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McCarron F, Cochran A, Ricker A, Mantha R, Driedger M, Beckman M, Vrochides D, Martinie J. 10 years, 100 robotic major hepatectomies: a single-center experience. Surg Endosc 2024; 38:902-907. [PMID: 37845533 DOI: 10.1007/s00464-023-10459-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 09/06/2023] [Indexed: 10/18/2023]
Abstract
INTRODUCTION Adoption of robotic liver resections has been gradually increasing throughout the HPB surgical community over the past decade. Currently there is limited literature which demonstrates a significant benefit of robotic surgery for major hepatectomies over open or laparoscopic. As one of the first centers to develop a robotic HPB program, we have experienced improved outcomes over time with increasing utilization of robotics. Herein, we present our 10-year experience and outcomes for major robotic liver resections. METHODS From 2012 to 2022, 361 robotic liver procedures were performed, including 100 major hepatectomies. A retrospective data review of the electronic medical record was performed evaluating outcomes after robotic major hepatectomy. Outcomes for the first 50 cases (Group A) and second 50 cases (Group B) were compared to identify any improvements in practice. Demographic and clinical outcome variables were analyzed. Data were assessed for normality, and Wilcoxon rank-sum, χ2 tests, and a logistic regression model were performed appropriate for the data. Stata v.17 was utilized, and significance was set as p < .05. RESULTS There was no difference in median operative time (258 vs 256 min), EBL (500 vs 500 mL), median LOS (5 vs 3.5 days), 90-day readmission (14% vs 24%), major complications (14% vs 20%), and 90-day mortality (6% vs 4%) between early and late cases, respectively. ICU admissions and conversion rates were significantly lower in group B (14.0% vs 48.0%), while expert level difficulty indices were higher (82% vs 58%). CONCLUSION Development of a robotic liver program with good outcomes is feasible over time. Our data suggest that our institutional learning curve for robotic major hepatectomy plateaued at approximately 50 cases.
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Affiliation(s)
- Frances McCarron
- Division of Hepatobiliary & Pancreas Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, 1025 Morehead Medical Dr. Suite 600, Charlotte, NC, 28204, USA.
| | - Allyson Cochran
- Carolinas Center for Surgical Outcomes Science, Atrium Health, Charlotte, NC, USA
| | - Ansley Ricker
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Rohit Mantha
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Michael Driedger
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Michael Beckman
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - Dionisios Vrochides
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
| | - John Martinie
- Division of HPB Surgery, Department of Surgery, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA
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Kato Y, Sugioka A, Kojima M, Uyama I. Impact of Minimally Invasive Surgery on Anatomic Liver Segmentectomy Using the Extrahepatic Glissonean Approach. J Pers Med 2024; 14:120. [PMID: 38276242 PMCID: PMC10820587 DOI: 10.3390/jpm14010120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/14/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024] Open
Abstract
Accurate minimally invasive anatomic liver (sub)segmentectomy (MIAS) is technically demanding and not yet standardized, and its surgical outcomes are undefined. To study the impact of the minimally invasive approach on perioperative outcomes of anatomic liver (sub)segmentectomy (AS), we retrospectively studied and compared perioperative outcomes of 99 open AS (OAS) and 112 MIAS (laparoscopic 77, robotic 35) cases using the extrahepatic Glissonean approach, based on the 1:1 propensity score matched analyses. After matching (71:71), MIAS was superior to OAS in terms of blood loss (p < 0.0001), maximum postoperative serum total bilirubin (p < 0.0001), C-reactive protein (p = 0.034) levels, R0 resection rate (p = 0.021), bile leak (p = 0.049), and length of hospital stay (p < 0.0001). The matched robotic and laparoscopic AS groups (30:30) had comparable outcomes in terms of operative time, blood loss, transfusion, open conversion, postoperative morbidity and mortality, R0 resection, and hospital stay, although the rate of Pringle maneuver application (p = 0.0002) and the postoperative aspartate aminotransferase level (p = 0.002) were higher in the robotic group. Comparing the matched posterosuperior (sub)segmentectomy cases or unmatched repeat hepatectomy cases between MIAS and OAS, we observed significantly less blood loss and shorter hospital stays in MIAS. Robotic AS yielded comparable outcomes with laparoscopic AS in the posterosuperior (sub)segmentectomy and repeat hepatectomy settings, despite the worse tumor and procedural backgrounds in robotic AS. In conclusion, various types of MIAS standardized by the extrahepatic Glissonean approach were feasible and safe with more favorable perioperative outcomes than those of OAS. Although robotic AS had almost comparable outcomes with laparoscopic AS, robotics may serve to decrease the surgical difficulty of MIAS in selected patients undergoing posterosuperior (sub)segmentectomy and repeat hepatectomy.
