1
|
van Dorst RWJJ, Ten Haaft BHEA, Franssen S, Borel Rinkes IHM, Groot Koerkamp B, Swijnenburg RJ, Hagendoorn J. Indocyanine green fluorescence perfusion testing in robot-assisted hepatic arterial infusion pump placement. Surg Endosc 2024:10.1007/s00464-024-11010-7. [PMID: 39017958 DOI: 10.1007/s00464-024-11010-7] [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: 11/20/2023] [Accepted: 06/30/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND Hepatic arterial infusion pump (HAIP) treatment is a technique used to treat liver localized malignancy with intra-arterial chemotherapy. Methylene blue is generally administered to verify hepatic perfusion and exclude inadvertent extrahepatic perfusion. The use of indocyanine green dye (ICG) combined with near-infrared (NIR) fluorescence imaging during robot-assisted HAIP placement may be an attractive alternative by providing high contrast without blue discoloration of the operative field. METHODS Data was collected retrospectively from 2 centers in the Netherlands. Intraoperative perfusion of the liver segments and extrahepatic perfusion were assessed using ICG/NIR as well as methylene blue on video imaging and correlated to postoperative 99 m-Tc perfusion scintigraphy. RESULTS 13 patients underwent robot-assisted surgery for HAIP placement; median length of stay was 4 days, complications occurred in 4 patients. Hepatic perfusion showed identical patterns when ICG was compared with methylene blue. In 1 patient, additional extrahepatic perfusion was found using ICG, leading to further vessel ligation. Intraoperative ICG perfusion was concordant with 99 m-Tc perfusion scintigraphy. DISCUSSION Liver and extrahepatic perfusion determined by ICG fluorescence imaging is concordant with blue dye perfusion and 99 m-Tc perfusion scintigraphy. Therefore, ICG fluorescence imaging is deemed a safe and reliable technique for perfusion testing during robot-assisted HAIP placement.
Collapse
Affiliation(s)
- Roderick W J J van Dorst
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
| | - Britte H E A Ten Haaft
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Stijn Franssen
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Inne H M Borel Rinkes
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands.
| |
Collapse
|
2
|
Wu S, Boyuan L, Zeng T, Ma B, Lin Z, Hu M. Feasibility and safety of robotic liver resection for huge (≥10 cm) hepatocellular carcinoma in a single centre: A propensity score-matched single-surgeon study. Int J Med Robot 2024; 20:e2628. [PMID: 38517689 DOI: 10.1002/rcs.2628] [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: 10/02/2023] [Revised: 02/29/2024] [Accepted: 03/12/2024] [Indexed: 03/24/2024]
Abstract
BACKGROUND The applicability of robot-assisted resection for huge hepatocellular carcinoma (HCC) of ≥10 cm remains contentious with limited available data. METHODS This retrospective analysis involved 337 patients who underwent robotic liver resection for HCC by a single surgeon. Propensity score matching (PSM) was employed to compare perioperative indicators between patients with regular and huge HCC. RESULTS The regular HCC group exhibited a shorter median operative duration than the huge HCC group. The IWATE criteria revealed higher scores in the huge HCC group than in the regular HCC group. No significant differences were observed between the two groups in Pringle time, drainage tube removal, duration of hospital stays, blood loss volume, blood product transfusion, margin status, conversion rate to open surgery, bile leakage, in-hospital mortality, and reoperation rate. CONCLUSION Robotic liver resection is feasible for huge HCC, with effective perioperative risk management potentially improving outcomes for subsequent minimally invasive surgeries.
Collapse
Affiliation(s)
- Shurui Wu
- Chinese PLA General Hospital, Beijing, China
| | - Liu Boyuan
- Chinese PLA General Hospital, Beijing, China
| | - Tao Zeng
- Chinese PLA General Hospital, Beijing, China
| | - Ben Ma
- Chinese PLA General Hospital, Beijing, China
| | - Zhaoyi Lin
- Chinese PLA General Hospital, Beijing, China
| | - Minggen Hu
- Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
3
|
Minamimura K, Aoki Y, Kaneya Y, Matsumoto S, Arai H, Kakinuma D, Oshiro Y, Kawano Y, Watanabe M, Nakamura Y, Suzuki H, Yoshida H. Current Status of Robotic Hepatobiliary and Pancreatic Surgery. J NIPPON MED SCH 2024; 91:10-19. [PMID: 38233127 DOI: 10.1272/jnms.jnms.2024_91-109] [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] [Indexed: 01/19/2024]
Abstract
Laparoscopic surgery is performed worldwide and has clear economic and social benefits in terms of patient recovery time. It is used for most gastrointestinal surgical procedures, but laparoscopic surgery for more complex procedures in the esophageal, hepatobiliary, and pancreatic regions remains challenging. Minimally invasive surgery that results in accurate tumor dissection is vital in surgical oncology, and development of surgical systems and instruments plays a key role in assisting surgeons to achieve this. A notable advance in the latter half of the 1990s was the da Vinci Surgical System, which involves master-slave surgical support robots. Featuring high-resolution three-dimensional (3D) imaging with magnification capabilities and forceps with multi-joint function, anti-shake function, and motion scaling, the system compensates for the drawbacks of conventional laparoscopic surgery. It is expected to be particularly useful in the field of hepato-biliary-pancreatic surgery, which requires delicate reconstruction involving complex liver anatomy with diverse vascular and biliary systems and anastomosis of the biliary tract, pancreas, and intestines. The learning curve is said to be short, and it is hoped that robotic surgery will be standardized in the near future. There is also a need for a standardized robotic surgery training system for young surgeons that can later be adapted to a wider range of surgeries. This systematic review describes trends and future prospects for robotic surgery in the hepatobiliary-pancreatic region.
Collapse
Affiliation(s)
| | - Yuto Aoki
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Youhei Kaneya
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | | | - Hiroki Arai
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Daisuke Kakinuma
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Yukio Oshiro
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | - Yoichi Kawano
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | | | | | - Hideyuki Suzuki
- Department of Surgery, Nippon Medical School Chiba Hokusoh Hospital
| | | |
Collapse
|
4
|
Liu R, Abu Hilal M, Wakabayashi G, Han HS, Palanivelu C, Boggi U, Hackert T, Kim HJ, Wang XY, Hu MG, Choi GH, Panaro F, He J, Efanov M, Yin XY, Croner RS, Fong YM, Zhu JY, Wu Z, Sun CD, Lee JH, Marino MV, Ganpati IS, Zhu P, Wang ZZ, Yang KH, Fan J, Chen XP, Lau WY. International experts consensus guidelines on robotic liver resection in 2023. World J Gastroenterol 2023; 29:4815-4830. [PMID: 37701136 PMCID: PMC10494765 DOI: 10.3748/wjg.v29.i32.4815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/22/2023] [Accepted: 08/09/2023] [Indexed: 08/25/2023] Open
Abstract
The robotic liver resection (RLR) has been increasingly applied in recent years and its benefits shown in some aspects owing to the technical advancement of robotic surgical system, however, controversies still exist. Based on the foundation of the previous consensus statement, this new consensus document aimed to update clinical recommendations and provide guidance to improve the outcomes of RLR clinical practice. The guideline steering group and guideline expert group were formed by 29 international experts of liver surgery and evidence-based medicine (EBM). Relevant literature was reviewed and analyzed by the evidence evaluation group. According to the WHO Handbook for Guideline Development, the Guidance Principles of Development and Amendment of the Guidelines for Clinical Diagnosis and Treatment in China 2022, a total of 14 recommendations were generated. Among them were 8 recommendations formulated by the GRADE method, and the remaining 6 recommendations were formulated based on literature review and experts' opinion due to insufficient EBM results. This international experts consensus guideline offered guidance for the safe and effective clinical practice and the research direction of RLR in future.
