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

Abstract

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.

Robotic versus laparoscopic liver resection in various settings: an international multicenter propensity score-matched study of 10,075 patients

“…These findings are also in line with the expectation that the enhanced dexterity and superior visual capabilities of the robotic approach could mainly be beneficial during more complex resections. 15,38 In spite of the ongoing debate on its advantages and disadvantages, the Pringle maneuver has been increasingly employed in recent decades to reduce blood loss during parenchymal transection and thus facilitate a dry surgical field. 39,40 In our analysis, we consistently found lower Pringle usage and shorter duration in the RLS group, which is in line with earlier reports.…”

“…13,46 Currently however, the properties of the robot seem to offer certain benefits in this regard, which allow surgeons to complete more procedures in a minimally invasive fashion. 15 Some authors have suggested that the decrease in conversion rates is related to the fact that there is less need to convert to achieve oncological radicality and control bleeding in RLS. 16,43 The exact reason for this difference however remains unclear, warranting additional studies focusing on this topic.…”

“…11 In fact, clear advantages of RLS over LLS have rarely been demonstrated, despite the technical advantages that the robot offers, such as integrated 3-dimensional systems, improved stability and dexterity. [15][16][17] Therefore, the exact role of the robotic approach in liver surgery remains to be defined. The aim of this study is thus to compare the perioperative outcomes of RLS and LLS in various settings.…”

An update on liver surgery – a new terminology and modern techniques

“…A recent review by Bozkurt et al. summarized the current evidence regarding robotic liver surgery [ 10 ]. The widely proven advantages of minimally invasive liver surgery are less intraoperative blood loss, less postoperative pain, and shorter hospital stay than open liver surgery.…”

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

“…Hepatectomy is increasingly performed via a robotic approach, like other gastrointestinal surgeries [1][2][3][4]. In open or laparoscopic liver resection, various optimized devices for parenchymal dissection (e.g., ultrasonic aspirator [5,6] and ultrasonic incision coagulator [7,8]) are available.…”