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Affiliation(s)
- Yutaro Kato
- Department of Gastroenterological Surgery, Bantane Hospital, Fujita Health University, Nagoya 454-8509, Japan
- Department of Advanced Robotic and Endoscopic Surgery, Fujita Health University, Toyoake 470-1192, Japan;
| | - Atsushi Sugioka
- International Medical Center, Fujita Health University Hospital, Toyoake 470-1192, Japan;
| | - Masayuki Kojima
- Department of Surgery, Fujita Health University, Toyoake 470-1192, Japan;
| | - Ichiro Uyama
- Department of Advanced Robotic and Endoscopic Surgery, Fujita Health University, Toyoake 470-1192, Japan;
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van Ramshorst TM, Edwin B, Han HS, Nakamura M, Yoon YS, Ohtsuka T, Tholfsen T, Besselink MG, Abu Hilal M. Learning curves in laparoscopic distal pancreatectomy: a different experience for each generation. Int J Surg 2023; 109:1648-1655. [PMID: 37144678 PMCID: PMC10389345 DOI: 10.1097/js9.0000000000000408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 04/06/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Learning curves of laparoscopic distal pancreatectomy (LDP) are mostly based on 'self-taught' surgeons who acquired sufficient proficiency largely through self-teaching. No learning curves have been investigated for 'trained' surgeons who received training and built on the experience of the 'self-taught' surgeons. This study compared the learning curves and outcome of LDP between 'self-taught' and 'trained' surgeons in terms of feasibility and proficiency using short-term outcomes. MATERIALS AND METHODS Data of consecutive patients with benign or malignant disease of the left pancreas who underwent LDP by four 'self-taught' and four 'trained' surgeons between 1997 and 2019 were collected, starting from the first patient operated by a contributing surgeon. Risk-adjusted cumulative sum (RA-CUSUM) analyses were performed to determine phase-1 feasibility (operative time) and phase-2 proficiency (major complications) learning curves. Outcomes were compared based on the inflection points of the learning curves. RESULTS The inflection points for the feasibility and proficiency learning curves were 24 and 36 procedures for 'trained' surgeons compared to 64 and 85 procedures for 'self-taught' surgeons, respectively. In 'trained' surgeons, operative time was reduced after completion of the learning curves (230.5-203 min, P= 0.028). In 'self-taught' surgeons, operative time (240-195 min, P ≤0.001), major complications (20.6-7.8%, P= 0.008), and length of hospital stay (9-5 days, P ≤0.001) reduced after completion of the learning curves. CONCLUSION This retrospective international cohort study showed that the feasibility and proficiency learning curves for LDP of 'trained' surgeons were at least halved as compared to 'self-taught' surgeons.
