 18 cases were analyzed, after excluding cases in which taping was not attempted due to adhesion from repeated hepatectomy. The median time taken for taping was 55 seconds (range: 11-162 seconds), and the median number of attempts for taping was one (range: 1-4). No accidental injury was observed during the procedure. Intraoperative blood loss was 24 mL (range: 5-400). No PHLF occurred, and complications occurred in two cases (one case of bile leakage and one case of pulmonary atelectasis). Conclusion Based on our findings, our method enables secureand time-efficient HL taping in RLR.

Validity of the Institut Mutualiste Montsouris classification system for robotic liver resection

BackgroundThe Institut Mutualiste Montsouris (IMM) classification system is one of several widely accepted difficulty scoring systems for laparoscopic liver resections. Nothing is yet known about the applicability of this system for robotic liver resections. MethodsWe conducted a retrospective review of 359 patients undergoing robotic hepatectomies between 2016 and 2022. Resections were classified into low, intermediate, and high difficulty level. Data were analyzed utilizing ANOVA of repeated measures, 3 x 2 contingency tables, and area under the receiving operating characteristic (AUROC) curves. Data are presented as median (mean ± SD). ResultsOf the 359 patients, 117 were classified as low-difficulty level, 92 as intermediate, and 150 as high. The IMM system correlates well with tumor size (p = 0.002). The IMM system was a strong predictor of intraoperative outcomes including operative duration (p<0.001) and estimated blood loss (EBL) (p<0.001). The IMM system also showed a strong calibration for predicting an open conversion (AUC=0.705) and intraoperative complications (AUC=0.79). In contrast, the IMM system was a poor predictor of postoperative complications, mortality, and readmission. ConclusionThe IMM system provides a strong correlation with intraoperative, but not postoperative outcomes. A dedicated difficulty scoring system should be developed for robotic hepatectomy.

Robotic liver surgery: A new reality. Descriptive analysis of 220 cases of minimally invasive liver surgery in 182 patients

IntroductionThe level of recommendation of the robotic approach in liver surgery is controversial. The objective of the study is to carry out a single-center retrospective descriptive analysis of the short-term results of the robotic and laparoscopic approach in liver surgery during the same period. MethodsDescriptive analysis of the short-term results of the robotic and laparoscopic approach on 220 resections in 182 patients undergoing minimally invasive liver surgery. ResultsBetween April 2018 and June 2022, a total of 92 robotic liver resections (RLR) were performed in 83 patients and 128 laparoscopic (LLR) in 99 patients. The LLR group showed a higher proportion of major surgery (P < .001) and multiple resections (P = .002). The two groups were similar in anatomical resections (RLR 64.1% vs. LLR 56.3%). In the LLS group, the average operating time was 212 min (SD 52.1). Blood loss was 276.5 mL (100–1000) and conversion 12.1%. Mean hospital stay was 5.7 (SD 4.9) days. Morbidity was 27.3% and 2% mortality. In the RLS group, the mean operative time was 217 min (SD 53.6), blood loss 169.5 mL (100.900), and conversion 2.5%. Mean hospital stay was 4.1 (SD 2.1) days. Morbidity was 15%, with no mortality. ConclusionMinimally invasive liver surgery is a safe technique, and in particular, RLS allows liver resections to be performed safely and reproducibly; it appears to be a non-inferior technique to LLS, but randomized studies are needed to determine the minimally invasive approach of choice in liver surgery.

Quick and Easy Application Method of TachoSil®️ During Laparoscopic and Robotic Liver Resections.

TachoSil®️, a fibrin sealant patch, is a sheet-type hemostatic agent. Therefore, it is technically demanding to put it on the target place especially in laparoscopic surgeries due to the motion restriction of straight-fixed instruments. This article describes a quick and easy technique of TachoSilapplication during laparoscopic liver surgeries, by sewing it to the laparoscopic gauze in advance. This method allows for one-handed operation and stress-free application even in the situation of active bleeding.

Robotic versus laparoscopic liver resection for huge (≥10 cm) liver tumors: an international multicenter propensity-score matched cohort study of 799 cases.