Collapse
Affiliation(s)
- Rong Liu
- Faculty of Hepato-Pancreato-Biliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing 100000, China
| | - Mohammed Abu Hilal
- Hepatobiliary Pancreatic, Robotic & Laparoscopic Surgery, Poliambulanza Foundation Hospital, Brescia 25100, Italy
| | - Go Wakabayashi
- Center for Advanced Treatment of HBP Diseases, Ageo Central General Hospital, Saitama 362-0075, Japan
| | - Ho-Seong Han
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul 03080, South Korea
| | - Chinnusamy Palanivelu
- GEM Hospital & Research Centre, GEM Hospital & Research Centre, Coimbatore 641045, India
| | - Ugo Boggi
- Division of General and Transplant Surgery, University of Pisa, Pisa 56126, Italy
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Hospital Hamburg-Eppendorf, Hamburg 20251, Germany
| | - Hong-Jin Kim
- Department of Surgery, Yeungnam University Hospital, Daegu 42415, South Korea
| | - Xiao-Ying Wang
- Department of Liver Surgery and Transplantation, Liver Cancer Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Ming-Gen Hu
- Faculty of Hepato-Pancreato-Biliary Surgery, The First Medical Center of Chinese PLA General Hospital, Beijing 100000, China
| | - Gi Hong Choi
- Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Severance Hospital, Yonsei University, College of Medicine, Seoul 03722, South Korea
| | - Fabrizio Panaro
- Department of Surgery/Division of Robotic and HBP Surgery, Montpellier University Hospital-School of Medicine, Montpellier 34090, France
| | - Jin He
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21218, United States
| | - Mikhail Efanov
- Department of Hepato-Pancreato-Biliary Surgery, Moscow Clinical Scientific Center, Moscow 111123, Russia
| | - Xiao-Yu Yin
- Department of Pancreatobiliary Surgery, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou 510080, Guangdong Province, China
| | - Roland S Croner
- Department of General, Visceral, Vascular and Transplant Surgery, University Hospital Magdeburg, Magdeburg 39120, Germany
| | - Yu-Man Fong
- Department of Surgery, City of Hope Medical Center, Duarte, CA 91010, United States
| | - Ji-Ye Zhu
- Department of Hepatobiliary Surgery, Peking University People’s Hospital, Beijing 100000, China
| | - Zheng Wu
- Department of Hepatobiliary Surgery, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, Shaanxi Province, China
| | - Chuan-Dong Sun
- Department of Hepatobiliary and Pancreatic Surgery, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong Province, China
| | - Jae Hoon Lee
- Division of Hepatobiliary & Pancreatic surgery, Asan Medical Center, University of Ulsan College of Medicine, Ulsan 682, South Korea
| | - Marco V Marino
- General Surgery Department, F. Tappeiner Hospital, Merano 39012, Italy
| | - Iyer Shridhar Ganpati
- Hepatobiliary and Pancreatic Surgery, National University Hospital, Singapore 189969, Singapore
| | - Peng Zhu
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
| | - Zi-Zheng Wang
- Department of Hepatobiliary Surgery, Senior Department of Hepatology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100000, China
| | - Ke-Hu Yang
- Evidence-Based Medicine Center, Lanzhou University, Lanzhou 730000, Gansu Province, China
| | - Jia Fan
- Zhongshan Hospital, Fudan University, Shanghai 200000, China
| | - Xiao-Ping Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430000, Hubei Province, China
| | - Wan Yee Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong 999077, China
| |
Collapse
|
5
|
Finotti M, D’Amico F, Mulligan D, Testa G. A narrative review of the current and future role of robotic surgery in liver surgery and transplantation. Hepatobiliary Surg Nutr 2023; 12:56-68. [PMID: 36860258 PMCID: PMC9944521 DOI: 10.21037/hbsn-21-115] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/02/2021] [Indexed: 11/06/2022]
Abstract
Background Minimally invasive surgery (MIS) is the technique of choice in selected patients for the treatment of liver tumors. The robotic approach is considered today the natural evolution of MIS. The application of the robotic technique in liver transplantation (LT) has been recently evaluated, especially in the living donation. The aim of this paper is to review the current role of the MIS and robotic donor hepatectomy in the literature and to evaluate the possible future implication in the transplant field. Methods We conducted a narrative review using PubMed and Google Scholar for reports published so far, using the following keywords: minimally invasive liver surgery, laparoscopic liver surgery, robotic liver surgery, robotic living donation, laparoscopic donor hepatectomy and robotic donor hepatectomy. Results Several advantages have been claimed in favor of robotic surgery: three-dimensional (3-D) imaging with stable and high-definition view; a more rapid learning curve than the laparoscopic one; the lack of hand tremors and the freedom of movements. Compared to open surgery, the benefits showed in the studies evaluating the robotic approach in the living donation are: less postoperative pain, the shorter period before returning to normal activity despite sustaining longer operation time. Furthermore, the 3-D and magnification view makes the technique excellent in distinguishing the right plane of transection, vascular and biliary anatomy, associated with high precision of the movements and a better bleeding control (essential for donor safety) and lower rate of vascular injury. Conclusions The current literature does not fully support the superiority of the robotic approach versus laparoscopic or open method in living donor hepatectomy. Robotic donor hepatectomy performed by teams with high expertise and in properly selected living donors is safe and feasible. However, further data are necessary to evaluate properly the role of robotic surgery in the field of living donation.
Collapse
Affiliation(s)
- Michele Finotti
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Francesco D’Amico
- Transplantation and Hepatobiliary Surgery, University of Padova, Padova, Italy
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - David Mulligan
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Giuliano Testa
- Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX, USA
| |
Collapse
|
6
|
Outcomes and Patient Selection in Laparoscopic vs. Open Liver Resection for HCC and Colorectal Cancer Liver Metastasis. Cancers (Basel) 2023; 15:cancers15041179. [PMID: 36831521 PMCID: PMC9954110 DOI: 10.3390/cancers15041179] [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: 11/07/2022] [Revised: 02/06/2023] [Accepted: 02/10/2023] [Indexed: 02/15/2023] Open
Abstract
Hepatocellular carcinoma (HCC) and colorectal liver metastasis (CRLM) are the two most common malignant tumors that require liver resection. While liver transplantation is the best treatment for HCC, organ shortages and high costs limit the availability of this option for many patients and make resection the mainstay of treatment. For patients with CRLM, surgical resection with negative margins is the only potentially curative option. Over the last two decades, laparoscopic liver resection (LLR) has been increasingly adopted for the resection of a variety of tumors and was found to have similar long-term outcomes compared to open liver resection (OLR) while offering the benefits of improved short-term outcomes. In this review, we discuss the current literature on the outcomes of LLR vs. OLR for patients with HCC and CRLM. Although the use of LLR for HCC and CRLM is increasing, it is not appropriate for all patients. We describe an approach to selecting patients best-suited for LLR. The four common difficulty-scoring systems for LLR are summarized. Additionally, we review the current evidence behind the emerging robotically assisted liver resection technology.
Collapse
|
7
|
Kato Y, Sugioka A, Kojima M, Kiguchi G, Mii S, Uchida Y, Takahara T, Uyama I. Initial experience with robotic liver resection: Audit of 120 consecutive cases at a single center and comparison with open and laparoscopic approaches. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:72-90. [PMID: 35737850 DOI: 10.1002/jhbp.1206] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 05/09/2022] [Accepted: 06/03/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND/PURPOSE Surgical outcomes and utility of robotic liver resection (RLR) are undefined. METHODS We retrospectively studied perioperative and long-term outcomes of the single-center 120 RLRs including non-anatomic (NAR, n = 58) and anatomic (AR, n = 62) resections. To evaluate the feasibility and safety of RLR, perioperative outcomes of RLR (n = 103) were compared to those of open (OLR, n = 495) or laparoscopic (LLR, n = 451) resection in liver-only resections without reconstruction, using 1:1 propensity score matching (PSM). The changing trends from the earlier to the later RLR cases were assessed. Long-term outcomes were compared between RLR and LLR. RESULTS Various types of RLR with different surgical difficulties were performed, with mostly comparable postoperative morbidity between AR and NAR, or among AR subtypes. In segmentectomy and sectionectomy cases, perioperative outcomes significantly improved in the later period. In comparison between PSM-selected OLR and RLR cases (87:87), RLR had significantly longer operative time, less blood loss, and shorter hospital stay. PSM-selected LLR and RLR cases (91:91) showed comparable perioperative outcomes. Overall and recurrence-free survivals after RLR for newly diagnosed hepatocellular carcinoma and colorectal metastasis were comparable to those after LLR. CONCLUSIONS RLR is applicable to various types of liver resection with acceptable perioperative and long-term outcomes in select patients.
Collapse
Affiliation(s)
- Yutaro Kato
- Department of Advanced Robotic and Endoscopic Surgery, Fujita Health University, Toyoake, Japan
| | - Atsushi Sugioka
- International Medical Center, Fujita Health University Hospital, Toyoake, Japan
| | - Masayuki Kojima
- Department of Surgery, Fujita Health University, Toyoake, Japan
| | - Gozo Kiguchi
- Department of Surgery, Hirakata Kosai Hospital, Hirakata, Japan
| | - Satoshi Mii
- Department of Surgery, Fujita Health University, Toyoake, Japan
| | - Yuichiro Uchida
- Department of Surgery, Fujita Health University, Toyoake, Japan
| | | | - Ichiro Uyama
- Department of Advanced Robotic and Endoscopic Surgery, Fujita Health University, Toyoake, Japan
| |
Collapse
|
8
|
Zwart MJW, Görgec B, Arabiyat A, Nota CLM, van der Poel MJ, Fichtinger RS, Berrevoet F, van Dam RM, Aldrighetti L, Fuks D, Hoti E, Edwin B, Besselink MG, Abu Hilal M, Hagendoorn J, Swijnenburg RJ. Pan-European survey on the implementation of robotic and laparoscopic minimally invasive liver surgery. HPB (Oxford) 2022; 24:322-331. [PMID: 34772622 DOI: 10.1016/j.hpb.2021.08.939] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/29/2021] [Accepted: 08/06/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Laparoscopic and robotic minimally invasive liver surgery (MILS) is gaining popularity. Recent data and views on the implementation of laparoscopic and robotic MILS throughout Europe are lacking. METHODS An anonymous survey consisting of 46 questions was sent to all members of the European-African Hepato-Pancreato-Biliary Association. RESULTS The survey was completed by 120 surgeons from 103 centers in 24 countries. Median annual center volume of liver resection was 100 [IQR 50-140]. The median annual volume of MILS per center was 30 [IQR 16-40]. For minor resections, laparoscopic MILS was used by 80 (67%) surgeons and robotic MILS by 35 (29%) surgeons. For major resections, laparoscopic MILS was used by 74 (62%) surgeons and robotic MILS by 33 (28%) surgeons. The majority of the surgeons stated that minimum annual volume of MILS per center should be around 21-30 procedures/year. Of the surgeons performing robotic surgery, 28 (70%) felt they missed specific equipment, such as a robotic-CUSA. Seventy (66%) surgeons provided a formal MILS training to residents and fellows. In 5 years' time, 106 (88%) surgeons felt that MILS would have superior value as compared to open liver surgery. CONCLUSION In the participating European liver centers, MILS comprised about one third of all liver resections and is expected to increase further. Laparoscopic MILS is still twice as common as robotic MILS. Development of specific instruments for robotic liver parenchymal transection might further increase its adoption.