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Affiliation(s)
- Tess M.E. van Ramshorst
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Amsterdam UMC, University of Amsterdam, Department of Surgery
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bjørn Edwin
- The Intervention Centre and Department of HPB Surgery, Oslo University Hospital, also Institute of Medicine, University of Oslo
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka
| | - Yoo-Seok Yoon
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Takao Ohtsuka
- First Department of Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Tore Tholfsen
- Department of Hepato-Pancreato-Biliary Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Marc G. Besselink
- Amsterdam UMC, University of Amsterdam, Department of Surgery
- Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Mohammad Abu Hilal
- Department of General Surgery, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
- Department of Surgery, University Hospital Southampton National Health Service, Southampton, Hampshire, United Kingdom
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Fuji T, Kojima T, Kajioka H, Sakamoto M, Oka R, Katayama T, Narahara Y, Niguma T. The preoperative M2BPGi score predicts operative difficulty and the incidence of postoperative complications in laparoscopic liver resection. Surg Endosc 2023; 37:1262-1273. [PMID: 36175698 DOI: 10.1007/s00464-022-09664-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 09/18/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Liver fibrosis or cirrhosis frequently makes parenchymal transection more difficult, but the difficulty score of laparoscopic liver resection (LLR), including the IWATE criteria, does not include a factor related to liver fibrosis. Therefore, this study aimed to evaluate M2BPGi as a predictor of the difficulty of parenchymal transection and the incidence of postoperative complications in LLR. METHODS Data from 54 patients who underwent laparoscopic partial liver resection (LLR-P) and 24 patients who underwent laparoscopic anatomical liver resection between 2017 and 2019 in our institution were retrospectively analyzed. All cases were classified according to M2BPGi scores, and reserve liver function, intraoperative blood loss, and postoperative complications were compared among these groups. RESULTS Sixteen cases (29.6%) were M2BPGi negative (cut-off index < 1.0), 25 cases (46.3%) were 1+ (1.0 ≤ cut-off index < 3.0), and 13 cases (24.1%) were 2+ (cut-off index ≥ 3.0). M2BPGi-positive cases had significantly worse hepatic reserve function (K-ICG: 0.16 vs 0.14 vs 0.08, p < 0.0001). Intraoperative bleeding was significantly greater in M2BPGi-positive cases [50 ml vs 150 ml vs 200 ml, M2BPGi (-) or (1+) vs M2BPGi (2+), p = 0.045]. Postoperative complications (Clavien-Dindo ≥ II) were significantly more frequent in M2BPGi-positive cases [0% vs 4% vs 33%, M2BPGi (-) or (1+) vs M2BPGi (2+), p = 0.001]. CONCLUSION M2BPGi could predict surgical difficulty and complications in LLR-P. In particular, it might be better not to select M2BPGi (2+) cases as teaching cases because of the massive bleeding during parenchymal transection.
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Affiliation(s)
- Tomokazu Fuji
- Department of Surgery, Okayama Saiseikai General Hospital, 2-25 Kokutaicho, Kita-ku, Okayama, 700-8511, Japan
| | - Toru Kojima
- Department of Surgery, Okayama Saiseikai General Hospital, 2-25 Kokutaicho, Kita-ku, Okayama, 700-8511, Japan.
| | - Hiroki Kajioka
- Department of Surgery, Okayama Saiseikai General Hospital, 2-25 Kokutaicho, Kita-ku, Okayama, 700-8511, Japan
| | - Misaki Sakamoto
- Department of Surgery, Okayama Saiseikai General Hospital, 2-25 Kokutaicho, Kita-ku, Okayama, 700-8511, Japan
| | - Ryoya Oka
- Department of Surgery, Okayama Saiseikai General Hospital, 2-25 Kokutaicho, Kita-ku, Okayama, 700-8511, Japan
| | - Tetsuya Katayama
- Department of Surgery, Okayama Saiseikai General Hospital, 2-25 Kokutaicho, Kita-ku, Okayama, 700-8511, Japan
| | - Yuki Narahara
- Department of Surgery, Okayama Saiseikai General Hospital, 2-25 Kokutaicho, Kita-ku, Okayama, 700-8511, Japan
| | - Takefumi Niguma
- Department of Surgery, Okayama Saiseikai General Hospital, 2-25 Kokutaicho, Kita-ku, Okayama, 700-8511, Japan
