Robotic-assisted right posterior segmentectomies for liver lesions: Single-center experience of an evolutional method in left semi-lateral position. J Robot Surg. 2019;13:231-237. [PMID: 29995223 DOI: 10.1007/s11701-018-0842-1]

Liver resection in stage 0-A HCC in segments 7/8: a propensity-matched analysis comparing open, laparoscopic, and robotic approach

BACKGROUND

Both laparoscopic hepatectomy (LH) and robotic hepatectomy (RH) have been performed for tumors in nearly all liver segments. However, few studies have compared the outcomes of patients who underwent open hepatectomy (OH), LH and RH for the treatment of Barcelona Clinic Liver Cancer (BCLC) stage 0-A HCC in S7/8.

METHODS

The clinical data of patients who underwent S7/8 resection for the treatment of BCLC stage 0-A HCC in the First Affiliated Hospital of Guangxi Medical University from July 2017 to July 2023 were retrospectively collected. To minimize selection bias, propensity score matching (PSM) analysis was performed using American Society of Anesthesiology (ASA), tumor size, body mass index (BMI), alpha-fetoprotein (AFP), tumor location, age, number of tumors, platelet (PLT), and Viral hepatitis.

RESULTS

A total of 401 patients met the study criteria. After PSM, 61 OH (28.6%), 74 LH (34.8%), and 78 RH (36.6%) were included. RH group had the least blood loss among the three groups (OH, 300 vs. LH, 215 vs. RH, 100 mL, P < 0.001). Conversion rate was significantly lower in RH group compared to LH group [LH, 10 (13.5%) vs. RH, 1 (1.3%), P = 0.003]. Although minimally invasive group (RH + LH) took slightly longer operative time (OH, 233 vs. LH, 255.5 vs. RH, 257 min, P = 0.068), there was no statistical difference. The minimally invasive group had fewer postoperative hospital stay (OH, 8 vs. LH, 6 vs. RH, 6 days, P < 0.001). The minimally invasive group had lower rates of surgical complications (OH, 37.7% vs. LH, 20.3% vs. RH, 11.5%). However, there were no statistically significant variations observed in the disease-free survival or overall survival rates among the three groups.

CONCLUSIONS

RH showed advantage over the OH and LH in short-term outcomes, and non-inferiority in survival outcomes for the treatment of BCLC stage 0-A HCC patients.

Three-Device (3D) Technique for Liver Parenchyma Dissection in Robotic Liver Surgery

Background: The implementation of robotics in liver surgery offers several advantages compared to conventional open and laparoscopic techniques. One major advantage is the enhanced degree of freedom at the tip of the robotic tools compared to laparoscopic instruments. This enables excellent vessel control during inflow and outflow dissection of the liver. Parenchymal transection remains the most challenging part during robotic liver resection because currently available robotic instruments for parenchymal transection have several limitations and there is no standardized technique as of yet. We established a new strategy and share our experience. Methods: We present a novel technique for the transection of liver parenchyma during robotic surgery, using three devices (3D) simultaneously: monopolar scissors and bipolar Maryland forceps of the robot and laparoscopic-guided waterjet. We collected the perioperative data of twenty-eight patients who underwent this procedure for minor and major liver resections between February 2019 and December 2020 from the Magdeburg Registry of minimally invasive liver surgery (MD-MILS). Results: Twenty-eight patients underwent robotic-assisted 3D parenchyma dissection within the investigation period. Twelve cases of major and sixteen cases of minor hepatectomy for malignant and non-malignant cases were performed. Operative time for major liver resections (≥ 3 liver segments) was 381.7 (SD 80.6) min vs. 252.0 (70.4) min for minor resections (p < 0.01). Intraoperative measured blood loss was 495.8 (SD 508.8) ml for major and 256.3 (170.2) ml for minor liver resections (p = 0.090). The mean postoperative stay was 13.3 (SD 11.1) days for all cases. Liver surgery-related morbidity was 10.7%, no mortalities occurred. We achieved an R0 resection in all malignant cases. Conclusions: The 3D technique for parenchyma dissection in robotic liver surgery is a safe and feasible procedure. This novel method offers an advanced locally controlled preparation of intrahepatic vessels and bile ducts. The combination of precise extrahepatic vessel handling with the 3D technique of parenchyma dissection is a fundamental step forward to the standardization of robotic liver surgery for teaching purposing and the wider adoption of robotic hepatectomy into routine patient care.

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.

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.

Comparison between robotic and open liver resection: a systematic review and meta-analysis of short-term outcomes

Minimally invasive liver surgery has evolved significantly during the last 2 decades. A growing number of published studies report outcomes from robotic liver resections (RLR). The aim of our meta-analysis was to evaluate short-term outcomes after RLR vs. open liver resection (OLR). A systematic search of Medline, Scopus, Google Scholar, Cochrane CENTRAL Register of Controlled Trials and Clinicaltrials.gov databases for articles published from January 2000 until November 2018 was performed. Ten non-randomized retrospective clinical studies comprising a total of 1248 patients were included in our meta-analysis. Four hundred and fifty-eight patients underwent RLR and 790 underwent OLR. RLRs were associated with lower overall morbidity rates (p =0.006) and shorter hospital stay (p <0.00001), whereas OLRs were associated with shorter operative time (p =0.003). No differences were shown between the two groups with regard to blood loss, blood transfusion requirements, R0 resection and mortality rates. Cumulative conversion rate was 4.6% in the RLR group. Due to limited available data, further prospective randomized studies are needed to better determine the potential beneficial role of the robotic approach in the treatment of malignant and benign hepatic tumors.