Collapse
Affiliation(s)
- Maurice J W Zwart
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Burak Görgec
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands; Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Abdullah Arabiyat
- Department of Surgery, The Royal Lancaster Infirmary, University Hospitals of Morecambe Bay, United Kingdom
| | - Carolijn L M Nota
- Department of Surgery, UMC Utrecht Cancer Center/Regional Academic Cancer Center Utrecht (RAKU), Utrecht, the Netherlands
| | - Marcel J van der Poel
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Robert S Fichtinger
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Frederik Berrevoet
- Department of General and HPB Surgery and Liver Transplantation, University Hospital Ghent, Ghent, Belgium
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; Department of General, Visceral and Transplant Surgery, University Hospital Aachen, Aachen, Germany
| | - Luca Aldrighetti
- Department of Surgery, Hepatobiliary Surgery Unit, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - David Fuks
- Department of Digestive Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Emir Hoti
- Department of Surgery, Saint Vincent's University Hospital, Dublin, Ireland
| | - Bjørn Edwin
- Interventional Centre and Department of Hepato-pancreato-biliary Surgery, Oslo University Hospital and Institute for Medicine, University in Oslo, Norway
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy.
| | - Jeroen Hagendoorn
- Department of Surgery, UMC Utrecht Cancer Center/Regional Academic Cancer Center Utrecht (RAKU), Utrecht, the Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, the Netherlands.
| | | |
Collapse
|
9
|
Milone M, Manigrasso M, Anoldo P, D’Amore A, Elmore U, Giglio MC, Rompianesi G, Vertaldi S, Troisi RI, Francis NK, De Palma GD. The Role of Robotic Visceral Surgery in Patients with Adhesions: A Systematic Review and Meta-Analysis. J Pers Med 2022; 12:jpm12020307. [PMID: 35207795 PMCID: PMC8878352 DOI: 10.3390/jpm12020307] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 12/17/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Marco Milone
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
- Correspondence: ; Tel.: +39-333-299-3637
| | - Michele Manigrasso
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (M.M.); (P.A.)
| | - Pietro Anoldo
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy; (M.M.); (P.A.)
| | - Anna D’Amore
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
| | - Ugo Elmore
- Department of Surgery, San Raffaele Hospital and San Raffaele Vita-Salute University, 20132 Milan, Italy;
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
| | - Gianluca Rompianesi
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
| | - Sara Vertaldi
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
| | - Roberto Ivan Troisi
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
| | | | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.D.); (M.C.G.); (G.R.); (S.V.); (R.I.T.); (G.D.D.P.)
| |
Collapse
|
10
|
Multivisceral Resection in Robotic Liver Surgery. Cancers (Basel) 2022; 14:cancers14020355. [PMID: 35053518 PMCID: PMC8773961 DOI: 10.3390/cancers14020355] [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: 12/22/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 11/23/2022] Open
Abstract
Simple Summary Liver surgery can be performed simultaneously with operations to remove other organs in certain circumstances, such as removal of colorectal cancer in the colon or rectum at the same time as metastatic lesions to the liver. These types of operations have been performed as open or laparoscopic procedures; however, more recently, they can be performed with a robotic approach. In this article, we review the literature and describe robotic liver resections performed with robotic resection of other organs, including colon, rectum, and pancreas. These published reports demonstrate that, in select cases and experienced hands, robotic multivisceral resection can be safely performed with good outcomes. Abstract Minimally invasive surgery techniques are expanding in utilization in liver resections and now include robotic approaches. Robotic liver resection has been demonstrated to have several benefits, including surgeon ergonomics, wrist articulation, and 3D visualization. Similarly, for multivisceral liver resections, the use of minimally invasive techniques has evolved and expanded from laparoscopy to robotics. The aim of this article is to review the literature and describe multivisceral resections, including hepatectomy, using a robotic technique. We describe over 50 published cases of simultaneous robotic liver resection with colon or rectal resection. In addition, we describe several pancreatectomies performed with liver resection and one extra-abdominal pulmonary resection with liver resection. In total, these select reported cases at experienced centers demonstrate the safety of robotic multivisceral resection in liver surgery with acceptable morbidity and rare conversion to open surgery. As robotic technology advances and experience with robotic techniques grows, robotic multivisceral resection in liver surgery should continue to be investigated in future studies.
Collapse
|
11
|
Tsekouras K, Spartalis E, Mamakos N, Tsourouflis G, Nikiteas NI, Dimitroulis D. The Use of Robotics in Surgery of Benign Liver Diseases: A Systematic Review. Surg Innov 2021; 29:258-268. [PMID: 34275339 DOI: 10.1177/15533506211031414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Surgical treatment of benign liver diseases (BLD) remains a field of conflict, due to increased risk and high complication rate. However, the introduction of minimally invasive surgery has led to increased number of patients with BLD being treated surgically, with similar outcomes and fewer complications. Current data support the application of laparoscopic surgery (LS) and robotic surgery (RS) in surgical treatment of liver malignancies, but there are insufficient data concerning the application of robotic surgery in BLD. In the present systematic review, we aimed to evaluate the application of RS in BLD surgery. METHODS After a thorough search of Medline, Scopus, and Cochrane Library, 12 studies were considered eligible with a total number of 115 patients with BLD. DISCUSSION In brief, RS appears to be a safe and feasible option for BLD surgery. When compared to open surgery, RS is associated with lower blood loss, shorter length of stay, and fewer complication rate. Regarding LS, the peri- and postoperative outcomes were similar, but RS can overcome the technical limitations of LS. However, the cost of RS remains a major drawback in its widespread application. CONCLUSIONS Considering our findings, RS can be a safe and feasible option for BLD surgery, but further studies are needed to justify the introduction of RS in liver surgery and to define the type of patients that will benefit the most from it.
Collapse
Affiliation(s)
- Konstantinos Tsekouras
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece
| | - Eleftherios Spartalis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece.,Second Department of Propaedeutic Surgery, Laiko Hospital, Athens Medical School, 68993National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Mamakos
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece
| | - Gerasimos Tsourouflis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece.,Second Department of Propaedeutic Surgery, Laiko Hospital, Athens Medical School, 68993National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos I Nikiteas
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece.,Second Department of Propaedeutic Surgery, Laiko Hospital, Athens Medical School, 68993National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Dimitroulis
- Hellenic Minimally Invasive and Robotic Surgery (MIRS) Study Group, Athens Medical School, 68989National and Kapodistrian University of Athens, Athens, Greece.,Second Department of Propaedeutic Surgery, Laiko Hospital, Athens Medical School, 68993National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
12
|
Aziz H, Hanna K, Lashkari N, Ahmad NUS, Genyk Y, Sheikh MR. Hospitalization Costs and Outcomes of Open, Laparoscopic, and Robotic Liver Resections. Am Surg 2021; 88:2331-2337. [PMID: 33861658 DOI: 10.1177/00031348211011063] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Most liver resections performed in the United States are open. With the ever-increasing role of robotic surgery, our study's role is to assess national outcomes based on the surgical approach. METHODS We performed a retrospective analysis of the 2015 National Readmission Database (NRD). We selected patients undergoing open, laparoscopic, and robotic hepatectomy. Propensity score matching was performed to match the three groups in terms of demographics, hospital characteristics, and resection type. Our primary outcome was 6-month readmission rates and associated costs. RESULTS 3,872 patients were included in the analysis (open = 3,420, laparoscopic = 343, and robotic = 109). Robotic liver resection has lower 6-month readmission rates (18.3%) than the laparoscopic (26.7%) and open (30%) counterparts. The robotic approach was more cost-effective ($127,716.56 ± 12,567.31) than the open ($157,880.82 ± 18,560.2) and laparoscopic approach ($152,060.78 ± 8,890.13) in terms of the total cost which includes cost per readmission. CONCLUSIONS There is a financial benefit of using robotics in terms of cost, hospital length of stay, and readmission rates in patients undergoing liver resection, cost.
Collapse
Affiliation(s)
- Hassan Aziz
- Department of Surgery, Keck School of Medicine, 5116University of Southern California, Los Angeles, CA, United States
| | - Kamil Hanna
- Department of Surgery, 8138Westchester Medical Center, Valhalla, NY, United States
| | - Nassim Lashkari
- Department of Surgery, Keck School of Medicine, 5116University of Southern California, Los Angeles, CA, United States
| | | | - Yuri Genyk
- Department of Surgery, Keck School of Medicine, 5116University of Southern California, Los Angeles, CA, United States
| | - Mohd Raashid Sheikh
- Department of Surgery, Keck School of Medicine, 5116University of Southern California, Los Angeles, CA, United States
| |
Collapse
|
13
|
Lorenz E, Arend J, Franz M, Rahimli M, Perrakis A, Negrini V, Gumbs AA, Croner RS. Robotic and laparoscopic liver resection-comparative experiences at a high-volume German academic center. Langenbecks Arch Surg 2021; 406:753-761. [PMID: 33834295 PMCID: PMC8106606 DOI: 10.1007/s00423-021-02152-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 03/15/2021] [Indexed: 01/21/2023]
Abstract
Purpose Minimally invasive liver surgery (MILS) is a feasible and safe procedure for benign and malignant tumors. There has been an ongoing debate on whether conventional laparoscopic liver resection (LLR) or robotic liver resection (RLR) is superior and if one approach should be favored over the other. We started using LLR in 2010, and introduced RLR in 2013. In the present paper, we report on our experiences with these two techniques as early adopters in Germany. Methods The data of patients who underwent MILS between 2010 and 2020 were collected prospectively in the Magdeburg Registry for Minimally Invasive Liver Surgery (MD-MILS). A retrospective analysis was performed regarding patient demographics, tumor characteristics, and perioperative parameters. Results We identified 155 patients fulfilling the inclusion criteria. Of these, 111 (71.6%) underwent LLR and 44 (29.4%) received RLR. After excluding cystic lesions, 113 cases were used for the analysis of perioperative parameters. Resected specimens were significantly bigger in the RLR vs. the LLR group (405 g vs. 169 g, p = 0.002); in addition, the tumor diameter was significantly larger in the RLR vs. the LLR group (5.6 cm vs. 3.7 cm, p = 0.001). Hence, the amount of major liver resections (three or more segments) was significantly higher in the RLR vs. the LLR group (39.0% vs. 16.7%, p = 0.005). The mean operative time was significantly longer in the RLR vs. the LLR group (331 min vs. 181 min, p = 0.0001). The postoperative hospital stay was significantly longer in the RLR vs. the LLR group (13.4 vs. LLR 8.7 days, p = 0.03). The R0 resection rate for solid tumors was higher in the RLR vs. the LLR group but without statistical significance (93.8% vs. 87.9%, p = 0.48). The postoperative morbidity ≥ Clavien-Dindo grade 3 was 5.6% in the LLR vs. 17.1% in the RLR group (p = 0.1). No patient died in the RLR but two patients (2.8%) died in the LLR group, 30 and 90 days after surgery (p = 0.53). Conclusion Minimally invasive liver surgery is safe and feasible. Robotic and laparoscopic liver surgery shows similar and adequate perioperative oncological results for selected patients. RLR might be advantageous for more advanced and technically challenging procedures.