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Zhang X, Chen W, Jiang J, Ye Y, Hu W, Zhai Z, Bai X, Liang T. A comparison of robotic versus laparoscopic distal pancreatectomy: a single surgeon's robotic experience in a high-volume center. Surg Endosc 2022; 36:9186-9193. [PMID: 35851817 DOI: 10.1007/s00464-022-09402-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 06/19/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Robotic surgery is the most recent advanced minimally invasive approach for distal pancreatectomy. However, its benefits over laparoscopic distal pancreatectomy (LDP) remain undetermined. Previous studies were limited by their small sample size or variations in surgeon skills. This study aimed to compare robotic distal pancreatectomy (RDP) performed by a single surgeon with LDP performed by skilled laparoscopic surgeons in a high-volume center. METHODS We retrospectively analyzed consecutive RDP performed by a single surgeon between December 2020 and November 2021 with LDP performed by experienced surgeons during the same period in a high-volume center. Patient characteristics and perioperative variables were compared. RESULTS The analysis included 55 RDP and 146 LDP procedures. The operative time in the RDP group was significantly shorter than the LDP group (171 vs. 222 min, P < 0.001), both in spleen-preserved (154 vs. 212 min, P < 0.001) and spleen-removed (192 vs. 230 min, P = 0.005) procedures. The RDP group made more frequent use of the stapler technique for pancreas transection (87.3 vs. 68.5%, P = 0.007), and its estimated blood loss was lower (79 vs. 155 mL, P < 0.001) than the LDP group. The postoperative hospital stay in the RDP group was significantly shorter than the LDP group (8 vs. 12 days, P < 0.001). The groups were similar in their complication distributions. CONCLUSION RDP is as safe and feasible a minimally invasive approach as LDP. The advanced manipulation and visualization capabilities of the robotic approach in distal pancreatectomy could help reduce operative time and blood loss, and is related to shorter postoperative hospital stay.
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Affiliation(s)
- Xiaoyu Zhang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou, 310003, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Chen
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou, 310003, China
| | - Jincai Jiang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou, 310003, China
| | - Yufu Ye
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou, 310003, China
| | - Wendi Hu
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou, 310003, China
| | - Zhenglong Zhai
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou, 310003, China
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou, 310003, China. .,Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China. .,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China.
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, No. 79 Qingchun Road, Hangzhou, 310003, China.,Zhejiang Provincial Key Laboratory of Pancreatic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Zhejiang Clinical Research Center of Hepatobiliary and Pancreatic Diseases, Hangzhou, China.,The Innovation Center for the Study of Pancreatic Diseases of Zhejiang Province, Hangzhou, China.,Cancer Center, Zhejiang University, Hangzhou, China
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Ueno M, Iida H, Komeda K, Kosaka H, Hirokawa F, Hayami S, Mori H, Kaibori M, Yamaue H. Dorsal vs ventral approach to the middle hepatic vein during laparoscopic left hemihepatectomy: multicenter retrospective observational study. Surg Endosc 2022; 36:6464-6472. [PMID: 35024938 DOI: 10.1007/s00464-021-08998-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/31/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Left hemihepatectomy requires exposure of the middle hepatic vein (MHV) at the cutting-surface. Two procedures are used to approach the MHV: a conventional ventral approach and a laparoscopy-specific dorsal approach. This multicenter retrospective observational study aimed to evaluate the perioperative outcomes of these two procedures. METHODS Clinical records of 38 consecutive patients that underwent laparoscopic left hemihepatectomy in four university hospitals between 2016 and 2021 were retrospectively reviewed. Outcome measurements were operative blood loss, operating time, trend of postoperative laboratory data within 7 days after hepatectomy, and postoperative complications. Quality of MHV exposure was also evaluated and compared by three-grade evaluation (excellent/good/poor) using recorded still images of the cut-surface of the remnant liver (n = 35). RESULTS Dorsal and ventral approaches were performed in 9 and 29 patients, respectively. Median operating time was 316 min (dorsal) and 314 min (ventral) (P = 0.71). Median operative blood loss was 45 ml (dorsal) and 105 ml (ventral) (P = 0.10). Two patients in the ventral approach group had bleeding in excess of 500 ml, which was not seen in the dorsal approach group. Excellent/good/poor MHV appearance on the cutting-surface was observed in 5/3/1 patients in the dorsal approach group, respectively, and in 7/8/11 patients in the ventral approach group, respectively (P = 0.03). In the ventral approach group, significant increases of aspartate aminotransferase (on postoperative day 1 and day 4/5) and of alanine aminotransferase (on postoperative day 2/3 and 4/5) were observed (P < 0.05). Postoperative complications were observed only in the ventral approach group (n = 3). CONCLUSIONS The dorsal approach could achieve safe and precise anatomical left hemihepatectomy with operation time and operative blood loss comparable to the conventional ventral approach.
