Robot assistance in liver surgery: a real advantage over a fully laparoscopic approach? Results of a comparative bi-institutional analysis

Short-Term Surgical Outcomes After Robotic Liver Surgery: A Propensity-Score Matched Analysis With Conventional Open Liver Surgery at a High-Volume Centre in Denmark

BACKGROUND

The aim of this study was to investigate the perioperative outcomes of robotic liver surgery (RLS) and Open liver surgery (OLS) in a centre with a high number of operations.

METHODS

A 1:1 propensity score matched (PSM) analysis of a retrospective database of RLS and OLS was performed. Cumulative sum (CUSUM) analysis was performed to identify learning curves.

RESULT

After PSM analysis, operative time was significantly longer in the RLS group (p < 0.001). Estimated blood loss was significantly lower in the RLS group (p < 0.001). Transfusion rates were significantly lower in the RLS group. The length of hospital stay was shorter in the RLS group (3.5vs6.3 days, p < 0.001). Readmission rates were significantly lower in the RLS group (p < 0.049). CUSUM analysis showed a learning curve for at least 8 low-intermediate RLS procedures and 27 advanced-Expert RLS procedures.

CONCLUSIONS

RLS has many advantages, including being safe to perform, less blood loss and faster postoperative recovery compared with OLS.

Exploring the feasibility of robotic liver resection in a limited resource setting

The transition from open hepatectomy to minimally invasive techniques has reduced morbidity and mortality. However, laparoscopic liver resection (LLR) requires substantial expertise. Robotic liver resection (RLR) combines minimal invasiveness with open surgical precision. It may facilitate complex procedures without the learning required for LLR. We evaluated RLR outcomes in a limited resource setting and assessed its efficacy and practicality. This retrospective study analyzed 67 robotic hepatectomies conducted from 2020 to 2023. Demographic, perioperative factors, and surgical outcomes were analyzed. Major hepatectomies were required in 46/67 (68.7%) patients who underwent RLR. No open conversions, 30-day mortalities, or readmissions occurred. Complications occurred in 7.4% of patients; major complications occurred in 5.9%. Learning curve analysis showed a negative correlation between operation sequence and operative time. Effective use of robotic technology combined with the expertise of well-trained surgeons facilitates successful execution of RLR with feasible surgical outcomes, even at smaller centers.

Navigating the future of guided dental implantology: A scoping review

BACKGROUND

The aim of this scoping review was to understand the development of robotics and its accuracy in placing dental implants when compared to other forms of guided surgery.

METHODS

An electronic search was conducted on the electronic databases of PubMed, Cochrane, and Science direct with the following queries: ((robotics) AND (dental implant)) AND (accuracy). The search timeline was between 2017 and 2022.

RESULTS

A total of 54 articles were screened for title and abstract, of which 16 were deemed eligible for inclusion. Thirty-one articles were excluded mainly because they were out of topic (not relevant) or not in English. In total, 16 articles were included for analysis.

CONCLUSIONS

This review thoroughly analyses 5 years of literature concerning the evolution of robotics in dental implant surgery, underscoring the necessity for additional research on nascent technologies reported and a comparative study with static and dynamic systems for clinical efficacy evaluation.

Propensity Score-Matching Analysis Comparing Robotic Versus Laparoscopic Limited Liver Resections of the Posterosuperior Segments: An International Multicenter Study

OBJECTIVE

The purpose of this study was to compare the outcomes of robotic limited liver resections (RLLR) versus laparoscopic limited liver resections (LLLR) of the posterosuperior segments.

BACKGROUND

Both laparoscopic and robotic liver resections have been used for tumors in the posterosuperior liver segments. However, the comparative performance and safety of both approaches have not been well examined in the existing literature.

METHODS

This is a post hoc analysis of a multicenter database of 5446 patients who underwent RLLR or LLLR of the posterosuperior segments (I, IVa, VII, and VIII) at 60 international centers between 2008 and 2021. Data on baseline demographics, center experience and volume, tumor features, and perioperative characteristics were collected and analyzed. Propensity score-matching (PSM) analysis (in both 1:1 and 1:2 ratios) was performed to minimize selection bias.

RESULTS

A total of 3510 cases met the study criteria, of whom 3049 underwent LLLR (87%), and 461 underwent RLLR (13%). After PSM (1:1: and 1:2), RLLR was associated with a lower open conversion rate [10 of 449 (2.2%) vs 54 of 898 (6.0%); P =0.002], less blood loss [100 mL [IQR: 50-200) days vs 150 mL (IQR: 50-350); P <0.001] and a shorter operative time (188 min (IQR: 140-270) vs 222 min (IQR: 158-300); P <0.001]. These improved perioperative outcomes associated with RLLR were similarly seen in a subset analysis of patients with cirrhosis-lower open conversion rate [1 of 136 (0.7%) vs 17 of 272 (6.2%); P =0.009], less blood loss [100 mL (IQR: 48-200) vs 160 mL (IQR: 50-400); P <0.001], and shorter operative time [190 min (IQR: 141-258) vs 230 min (IQR: 160-312); P =0.003]. Postoperative outcomes in terms of readmission, morbidity and mortality were similar between RLLR and LLLR in both the overall PSM cohort and cirrhosis patient subset.

CONCLUSIONS

RLLR for the posterosuperior segments was associated with superior perioperative outcomes in terms of decreased operative time, blood loss, and open conversion rate when compared with LLLR.

Awake robotic liver surgery: A case report

BACKGROUND

In recent years, minimally invasive liver resection has become a standard of care for liver tumors. Considering the need to treat increasingly fragile patients, general anesthesia is sometimes avoided due to respiratory complications. Therefore, surgical treatment with curative intent is abandoned in favor of a less invasive and less radical approach. Epidural anesthesia has been shown to reduce respiratory complications, especially in elderly patients with pre-existing lung disease.

CASE SUMMARY

A 77-year-old man with hepatitis-C-virus-related chronic liver disease underwent robotic liver resection for hepatocellular carcinoma. The patient was suffering from hypertension, diabetes and chronic obstructive pulmonary disease. The National Surgical Quality Improvement Program score for developing pneumonia was 9.2%. We planned a combined spinal-epidural anesthesia with conscious sedation to avoid general anesthesia. No modification of the standard surgical technique was necessary. Hemodynamics were stable and bleeding was minimal. The postoperative course was uneventful.

CONCLUSION

Robotic surgery in locoregional anesthesia with conscious sedation could be considered a safe and suitable approach in specialized centers and in selected patients.

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

INTRODUCTION

The 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.

METHODS

Descriptive analysis of the short-term results of the robotic and laparoscopic approach on 220 resections in 182 patients undergoing minimally invasive liver surgery.

RESULTS

Between 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.

CONCLUSION

Minimally 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.

Preoperative planning and intraoperative real-time navigation with indocyanine green fluorescence in robotic liver surgery

PURPOSE

We aimed at exploring indocyanine green (ICG) fluorescence wide spectrum of applications in hepatobiliary surgery as can result particularly useful in robotic liver resections (RLR) in order to overcome some technical limitations, increasing safety, and efficacy.

METHODS

We describe our experience of 76 RLR performed between March 2020 and December 2022 exploring all the possible applications of pre- and intraoperative ICG administration.