Collapse
Affiliation(s)
- E Lorenz
- Department of General, Visceral, Vascular, and Transplant Surgery, University Hospital Magdeburg, Leipziger Strasse 44, 39120, Magdeburg, Germany.
| | - J Arend
- Department of General, Visceral, Vascular, and Transplant Surgery, University Hospital Magdeburg, Leipziger Strasse 44, 39120, Magdeburg, Germany
| | - M Franz
- Department of General, Visceral, Vascular, and Transplant Surgery, University Hospital Magdeburg, Leipziger Strasse 44, 39120, Magdeburg, Germany
| | - M Rahimli
- Department of General, Visceral, Vascular, and Transplant Surgery, University Hospital Magdeburg, Leipziger Strasse 44, 39120, Magdeburg, Germany
| | - A Perrakis
- Department of General, Visceral, Vascular, and Transplant Surgery, University Hospital Magdeburg, Leipziger Strasse 44, 39120, Magdeburg, Germany
| | - V Negrini
- Department of General, Visceral, Vascular, and Transplant Surgery, University Hospital Magdeburg, Leipziger Strasse 44, 39120, Magdeburg, Germany
| | - A A Gumbs
- Centre Hospitalier Intercommunal de Poissy/Saint-Germain-En-Laye, 10 Rue du Champ Gaillard, 78300, Poissy, France
| | - R S Croner
- Department of General, Visceral, Vascular, and Transplant Surgery, University Hospital Magdeburg, Leipziger Strasse 44, 39120, Magdeburg, Germany
| |
Collapse
|
14
|
Labadie KP, Droullard DJ, Lois AW, Daniel SK, McNevin KE, Gonzalez JV, Seo YD, Sullivan KM, Bilodeau KS, Dickerson LK, Utria AF, Calhoun J, Pillarisetty VG, Sham JG, Yeung RS, Park JO. IWATE criteria are associated with perioperative outcomes in robotic hepatectomy: a retrospective review of 225 resections. Surg Endosc 2021; 36:889-895. [PMID: 33608766 PMCID: PMC8758630 DOI: 10.1007/s00464-021-08345-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 01/27/2021] [Indexed: 02/06/2023]
Abstract
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.
Collapse
Affiliation(s)
- Kevin P Labadie
- Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195, USA
| | - David J Droullard
- Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195, USA
| | - Alex W Lois
- Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195, USA
| | - Sara K Daniel
- Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195, USA
| | - Kathryn E McNevin
- Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195, USA
| | - Jaqueline Valdez Gonzalez
- Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195, USA
| | - Yongwoo D Seo
- Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195, USA
| | - Kevin M Sullivan
- Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195, USA
| | - Kyle S Bilodeau
- Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195, USA
| | - Lindsay K Dickerson
- Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195, USA
| | - Alan F Utria
- Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195, USA
| | - John Calhoun
- Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195, USA
| | - Venu G Pillarisetty
- Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195, USA
- Center for Advanced Minimally Invasive Liver Oncologic Therapies (CAMILOT), University of Washington, Seattle, WA, 98195, USA
- Hepatobiliary Surgical Oncology, Department of Surgery, University of Washington Medical Center, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195-6410, USA
| | - Jonathan G Sham
- Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195, USA
- Center for Advanced Minimally Invasive Liver Oncologic Therapies (CAMILOT), University of Washington, Seattle, WA, 98195, USA
- Hepatobiliary Surgical Oncology, Department of Surgery, University of Washington Medical Center, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195-6410, USA
| | - Raymond S Yeung
- Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195, USA
- Center for Advanced Minimally Invasive Liver Oncologic Therapies (CAMILOT), University of Washington, Seattle, WA, 98195, USA
- Hepatobiliary Surgical Oncology, Department of Surgery, University of Washington Medical Center, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195-6410, USA
| | - James O Park
- Department of Surgery, University of Washington School of Medicine, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195, USA.
- Center for Advanced Minimally Invasive Liver Oncologic Therapies (CAMILOT), University of Washington, Seattle, WA, 98195, USA.
- Hepatobiliary Surgical Oncology, Department of Surgery, University of Washington Medical Center, 1959 NE Pacific Street, Health Sciences Bldg. Room BB-442, Box 356410, Seattle, WA, 98195-6410, USA.
| |
Collapse
|
15
|
Mehdorn AS, Beckmann JH, Braun F, Becker T, Egberts JH. Usability of Indocyanine Green in Robot-Assisted Hepatic Surgery. J Clin Med 2021; 10:456. [PMID: 33503996 PMCID: PMC7865567 DOI: 10.3390/jcm10030456] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/17/2020] [Accepted: 01/21/2021] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
Affiliation(s)
| | | | | | | | - Jan-Hendrik Egberts
- Department of General, Abdominal, Thoracic, Transplantation and Pediatric Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105 Kiel, Germany; (A.-S.M.); (J.H.B.); (F.B.); (T.B.)
| |
Collapse
|
16
|
Lee KF, Chong C, Cheung S, Wong J, Fung A, Lok HT, Lo E, Lai P. Robotic versus open hemihepatectomy: a propensity score-matched study. Surg Endosc 2020; 35:2316-2323. [PMID: 33185767 DOI: 10.1007/s00464-020-07645-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 05/13/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Minimally invasive approach has been increasingly applied in liver resection. However, laparoscopic major hepatectomy is technically demanding and is practiced only in expert centers around the world. Conversely, use of robot may help to overcome the difficulty and facilitate major hepatectomy. METHODS Between September 2010 and March 2019, 151 patients received robotic hepatectomy for various indications in our center. 36 patients received robotic hemihepatectomy: 26 left hepatectomy and 10 right hepatectomy. During the same period, 737 patients received open hepatectomy and out of these, 173 patients received open hemihepatectomy. A propensity score-matched analysis was performed in a 1:1 ratio. RESULTS After matching, there were 36 patients each in the robotic and open group. The two groups were comparable in demographic data, type of hemihepatectomy, underlying pathology, size of tumor, and background cirrhosis. Conversion was needed in 3 patients (8.3%) in the robotic group. There was no operative mortality. The operative blood loss and resection margin were similar. Though not significantly different, there was a higher rate of complications in the robotic group (36.1% vs. 22.2%) and this difference was mostly driven by higher intra-abdominal collection (16.7% vs. 5.6%) and bile leak (5.6% vs. 2.8%). Operative time was significantly longer (400.8 ± 136.1 min vs 255.4 ± 74.4 min, P < 0.001) but the postoperative hospital stay was significantly shorter (median 5 days vs 6.5 days, P = 0.040) in the robotic group. When right and left hepatectomy were analyzed separately, the advantage of shorter hospital stay remained in left but not right hepatectomy. For patients with hepatocellular carcinoma, there was no difference between the two groups in 5-year overall and disease-free survival. CONCLUSION Compared with the open approach, robotic hemihepatectomy has longer operation time but shorter hospital stay. Thus, use of robot is feasible and effective in hemihepatectomy with the benefit of shorter hospital stay.
Collapse
Affiliation(s)
- Kit-Fai Lee
- Department of Surgery, Prince of Wales Hospital, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong.
