Improving safety of robotic major hepatectomy with extrahepatic inflow control and laparoscopic CUSA parenchymal transection: technical description and initial experience

Hawksworth, Jason; Radkani, Pejman; Nguyen, Brian; Belyayev, Leonid; Llore, Nathaly; Holzner, Matthew L.; Mateo, Rod; Meslar, Erin; Winslow, Emily R.; Fishbein, Thomas M.

doi:10.1007/s00464-021-08639-z

Cited by 18 publications

(7 citation statements)

References 25 publications

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“…Hybrid techniques with the use of laparoscopic CUSA by the tableside surgeon have been described, claiming increasing safety and reduced morbidity. 37 The use of CUSA from the tableside results in 2 major issues. First, it shifts the role of the robot from operating to exposing, which becomes detrimental from the cost-effectiveness point of view.…”

Section: Discussionmentioning

confidence: 99%

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Safety and Efficacy of Robotic vs Open Liver Resection for Hepatocellular Carcinoma

et al. 2023

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ImportanceLong-term oncologic outcomes of robotic surgery remain a hotly debated topic in surgical oncology, but sparse data have been published thus far.ObjectiveTo analyze short- and long-term outcomes of robotic liver resection (RLR) for hepatocellular carcinoma (HCC) from Western high-volume centers to assess the safety, reproducibility, and oncologic efficacy of this technique.Design, Setting, and ParticipantsThis cohort study evaluated the outcomes of patients receiving RLR vs open liver resection (OLR) for HCC between 2010 and 2020 in 5 high-volume centers. After 1:1 propensity score matching, a group of patients who underwent RLR was compared with a validation cohort of OLR patients from a high-volume center that did not perform RLR.Main Outcomes and MeasuresA retrospective analysis was performed of prospectively maintained databases at 2 European and 2 US institutions of patients who underwent RLR for HCC between January 1, 2010, and September 30, 2020. The main outcomes were safety and feasibility of RLR for HCC and its oncologic outcomes compared with a European OLR validation cohort. A 2-sided P &lt; .05 was considered significant.ResultsThe study included 398 patients (RLR group: 125 men, 33 women, median [IQR] age, 66 [58-71] years; OLR group: 315 men, 83 women; median [IQR] age, 70 [64-74] years), and 106 RLR patients were compared with 106 OLR patients after propensity score matching. The RLR patients had a significantly longer operative time (median [IQR], 295 [190-370] minutes vs 200 [165-255] minutes, including docking; P &lt; .001) but a significantly shorter hospital length of stay (median [IQR], 4 [3-6] days vs 10 [7-13] days; P &lt; .001) and a lower number of admissions to the intensive care unit (7 [6.6%] vs 21 [19.8%]; P = .002). Incidence of posthepatectomy liver failure was significantly lower in the RLR group (8 [7.5%] vs 30 [28.3%]; P = .001), with no cases of grade C failure. The 90-day overall survival rate was comparable between the 2 groups (RLR, 99.1% [95% CI, 93.5%-99.9%]; OLR, 97.1% [95% CI, 91.3%-99.1%]), as was the cumulative incidence of death related to tumor recurrence (RLR, 8.8% [95% CI, 3.1%-18.3%]; OLR, 10.2% [95% CI, 4.9%-17.7%]).Conclusions and RelevanceThis study represents the largest Western experience to date of full RLR for HCC. Compared with OLR, RLR performed in tertiary centers represents a safe treatment strategy for patients with HCC and those with compromised liver function while achieving oncologic efficacy.

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Section: Discussionmentioning

confidence: 99%

“…Instrumentation is another hotly debated topic, with a particular focus on the lack of CUSA among robotic tools. Hybrid techniques with the use of laparoscopic CUSA by the tableside surgeon have been described, claiming increasing safety and reduced morbidity . The use of CUSA from the tableside results in 2 major issues.…”

Section: Discussionmentioning

confidence: 99%

Safety and Efficacy of Robotic vs Open Liver Resection for Hepatocellular Carcinoma

et al. 2023

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“…Robotic surgical systems—which were developed to reduce the errors caused by lack of dexterity and human-related factors with the feedback they provide during the implementation of the defined surgical procedures—have been used for nearly 20 years and in liver surgery since 2006 [ 7 ]. Thanks to robotic surgical systems, surgeons can perform surgeries in anatomical locations that are difficult to reach with conventional open or laparoscopic surgical systems in a more sensitive, flexible, and controlled manner.…”

Section: Future Outlookmentioning

confidence: 99%

“…Although robotic liver surgery is now widely applied, no standardized, replicable and safe technique has been described yet, despite the increasing literature on the topic ( Figure 1 ). This is possibly due to the specific technical difficulties in liver surgery and a lack of customized surgical instruments, especially for the parenchymal transection phase [ 7 ]. The aforementioned example has made some surgeons wary of the application of robotic liver surgery.…”

Section: Introductionmentioning

confidence: 99%

What Is the Current Role and What Are the Prospects of the Robotic Approach in Liver Surgery?