RESULTS

Hepatocellular carcinoma and colorectal liver metastases were the most common indications for RLR (34.2% and 26.7% of patients, respectively), and 51.3% of cases were complex resections with high IWATE difficulty scores. ICG was administered preoperatively in 61 patients (80.3%), intraoperatively in 42 patients (55.3%) and in both contexts in 25 patients (32.9%), with no observed adverse events. The most frequent ICG goal was to achieve tumor enhancement (59 patients, 77.6%), with a success rate of 94.9% and the detection of 3 additional malignant lesions. ICG facilitated evaluation of the resection margin for residual tumor and perfusion adequacy in 33.9% and 32.9% of cases, respectively, mandating a resection enlargement in 7.9% of patients. ICG fluorescence allowed the identification of the transection plane through negative staining in the 25% of cases. Vascular and biliary structures were visualized in 21.1% and 9.2% of patients, with a success rate of 81.3% and 85.7%, respectively.

CONCLUSION

RLR can benefit from the routine integration of ICG fluoresce evaluation according to each individual patient and condition-specific goals and issues, allowing liver functional assessment, anatomical and vascular evaluation, tumor detection, and resection margins assessment.

Accuracy of an autonomous dental implant robotic system versus static guide-assisted implant surgery: A retrospective clinical study

STATEMENT OF PROBLEM

The accuracy of implant placement is a prerequisite for prosthetically driven implant surgery and is necessary to ensure the long-term stability of dental implants. Imprecise implant position may bring difficulties for restoration, damage anatomic structures, affect peri-implant tissues, and lead to ultimate implant failure.

PURPOSE

The purpose of this retrospective clinical study was to compare the accuracy of implants placed with an autonomous dental implant robotic (ADIR) system with those placed with static computer assisted implant surgery (sCAIS).

MATERIAL AND METHODS

Thirty-nine participants were enrolled in this retrospective study: 20 participants had received implant surgery with the ADIR system and 19 participants had implants placed with sCAIS. The preoperative plans and postoperative cone beam computed tomography (CBCT) scans after implant placement were matched during the study. The coronal, apical, and angular deviations were measured and analyzed. A linear regression model was established to analyze the source of deviation. MANOVA was used to compare differences in the major outcome variables (α=.05).

RESULTS

A total of 60 implants were placed in 39 participants (30 in each of the 2 groups). The mean ±standard deviation coronal, apical, and angular deviation of the ADIR system group and sCAIS group were 0.43 ±0.18 mm versus 1.31 ±0.62 mm (P<.001), 0.56 ±0.18 mm versus 1.47 ±0.65 mm (P<.001), and 1.48 ±0.59 degrees versus 2.42 ±1.55 degrees (P=.003), respectively. In addition, there was no significant difference in accuracy in the different implant regions (anterior, premolar, molar, maxilla, mandible) (P>.05). No complications were observed.

CONCLUSIONS

The accuracy of the implant position using the ADIR system was significantly higher than with sCAIS, suggesting that the ADIR system can achieve minimally invasive and excellent accuracy. In addition, implant regions had no significant influence on the accuracy of implant placement. (Keywords: Robotic system, Implant surgery, Static guide, Autonomous, Accuracy).

[Robots in visceral and thoracic surgery-Quo vadis?]

Robotic surgical systems are now an inherent part of the German hospital landscape. In recent years, there has been an enormous increase in installed systems and operations performed, especially in abdominal surgery. Even though there is a lack of studies with the highest grade of evidence, the advantages of the technique are obvious-particularly technically demanding operations can now be performed safely and less invasively for patients. Robotics are now being implemented in many non-university institutions. At the Israelite Hospital (Israelitisches Krankenhaus) Hamburg it could be demonstrated that with systematic and modular training, i.e. execution of certain surgical steps, it is possible to significantly flatten the learning curve while maintaining excellent oncological quality, postoperative morbidity and mortality. The costs to have a system up and running are the main limitations for the implementation of robotic surgery. The acquisition, material and maintenance costs are substantial so that the type of intervention and the training of prospective surgeons are limited by the costs. The robotic approach will fully unroll its disruptive character compared to laparoscopy once it is competitive not only qualitatively in the field of medical contents but also economically. In the future the ROBIN working group of the German Society for General and Visceral Surgery (DGAV) wants to create the basic prerequisites for valid studies by working with registers and could act as an independent central intermediary between hospitals and the industry to promote practical innovations and systematic training for surgeons.

Limited liver resections in the posterosuperior segments: international multicentre propensity score-matched and coarsened exact-matched analysis comparing the laparoscopic and robotic approaches

Background

Limited liver resections (LLRs) for tumours located in the posterosuperior segments of the liver are technically demanding procedures. This study compared outcomes of robotic (R) and laparoscopic (L) LLR for tumours located in the posterosuperior liver segments (IV, VII, and VIII).

Methods

This was an international multicentre retrospective analysis of patients who underwent R-LLR or L-LLR at 24 centres between 2010 and 2019. Patient demographics, perioperative parameters, and postoperative outcomes were analysed; 1 : 3 propensity score matching (PSM) and 1 : 1 coarsened exact matching (CEM) were performed.

Results

Of 1566 patients undergoing R-LLR and L-LLR, 983 met the study inclusion criteria. Before matching, 159 R-LLRs and 824 L-LLRs were included. After 1 : 3 PSM of 127 R-LLRs and 381 L-LLRs, comparison of perioperative outcomes showed that median blood loss (100 (i.q.r. 40–200) versus 200 (100–500) ml; P = 0.003), blood loss of at least 500 ml (9 (7.4 per cent) versus 94 (27.6 per cent); P &lt; 0.001), intraoperative blood transfusion rate (4 (3.1 per cent) versus 38 (10.0 per cent); P = 0.025), rate of conversion to open surgery (1 (0.8 per cent) versus 30 (7.9 per cent); P = 0.022), median duration of Pringle manoeuvre when applied (30 (20–46) versus 40 (25–58) min; P = 0.012), and median duration of operation (175 (130–255) versus 224 (155–300); P &lt; 0.001) were lower in the R-LLR group compared with the L-LLR group. After 1 : 1 CEM of 104 R-LLRs with 104 L-LLRs, R-LLR was similarly associated with significantly reduced blood loss and a lower rate of conversion to open surgery.

Conclusion

Based on a matched analysis of well selected patients, both robotic and laparoscopic access could be undertaken safely with good outcomes for tumours in the posterosuperior liver segments.

Laparoscopic versus Robotic Hepatectomy: A Systematic Review and Meta-Analysis

This study aimed to assess the surgical outcomes of robotic compared to laparoscopic hepatectomy, with a special focus on the meta-analysis method. Original studies were collected from three Chinese databases, PubMed, EMBASE, and Cochrane Library databases. Our systematic review was conducted on 682 patients with robotic liver resection, and 1101 patients were operated by laparoscopic platform. Robotic surgery has a long surgical duration (MD = 43.99, 95% CI: 23.45-64.53, p = 0.0001), while there is no significant difference in length of hospital stay (MD = 0.10, 95% CI: -0.38-0.58, p = 0.69), blood loss (MD = -20, 95% CI: -64.90-23.34, p = 0.36), the incidence of conversion (OR = 0.84, 95% CI: 0.41-1.69, p = 0.62), and tumor size (MD = 0.30, 95% CI: -0-0.60, p = 0.05); the subgroup analysis of major and minor hepatectomy on operation time is (MD = -7.08, 95% CI: -15.22-0.07, p = 0.09) and (MD = 39.87, 95% CI: -1.70-81.44, p = 0.06), respectively. However, despite the deficiencies of robotic hepatectomy in terms of extended operation time compared to laparoscopic hepatectomy, robotic hepatectomy is still effective and equivalent to laparoscopic hepatectomy in outcomes. Scientific evaluation and research on one portion of the liver may produce more efficacity and more precise results. Therefore, more clinical trials are needed to evaluate the clinical outcomes of robotic compared to laparoscopic hepatectomy.