| | - Charing Chong
- Department of Surgery, Prince of Wales Hospital, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong
| | - Sunny Cheung
- Department of Surgery, Prince of Wales Hospital, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong
| | - John Wong
- Department of Surgery, Prince of Wales Hospital, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong
| | - Andrew Fung
- Department of Surgery, Prince of Wales Hospital, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong
| | - Hon-Ting Lok
- Department of Surgery, Prince of Wales Hospital, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong
| | - Eugene Lo
- Department of Surgery, Prince of Wales Hospital, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong
| | - Paul Lai
- Department of Surgery, Prince of Wales Hospital, 30-32, Ngan Shing Street, Shatin, NT, Hong Kong
| |
Collapse
|
17
|
van der Heijde N, Ratti F, Aldrighetti L, Benedetti Cacciaguerra A, Can MF, D'Hondt M, Di Benedetto F, Ivanecz A, Magistri P, Menon K, Papoulas M, Vivarelli M, Besselink MG, Abu Hilal M. Laparoscopic versus open right posterior sectionectomy: an international, multicenter, propensity score-matched evaluation. Surg Endosc 2020; 35:6139-6149. [PMID: 33140153 PMCID: PMC8523385 DOI: 10.1007/s00464-020-08109-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/16/2020] [Indexed: 12/22/2022]
Abstract
Background Although laparoscopic liver resection has become the standard for minor resections, evidence is lacking for more complex resections such as the right posterior sectionectomy (RPS). We aimed to compare surgical outcomes between laparoscopic (LRPS) and open right posterior sectionectomy (ORPS). Methods An international multicenter retrospective study comparing patients undergoing LRPS or ORPS (January 2007—December 2018) was performed. Patients were matched based on propensity scores in a 1:1 ratio. Primary endpoint was major complication rate defined as Accordion ≥ 3 grade. Secondary endpoints included blood loss, length of hospital stay (LOS) and resection status. A sensitivity analysis was done excluding the first 10 LRPS patients of each center to correct for the learning curve. Additionally, possible risk factors were explored for operative time, blood loss and LOS. Results Overall, 399 patients were included from 9 centers from 6 European countries of which 150 LRPS could be matched to 150 ORPS. LRPS was associated with a shorter operative time [235 (195–285) vs. 247 min (195–315) p = 0.004], less blood loss [260 (188–400) vs. 400 mL (280–550) p = 0.009] and a shorter LOS [5 (4–7) vs. 8 days (6–10), p = 0.002]. Major complication rate [n = 8 (5.3%) vs. n = 9 (6.0%) p = 1.00] and R0 resection rate [144 (96.0%) vs. 141 (94.0%), p = 0.607] did not differ between LRPS and ORPS, respectively. The sensitivity analysis showed similar findings in the previous mentioned outcomes. In multivariable regression analysis blood loss was significantly associated with the open approach, higher ASA classification and malignancy as diagnosis. For LOS this was the open approach and a malignancy. Conclusion This international multicenter propensity score-matched study showed an advantage in favor of LRPS in selected patients as compared to ORPS in terms of operative time, blood loss and LOS without differences in major complications and R0 resection rate. Electronic supplementary material The online version of this article (10.1007/s00464-020-08109-y) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Nicky van der Heijde
- Department of Surgery, Southampton University Hospital, Southampton, UK
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | | | - Andrea Benedetti Cacciaguerra
- HPB Surgery and Transplantation Unit, Department of Clinical and Experimental Medicine, Polytechnic University of Marche, Ancona, Italy
- Department of Surgery, Fondazione Poliambulanza - Instituto Ospedaliero, Brescia, Italy
| | - Mehmet F Can
- Department of Surgery, Lokman Hekim University School of Medicine, Ankara, Turkey
| | - Mathieu D'Hondt
- Department of Surgery, AZ Groeninge Hospital, Kortrijk, Belgium
| | | | - Arpad Ivanecz
- Department of Abdominal and General Surgery, University Medical Centre Maribor, Maribor, Slovenia
| | - Paolo Magistri
- Department of Surgery, University of Modena, Modena, Italy
| | - Krishna Menon
- Department of Surgery, King's College Hospital, London, UK
| | | | - Marco Vivarelli
- HPB Surgery and Transplantation Unit, Department of Clinical and Experimental Medicine, Polytechnic University of Marche, Ancona, Italy
| | - Marc G Besselink
- Department of Surgery, Cancer Centre Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Mohammed Abu Hilal
- Department of Surgery, Southampton University Hospital, Southampton, UK.
- Department of Surgery, Fondazione Poliambulanza - Instituto Ospedaliero, Brescia, Italy.
| |
Collapse
|
18
|
Ziogas IA, Giannis D, Esagian SM, Economopoulos KP, Tohme S, Geller DA. Laparoscopic versus robotic major hepatectomy: a systematic review and meta-analysis. Surg Endosc 2020; 35:524-535. [DOI: 10.1007/s00464-020-08008-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 09/16/2020] [Indexed: 02/08/2023]
|
19
|
Short-term Outcomes of "Difficult" Laparoscopic Liver Resection at Specialized Centers: Report From INSTALL (International Survey on Technical Aspects of Laparoscopic Liver Resection)-2 on 4478 Patients. Ann Surg 2020; 275:940-946. [PMID: 32889884 DOI: 10.1097/sla.0000000000004434] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To define the current status of "difficult" LLR, a global database was created and investigated. BACKGROUND In the Second International Consensus Conference in 2014, minor LLR was considered as a standard practice and major LLR remained an innovative procedure. Since then, no updates on worldwide trends have been available. METHODS A questionnaire on all consecutive patients who underwent difficult LLR (major hepatectomy, posterosuperior segmentectomy, sectionectomy, living donor hepatectomy, tumor size ≥10 cm, Child-Pugh grade ≥B, combined with biliary reconstruction, and Iwate criteria difficulty score ≥7) in 2014-2018 was distributed via email to 65 high-volume LLR centers worldwide. Individual data on patient and tumor demographics, surgical information, and short-term outcomes were obtained to create a large-scale international registry for analyses. RESULTS Overall, 58 centers in 19 countries performed 4478 difficult LLR (median, 58.5; range, 5-418) during the study period. Hepatocellular carcinoma accounted for ≥40% of all indications. Half of the patients underwent major hepatectomy, followed by sectionectomy, posterosuperior segmentectomy, and living donor hepatectomy. In the vast majority of procedures, Clavien-Dindo grade ≥IIIa complication rates of ≈10% and 90-day mortality rates of ≈1% were achieved. Left or right trisectionectomy had the worst Clavien-Dindo grade ≥IIIa complication rate of ≥10% and 90-day mortality rate of 5%-10%. No significant correlation was observed between center volume and short-term outcomes. CONCLUSIONS Total 4478 patients underwent difficult LLR worldwide in 2014-2018. Most procedures are safe and feasible when conducted in specialized centers.
Collapse
|
20
|
Comparison of the learning curves for robotic left and right hemihepatectomy: A prospective cohort study. Int J Surg 2020; 81:19-25. [PMID: 32739547 DOI: 10.1016/j.ijsu.2020.07.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 06/11/2020] [Accepted: 07/07/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Robotic hepatectomy has been continuously improving and shown to be safe and reliable. The learning curve of robotic hemihepatectomy is required which enable beginners to benefit from previous experience. The aim of this study was to assess the learning curve of robotic left (RLH) and right hemihepatectomy (RRH) in terms of operative time (OT) to determine which procedure has an easier learning curve for beginners. METHODS Data records for each 100 consecutive patients who underwent RLH and RRH between July 2012 and May 2019 were collected prospectively and analyzed retrospectively. The data included demographics, OT, estimated blood loss (EBL), postoperative hospital stay (PHS), and rates of morbidity and mortality. The cumulative sum method was used to evaluate the learning curve of OT. RESULTS All patients underwent the RRH and RLH procedure performed by the same surgical team. RRH and RLH learning curve consisted of two phases: the first and second phase. The first phase of RRH included 45 patients, while RLH outcomes were optimized after 35 cases were completed. Compared with the first phase, the mean OT and the median blood loss were decreased significantly in the second phase in both learning curves. No significant decrease in the rates of morbidity and conversion to laparotomy or PHS was observed. CONCLUSIONS This study demonstrated the safety and feasibility of RLH and RRH. The surgeons who previously lacked robotic experience are able to overcome the learning curve for RLH faster than RRH.
Collapse
|
21
|
Sucandy I, Giovannetti A, Ross S, Rosemurgy A. Institutional First 100 Case Experience and Outcomes of Robotic Hepatectomy for Liver Tumors. Am Surg 2020. [DOI: 10.1177/000313482008600328] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The nascent robotic approach for hepatic resections is gaining momentum in the United States because it offers solutions to the known limitations of laparoscopic approach. Herein, we report our initial experience and short-term outcomes of the first 100 robotic hepatectomies. With Institutional Review Board approval, all patients undergoing robotic hepatectomy were prospectively followed up. Patient demographics, operative outcomes, complications, and 30-day readmissions were collected and analyzed. Data are presented as median (mean ± SD). One hundred consecutive patients underwent robotic hepatectomy. Patients were aged 62 (63 ± 13.6) years, 66 per cent were women, and BMI was 29 (29 ± 6.4) kg/m2. In all, 76 per cent of the hepatectomies were undertaken for malignancy [metastatic colorectal cancer (28%), hepatocellular carcinoma (21%), and intrahepatic cholangiocarcinoma (15%)], and 20 per cent for benign lesions; 66 per cent of patients underwent nonanatomical partial hepatectomies, 17 per cent right hepatectomies, 16 per cent left hepatectomies, and 1 per cent trisegmentectomy. Operative time was 233 (268 ± 109.3) minutes, and the estimated blood loss was 123 (269 ± 322.1) mL. Conversion to “open” approach was necessary in one patient. The length of stay was 3 (5 ± 4.6) days. There were no intraoperative complications. Twelve patients experienced postoperative complications. Six patients required readmission to the hospital within 30 days of discharge. Robotic hepatectomy is safe and feasible with favorable short-term outcomes. The robotic system enhances application of minimally invasive surgery for complex hepatobiliary operations.