Bozkurt

Sijberden

Hilal

2022

Cancers

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In parallel with the historical development of minimally invasive surgery, the laparoscopic and robotic approaches are now frequently utilized to perform major abdominal surgical procedures. Nevertheless, the role of the robotic approach in liver surgery is still controversial, and a standardized, safe technique has not been defined yet. This review aims to summarize the currently available evidence and prospects of robotic liver surgery. Minimally invasive liver surgery has been extensively associated with benefits, in terms of less blood loss, and lower complication rates, including liver-specific complications such as clinically relevant bile leakage and post hepatectomy liver failure, when compared to open liver surgery. Furthermore, comparable R0 resection rates to open liver surgery have been reported, thus, demonstrating the safety and oncological efficiency of the minimally invasive approach. However, whether robotic liver surgery has merits over laparoscopic liver surgery is still a matter of debate. In the current literature, robotic liver surgery has mainly been associated with non-inferior outcomes compared to laparoscopy, although it is suggested that the robotic approach has a shorter learning curve, lower conversion rates, and less intraoperative blood loss. Robotic surgical systems offer a more realistic image with integrated 3D systems. In addition, the improved dexterity offered by robotic surgical systems can lead to improved intra and postoperative outcomes. In the future, integrated and improved haptic feedback mechanisms, artificial intelligence, and the introduction of more liver-specific dissectors will likely be implemented, further enhancing the robots’ abilities.

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“…Entscheidet man sich, den CUSA über einen Assistententrokar durch einen am OP-Tisch stehenden (Zweit-)Operateur zu verwenden, können robotische Hybridleberresektionen analog laparoskopischer Resektionen vorgenommen werden [12]. Ein klarer Nachteil dieser Hybridverfahren ist, dass die Kosten steigen und so die Kurz-und Langzeitkosteneffizienz wahrscheinlich nie mit der offenen oder laparoskopischen Leberchirurgie wird mithalten können.…”

Section: Dissektionstechnikenunclassified

Robotik in der Leberchirurgie – Tipps und Tricks

2023

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ZusammenfassungDie minimalinvasive Leberchirurgie hat nachgewiesene Vorteile gegenüber dem offenen Vorgehen. Insofern sollte die minimalinvasive Leberchirurgie auch in Deutschland breitere Anwendung finden. Die minimalinvasive Leberchirurgie hat in den vergangenen Jahren eine signifikante Entwicklung durchlaufen, in deren Rahmen sich auch die robotische Technik zunehmend etabliert. Aktuelle Analysen suggerieren geringere Blutverluste, Komplikationsraten und Krankenhausverweildauern im Vergleich zu offener und laparoskopischer Leberchirurgie. Im Gegensatz zur laparoskopischen ist das Setting bei der robotischen Technik weitgehend unabhängig von der Art der Resektion. Trotz einiger theoretischer Vorteile sollten die robotische und laparoskopische Leberchirurgie aktuell als gleichwertig erachtet werden. Allerdings deuten aktuelle Arbeiten auf Verbesserungen durch den Einsatz der Robotik hin, und das Entwicklungspotenzial der robotischen Chirurgie mithilfe von Artificial Intelligence und Machine Learning erscheint deutlich größer. Die einzelnen Operationsschritte können weitgehend aus der offenen und laparoskopischen Chirurgie übernommen werden. Für die Parenchymdissektion fehlt jedoch noch ein CUSA-System, sodass unterschiedliche Techniken und Hilfsmittel zum Einsatz kommen. Aufgrund der technischen Unterschiede zur laparoskopischen Technik sollten vor der Etablierung eines robotischen Programms intensive Übungsphasen des gesamten Teams genutzt werden.

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Improving safety of robotic major hepatectomy with extrahepatic inflow control and laparoscopic CUSA parenchymal transection: technical description and initial experience

Cited by 18 publications

References 25 publications

Safety and Efficacy of Robotic vs Open Liver Resection for Hepatocellular Carcinoma

Safety and Efficacy of Robotic vs Open Liver Resection for Hepatocellular Carcinoma

What Is the Current Role and What Are the Prospects of the Robotic Approach in Liver Surgery?

Robotik in der Leberchirurgie – Tipps und Tricks

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