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

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.

Does Robotic Liver Surgery Enhance R0 Results in Liver Malignancies during Minimally Invasive Liver Surgery?—A Systematic Review and Meta-Analysis

Background: Robotic procedures are an integral part of modern liver surgery. However, the advantages of a robotic approach in comparison to the conventional laparoscopic approach are the subject of controversial debate. The aim of this systematic review and meta-analysis is to compare robotic and laparoscopic liver resection with particular attention to the resection margin status in malignant cases. Methods: A systematic literature search was performed using PubMed and Cochrane Library in accordance with the PRISMA guidelines. Only studies comparing robotic and laparoscopic liver resections were considered for this meta-analysis. Furthermore, the rate of the positive resection margin or R0 rate in malignant cases had to be clearly identifiable. We used fixed or random effects models according to heterogeneity. Results: Fourteen studies with a total number of 1530 cases were included in qualitative and quantitative synthesis. Malignancies were identified in 71.1% (n = 1088) of these cases. These included hepatocellular carcinoma, cholangiocarcinoma, colorectal liver metastases and other malignancies of the liver. Positive resection margins were noted in 24 cases (5.3%) in the robotic group and in 54 cases (8.6%) in the laparoscopic group (OR = 0.71; 95% CI (0.42–1.18); p = 0.18). Tumor size was significantly larger in the robotic group (MD = 6.92; 95% CI (2.93–10.91); p = 0.0007). The operation time was significantly longer in the robotic procedure (MD = 28.12; 95% CI (3.66–52.57); p = 0.02). There were no significant differences between the robotic and laparoscopic approaches regarding the intra-operative blood loss, length of hospital stay, overall and severe complications and conversion rate. Conclusion: Our meta-analysis showed no significant difference between the robotic and laparoscopic procedures regarding the resection margin status. Tumor size was significantly larger in the robotic group. However, randomized controlled trials with long-term follow-up are needed to demonstrate the benefits of robotics in liver surgery.

The Role of Robotic Visceral Surgery in Patients with Adhesions: A Systematic Review and Meta-Analysis

Abdominal adhesions are a risk factor for conversion to open surgery. An advantage of robotic surgery is the lower rate of unplanned conversions. A systematic review was conducted using the terms “laparoscopic” and “robotic”. Inclusion criteria were: comparative studies evaluating patients undergoing laparoscopic and robotic surgery; reporting data on conversion to open surgery for each group due to adhesions and studies including at least five patients in each group. The main outcomes were the conversion rates due to adhesions and surgeons’ expertise (novice vs. expert). The meta-analysis included 70 studies from different surgical specialities with 14,329 procedures (6472 robotic and 7857 laparoscopic). The robotic approach was associated with a reduced risk of conversion (OR 1.53, 95% CI 1.12–2.10, p = 0.007). The analysis of the procedures performed by “expert surgeons” showed a statistically significant difference in favour of robotic surgery (OR 1.48, 95% CI 1.03–2.12, p = 0.03). A reduced conversion rate due to adhesions with the robotic approach was observed in patients undergoing colorectal cancer surgery (OR 2.62, 95% CI 1.20–5.72, p = 0.02). The robotic approach could be a valid option in patients with abdominal adhesions, especially in the subgroup of those undergoing colorectal cancer resection performed by expert surgeons.

A Cylindrical Grip Type of Tactile Device Using Magneto-Responsive Materials Integrated with Surgical Robot Console: Design and Analysis

This paper proposes a cylindrical grip type of tactile device that is effectively integrated to a surgical robot console so that a surgeon can easily touch and feel the same stiffness as the operating organs. This is possible since the yield stress (or stiffness) of magnetic-responsive materials can be tuned or controlled by the magnetic field intensity. The proposed tactile device consists of two main parts: a magnetorheological elastomer (MRE) layer and a magnetorheological fluid (MRF) core. The grip shape of the device to be positioned on the handle part of the master of the surgical robot is configured and its operating principle is discussed. Then, a couple of equations to calculate the stiffness from the gripping force and the field-dependent yield stress of MRF are derived and integrated using the finite element analysis (FEA) model. After simulating the stiffness of the proposed tactile device as a function of the magnetic field intensity (or current), the stiffnesses of various human organs, including the liver and heart, are calculated from known data of an elastic modulus. It is demonstrated from comparative data between calculated stiffness from human tissues and simulated stiffness from FEA that the proposed tactile device can generate sufficient stiffness with a low current level to recognize various human organs which are significantly required in the surgical robot system.

Maturation of robotic liver resection during the last decade: A systematic review and meta-analysis

BACKGROUND

Minimally invasive hepatectomy techniques have developed rapidly since 2000. Pure laparoscopic liver resection (LLR) has become the primary approach for managing liver tumors and procuring donor organs for liver transplantation. Robotic liver resection (RLR) has emerged during the last decade. The technical status of RLR seems to be improving.

AIM

To conduct a systematic review and meta-analysis comparing the short-term clinical outcomes of LLR and RLR over two 5-year periods.

METHODS

A systematic literature search was performed using PubMed and Medline, including the Cochrane Library. The following inclusion criteria were set for the meta-analysis: (1) Studies comparing LLR vs RLR; and (2) Studies that described clinical outcomes, such as the operative time, intraoperative bleeding, intraoperative conversion rate, and postoperative complications.

RESULTS

A total of 25 articles were included in this meta-analysis after 40 articles had been subjected to full-text evaluations. The studies were divided into early (n = 14) and recent (n = 11) groups. In the recent group, the operative time did not differ significantly between LLR and RLR (P = 0.70), whereas in the early group the operative time of LLR was significantly shorter than that of RLR (P < 0.001).

CONCLUSION

The initial disadvantages of RLR, such as its long operation time, have been overcome during the last 5 years. The other clinical outcomes of RLR are comparable to those of LLR. The cost and quality-of-life outcomes of RLR should be evaluated in future studies to promote its routine clinical use.

Current trends in three-dimensional visualization and real-time navigation as well as robot-assisted technologies in hepatobiliary surgery

With the continuous development of digital medicine, minimally invasive precision and safety have become the primary development trends in hepatobiliary surgery. Due to the specificity and complexity of hepatobiliary surgery, traditional preoperative imaging techniques such as computed tomography and magnetic resonance imaging cannot meet the need for identification of fine anatomical regions. Imaging-based three-dimensional (3D) reconstruction, virtual simulation of surgery and 3D printing optimize the surgical plan through preoperative assessment, improving the controllability and safety of intraoperative operations, and in difficult-to-reach areas of the posterior and superior liver, assistive robots reproduce the surgeon’s natural movements with stable cameras, reducing natural vibrations. Electromagnetic navigation in abdominal surgery solves the problem of conventional surgery still relying on direct visual observation or preoperative image assessment. We summarize and compare these recent trends in digital medical solutions for the future development and refinement of digital medicine in hepatobiliary surgery.

Robotic surgery for colorectal liver metastases resection: A systematic review

BACKGROUND

The role of robotic surgery for colorectal cancer liver metastases (CRCLMs) has never been investigated in large series.

METHODS

A systematic literature review was carried out on PubMed and Cochrane libraries.