Collapse
Affiliation(s)
- Iswanto Sucandy
- From the Digestive Health Institute, AdventHealth Tampa, University of Central Florida, Tampa, Florida
| | - Andres Giovannetti
- From the Digestive Health Institute, AdventHealth Tampa, University of Central Florida, Tampa, Florida
| | - Sharona Ross
- From the Digestive Health Institute, AdventHealth Tampa, University of Central Florida, Tampa, Florida
| | - Alexander Rosemurgy
- From the Digestive Health Institute, AdventHealth Tampa, University of Central Florida, Tampa, Florida
| |
Collapse
|
22
|
Kose E, Karahan SN, Berber E. Robotic Liver Resection: Recent Developments. CURRENT SURGERY REPORTS 2020. [DOI: 10.1007/s40137-020-00254-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
|
23
|
Sucandy I, Giovannetti A, Spence J, Ross S, Rosemurgy A. Does preoperative MELD score affect outcomes following robotic hepatectomy for liver tumors? J Robot Surg 2020; 14:725-731. [PMID: 31989441 DOI: 10.1007/s11701-020-01046-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 01/18/2020] [Indexed: 12/11/2022]
Abstract
The model for end-stage liver disease (MELD) score is objective, reproducible, and it has shown to predict mortality related to cirrhosis. This study was undertaken to investigate safety of robotic hepatectomy in patients with elevated preoperative MELD score and to examine correlation between preoperative MELD scores and postoperative outcomes after robotic hepatectomy for liver tumors. Demographic data, MELD score, and clinical outcomes were prospectively collected. Regression analysis was used. Data are presented as median (mean ± SD). 75 patients underwent robotic hepatectomy. Age was 64 (62.5 ± 14.2) years and BMI 28 (29 ± 7.0) kg/m2; 56% women. 60 (81%) of the hepatectomies were undertaken for malignancy (25% hepatocellular carcinoma, 20% colorectal metastasis, 15% cholangiocarcinoma). On regression analysis, MELD score did not correlate with operative time (p = 0.518) or blood loss (p = 0.583). MELD score, however, correlated with length of stay (p = 0.002). 8 (11%) patients experienced postoperative complications; their MELD score was 7 (8 ± 2.5). 68 (91%) patients did not experience postoperative complications; their MELD score was 7 (8 ± 2.8) (p = 0.803). One patient died in this series. In patients undergoing robotic hepatectomy to treat liver tumors, preoperative MELD score only correlates with length of stay. Preoperative MELD score does not correlate with operative time and amount of blood loss. An elevated MELD score should not deter surgeons from offering robotic hepatectomy.
Collapse
Affiliation(s)
- Iswanto Sucandy
- AdventHealth Tampa, 3000 Medical Park Drive, Suite 500, Tampa, FL, 33613, USA.
| | - Andres Giovannetti
- AdventHealth Tampa, 3000 Medical Park Drive, Suite 500, Tampa, FL, 33613, USA
| | - Janelle Spence
- AdventHealth Tampa, 3000 Medical Park Drive, Suite 500, Tampa, FL, 33613, USA
| | - Sharona Ross
- AdventHealth Tampa, 3000 Medical Park Drive, Suite 500, Tampa, FL, 33613, USA
| | - Alexander Rosemurgy
- AdventHealth Tampa, 3000 Medical Park Drive, Suite 500, Tampa, FL, 33613, USA
| |
Collapse
|
24
|
Minimally invasive hepatectomy is associated with decreased morbidity and resource utilization in the elderly. Surg Endosc 2019; 34:5030-5040. [PMID: 31820156 DOI: 10.1007/s00464-019-07298-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 11/28/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of this study was to evaluate whether elderly patients undergoing elective hepatectomy experience increased morbidity/mortality and whether these outcomes could be mitigated by minimally invasive hepatectomy (MIH). METHODS 15,612 patients from 2014 to 2017 were identified in the Hepatectomy Targeted Procedure Participant Use File of the American College of Surgeons National Surgical Quality Improvement Program. Multivariable logistic regression models were constructed to examine the effect of elderly status (age ≥ 75 years, N = 1769) on outcomes with a subgroup analysis of elderly only patients by open (OH) versus MIH (robotic, laparoscopic, and hybrid, N = 4044). Propensity score matching was conducted comparing the effect of MIH to OH in elderly patients to ensure that results are not the artifact of imbalance in baseline characteristics. RESULTS Overall, elderly patients had increased risk for 30-day mortality, major morbidity, prolonged length of hospital stay, and discharge to destination other than home. In the elderly subgroup, MIH was associated with decreased major morbidity (OR 0.71, P = 0.031), invasive intervention (OR 0.61, P = 0.032), liver failure (OR 0.15, P = 0.011), bleeding (OR 0.46, P < 0.001), and prolonged length of stay (OR 0.46, P < 0.001). Propensity score-matched analyses successfully matched 4021 pairs of patients treated by MIH vs. OH, and logistic regression analyses on this matched sample found that MIH was associated with decreased major complications (OR 0.69, P = 0.023), liver failure (OR 0.14, P = 0.010), bile leak (OR 0.46, P = 0.009), bleeding requiring transfusion (OR 0.46, P < 0.001), prolonged length of stay (OR 0.46, P < 0.001), and discharge to destination other than home (OR 0.691, P = 0.035) compared to OH. CONCLUSION MIH is associated with decreased risk of major morbidity, liver failure, bile leak, bleeding, prolonged length of stay, and discharge to destination other than home among elderly patients in this retrospective study. However, MIH in elderly patients does not protect against postoperative mortality.
Collapse
|
25
|
van der Poel MJ, Fichtinger RS, Bemelmans M, Bosscha K, Braat AE, de Boer MT, Dejong CHC, Doornebosch PG, Draaisma WA, Gerhards MF, Gobardhan PD, Gorgec B, Hagendoorn J, Kazemier G, Klaase J, Leclercq WKG, Liem MS, Lips DJ, Marsman HA, Mieog JSD, Molenaar QI, Nieuwenhuijs VB, Nota CL, Patijn GA, Rijken AM, Slooter GD, Stommel MWJ, Swijnenburg RJ, Tanis PJ, Te Riele WW, Terkivatan T, van den Tol PM, van den Boezem PB, van der Hoeven JA, Vermaas M, Abu Hilal M, van Dam RM, Besselink MG. Implementation and outcome of minor and major minimally invasive liver surgery in the Netherlands. HPB (Oxford) 2019; 21:1734-1743. [PMID: 31235430 DOI: 10.1016/j.hpb.2019.05.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/25/2019] [Accepted: 05/07/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND While most of the evidence on minimally invasive liver surgery (MILS) is derived from expert centers, nationwide outcomes remain underreported. This study aimed to evaluate the implementation and outcome of MILS on a nationwide scale. METHODS Electronic patient files were reviewed in all Dutch liver surgery centers and all patients undergoing MILS between 2011 and 2016 were selected. Operative outcomes were stratified based on extent of the resection and annual MILS volume. RESULTS Overall, 6951 liver resections were included, with a median annual volume of 50 resections per center. The overall use of MILS was 13% (n = 916), which varied from 3% to 36% (P < 0.001) between centers. The nationwide use of MILS increased from 6% in 2011 to 23% in 2016 (P < 0.001). Outcomes of minor MILS were comparable with international studies (conversion 0-13%, mortality <1%). In centers which performed ≥20 MILS annually, major MILS was associated with less conversions (14 (11%) versus 41 (30%), P < 0.001), shorter operating time (184 (117-239) versus 200 (139-308) minutes, P = 0.010), and less overall complications (37 (30%) versus 58 (42%), P = 0.040). CONCLUSION The nationwide use of MILS is increasing, although large variation remains between centers. Outcomes of major MILS are better in centers with higher volumes.
Collapse
Affiliation(s)
- Marcel J van der Poel
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Robert S Fichtinger
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands; RWTH Aachen, Germany
| | - Marc Bemelmans
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands; RWTH Aachen, Germany
| | - Koop Bosscha
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands
| | - Andries E Braat
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke T de Boer
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Cornelis H C Dejong
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands; RWTH Aachen, Germany
| | - Pascal G Doornebosch
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - Werner A Draaisma
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands; Department of Surgery, Meander Medical Center, Amersfoort, the Netherlands
| | | | | | - Burak Gorgec
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Geert Kazemier
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | - Joost Klaase
- Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands; Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | | | - Mike S Liem
- Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | - Daan J Lips
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, the Netherlands; Department of Surgery, Medical Spectrum Twente, Enschede, the Netherlands
| | | | - J Sven D Mieog
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Quintus I Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Carolijn L Nota
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Gijs A Patijn
- Department of Surgery, Isala, Zwolle, the Netherlands
| | - Arjen M Rijken
- Department of Surgery, Amphia Hospital, Breda, the Netherlands
| | - Gerrit D Slooter
- Department of Surgery, Máxima Medical Center, Veldhoven, the Netherlands
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rutger-Jan Swijnenburg
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands; Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Pieter J Tanis
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Wouter W Te Riele
- Department of Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Türkan Terkivatan
- Department of Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Petrousjka M van den Tol
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, Vrije Universiteit Amsterdam, the Netherlands
| | | | | | - Maarten Vermaas
- Department of Surgery, IJsselland Hospital, Capelle aan den IJssel, the Netherlands
| | - Moh'd Abu Hilal
- Department of Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ronald M van Dam
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands; RWTH Aachen, Germany
| | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, the Netherlands.
| |
Collapse
|
26
|
Goja S, Yadav SK, Chaudhary RJ, Singh MK, Soin AS. Transition from open to robotic assisted liver resection: A retrospective comparative study. Is experience of laparoscopic liver resections needed? LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2019. [DOI: 10.1016/j.lers.2019.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
|
27
|
Troisi RI, Pegoraro F, Giglio MC, Rompianesi G, Berardi G, Tomassini F, De Simone G, Aprea G, Montalti R, De Palma GD. Robotic approach to the liver: Open surgery in a closed abdomen or laparoscopic surgery with technical constraints? Surg Oncol 2019; 33:239-248. [PMID: 31759794 DOI: 10.1016/j.suronc.2019.10.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 10/24/2019] [Indexed: 02/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- Roberto Ivan Troisi
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy; Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium.