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Affiliation(s)
- Masaki Ueno
- Second Department of Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan.
| | - Hiroya Iida
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Koji Komeda
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Hisashi Kosaka
- Department of Surgery, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Fumitoshi Hirokawa
- Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, Osaka, Japan
| | - Shinya Hayami
- Second Department of Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
| | - Haruki Mori
- Department of Surgery, Shiga University of Medical Science, Otsu, Japan
| | - Masaki Kaibori
- Department of Surgery, Kansai Medical University Hirakata Hospital, Osaka, Japan
| | - Hiroki Yamaue
- Second Department of Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8510, Japan
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Survival Study: International Multicentric Minimally Invasive Liver Resection for Colorectal Liver Metastases (SIMMILR-2). Cancers (Basel) 2022; 14:cancers14174190. [PMID: 36077728 PMCID: PMC9454893 DOI: 10.3390/cancers14174190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/12/2022] [Accepted: 08/23/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: Study: International Multicentric Minimally Invasive Liver Resection for Colorectal Liver Metastases (SIMMILR-CRLM) was a propensity score matched (PSM) study that reported short-term outcomes of patients with CRLM who met the Milan criteria and underwent either open (OLR), laparoscopic (LLR) or robotic liver resection (RLR). This study, designated as SIMMILR-2, reports the long-term outcomes from that initial study, now referred to as SIMMILR-1. Methods: Data regarding neoadjuvant chemotherapeutic (NC) and neoadjuvant biological (NB) treatments received were collected, and Kaplan−Meier curves reporting the 5-year overall (OS) and recurrence-free survival (RFS) for OLR, LLR and RLR were created for patients who presented with synchronous lesions only, as there was insufficient follow-up for patients with metachronous lesions. Results: A total of 73% of patients received NC and 38% received NB in the OLR group compared to 70% and 28% in the LLR group, respectively (p = 0.5 and p = 0.08). A total of 82% of patients received NC and 40% received NB in the OLR group compared to 86% and 32% in the RLR group, respectively (p > 0.05). A total of 71% of patients received NC and 53% received NB in the LLR group compared to 71% and 47% in the RLR group, respectively (p > 0.05). OS at 5 years was 34.8% after OLR compared to 37.1% after LLR (p = 0.4), 34.3% after OLR compared to 46.9% after RLR (p = 0.4) and 30.3% after LLR compared to 46.9% after RLR (p = 0.9). RFS at 5 years was 12.1% after OLR compared to 20.7% after LLR (p = 0.6), 33.3% after OLR compared to 26.3% after RLR (p = 0.6) and 22.7% after LLR compared to 34.6% after RLR (p = 0.6). Conclusions: When comparing OLR, LLR and RLR, the OS and RFS were all similar after utilization of the Milan criteria and PSM. Biological agents tended to be utilized more in the OLR group when compared to the LLR group, suggesting that highly aggressive tumors are still managed through an open approach.
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Rahimli M, Perrakis A, Andric M, Stockheim J, Franz M, Arend J, Al-Madhi S, Abu Hilal M, Gumbs AA, Croner RS. Does Robotic Liver Surgery Enhance R0 Results in Liver Malignancies during Minimally Invasive Liver Surgery?—A Systematic Review and Meta-Analysis. Cancers (Basel) 2022; 14:cancers14143360. [PMID: 35884421 PMCID: PMC9320889 DOI: 10.3390/cancers14143360] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/05/2022] [Accepted: 07/08/2022] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Mirhasan Rahimli
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany; (A.P.); (M.A.); (J.S.); (M.F.); (J.A.); (S.A.-M.); (R.S.C.)