RESULTS

We selected nine studies between 2008 and 2021. Two hundred sixty-two patients were included. One hundred thirty-one patients underwent simultaneous resections. The mean blood loss was 309.4 ml (range, 200-450 ml), the mean operative time was 250.5 min (range, 198.5-449.0 min). The mean length of hospital stay was 7.98 days (range, 4.5 to 12 days). The overall postoperative mortality was 0.4%. The overall morbidity rate was 37.0%, Clavien-Dindo grade III-IV complications were 8.4%. The mean 3-year overall survival was 55.25% (range, 44.4-66.1%), the mean 3-year disease free survival was 37% (range, 33.3-41.9%) CONCLUSION: We can conclude that robotic-assisted surgery might be considered as a technical upgrade option for minimally invasive approach to CRCLM resections even for simultaneous operations and challenging cases.

Robotic resection for hydatid disease of the liver

Robotic-assisted surgery for the management of hepatic echinococcosis was introduced in 2016. The advantage it offers over laparoscopy is less rigidity with the use of the 360° rotation of the Endo-Wrist technology, thus allowing the preservation of the integrity of the liver tissue. Herein, we report the first successful robotic resection of the left lobe of the liver for hydatid disease in the Middle East. Our patient is a 71-year-old man found to have a large left hepatic lobe hydatid disease on CT scan. The hydatid liver disease was resected completely with an operation time of 130 min and minimal intraoperative blood loss. Patient did well postoperatively and was discharged home on day 2. Our experience shows that robotic surgery for hydatid disease of the liver can be safely performed, with an excellent outcome to the patient. It also provides unique technical advantages in the field of minimal-invasive surgery.

Robotic liver surgery: literature review and future perspectives

INTRODUCTION

Minimally invasive liver resections (MILR) have been gaining popularity over the last decades. MILR provides superior peri-operative outcome. Despite these advantages, the penetrance of MILR in the clinical setting has been limited, and it was slowed down, among other factors, also by the laparoscopic technological limitations.

EVIDENCE ACQUISITION

A literature review has been carried out (Pubmed, Embase and Scopus platforms) focusing on the role of robotic surgery in MILR.

EVIDENCE SYNTHESIS

The literature review results are presented and our additional remarks on the topic are discussed.

CONCLUSIONS

Robotic MILR has been helping to expand the penetrance of MIS in liver surgery by making possible increasingly more challenging procedures. Minor resections still represent most of the robotic liver surgery data currently available. Robotic liver surgery is safe and effective, and it shows perioperative outcomes comparable with laparoscopic and open surgery. The oncological efficacy, within the limitations of the current level of evidence (mostly retrospective studies and literature heterogeneity), seems to show promising result. High quality prospective randomized studies, the use of prospective registry data, and multi-institutional efforts are needed.

IWATE criteria are associated with perioperative outcomes in robotic hepatectomy: a retrospective review of 225 resections

Background

Robotic hepatectomy (RH) is increasingly utilized for minor and major liver resections. The IWATE criteria were developed to classify minimally invasive liver resections by difficulty. The objective of this study was to apply the IWATE criteria in RH and to describe perioperative and oncologic outcomes of RH over the last decade at our institution.

Methods

Perioperative and oncologic outcomes of patients who underwent RH between 2011 and 2019 were retrospectively collected. The difficulty level of each operation was assessed using the IWATE criteria, and outcomes were compared at each level. Univariate linear regression was performed to characterize the relationship between IWATE criteria and perioperative outcomes (OR time, EBL, and LOS), and a multivariable model was also developed to address potential confounding by patient characteristics (age, sex, BMI, prior abdominal surgery, ASA class, and simultaneous non-hepatectomy operation).

Results

Two hundred and twenty-five RH were performed. Median IWATE criteria for RH were 6 (IQR 5–9), with low, intermediate, advanced, and expert resections accounting for 23% (n = 51), 34% (n = 77), 32% (n = 72), and 11% (n = 25) of resections, respectively. The majority of resections were parenchymal-sparing approaches, including anatomic segmentectomies and non-anatomic partial resections. 30-day complication rate was 14%, conversion to open surgery occurred in 9 patients (4%), and there were no deaths within 30 days postoperatively. In the univariate linear regression analysis, IWATE criteria were positively associated with OR time, EBL, and LOS. In the multivariable model, IWATE criteria were independently associated with greater OR time, EBL, and LOS. Two-year overall survival for hepatocellular carcinoma and intrahepatic cholangiocarcinoma was 94% and 50%, respectively.

Conclusion

In conclusion, the IWATE criteria are associated with surgical outcomes after RH. This series highlights the utility of RH for difficult hepatic resections, particularly parenchymal-sparing resections in the posterosuperior sector, extending the indication of minimally invasive hepatectomy in experienced hands and potentially offering select patients an alternative to open hepatectomy or other less definitive liver-directed treatment options.

Usability of Indocyanine Green in Robot-Assisted Hepatic Surgery

Recent developments in robotic surgery have led to an increasing number of robot-assisted hepatobiliary procedures. However, a limitation of robotic surgery is the missing haptic feedback. The fluorescent dye indocyanine green (ICG) may help in this context, which accumulates in hepatocellular cancers and around hepatic metastasis. ICG accumulation may be visualized by a near-infrared camera integrated into some robotic systems, helping to perform surgery more accurately. We aimed to test the feasibility of preoperative ICG application and its intraoperative use in patients suffering from hepatocellular carcinoma and metastasis of colorectal cancer, but also of other origins. In a single-arm, single-center feasibility study, we tested preoperative ICG application and its intraoperative use in patients undergoing robot-assisted hepatic resections. Twenty patients were included in the final analysis. ICG staining helped in most cases by detecting a clear lesion or additional metastases or when performing an R0 resection. However, it has limitations if applied too late before surgery and in patients suffering from severe liver cirrhosis. ICG staining may serve as a beneficial intraoperative aid in patients undergoing robot-assisted hepatic surgery. Dose and time of application and standardized fluorescence intensity need to be further determined.

Minimally Invasive Hepatectomy in North America: Laparoscopic Versus Robotic

BACKGROUND

Minimally invasive hepatectomy has been shown to be associated with improved outcomes when compared with open surgery. However, data comparing laparoscopic and robotic hepatectomy is lacking and limited to single-center studies.

METHODS

Patients undergoing major (≥ 3 segments) or partial (≤ 2 segments) hepatectomy were identified in the 2014-2017 ACS-NSQIP hepatectomy targeted database. Patients undergoing laparoscopic and robotic approaches were compared, and propensity score matching was utilized to adjust for bias.

RESULTS

Of 3152 minimally invasive hepatectomies (MIHs), 86% (N = 2706) were partial and 14% (N = 446) were major. The laparoscopic approach was utilized in 92% of patients (N = 2905) and 8% were performed robotically (N = 247). The percentage of MIHs increased over time (p < 0.01). After matching, 240 were identified in each cohort. Compared with the robotic approach, patients undergoing laparoscopic hepatectomy had a significantly higher conversion rate (23% vs. 7.4%) but had shorter operative time (159 vs. 204 min) (p < 0.001). Laparoscopic cases undergoing an unplanned conversion to open were associated with increased morbidity (p < 0.001), but this difference was not observed in robotic cases. Both MIH approaches had low mortality (1.0%, p = 1.00), overall morbidity (17%, p = 0.47), and very short length of stay (3 days, p = 0.80).

CONCLUSION

Minimally invasive hepatectomy is performed primarily for partial hepatectomies. Laparoscopic hepatectomy is associated with a significantly higher conversion rate, and converted cases have worse outcomes. Both minimally invasive approaches are safe with similar mortality, morbidity, and a very short length of stay. Graphical Abstract.

Minimally Invasive Hepatectomy in North America: Laparoscopic Versus Robotic

BACKGROUND

Minimally invasive hepatectomy has been shown to be associated with improved outcomes when compared with open surgery. However, data comparing laparoscopic and robotic hepatectomy is lacking and limited to single-center studies.

