Robotic Approach for Lymphadenectomy in Biliary Tumors

Abstract

Objective: This study aimed to evaluate the oncological adequacy of lymphadenectomy (LND) for biliary tumors and surgical outcomes of resections performed using robotic, laparoscopic, and open approaches and to compare the techniques within a weighted propensity score analysis. Background: The need to perform formal LND is considered a limit for the applicability of minimally invasive liver surgery. Methods: Overall, 25 robotic resections with LND (2021-2022) from a single-center constituted the study group (Rob group), matched by inverse probability treatment weighting with 97 laparoscopic (Lap group) and 113 open (Open group) procedures to address the primary endpoint. A "per-period" analysis was performed comparing the characteristics and outcomes of the Rob group with the first 25 consecutive laparoscopic liver resections with associated LND (LapInit group). Results: Minimally invasive techniques performed equally well regarding the number of harvested nodes, blood transfusions, functional recovery, length of stay, and major morbidity and provided a short-term benefit to patients when compared with the open technique. A better performance of the robotic approach over laparoscopic approach (and both approaches over the open technique) was recorded for patients achieving LND with retrieval of > 6 nodes. The open approach reduced both the operative time and time for LND, and robotic surgery performed better than laparoscopic surgery. Conclusions: Minimally invasive techniques are excellent tools for the management of LND in patients with biliary tumors, showing feasibility, and oncological adequacy. Robotics could contribute to the large-scale diffusion of these procedures with a high profile of complexity.

Is HPB robotic-assisted surgery an evolution or a revolution in laparoscopy?

“…These advantages are clearly demonstrated in particular hepatobiliary and pancreatic surgery procedures, such as lymphadenectomy, bilioenterostomy, pancreatoenterostomy (6)(7)(8)(9). More importantly, the need for robotic surgery directly originates from the shortcoming of laparoscopic technology.…”

“…The highly flexible robotic arm design also enlarges operation angles, and the human hand tremor filtering system provides opportunities for operating complicated surgery in a small surgical field, which ultimately improves the quality of surgery and shortens the learning curve. These advantages are clearly demonstrated in particular hepatobiliary and pancreatic surgery procedures, such as lymphadenectomy, bilioenterostomy, pancreatoenterostomy ( 6 - 9 ). More importantly, the need for robotic surgery directly originates from the shortcoming of laparoscopic technology.…”

Robo-Lap Approach Optimizes Intraoperative Outcomes in Robotic Left and Right Hepatectomy

“…For all resections, a laparoscopic 10-mm trocar was positioned in right pararectal position, along the umbilical line. 1,10 Four robotic trocars were positioned in a standardized configuration with one trocar in right flank, one along the mid-clavicular line, one along the midline and one in left hypochondrium and the robotic platform was docked to operating table coming from the head (Da Vinci X platform) or from the right side (Da Vinci Xi platform) of the patient, oriented in reverse-Trendelenburg position. A second laparoscopic access was positioned in right hypochondrium (between robotic arms 1 and 2 or between 2 and 3) only after docking of robotic arms, to exclude conflicts among laparoscopic and robotic instruments and to improve ergonomics.…”

“…The minimally invasive approach has gained a main role in the setting of liver surgery due to well-documented perioperative advantages for the patient and to maintained oncological efficacy compared with the open approach. [1][2][3][4] This evolution has been supported by the progressive technical and technological improvement that occurred over the course of the past 20 years. 5,6 Furthermore, the encouraging outcomes of minimally invasive liver Surgery (MILS) have constituted an incentive for technological investment to overcome technical difficulties initially described in this area.…”

Robotic Systematic Portal Lymphadenectomy. Description of Surgical Technique

“…In a recent study by Ratti et al, the issue of robotic vs laparoscopic and open lymphadenectomy was discussed. 3,4 In their study, 25 robotic resections with portal lymphadenectomy from a single center institution were included and matched by inverse probability treatment weighting with 97 laparoscopic and 113 open procedures. An analysis was performed comparing the characteristics and outcomes of the robotic vs laparoscopic portal lymphadenectomy.…”