| | - Francesca Pegoraro
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | - Mariano Cesare Giglio
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | | | - Giammauro Berardi
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium
| | - Federico Tomassini
- Department of Human Structure and Repair, Ghent University Faculty of Medicine, Belgium
| | - Giuseppe De Simone
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | - Giovanni Aprea
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| | - Roberto Montalti
- Department of Public Health, Federico II University Naples, Italy
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, Interuniversity Center for Technological Innovation Interdepartmental Center for Robotic Surgery, Federico II University Naples, Italy
| |
Collapse
|
28
|
Zhu P, Liao W, Ding ZY, Chen L, Zhang WG, Zhang BX, Chen XP. Learning Curve in Robot-Assisted Laparoscopic Liver Resection. J Gastrointest Surg 2019; 23:1778-1787. [PMID: 30406576 DOI: 10.1007/s11605-018-3689-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/08/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The objective of this study was to evaluate the learning curve effect on the safety and feasibility of robot-assisted liver resection (RALR). METHODS In 140 consecutive cases, all data about demographic, surgical procedure, postoperative course were collected prospectively and analyzed. Risk-adjusted cumulative sum model was used for determining the learning curve based on the need for conversion. RESULTS Among all 140 patients, no patients suffered from any organ dysfunction postoperatively and the operative mortality was 0%. The CUSUM analysis showed that at the 30th consecutive patient, the open conversion rate reached to the average value, and it further improved thereafter. In the last 70 patients, only 3 patients (4.3%) required conversion and 7 patients (10%) needed blood transfusion. Only 1 patient (1.3%) out of 79 patients with HCC had a positive resection margin. Univariate analyses showed the following risk factors associated with significantly higher risks of conversion (P < 0.05): tumor number > 1, lesions in segments 1/4a/7/8, right posterior sectionectomy, and lesions which were beyond the indications of the Louisville statement. Multivariate logistic analysis revealed that both tumor number > 1 (OR: 2.10, P < 0.05) and right posterior sectionectomy (OR: 11.19, P < 0.01) were risk factors of conversion. CONCLUSIONS The robotic approach for hepatectomy is safe and feasible. A learning curve effect was demonstrated in this study after the 30th consecutive patient. The long-term oncological outcomes of robotic hepatectomy still need further investigation.
Collapse
Affiliation(s)
- Peng Zhu
- Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Liao
- Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ze-Yang Ding
- Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lin Chen
- Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wan-Guang Zhang
- Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bi-Xiang Zhang
- Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Xiao-Ping Chen
- Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| |
Collapse
|
29
|
Use of indocyanine green (ICG) augmented near-infrared fluorescence imaging in robotic radical resection of gallbladder adenocarcinomas. Surg Endosc 2019; 34:2490-2494. [PMID: 31388807 DOI: 10.1007/s00464-019-07053-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/31/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gallbladder cancer remains a rare cancer with a poor prognosis. National guidelines recommend radical resection in the absence of metastatic disease. This often requires extensive dissection around the extrahepatic bile ducts. We report our experience of real-time near-infrared fluorescence imaging using indocyanine green during robotic radical resection of gallbladder adenocarcinomas. METHODS Ten patients with gallbladder adenocarcinoma underwent robotic radical resection entailing central hepatectomy (segments IV-B and V) with regional lymphadenectomy. Real-time NIRF imaging was performed using the da Vinci® Firefly system after intravenous administration of ICG 30 to 60 min preoperatively. Primary objective was to determine safety of this technique. RESULTS Procedure was successfully completed in all patients. Seven patients (70%) had incidentally discovered gallbladder cancer after laparoscopic cholecystectomy and five patients had preoperatively known positive margins. Mean operative time was 173 min. Mean intraoperative blood loss was 88 mL (30-200 mL). Median number of lymph nodes retrieved was 5 (2-8). High ligation of cystic duct was performed close to the common bile duct (CBD) junction with the assist of NIRF and negative margins were achieved in all patients. No major complications (Grade III-IV) or mortality was seen at 30 days post-op. CONCLUSIONS Results from our limited experience demonstrate procedural safety and beneficial use of NIRF using ICG during robotic radical resection of gallbladder adenocarcinomas. It may assist in attainment of negative cystic duct margin and lymphatic clearance around the biliary tree especially in complex re-explorative biliary surgery.
Collapse
|
30
|
Wang Z, Tang W, Hu M, Zhao Z, Zhao G, Li C, Tan X, Zhang X, Lau WY, Liu R. Robotic vs laparoscopic hemihepatectomy: A comparative study from a single center. J Surg Oncol 2019; 120:646-653. [DOI: 10.1002/jso.25640] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 06/25/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Zi‐Zheng Wang
- Department of Hepatopancreatobiliary Surgical Oncology, Military Institution of Hepatopancreatobiliary SurgeryThe First Medical Center of Chinese People's Liberation Army (PLA) General HospitalBeijing China
| | - Wen‐Bo Tang
- Department of Hepatopancreatobiliary Surgical Oncology, Military Institution of Hepatopancreatobiliary SurgeryThe First Medical Center of Chinese People's Liberation Army (PLA) General HospitalBeijing China
| | - Ming‐Gen Hu
- Department of Hepatopancreatobiliary Surgical Oncology, Military Institution of Hepatopancreatobiliary SurgeryThe First Medical Center of Chinese People's Liberation Army (PLA) General HospitalBeijing China
| | - Zhi‐Ming Zhao
- Department of Hepatopancreatobiliary Surgical Oncology, Military Institution of Hepatopancreatobiliary SurgeryThe First Medical Center of Chinese People's Liberation Army (PLA) General HospitalBeijing China
| | - Guo‐Dong Zhao
- Department of Hepatopancreatobiliary Surgical Oncology, Military Institution of Hepatopancreatobiliary SurgeryThe First Medical Center of Chinese People's Liberation Army (PLA) General HospitalBeijing China
| | - Cheng‐Gang Li
- Department of Hepatopancreatobiliary Surgical Oncology, Military Institution of Hepatopancreatobiliary SurgeryThe First Medical Center of Chinese People's Liberation Army (PLA) General HospitalBeijing China
| | - Xiang‐Long Tan
- Department of Hepatopancreatobiliary Surgical Oncology, Military Institution of Hepatopancreatobiliary SurgeryThe First Medical Center of Chinese People's Liberation Army (PLA) General HospitalBeijing China
| | - Xuan Zhang
- Department of Hepatopancreatobiliary Surgical Oncology, Military Institution of Hepatopancreatobiliary SurgeryThe First Medical Center of Chinese People's Liberation Army (PLA) General HospitalBeijing China
| | - Wan Yee Lau
- Faculty of MedicineThe Chinese University of Hong KongShatin Hong Kong Special Administrative Region China
| | - Rong Liu
- Department of Hepatopancreatobiliary Surgical Oncology, Military Institution of Hepatopancreatobiliary SurgeryThe First Medical Center of Chinese People's Liberation Army (PLA) General HospitalBeijing China
| |
Collapse
|
31
|
Antico M, Sasazawa F, Wu L, Jaiprakash A, Roberts J, Crawford R, Pandey AK, Fontanarosa D. Ultrasound guidance in minimally invasive robotic procedures. Med Image Anal 2019; 54:149-167. [DOI: 10.1016/j.media.2019.01.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/01/2019] [Accepted: 01/09/2019] [Indexed: 12/20/2022]
|
32
|
Tsirlis T, Thakkar R, Sen G, Logue J, Robinson S, French JJ, White SA. Robotic fenestration of massive liver cysts using EndoWrist technology. Int J Med Robot 2019; 15:e1994. [DOI: 10.1002/rcs.1994] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/14/2019] [Accepted: 02/24/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Theodoros Tsirlis
- Department of HPB SurgeryThe Freeman Hospital Newcastle upon Tyne UK
| | - Rohan Thakkar
- Department of HPB SurgeryThe Freeman Hospital Newcastle upon Tyne UK
| | - Gourab Sen
- Department of HPB SurgeryThe Freeman Hospital Newcastle upon Tyne UK
| | - Jennifer Logue
- Department of HPB SurgeryThe Freeman Hospital Newcastle upon Tyne UK
| | - Stuart Robinson
- Department of HPB SurgeryThe Freeman Hospital Newcastle upon Tyne UK
| | | | - Steven Alan White
- Department of HPB SurgeryThe Freeman Hospital Newcastle upon Tyne UK
| |
Collapse
|
33
|
Mejia A, Cheng SS, Vivian E, Shah J, Oduor H, Archarya P. Minimally invasive liver resection in the era of robotics: analysis of 214 cases. Surg Endosc 2019; 34:339-348. [PMID: 30937618 DOI: 10.1007/s00464-019-06773-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 03/21/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Minimally Invasive Liver Resection (MILR) techniques range from a hybrid-technique to full robotic approaches. When compared with open techniques, MILR has been shown to be advantageous by reducing pain, complications, length of stay and blood loss. The aim of this study was to compare clinical outcomes and hospital resource utilization between full laparoscopic, hand-assisted, and robotic liver resections among major (≥ 3 segments) and minor (≤ 2 segments) resections. METHODS A single-center comparative retrospective review was completed on 214 patients undergoing full laparoscopic, hand-assisted, or robotic liver resection procedures between 2005 and 2018. RESULTS Among minor resections: 85 full laparoscopic, 40 hand-assisted, and 35 robotic liver resection cases were analyzed; and among major resections: 13, 33, and 8 cases were analyzed, respectively. In the adjusted subgroup analysis of minor resections, OR time was significantly longer for the minor hand-assisted group ([Formula: see text] = 181 min; p < 0.05), and the average lesion size was smaller for the minor full laparoscopic group ([Formula: see text] = 4.2 cm; p < 0.05). Overall, direct hospital charges were lowest in the group of patients who underwent a minor resection using the full laparoscopic technique ([Formula: see text] = $39,054.90; p < 0.05), compared to the robotic technique. Due to the smaller sample size (n = 54) in the major resection subgroup, only two significant observations were made - the full laparoscopic group had the least amount of blood loss ([Formula: see text] = 227 cc; p < 0.05) and incurred the least amount of room and board charges compared to the other two techniques. CONCLUSIONS The robotic approach appears favorable for minor resections as evidenced by shorter length of stay but more costly than full laparoscopy. Clinical outcomes appear to be more dependent upon the magnitude of the resection (i.e. major vs. minor) than the MILR technique chosen. Randomized trials may be indicated to discern the best indications and advantages of each technique.