METHODS

Patients undergoing major (≥ 3 segments) or partial (≤ 2 segments) hepatectomy were identified in the 2014-2017 ACS-NSQIP hepatectomy targeted database. Patients undergoing laparoscopic and robotic approaches were compared, and propensity score matching was utilized to adjust for bias.

RESULTS

Of 3152 minimally invasive hepatectomies (MIHs), 86% (N = 2706) were partial and 14% (N = 446) were major. The laparoscopic approach was utilized in 92% of patients (N = 2905) and 8% were performed robotically (N = 247). The percentage of MIHs increased over time (p < 0.01). After matching, 240 were identified in each cohort. Compared with the robotic approach, patients undergoing laparoscopic hepatectomy had a significantly higher conversion rate (23% vs. 7.4%) but had shorter operative time (159 vs. 204 min) (p < 0.001). Laparoscopic cases undergoing an unplanned conversion to open were associated with increased morbidity (p < 0.001), but this difference was not observed in robotic cases. Both MIH approaches had low mortality (1.0%, p = 1.00), overall morbidity (17%, p = 0.47), and very short length of stay (3 days, p = 0.80).

CONCLUSION

Minimally invasive hepatectomy is performed primarily for partial hepatectomies. Laparoscopic hepatectomy is associated with a significantly higher conversion rate, and converted cases have worse outcomes. Both minimally invasive approaches are safe with similar mortality, morbidity, and a very short length of stay. Graphical Abstract.

Long-Term and Oncologic Outcomes of Robotic Versus Laparoscopic Liver Resection for Metastatic Colorectal Cancer: A Multicenter, Propensity Score Matching Analysis

BACKGROUND

To assess long-term oncologic outcomes of robotic-assisted liver resection (RLR) for colorectal cancer (CRC) metastases as compared to a propensity-matched cohort of laparoscopic liver resections (LLR). Although safety and short-term outcomes of RLR have been described and previously compared to LLR, long-term and oncologic data are lacking.

METHODS

A retrospective study was performed of all patients who underwent RLR and LLR for CRC metastases at six high-volume centers in the USA and Europe between 2002 and 2017. Propensity matching was used to match baseline characteristics between the two groups. Data were analyzed with a focus on postoperative and oncologic outcomes, as well as long-term recurrence and survival.

RESULTS

RLR was performed in 115 patients, and 514 patients underwent LLR. Following propensity matching 115 patients in each cohort were compared. Perioperative outcomes including mortality, morbidity, reoperation, readmission, intensive care requirement, length-of-stay and margin status were not statistically different. Both prematching and postmatching analyses demonstrated similar overall survival (OS) and disease-free survival (DFS) between RLR and LLR at 5 years (61 vs. 60% OS, p = 0.87, and 38 vs. 31% DFS, p = 0.25, prematching; 61 vs. 60% OS, p = 0.78, and 38 vs. 44% DFS, p = 0.62, postmatching).

CONCLUSIONS

Propensity score matching with a large, multicenter database demonstrates that RLR for colorectal metastases is feasible and safe, with perioperative and long-term oncologic outcomes and survival that are largely comparable to LLR.

The impact of robotics in liver surgery: A worldwide systematic review and short-term outcomes meta-analysis on 2,728 cases

BACKGROUND

The dissemination of robotic liver surgery is slow-paced and must face the obstacle of demonstrating advantages over open and laparoscopic (LLS) approaches. Our objective was to show the current position of robotic liver surgery (RLS) worldwide and to identify if improved short-term outcomes are observed, including secondary meta-analyses for type of resection, etiology, and cost analysis.

METHODS

A PRISMA-based systematic review was performed to identify manuscripts comparing RLS vs open or LLS approaches. Quality analysis was performed using the Newcatle-Ottawa score. Statistical analysis was performed after heterogeneity test and fixed- or random-effect models were chosen accordingly.

RESULTS

After removing duplications, 2728 RLS cases were identified from the final set of 150 manuscripts. More than 75% of the cases have been performed on malignancies. Meta-analysis from the 38 comparative reports showed that RLS may offer improved short-term outcomes compared to open procedures in most of the variables screened. Compared to LLS, some advantages may be observed in favour of RLS for major resections in terms of operative time, hospital stay and rate of complications. Cost analyses showed an increased cost per procedure of around US$5000.

CONCLUSIONS

The advantages of RLS still need to be demonstrated although early results are promising. Advantages vs open approach are demonstrated. Compared to laparoscopic surgery, minor perioperative advantages may be observed for major resections although cost analyses are still unfavorable to the robotic approach.

State of the art in robotic liver surgery: a meta-analysis

Although the number of robotic hepatectomy (RH) performed is increasing, few studies have reported its efficacy in comparison with the conventional surgical modalities. The aim of this meta-analysis was to evaluate the perioperative results of RH vs. open hepatectomy (OH) and RH vs. laparoscopic hepatectomy (LH). We systematically searched for English papers published in PubMed (Medline), Embase, and Cochrane library before March 1, 2020. A total of 39 papers and 2999 patients were eventually included. Among the included patients, 1249, 1010, and 740 underwent RH, LH, and OH, respectively. Compared with OH, the operation time was significantly increased but the intraoperative blood loss, blood transfusion rate, incidence of severe complications, and length of postoperative hospitalization were significantly reduced in patients with RH. However, there was no significant difference in the use of Pringle maneuver and overall incidence of complications. Compared with LH, the operation time was significantly increased, and the intraoperative blood loss was also more in RH. However, there were no differences in blood transfusion rate, use of Pringle maneuver, incidence of complications, incidence of severe complications, and length of postoperative hospitalization between the two groups. A longer operation time remains the main shortcoming of RH. However, based on the perioperative clinical efficacy, we conclude that RH is comparable to LH but is better than OH for selected patients.

Comparative clinical outcomes of robot-assisted liver resection versus laparoscopic liver resection: A meta-analysis

BACKGROUND

As an emerging technology, robot-assisted surgical system has some potential merits in many complicated endoscopic procedures compared with laparoscopic surgery. But robot-assisted liver resection is still a controversial problem on its advantages compared with laparoscopic liver resection. We aimed to perform the meta-analysis to assess and compare the clinical outcomes of robot-assisted and laparoscopic liver resection.

METHODS

We searched PubMed, Cochrane Library, Embase databases, Clinicaltrials, and Opengrey through March 24, 2020, including references of qualifying articles. English-language, original investigations in humans about robot-assisted and laparoscopic hepatectomy were included. Titles, abstracts, and articles were reviewed by at least 2 independent readers. Continuous and dichotomous variables were compared by the weighted mean difference (WMD) and odds ratio (OR), respectively.

RESULTS

Of 936 titles identified in our original search, 28 articles met our criteria, involving 3544 patients. Compared with laparoscopy, the robot-assisted groups had longer operative time (WMD: 36.93; 95% CI, 19.74-54.12; P < 0.001), lower conversion rate (OR: 0.63; 95% CI, 0.46-0.87; P = 0.005), higher transfusion rate (WMD: 2.39; 95% CI, 1.51-3.76; P < 0.001) and higher total cost (WMD:0.49; 95% CI, 0.42-0.55; P < 0.001). In addition, the baseline characteristics of patients about largest tumor size was larger (WMD: 0.36; 95% CI, 0.16-0.56; P < 0.001) and malignant lesions rate was higher (WMD: 1.50; 95% CI, 1.21-1.86; P < 0.001) in the robot-assisted versus laparoscopic hepatectomy. The subgroup analysis of minor hepatectomy showed robot-assisted was associated with longer operative time (WMD: 36.00; 95% CI, 12.59-59.41; P = 0.003), longer length of stay (WMD: 0.51; 95% CI, 0.02-1.01; p = 0.04) and higher total cost (WMD: 0.48; 95% CI, 0.25-0.72; P < 0.001) (Table 3); while the subgroup analysis of major hepatectomy showed robot-assisted was associated with lower estimated blood loss (WMD: -122.43; 95% CI, -151.78--93.08; P < 0.001).