The use of laparoscopic (LLR) and robotic liver resections (RLR) has been safely performed in many institutions for liver tumours. A large scale international multicenter study would provide stronger evidence and insight into application of these techniques for huge liver tumours ≥10 cm. This was a retrospective review of 971 patients who underwent LLR and RLR for huge (≥10 cm) tumors at 42 international centers between 2002-2020. One hundred RLR and 699 LLR which met study criteria were included. The comparison between the 2 approaches for patients with huge tumors were performed using 1:3 propensity-score matching (PSM) (73 vs. 219). Before PSM, LLR was associated with significantly increased frequency of previous abdominal surgery, malignant pathology, liver cirrhosis and increased median blood. After PSM, RLR and LLR was associated with no significant difference in key perioperative outcomes including media operation time (242 vs. 290 min, P=0.286), transfusion rate rate (19.2% vs. 16.9%, P=0.652), median blood loss (200 vs. 300 mL, P=0.694), open conversion rate (8.2% vs. 11.0%, P=0.519), morbidity (28.8% vs. 21.9%, P=0.221), major morbidity (4.1% vs. 9.6%, P=0.152), mortality and postoperative length of stay (6 vs. 6 days, P=0.435). RLR and LLR can be performed safely for selected patients with huge liver tumours with excellent outcomes. There was no significant difference in perioperative outcomes after RLR or LLR.

Non-Stick Liver Parenchymal Transection With Saline-Linked Bipolar Clamp-Crush Technique in Robotic Liver Resection.

Background Without satisfactory instruments, liver parenchymal transection during robotic liver resection (RLR) remains challenging. We combined the commonly used bipolar clamp-crush technique with the saline drip, achieving a comfortable liver resection without coagulated liver tissues sticking to the bipolar forceps. Methods Between December 2022 and March 2023, six RLRs were performed using the saline-linked bipolar clamp-crush method for both anatomical and non-anatomical liver resections. We assessed the safety and feasibility of our robotic liver parenchymal transection technique. Results Three of six patients were diagnosed with colorectal liver metastasis, two with hepatocellular carcinoma (HCC), and the other with intrahepatic bile duct stricture. Three of the six patients received anatomical liver resection, and the other three underwent non-anatomical liver resection. There were no conversions to open surgery. The median operative time and estimated blood loss were 406.5 minutes (196-670 minutes) and 5 ml (5-465 ml), respectively. The median length of the postoperative hospital stay was nine days (7-10 days). Postoperative complications (Clavien-Dindo classification grade II or more) or mortality were not encountered in this cohort. Conclusion We presented here our saline-linked bipolar clamp-crush method for liver parenchymal transection in RLR. By simply adding the saline drip to the commonly used bipolar clamp-crush technique, non-stick and comfortable liver parenchymal transection is now possible. This technique may help overcome the limitations of currently available robotic instruments for liver parenchymal resection.

Robotic versus laparoscopic liver resection in posterosuperior region: a retrospective study of consecutive cases.

Minimally invasive liver resection of the posterosuperior region is considered a challenging procedure due to poor exposure and difficult bleeding control. A robotic approach is supposed to be advantageous in posterosuperior segmentectomy. Its benefits over laparoscopic liver resection (LLR) remain undetermined. This study compared robotic liver resection (RLR) and LLR in the posterosuperior region performed by a single surgeon. We retrospectively analyzed consecutive RLR and LLR performed by a single surgeon between December 2020 and March 2022. Patient characteristics and perioperative variables were compared. A 1:1 propensity score matched (PSM) analysis was performed between both groups. The analysis included 48 RLR and 57 LLR procedures in the posterosuperior region. After PSM analysis, 41 cases of both groups were retained. In pre-PSM cohort, the operative time in the RLR group was significantly shorter than in the LLR group (160 vs. 208min, P = 0.001), especially in radical resection of malignant tumors (176 vs. 231min, P = 0.004). The total Pringle maneuver duration was also markedly shorter (40 vs. 51min, P = 0.047), and the estimated blood loss in the RLR group was lower (92 vs. 150mL, P = 0.005). The postoperative hospital stay (POHS) in the RLR group was significantly shorter (5.4 vs. 7.5days, P = 0.048). In PSM cohort, operative time in the RLR group was also significantly shorter (163 vs. 193min, P = 0.036), and the estimated blood loss was lower (92 vs. 144mL, P = 0.024). However, the total Pringle maneuver duration and POHS showed no significant difference. The complications were similar between two groups in both pre-PSM and PSM cohorts. RLR in the posterosuperior region was as safe and feasible as LLR. RLR was associated with reduced operative time and blood loss than LLR.

