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

Four clamp-crush techniques in robotic hepatectomy (with video)

Recently, reports of robotic hepatectomies have increased. In a laparoscopic hepatectomy, various energy devices are used for parenchymal transections, especially the clamp-crush method and the Cavitron Ultrasonic Surgical Aspirator (CUSA) system are popular; however, there is no CUSA that can be operated from the robot console. We believe that conventional clamp-crush method can be classified into four categories and have tried to verbalize them. We aim to explain the four types of clamp-crush techniques of robotic hepatectomy that we have performed and to assess their outcomes, safety, and feasibility. The data of patients who underwent robotic hepatectomy at Iwate Medical University Hospital between June 2022 and April 2024 were retrospectively reviewed. For comparison, 298 patients who underwent pure laparoscopic hepatectomy at Iwate Medical University Hospital between January 2014 and December 2020 were enrolled and analyzed. Our four clamp-crush techniques (Clamp, Peck, Open, Sweep) are demonstrated in the video clips provided with our study's electronic data. In the present study, 58 patients were included. In 27 cases (46.6%), a limited resection was performed; in 9 cases (15.5%), a subsegmentectomy; in 15 cases (25.9%), a sectionectomy; and in 7 cases (12.1%), a hemihepatectomy. The mean operative time was 205.9±90.5 min, and the mean intraoperative blood loss was 103.1±200.7 mL. There were no cases of conversion to a laparotomy. In comparison with laparoscopic hepatectomies, there were no significant differences in perioperative outcomes. The present findings indicate that robotic hepatectomies are safe and feasible in high-volume specialized centers with a team experienced in laparoscopic liver surgeries. It is possible to transition from laparoscopic hepatectomy to robotic hepatectomy without stress due to the fact that the same four clamp-crush techniques that are used in laparoscopic hepatectomy, which can be done in a robotic hepatectomy.

Implications of robotic platforms for repeat hepatectomies: a propensity score matched study of clinical outcomes

Robotic surgical approaches have demonstrated improved outcomes in primary hepatectomies. However, data on their effectiveness in redo hepatectomies (subsequent liver resections) are limited. This study aims to compare the outcomes of patients undergoing primary and redo robotic hepatectomies, with additional analysis comparing outcomes of robotic versus open redo hepatectomies. With IRB approval, we prospectively followed 101 patients from a parent population of 465, who were classified as either primary (non-redo) or redo robotic hepatectomy patients between 2013 and 2023. A Propensity Score Matched (PSM) analysis was conducted to compare perioperative variables between the two cohorts, using age, sex, BMI, IWATE score, tumor size, and tumor type as matching variables. Data are presented as median (mean ± standard deviation). Significance was accepted at p ≤ 0.05. After 3:1 PSM analysis (3 primary patients to 1 robotic redo patient), no significant differences were observed in pre-, intra-, or postoperative variables, except for the Model for End-Stage Liver Disease (MELD) score (p = 0.022). Additional analysis comparing robotic and open redo hepatectomies showed similar perioperative outcomes, with the robotic approach demonstrating comparable safety and feasibility. Length of stay, blood loss, operative duration, morbidity, and mortality showed no significant differences between the two groups. Major complications (Clavien-Dindo score ≥ III) occurred in 4% of non-redo patients, with none observed in the redo group. The findings suggest that patients undergoing redo robotic hepatectomies achieve outcomes comparable to those of primary hepatectomy patients. This indicates the potential of robotic platforms to mitigate the added complexities and risks associated with redo hepatectomies. Further multi-center collaboration is necessary to validate these findings.

Robot-assisted liver resection: the real benefit so far

BACKGROUND

Minimally invasive liver resection is associated with lower perioperative morbidity and shorter hospital stay. However, the added benefit of the robotic platform over conventional laparoscopy is a matter of ongoing investigation.

PURPOSE

The purpose of this narrative review is to provide an up-to-date and balanced evaluation of the benefits and shortcomings of robotic liver surgery for the modern hepatobiliary surgeon.

CONCLUSIONS

Advantages of a robotic approach to liver resection include a shortened learning curve, the ability to complete more extensive or complex minimally invasive operations, and integrated fluorescence guidance. However, the robotic platform remains limited by a paucity of parenchymal transection devices, complete lack of haptic feedback, and added operating time associated with docking and instrument exchange. Like laparoscopic hepatectomy, robotic hepatectomy may provide patients with more rapid recovery and a shorter hospital stay, which can help offset the substantial costs of robot acquisition and maintenance. The oncologic outcomes of robotic hepatectomy appear to be equivalent to laparoscopic and open hepatectomy for appropriately selected patients.

Assessing the perioperative complications and outcomes of robotic pancreaticoduodenectomy using the National Cancer Database: is it ready for prime time?

Robotic pancreaticoduodenectomy has generated significant interest in recent years. Our study aimed to evaluate the difference in surgical, oncological, and survival outcomes after pancreaticoduodenectomy (PD) by either a robotic (RPD) or open approach (OPD). Using the National Cancer Database, we identified patients from 2010 and 2017 diagnosed with pancreatic adenocarcinoma and underwent pancreaticoduodenectomy by either robotic PD or open approach. Patients who underwent robotic PD during 2010 were compared to patients receiving the same procedure in 2017. In addition, a secondary analysis was performed to assess outcomes of robotic PD to open PD for the 2017 patient cohorts. Our primary outcomes included 30-day and 90-day mortality, length of stay, as well as 30-day readmission. Secondary outcome measures were surgical margins, lymph node yield, and adjuvant chemotherapy initiation within 12 weeks of surgery. When we compared the 2017 data to 2010 data, we found that robotic pancreaticoduodenectomy had lower 30- and 90-day mortality rates in 2017 compared to 2010. Additionally, we found that the lymph node yield in robotic PD increased during the study period. When we compared robotic PD to open PD for 2017, we found no statistically significant differences in readmission rates (10.1% vs. 9.7%: p-0.4), lymph node yield, or negative margin between the groups. Outcomes of robotic PD have improved over the years. In 2017, outcomes of robotic PD were similar to open PD.