CONCLUSIONS

Our meta-analysis revealed that robot-assisted was associated with longer operative time, lower conversion rate, higher transfusion rate and total cost, and robot-assisted has certain advantages in major hepatectomy compared with laparoscopic hepatectomy.

Transitioning From Open to Robotic Liver Resection. Results of 46 Consecutive Procedures Including a Majority of Major Hepatectomies

Aims. Minimally invasive liver resection is a complex and challenging operation. Although authors have reported robotic liver resection shows improved safety and efficacy compared with open liver resection, robotic major liver resections for malignant liver lesions treatment remain inadequately evaluated. The aims of the present study were to evaluate the feasibility and safety of transitioning from open to robotic liver resection in a nonuniversity hospital. Patients and Methods. From December 2015 to March 2020, 46 patients underwent totally robotic-assisted liver resections out of 446 robotic procedures. Also, we retrospectively reviewed the last 27 open right hepatectomies (ORHs) and compared then with the first 25 anatomic robotic-assisted right hepatectomies (RRHs). Results. Mean operative time, mean blood lost, rate of complications, and mean hospital stay were associated with the complexity of the procedure. The comparison between ORH and RRH showed that intraoperative complications were less frequently observed during ORH whereas RRH showed a trend in favor of less blood loss. ORH had a trend toward smaller surgical margins and higher rate of R1 resections. Recurrence occurred in 31 (59%) patients and was more frequently observed after ORH. However, the mean follow-up was significantly shorter after RRH. Conclusion. Our study demonstrated the technical feasibility and safety of transitioning from open to robotic liver resection (including major hepatectomies) in a nonuniversity setting. Higher costs remain an important drawback for robotic surgery.

Safety and feasibility of robotic major hepatectomy for novice surgeons in robotic liver surgery: A prospective multicenter pilot study

BACKGROUND

Robotic liver resection has not yet been widely implemented. We aimed to evaluate the feasibility and safety of robotic major liver resection by performing a prospective multicenter study.

METHODS

From July 2017 to December 2018, five surgeons from five tertiary hospitals who were novices in robotic liver resection but experienced in open and laparoscopic liver resection performed 46 cases of robotic major anatomical liver resections. Perioperative clinical data and surgical data, including detailed procedure times were prospectively collected. All operations were performed according to a protocol for unify surgical techniques and instruments.

RESULTS

Twenty-two cases of left hemihepatectomy, one case of extended left hemihepatectomy, 14 cases of right hemihepatectomy, two cases of right anterior sectionectomy, six cases of right posterior sectionectomy, and one case of central bisectionectomy were performed. The most common indications were hepatocellular carcinoma (21 cases) followed by intrahepatic duct stones (10 cases), intrahepatic cholangiocellular carcinoma (7 cases), liver metastases (3 cases), intraductal papillary neoplasms (2 cases), sarcoma (1 case), mucinous cystic neoplasm (1 case), and hemangioma (1 case). Surgical resection margins for all tumor cases were negative. The mean operation time was 378.58 ± 124.31 (190-696) minutes and the estimated intraoperative blood loss was 276.67 ± 397.41 mL (range, 10-2600 mL). Overall complications developed in 16 cases (34.8%). There were three cases of severe surgical complications (Clavien-Dindo classification of III or more). Only one of 46 cases was converted to conventional open left hemihepatectomy because of bleeding. The mean hospital stay was 7.3 ± 2.5 (4-18) days.

CONCLUSIONS

The results of this study indicate that robotic anatomic major liver resection can be safely performed by robotic beginners who are advanced open and laparoscopic liver surgeons.

Robotic Versus Conventional Laparoscopic Liver Resections: A Systematic Review and Meta-Analysis

BACKGROUND

Theoretical advantages of robotic surgery compared to conventional laparoscopic surgery include improved instrument dexterity, 3D visualization, and better ergonomics. This systematic review and meta-analysis aimed to determine advantages of robotic surgery over laparoscopic surgery in patients undergoing liver resections.

METHOD

A systematic literature search was conducted for studies comparing robotic assisted or totally laparoscopic liver resection. Meta-analysis of intraoperative (operative time, blood loss, transfusion rate, conversion rate), oncological (R0 resection rates), and postoperative (bile leak, surgical site infection, pulmonary complications, 30-day and 90-day mortality, length of stay, 90-day readmission and reoperation rates) outcomes was performed using a random effects model.

RESULT

Twenty-six non-randomized studies including 2630 patients (950 robotic and 1680 laparoscopic) were included, of which 20% had major robotic liver resection and 14% had major laparoscopic liver resection. Intraoperatively, robotic liver resection was associated with significantly less blood loss (mean: 286 vs 301 mL, p < 0.001) but longer operating time (mean: 281 vs 221 min, p < 0.001). There were no significant differences in conversion rates or transfusion rates between robotic liver resection and laparoscopic liver resection. Postoperatively, there were no significant differences in overall complications, bile leaks, and length of hospital stay between robotic liver resection and laparoscopic liver resection. However, robotic liver resection was associated with significantly lower readmission rates than laparoscopic liver resection (odds ratio: 0.43, p = 0.005).

CONCLUSION

Robotic liver resection appears to offer some advantages compared to conventional laparoscopic surgery, although both techniques appear equivalent. Importantly, the quality of evidence is generally limited to cohort studies and a high-quality randomized trial comparing both techniques is needed.

Successful robotic radical resection of hepatic echinococcosis located in posterosuperior liver segments

BACKGROUND

Radical resection is an important treatment method for hepatic echinococcosis. The posterosuperior segments of the liver remain the most challenging region for laparoscopic or robotic hepatectomy.

AIM

To demonstrate the safety and preliminary experience of robotic radical resection of cystic and alveolar echinococcosis in posterosuperior liver segments.

METHODS

A retrospective analysis was conducted on the clinical data of 5 patients with a median age of 37 years (21-56 years) with cystic and alveolar echinococcosis in difficult liver lesions admitted to two centers from September to December 2019. The surgical methods included total pericystectomy, segmental hepatectomy, or hemihepatectomy.

RESULTS

Among the 5 patients, 4 presented with cystic echinococcosis and 1 presented with alveolar echinococcosis, all of whom underwent robotic radical operation successfully without conversion to laparotomy. Total caudate lobectomy was performed in 2 cases, hepatectomy of segment VII in 1 case, total pericystectomy of segment VIII in 1 case, and right hemihepatectomy in 1 case. Operation time was 225 min (175-300 min); blood loss was 100 mL (50-600 mL); and postoperative hospital stay duration was 10 d (5-19 d). The Clavien-Dindo complication grade was I in 4 cases and II in 1 case. No recurrence of echinococcosis was found in any patient at the 3 mo of follow-up.

CONCLUSION

Robotic radical surgery for cystic and selected alveolar echinococcosis in posterosuperior liver segments is safe and feasible.

Robotic approach as a valid strategy to improve the access to posterosuperior hepatic segments-Case series and review of literature

INTRODUCTION

Although the laparoscopy liver resection (LLR) has become a useful approach for minor resections, it seems that lesions in posterosuperior (PS) segments still represent technical challenges. We report a series of robotic approach as an alternative option for these lesions, and a systematic review of the literature to show its feasibility.