- Correspondence:
| | - Aristotelis Perrakis
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany; (A.P.); (M.A.); (J.S.); (M.F.); (J.A.); (S.A.-M.); (R.S.C.)
| | - Mihailo Andric
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany; (A.P.); (M.A.); (J.S.); (M.F.); (J.A.); (S.A.-M.); (R.S.C.)
| | - Jessica Stockheim
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany; (A.P.); (M.A.); (J.S.); (M.F.); (J.A.); (S.A.-M.); (R.S.C.)
| | - Mareike Franz
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany; (A.P.); (M.A.); (J.S.); (M.F.); (J.A.); (S.A.-M.); (R.S.C.)
| | - Joerg Arend
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany; (A.P.); (M.A.); (J.S.); (M.F.); (J.A.); (S.A.-M.); (R.S.C.)
| | - Sara Al-Madhi
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany; (A.P.); (M.A.); (J.S.); (M.F.); (J.A.); (S.A.-M.); (R.S.C.)
| | - Mohammed Abu Hilal
- Unità Chirurgia Epatobiliopancreatica, Robotica e Mininvasiva, Fondazione Poliambulanza Istituto Ospedaliero, Via Bissolati, 57, 25124 Brescia, Italy;
| | - Andrew A. Gumbs
- Department of Surgery, Centre Hospitalier Intercommunal de Poissy/Saint-Germain-en-Laye, 10 Rue du Champ Gaillard, 78300 Poissy, France;
| | - Roland S. Croner
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Leipziger Str. 44, 39120 Magdeburg, Germany; (A.P.); (M.A.); (J.S.); (M.F.); (J.A.); (S.A.-M.); (R.S.C.)
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Stockheim J, Perrakis A, Sabel BA, Waschipky R, Croner RS. RoCS: Robotic Curriculum for young Surgeons. J Robot Surg 2022; 17:495-507. [PMID: 35810233 PMCID: PMC10076401 DOI: 10.1007/s11701-022-01444-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/26/2022] [Indexed: 11/26/2022]
Abstract
Robotic-assisted procedures gain increasing acceptance for daily surgical routine. However, structured training programs are designed for surgeons with high expertise. Hence, a comprehensive training curriculum was established to ensure a basic competence in robotic abdominal surgery for young surgeons during their residency. The aim of the current work is to propose a feasible and effective training concept. The development process of this training curriculum is based on a comprehensive literature review which led to the concept of "robotic curriculum for young surgeons" (RoCS). It was implemented in the daily routine of a German university hospital starting in 2020. The robotic assessment questionnaire (RAQ) was used for electronic data collection. After the initial phase adjustments, it led to an improvement of the initial version of the curriculum. RoCS is a multimodal training program containing basic training through assistance at the operation table during robotic-assisted operations and basic console training. Key elements are the robotic team time-out (rTTO), perioperative process standardization including feasible personnel scheduling and useful procedure clustering into organ systems, procedural steps and procedural step complexity. Evaluation of standardized communication, performance assessment, patient factors and individual overall workload using NASA Task Load Index is realizable. Flexibility and adaptability to internal organization processes of surgical departments are the main advantages of the concept. RoCS is a strong training tool to meet the specific needs of young surgeons and evaluate their learning success of robotic procedural training. Furthermore, comparison within the different robotic systems should be considered. Further studies are needed to validate a multicenter concept design.
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Affiliation(s)
- Jessica Stockheim
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany.
| | - Aristotelis Perrakis
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Bernhard A Sabel
- Institute of Medical Psychology, Otto-Von-Guericke University Magdeburg, Magdeburg, Germany
| | - Robert Waschipky
- Department of Information Technology (IT) and Medical Engineering, Otto-Von-Guericke University Magdeburg, Magdeburg, Germany
| | - Roland S Croner
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
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Marino R, Olthof PB, Shi HJ, Tran KTC, Ijzermans JNM, Terkivatan T. Minimally Invasive Liver Surgery: A Snapshot from a Major Dutch HPB and Transplant Center. World J Surg 2022; 46:3090-3099. [PMID: 36161353 PMCID: PMC9636118 DOI: 10.1007/s00268-022-06754-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Minimally invasive liver surgery (MILS) has been progressively adopted on a nationwide scale. The aim of this study is to investigate MILS implementation in a high-volume Dutch hepato-pancreato-biliary and transplant center, which is considered a moderate to low-volume center from a European standpoint. METHODS All patients who underwent MILS at Erasmus Medical Center between April 2010 and December 2021 were retrospectively reviewed. Patients' surgical outcomes were compared after stratification according to resections' difficulty and liver cirrhosis. RESULTS A total of 212 cases were included. Major liver resections were performed in 24 patients (11%), while minor resections were performed in 188 patients (89%). Among those, 177 (94%) resections were classified as technically minor and 11 (6%) as technically major. Major morbidity was reported in 14/177 patients (8%) after technically minor resections and in 3/24 patients (13%) after major resections. Anatomically and technically major resections had higher intraoperative blood losses (425 (0-2100) vs. 240 (50-110) vs. 100 (0-2400) mL; p-value < 0.001) and longer hospital stay (6 (3-25) vs. 5 (2-9) vs. 3 (1-44); p-value < 0.001) when compared with the technically minor counterpart. Perioperative outcomes were similar when comparing cirrhotic MILS with the non-cirrhotic cohort. CONCLUSION MILS program implementation can lead to encouraging surgical outcomes even in low- to moderate-volume centers. Although low procedural volume might be predictive of impaired outcomes, long-standing experience in the HPB and liver transplant field could mitigate low-case volume effects on surgical outcomes.