Robotic hepatectomy: current evidence and future directions.

Minimally invasive hepatectomy continues to gain popularity and acceptance for treatment of benign and malignant liver disease. Robotic hepatectomy offers potential advantages over open and conventional laparoscopic approaches. Review of the literature on robotic hepatectomy was performed. Search terms included "robotic hepatectomy" and "minimally invasive hepatectomy." Search was further customized to include articles related to robotic surgical technology. Across many parameters in liver surgery, robotic liver resection appears to have comparable outcomes with respect to laparoscopic resection. The benefits over open resection are largely related to less morbidity and faster recovery times. There is evidence that the robotic approach may have a shorter learning curve and enable more difficult resections to be performed minimally invasively. The robotic platform may have the potential to achieve superior margin status or parenchymal sparing resection in oncologic resections, but numerous obstacles remain. The robotic platform has not been applied to liver surgery to the same extent as either laparoscopic or open surgery. Robotic surgical technology will need to continue developing to deliver on its potential advantages.

Robotic liver resection in the posterosuperior segments as a way to extent the mini-invasive arsenal: a comparison with transthoracic laparoscopic approach.

The field of robotic liver resection (RLR) has developed in the past decades. This technique seems to improve the access to the posterosuperior (PS) segments. Evidence of a possible advantage over transthoracic laparoscopy (TTL) is not yet available. We aimed to compare RLR to TTL for tumors located in the PS segments of the liver in terms of feasibility, difficulty scoring, and outcome. This retrospective study compared patients undergoing robotic liver resections and transthoracic laparoscopic resections of the PS segments between January 2016 and December 2022 in a high-volume HPB center. Patients' characteristics, perioperative outcomes, and postoperative complications were evaluated. In total, 30 RLR and 16 TTL were included. Only wedge resections were performed in the TTL group, while 43% of the patients in the RLR group had an anatomical resection (p < 0.001). The difficulty score according to the IWATE difficulty scoring system was significantly higher in the RLR group (p < 0.001). Total operative time was similar between the two groups. Complication rates, either overall or major, were comparable between the two techniques and hospital stay was significantly shorter in the RLR group. Patients in the TTL group were found to have more pulmonary complications (p = 0.01). RLR may provide some advantages over TTL for the resection of tumors located in the PS segments.

Global scientific production of robotic liver resection from 2003 to 2022: A bibliometric analysis

ObjectiveWith the widespread application of robotic liver surgery, the body of literature related to robotic liver resection is growing. However, there is a lack of understanding of the publication activities surrounding robotic liver resection research. This bibliometric study aimed to detect the global publication distributions of robotic liver resection research over the past 20 years. MethodsArticles on robotic liver resection published from January 1, 2003 to August 31, 2022 were extracted from the Web of Science Core Collection database. The publication language was restricted to English. Literature distribution analyses were performed at the country/region, institution, author, and journal levels. In addition, each author's productivity was assessed with Lotka's law. Academic influence was assessed by local citation score and global citation score. The keywords evolution was also analyzed. R software and HistCite were applied for the analyses. ResultsA total of 685 articles were identified, with 4107 local citations and 9458 global citations. These articles were published in 156 journals and written by 2449 authors from 785 institutions in 49 countries/regions. The cumulative publication number of the last 5 years accounted for 66.3% (454/685) of the total publication number. The USA played a leading role in the publication output (212, 30.9%), followed by Italy (120, 17.5%) and China (104, 15.2%). The three countries also had the most citations. Yonsei University from South Korea had the highest publication number (30, 4.4%). The Asian Journal of Surgery published the most articles (51, 7.4%), and Surgical Endoscopy and Other Interventional Techniques had the most local citations (575) and global citations (1115). Sucandy published 44 articles, ranking first in productivity. Choi had many more citations than other scholars, with 465 local citations and 1253 global citations. Lotka's law reflected that the majority of the authors (1783, 72.8%) wrote one document. The top 5 most prominent keywords were “surgery”, “hepatocellular-carcinoma”, “outcomes”, “hepatectomy”, and “experience”. ConclusionThe number of publications on robotic liver resection research has been rapidly increasing over the last 20 years. The most prolific countries/regions and institutions also had strong academic influence. The articles, institutions and authors with high citations mainly came from USA, China, South Korea, Italy, and Singapore. The research hotspots shifted from survival to complications, mortality, and augmented reality.