METHODS

Consecutive patients who underwent liver resection for solitary lesions in PS segments by da Vinci SI robot, and by the same team. A systematic review of the literature was made to evaluate the feasibility of a robotic approach for PS hepatectomies.

RESULTS

From April 2016 to April 2017, five cases of robotic nonanatomical PS resections of colorectal liver metastases (CRLM) were performed. A systematic review encountered five articles plus this series reporting outcomes for this approach. Briefly, a total of five patients in our series underwent this approach, all females, and one patient presented a grade 2 complication.

CONCLUSION

Robotic hepatectomy seems to be a useful and valid strategy to resect lesions on PS hepatic segments simplifying liver-sparing hepatectomies. Even though the operative time is still high, the short length of stay, low number of complications and the low need for blood transfusions seems to surpass the intrinsic cost of robotic surgery.

Robotic simultaneous resection for colorectal liver metastasis: feasibility for all types of liver resection

BACKGROUND

A laparoscopic approach is increasingly being utilized in simultaneous colorectal and liver resection (SCLR) for colorectal cancer with liver metastasis. However, this approach is technically challenging and hence has not been widely adopted. Robotic surgical systems could potentially overcome this problem. We aim to describe the feasibility and outcomes of robotic SCLR for colorectal carcinoma with liver metastasis.

METHODS

The medical records of 12 patients who underwent robotic SCLR for colorectal cancer with liver metastasis between January 2008 and September 2018 were reviewed retrospectively.

RESULTS

The mean age was 59 years (range, 37-77 years). The liver resections were comprised of two right hepatectomies, one left hepatectomy, one left lateral sectionectomy, one segmentectomy of S3 and wedge resection (segment 7), one caudate lobectomy, one associated liver partition and portal vein ligation for staged hepatectomy, and five wedge resections involving segments 4, 5, 6, 7, or 8. The colorectal procedures involved seven low-anterior resections, two anterior resections, two right hemicolectomies, and one left hemicolectomy. The mean operative time was 449 min (range, 135-682 min) with a mean estimated blood loss of 274.3 mL (range, 40-780 mL). The mean length of hospital stay was 12 days (range, 5-28 days). No patients required conversion to laparotomy. Liver resection-related complications were two liver abscesses (Clavien-Dindo classification, one grade II and one grade III) and one case of ascites (grade I), whereas colorectal resection-related complications included one anastomosis leak (grade III) and one superficial wound infection (grade II). There were no deaths reported within 30 days of the procedure. With a mean follow-up duration of 31.5 ± 26.1 months, the overall survival and disease-free survival values were 75.2 and 47.1 months, respectively.

CONCLUSION

Robotic SCLR for colorectal neoplasm with liver metastasis can be performed safely even in cases requiring major liver resections, especially in a specialized center with a well-trained team.

Short- and Long-term Outcomes after Robotic and Laparoscopic Liver Resection for Malignancies: A Propensity Score-Matched Study

OBJECTIVES

A laparoscopic approach improves short-term outcomes and maintains long-term outcomes compared to an open approach. In turn, the recent development of robotic surgery raises the question whether it performs as well as laparoscopic surgery. The aim of this study was to compare the short- and long-term outcomes of laparoscopic liver resection (LLR) and robotic liver resection (RLR) for malignancies.

METHOD

From 2011 to 2017, the study population included 111 patients in the LLR group and 61 in the RLR group. Short- and long-term outcomes were compared before and after propensity score matching (PSM).

RESULTS

Operative mortality rate was nil. The intraoperative blood transfusion rate was higher during RLR (15% vs. 2%, p = 0.0009). Major morbidity and hospital stay were not different between the two groups. The resection margin width (LLR 7 mm vs. RLR 10 mm, p = 0.13) and R1 resection rates (resection margin width < 1 mm; LLR 15% vs. RLR 11%, p = 0.49) were similar. After PSM (55 patients in each group), the blood transfusion, major morbidity, hospital stay and R1 resection were similar between the two groups. When considering the largest subset of patients with hepatocellular carcinoma including 114 patients (66%), the 3-year overall survival rate was 80% in the LLR group and 97% in the RLR group (p = 0.10) and remained similar after PSM (p = 0.27). The 3-year recurrence-free survival rate was 50% in the LLR group and 64% in the RLR group (p = 0.30) and remained similar after PSM (p = 0.26).

CONCLUSIONS

No differences were found in blood transfusion, incidence of positive resection margins and long-term outcomes between the two techniques. RLR does not compromise short-term and oncologic outcomes in patients with liver cancers.

Robotic approach to the liver: Open surgery in a closed abdomen or laparoscopic surgery with technical constraints?

The application of the minimally invasive approach has shown to be safe and effective for liver surgery and is in constant growth. The indications for laparoscopic surgery are steadily increasing across the field. In the early 2000s, robotic surgery led to some additional improvements, such as tremor filtration, instrument stability, 3D view and more comfort for the surgeon. These techniques bring in some advantages compared to the traditional OLR: less blood loss, shorter admissions, fewer adhesions, and a faster postoperative recovery and better outcomes in case of further hepatectomy for tumor recurrence has been shown. Concerning which is the best minimally invasive approach between laparoscopic and robotic surgery, the evidence is still conflicting. The latter shows good potential, since the endo-wristed instruments work similarly to the surgeon's hands, even with an intact abdominal wall. However, the technique is still under development, burdened by important costs, and limited by the lack of some instruments available for the laparoscopic approach. The paucity of universally accepted and proven data, especially concerning long-term outcomes, hampers drawing univocal acceptance at present. Furthermore, the number of variables related both to the patient and the disease further complicates the decision leading to a treatment tailored to each patient with strict selection. This review aims to explore the main differences between laparoscopic and robotic surgery, focusing on indications, operative technique and current debated clinical issues in recent literature.

[Evidence for robotic surgery in oncological visceral surgery]

The superiority of minimally invasive operative methods compared to open surgery with respect to various parameters of short-term outcome with adequate oncological long-term results has already been confirmed for many tumor entities in high-quality studies. The continuously expanding robotic surgery offers certain additional benefits in minimally invasive oncological visceral surgery, such as a high-resolution stable 3‑dimensional view, optimal freedom of movement in situ, elimination of natural tremor and better ergonomics. This article evaluates whether these postulated advantages are reflected in an improvement of the short-term perioperative and long-term oncological results compared to conventional minimally invasive surgery in oncological visceral surgery (rectum, colon, stomach, esophagus, pancreas, liver) according to the criteria of evidence-based medicine. With the exception of colorectal surgery, there are currently no randomized controlled studies comparing robotic to laparoscopic surgery in oncological visceral surgery. There is still a clear imbalance between the exponentially expanding application of robotic surgery and the existing lack of high-quality evidence. Further randomized controlled clinical trials urgently need to be performed especially considering the great technological development potential of robotic surgery.

Not just minor resections: robotic approach for cystic echinococcosis of the liver

INTRODUCTION

Human echinococcosis is among the 17 neglected tropical diseases recognized by the World Health Organization. It is responsible for over $3 billion of health costs every year being endemic in large areas worldwide, and liver is affected in 70% of the cases. Surgery associated to medical treatment is the gold standard and robotic approach may be a valuable tool to achieve safe, parenchyma sparing resections.

METHODS

We retrospectively analyzed the outcomes of patients that underwent robotic radical surgical treatment for hydatid liver disease, from prospectively maintained databases of three Italian centers.