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Affiliation(s)
- Rebecca Marino
- Hepatobiliary Surgery Division, IRCCS San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy ,Department of Surgery, Division of HPB & Transplant Surgery, University Medical Centre Rotterdam, Dr. Molewaterplein 40, Erasmus MC, 3015 GD Rotterdam, The Netherlands
| | - Pim B. Olthof
- Department of Surgery, Division of HPB & Transplant Surgery, University Medical Centre Rotterdam, Dr. Molewaterplein 40, Erasmus MC, 3015 GD Rotterdam, The Netherlands
| | - Hong J. Shi
- Department of Surgery, Division of HPB & Transplant Surgery, University Medical Centre Rotterdam, Dr. Molewaterplein 40, Erasmus MC, 3015 GD Rotterdam, The Netherlands
| | - Khe T. C. Tran
- Department of Surgery, Division of HPB & Transplant Surgery, University Medical Centre Rotterdam, Dr. Molewaterplein 40, Erasmus MC, 3015 GD Rotterdam, The Netherlands
| | - Jan N. M. Ijzermans
- Department of Surgery, Division of HPB & Transplant Surgery, University Medical Centre Rotterdam, Dr. Molewaterplein 40, Erasmus MC, 3015 GD Rotterdam, The Netherlands
| | - Türkan Terkivatan
- Department of Surgery, Division of HPB & Transplant Surgery, University Medical Centre Rotterdam, Dr. Molewaterplein 40, Erasmus MC, 3015 GD Rotterdam, The Netherlands
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Does the Endoscopic Surgical Skill Qualification System improve patients' outcome following laparoscopic surgery for colon cancer? A multicentre, retrospective analysis with propensity score matching. World J Surg Oncol 2021; 19:53. [PMID: 33608034 PMCID: PMC7893747 DOI: 10.1186/s12957-021-02155-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 01/31/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND This study aimed to investigate the short-term and oncological impact of the Endoscopic Surgical Skill Qualification System (ESSQS) by the Japan Society for Endoscopic Surgery on the operator performing laparoscopic surgery for colon cancer. METHODS This retrospective cohort study was based on medical records from a multicentre database. A total of 417 patients diagnosed with stage II/III colon and rectosigmoid cancer treated with curative resection were divided into two groups according to whether they were operated on by qualified surgeons (Q group, n=352) or not (NQ group, n=65). Through strict propensity score matching, 98 cases (49 in each group) were assessed. RESULTS Operative time was significantly longer in the NQ group than in the Q group (199 vs. 168 min, p=0.029). The amount of blood loss, post-operative complications, and duration of hospitalisation were similar between both groups. No mortality was observed. One conversion case was seen in the NQ group. The 3-year recurrence-free survival rate was 86.6% in the NQ group and 88.2% in the Q group, which was not statistically significant (log-rank p=0.966). CONCLUSION Direct operation by ESSQS-qualified surgeons contributed to a shortened operation time. Under an organised educational environment, almost equivalent safety and oncological outcomes are expected regardless of the surgeon's qualifications.
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