Risk factors and outcomes in patients undergoing minimally invasive hepatectomy with unplanned conversion: a contemporary NSQIP analysis

BackgroundMinimally invasive techniques are growing for hepatectomies. Laparoscopic and robotic liver resections have been shown to differ in conversions. We hypothesize that robotic approach will have decreased conversion to open and complications despite being a newer technique than laparoscopy. MethodsACS NSQIP study using the targeted Liver PUF from 2014 to 2020. Patients grouped based on hepatectomy type and approach. Multivariable and propensity scored matching (PSM) was used to analyze the groups. ResultsOf 7767 patients who underwent hepatectomy, 6834 were laparoscopic and 933 were robotic. The rate of conversions was significantly lower in robotic vs laparoscopic (7.8% vs 14.7%; p < 0.001). Robotic hepatectomy was associated with decreased conversion for minor (6.2% vs 13.1%; p < 0.001), but not major, right, or left hepatectomy. Operative factors associated with conversion included Pringle (OR = 2.09 [95% CI 1.05–4.19]; p = 0.0369), and a laparoscopic approach (OR = 1.96 [95% CI 1.53–2.52]; p < 0.001). Undergoing conversion was associated with increases in bile leak (13.7% vs 4.9%; p < 0.001), readmission (11.5% vs 6.1%; p < 0.001), mortality (2.1% vs 0.6%; p < 0.001), length of stay (5 days vs 3 days; p < 0.001), and surgical (30.5% vs 10.1%; p < 0.001), wound (4.9% vs 1.5%; p < 0.001) and medical (17.5% vs 6.7%; p < 0.001) complications. ConclusionMinimally invasive hepatectomy with conversion is associated with increased complications, and conversion is increased in the laparoscopic compared to a robotic approach.

Minimally invasive approaches to intrahepatic cholangiocarcinoma

While the incidence of intrahepatic cholangiocarcinoma (ICC) is increasing, few patients are surgical candidates, and recurrence rates remain high. Surgical resection remains the only potential curative therapy for ICC, and many retrospective cohorts have demonstrated comparable short-term and long-term outcomes between open, laparoscopic, and robotic liver resection (RLR) for ICC. However, rates of lymphadenectomy remain low amongst all groups, especially in laparoscopic approaches, despite its role in prognostication and therapeutic management. RLR may offer many of the short-term benefits of laparoscopic liver resection (LLR) and facilitate adequate lymphadenectomy while also increasing the ability to access posterosuperior segments and perform major hepatectomies.

Robotic right hepatectomy for giant hemangioma - Parenchyma dissection with robotic scissors

Background: Robotic liver resection has expanded the role of benign and malignant liver tumors. For benign lesions, minimally invasive robotic surgery has advantages compared to open surgery. Parenchyma dissection is still challenging in the setting where CUSA is unavailable for robotic platforms.

Robotic Liver Resection Plus Lymphadenectomy for Biliary Tract Cancers

Robotic Liver Resection Plus Lymphadenectomy for Biliary Tract Cancers

Primary or Iterative Robotic Liver Resection for Lesion Located in Seg VII

Primary or Iterative Robotic Liver Resection for Lesion Located in Seg VII