RESULTS

15 patients were included in this study, median age 51 years (24-76). 1 right hepatectomy, 2 left lateral sectionectomies, 5 segmentectomies (including 1 caudatectomy), 3 wedge resections and 5 cyst-pericystectomies were performed. Median estimated blood loss was of 100 ml (50-550 ml), and median operative time including docking was 210 min (95-590 min), with no need for conversion to open. Median hospital stay was 4 days, with only one readmission for fever. Only one patient experienced recurrence in a different liver segment.

CONCLUSIONS

In our experience, robotic approach for cystic echinococcosis of the liver proved to be a safe and effective strategy also in the so-called "difficult segments", with short post-operative stay and quick return to daily activities, along with the absence of surgical site recurrences. To the best of our knowledge, this is the largest report of robotic approach to hydatid liver disease.

Robotic Surgery for Malignant Liver Disease: a Systematic Review of Oncological and Surgical Outcomes

Robot-assisted laparoscopic surgery is yet another modification of minimally invasive liver surgery. It is described as feasible and safe from the surgical point of view; however, oncological outcomes need to be adequately analysed to justify the use of this technique when resecting malignant liver tumours. We reviewed existing English medical literature on robot-assisted laparoscopic liver surgery. We analysed surgical outcomes and oncological outcomes. We analysed operative parameters including operative time, type of hepatectomy, blood loss, conversion rate, morbidity and mortality rates and length of stay. We also analysed oncological outcomes including completeness of resection (R status), recurrence, survival and follow-up data. A total of 582 patients undergoing robot-assisted laparoscopic liver surgery were analysed from 17 eligible publications. Only 5 publications reported survival data. The overall morbidity was 19% with 0.2% reported mortality. R0 resection was achieved in 96% of patients. Robotic liver surgery is feasible and safe with acceptable morbidity and oncological outcomes including resection margins. However, well-designed trials are required to provide evidence in terms of survival and disease-free intervals when performed for malignancy.

Surgical and oncological outcomes after ultrasound-guided robotic liver resections for malignant tumor. Analysis of a prospective database

AIM

Robotic surgery is thought to have a role in widening the application of minimally invasive liver surgery. Nonetheless, data concerning surgical results for liver malignancies are presently still lacking. We aimed to evaluate the surgical and oncological outcomes of ultrasound guided robotic liver resections for hepatic malignancies.

METHODS

All consecutive patients who received robotic resection of primary and secondary liver malignancies from September 2008 to January 2017 were analyzed. The same surgical team performed all procedures following the principle of parenchymal-sparing surgery.

RESULTS

From a total of 51 patients, 13 patients (25%) underwent major and 38 (75%) minor hepatectomy. No mortality occurred. Two procedures were converted to open surgery. Five patients experienced major complications, with a reintervention rate of 6%. Median hospital stay was 5 days.

CONCLUSIONS

Robotic surgery is a safe and feasible procedure for liver resection even when dealing with malignancies. Our data show that robotic surgery can be considered a valid option to treat patients with liver malignancies in a minimally invasive manner, without compromise the oncological results.

International consensus statement on robotic hepatectomy surgery in 2018

The robotic surgical system has been applied in liver surgery. However, controversies concerns exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness of robotic surgery. To promote the development of robotic hepatectomy, this study aimed to evaluate the current status of robotic hepatectomy and provide sixty experts’ consensus and recommendations to promote its development. Based on the World Health Organization Handbook for Guideline Development, a Consensus Steering Group and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 22 topics were prepared analyzed and widely discussed during the 4 meetings. Based on the published articles and expert panel opinion, 7 recommendations were generated by the GRADE method using an evidence-based method, which focused on the safety, feasibility, indication, techniques and cost-effectiveness of hepatectomy. Given that the current evidences were low to very low as evaluated by the GRADE method, further randomized-controlled trials are needed in the future to validate these recommendations.

Robotic hepatic surgery in malignancy: review of the current literature

The use of minimally invasive liver surgery, such as laparoscopic and robotic surgery, is increasing worldwide. Robot-assisted laparoscopy is a new surgical technique that improves surgical handling. The advantage of this technique is improved dexterity, which leads to increased surgical precision and no tremor or fatigue. Comparable oncological results were documented for laparoscopic and open surgery. Currently, "conventional" laparoscopic liver surgery has limitations with respect to the treatment of lesions in the posterior-superior segments, and there are limited technical features for the reconstruction steps. These limitations might be overcome with the use of robotic surgery. The use of robotic surgery for hepatic procedures originated because of the technical potential to overcome several of the major technical limitations known from conventional laparoscopy and the possibility of performing more extended liver resections. Additionally, there is increasing evidence indicating that robotic hepatic surgery is feasible and safe in resections of the posterior segments. Studies showed that using the robotic technique is associated with a decreased or at least equal amount of intraoperative blood loss compared to that of the conventional laparoscopic or open technique. There is increasing evidence that robotic liver surgery might be as safe as conventional laparoscopic procedures in cancer cases in terms of resection margins, disease-free and overall survival. Furthermore, robotic surgery might be more favorable with respect to postoperative patient recovery. Despite promising results, still large, multicenter, randomized and prospective studies are needed to analyze the exact value of robotic liver surgery in patients with malignant liver tumors.

Outcomes of robotic liver resections for colorectal liver metastases. A multi-institutional analysis of minimally invasive ultrasound-guided robotic surgery

BACKGROUND

Current evidence supporting robotics to perform minimally invasive liver resection is based on single center case series reporting surgical outcomes in heterogeneous groups of patients. On the contrary, relatively scarce data specifically focusing on secondary hepatic malignancies is available. The objective of this study is to assess short- and long-term outcomes following liver resection for colorectal liver metastasis on a multi-institutional series of patients.

METHODS

All consecutive patients undergoing robotic surgery for colorectal liver metastasis at three different tertiary hospitals over a 10-year time frame were included in this analysis. All patients received ultrasound-guided liver resection according to tumor location following the principle of parenchymal sparing surgery. Perioperative, clinicopathologic and oncological outcomes were assessed.

RESULTS

A total of 59 patients underwent liver resection. There were 7 cases of conversion to open surgery. The postoperative complication rate was 27%, 5% being the rate of major morbidity. Overall, the mean postoperative hospital stay was 6 days and no mortality occurred. R0 resection was achieved for 92% of lesions. At a mean follow-up of 19 months, the 1-year and 3-year DFS was 83.5% and 41.9%, while the 1-year and 3-year OS was 90.4% and 66.1%, respectively.

CONCLUSIONS

Robotic liver surgery does not impair surgical outcome and oncological results in patients with liver metastases from colorectal cancer.

Is robotic hepatectomy cost-effective? In view of patient-reported outcomes

BACKGROUND

Robotic hepatectomy has been accepted as an alternative for patients needing surgery. However, few reports addressed the patient-reported outcomes and long-term quality of life (QoL) of patients having undergone robotic liver surgery.

METHODS

This study presented the QoL and cost-effectiveness associated with robotic and open hepatectomy by performing a comparative survey using two standardized questionnaires (Short Form-36 and Gastrointestinal Quality of Life Index).

RESULTS

One hundred patients completed the study. The robotic group tended to experienced longer operation time but shorter length of hospital stay compared to open group. Moreover, the robotic group had faster return to daily activities, less need of patient-controlled anesthesia, and less wound-related complaints in long-term follow-up. The robotic group incurred higher peri-operative expenses; however, the cost of inpatient care was lower.

CONCLUSIONS

Our study suggested that robotic hepatectomy provided good post-operative QoL and recovery of daily activity. However, efforts for lowering the financial burden of medical care by reducing the cost of robotic surgery is necessary for further application.