Collapse
Affiliation(s)
- Alejandro Mejia
- The Liver Institute, Methodist Dallas Medical Center, 1411 Beckley Avenue, Suite 268, Dallas, TX, 75203, USA.
| | - Stephen S Cheng
- The Liver Institute, Methodist Dallas Medical Center, 1411 Beckley Avenue, Suite 268, Dallas, TX, 75203, USA
| | - Elaina Vivian
- Methodist Digestive Institute, Methodist Dallas Medical Center, Dallas, TX, USA
| | - Jimmy Shah
- Methodist Digestive Institute, Methodist Dallas Medical Center, Dallas, TX, USA
| | - Hellen Oduor
- Methodist Digestive Institute, Methodist Dallas Medical Center, Dallas, TX, USA
| | - Priyanka Archarya
- Clinical Research Institute, Methodist Health System, Dallas, TX, USA
| |
Collapse
|
34
|
Nota CL, Hagendoorn J, Fong Y. ASO Author Reflections: The Role of Robotic Surgery in Liver Resection. Ann Surg Oncol 2018; 26:591-592. [PMID: 30539495 DOI: 10.1245/s10434-018-7082-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Carolijn L Nota
- Department of Surgery, City of Hope National Medical Center, City of Hope Hospital Duarte, Duarte, CA, USA.,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, City of Hope Hospital Duarte, Duarte, CA, USA.
| |
Collapse
|
35
|
Nota CLMA, Smits FJ, Woo Y, Borel Rinkes IHM, Molenaar IQ, Hagendoorn J, Fong Y. Robotic Developments in Cancer Surgery. Surg Oncol Clin N Am 2018; 28:89-100. [PMID: 30414684 DOI: 10.1016/j.soc.2018.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Indications for robotic surgery have been rapidly expanding since the first introduction of the robotic surgical system in the US market in 2000. As the robotic systems have become more sophisticated over the past decades, there has been an expansion in indications. Many new tools have been added with the aim of optimizing outcomes after oncologic surgery. Complex abdominal cancers are increasingly operated on using robot-assisted laparoscopy and with acceptable outcomes. In this article, the authors discuss robotic developments, from the past and the future, with an emphasis on cancer surgery.
Collapse
Affiliation(s)
- Carolijn L M A Nota
- Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA; Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Francina Jasmijn Smits
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Yanghee Woo
- Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Inne H M Borel Rinkes
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Izaak Quintus Molenaar
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Jeroen Hagendoorn
- Department of Surgery, UMC Utrecht Cancer Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA.
| |
Collapse
|
36
|
Nota CL, Woo Y, Raoof M, Boerner T, Molenaar IQ, Choi GH, Kingham TP, Latorre K, Borel Rinkes IHM, Hagendoorn J, Fong Y. Robotic Versus Open Minor Liver Resections of the Posterosuperior Segments: A Multinational, Propensity Score-Matched Study. Ann Surg Oncol 2018; 26:583-590. [PMID: 30334196 DOI: 10.1245/s10434-018-6928-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Minor liver resections of posterosuperior segments (1, 4A, 7, 8) are challenging to perform laparoscopically and are mainly performed using an open approach. We determined the feasibility of robotic resections of posterosuperior segments and compared short-term outcomes with the open approach. METHODS Data on open and robotic minor (≤ 3 segments) liver resections including the posterosuperior segments, performed between 2009 and 2016, were collected retrospectively from four hospitals. Robotic and open liver resections were compared, before and after propensity score matching. RESULTS In total, 51 robotic and 145 open resections were included. After matching, 31 robotic resections were compared with 31 open resections. Median hospital stay was 4 days (interquartile range [IQR] 3-7) for the robotic group, versus 8 days (IQR 6-10) for the open group (p < 0.001). Median operative time was 222 min (IQR 164-505) for robotic cases versus 231 min (IQR 190-301) for open cases (p = 0.668). Median estimated blood loss was 200 mL (IQR 100-400) versus 300 mL (IQR 125-750), respectively (p = 0.212). In the robotic group, one patient (3%) had a major complication, versus three patients (10%) in the open group (p = 0.612). Readmissions were similar-10% in the robotic group versus 6% in the open group (p > 0.99). There was no mortality in either group. CONCLUSION Minor robotic liver resections of the posterosuperior segments are safe and feasible and display a shorter length of stay than open resections in selected patients at expert centers.
Collapse
Affiliation(s)
- Carolijn L Nota
- Department of Surgery, City of Hope National Medical Center, City of Hope Hospital Duarte, Duarte, CA, USA.,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yanghee Woo
- Department of Surgery, City of Hope National Medical Center, City of Hope Hospital Duarte, Duarte, CA, USA
| | - Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, City of Hope Hospital Duarte, Duarte, CA, USA
| | - Thomas Boerner
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Gi Hong Choi
- Department of Surgery, Yonsei University Severance Hospital, Seoul, Republic of Korea
| | - T Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Karen Latorre
- Department of Surgery, Yonsei University Severance Hospital, Seoul, Republic of Korea
| | | | - Jeroen Hagendoorn
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, City of Hope Hospital Duarte, Duarte, CA, USA.
| |
Collapse
|
37
|
Guerra F, Di Marino M, Coratti A. Robotic Surgery of the Liver and Biliary Tract. J Laparoendosc Adv Surg Tech A 2018; 29:141-146. [PMID: 30118390 DOI: 10.1089/lap.2017.0628] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The laparoscopic methods for major abdominal surgery are gaining increasing acceptance worldwide. Despite its relatively recent introduction in clinical practice, robotics has been accepted as an effective option to perform high-demanding procedures such as those required in hepatobiliary surgery. Some potential advantages over conventional laparoscopy have been suggested, but its actual role in clinical practice is still to be defined. METHODS The objective of this work is to critically review the available evidence on the application of robotic surgery to the liver and biliary tract. PubMed, Embase, and the Cochrane Library electronic databases were systematically searched for studies reporting on robotic hepatobiliary surgery with or without comparison with open surgery or conventional laparoscopy. RESULTS This review provides a comprehensive snapshot of the current application of the robot to the surgery of the liver and biliary tract. The overall available data show the noninferiority of the robotic system to conventional open and laparoscopic surgery. A number of studies suggest some potential advantages in performing high-demanding procedures in a minimally invasive fashion. CONCLUSIONS The robot can be used to perform various types of liver surgeries quite safely and competently, although the lack of randomized control trials, comparing it with open and laparoscopic surgery, precludes the possibility to reach definitive conclusions.
Collapse
Affiliation(s)
- Francesco Guerra
- Division of Oncological and Robotic General Surgery, Careggi University Hospital , Florence, Italy
| | - Michele Di Marino
- Division of Oncological and Robotic General Surgery, Careggi University Hospital , Florence, Italy
| | - Andrea Coratti
- Division of Oncological and Robotic General Surgery, Careggi University Hospital , Florence, Italy
| |
Collapse
|
38
|
Abstract
Robotic liver resection can overcome some of the limitations of laparoscopic liver surgery; therefore, it is a promising tool to increase the proportion of minimally invasive liver resections. The present article gives an overview of the current literature. Furthermore, the results of a nationwide survey on robotic liver surgery among hospitals in Germany with a DaVinci system used in general visceral surgery and the perioperative results of two German robotic centers are presented.
Collapse
|
39
|
Melstrom LG, Warner SG, Woo Y, Sun V, Lee B, Singh G, Fong Y. Selecting incision-dominant cases for robotic liver resection: towards outpatient hepatectomy with rapid recovery. Hepatobiliary Surg Nutr 2018; 7:77-84. [PMID: 29744334 DOI: 10.21037/hbsn.2017.05.05] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background The premise of minimally invasive surgery (MIS) is to minimize facial and muscle injury in order to enhance recovery from surgery. Robotic MIS surgery for resection of tumors in solid organs is gaining traction, though clear superiority of this approach is lacking and robotic surgery is more expensive. Our philosophy in robotically-assisted hepatectomy has been to employ this approach for cases where location of tumors make difficult a classical laparoscopic approach (superior/posterior tumors), and cases where the incision for an open operation dominates the course of recovery. Methods This is a retrospective review of a prospectively collected database. Results In this study we report 97 cases of liver resection subjected to the robotic approach, of which 90% were resected robotically. The mean operative time was 186±9 min; mean blood loss was 111±15 mL, and complications occurred in 9%. Two thirds of the patients remained in hospital 3 days or less, including three patients subjected to hemihepatectomy (2 left and 1 right). Fourteen individuals were discharged on the same day. The strongest predictors of long hospital stay (>3 days) were major hepatectomy (P=0.007), complications (P=0.008), and operative time >210 min (P=0.001). Conclusions With thoughtful case selection, this is a first demonstration that hepatectomy can be conducted as an out-patient or short-stay procedure.
Collapse
Affiliation(s)
- Laleh G Melstrom
- Department of Surgery, City of Hope Medical Center, Duarte, CA, USA
| | - Susanne G Warner
- Department of Surgery, City of Hope Medical Center, Duarte, CA, USA
| | - Yanghee Woo
- Department of Surgery, City of Hope Medical Center, Duarte, CA, USA
| | - Virginia Sun
- Department of Surgery, City of Hope Medical Center, Duarte, CA, USA
| | - Byrne Lee
- Department of Surgery, City of Hope Medical Center, Duarte, CA, USA
| | - Gagandeep Singh
- Department of Surgery, City of Hope Medical Center, Duarte, CA, USA
| | - Yuman Fong
- Department of Surgery, City of Hope Medical Center, Duarte, CA, USA
| |
Collapse
|
40
|
Wang WH, Kuo KK, Wang SN, Lee KT. Oncological and surgical result of hepatoma after robot surgery. Surg Endosc 2018; 32:3918-3924. [PMID: 29488090 DOI: 10.1007/s00464-018-6131-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 02/23/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Most liver resections are currently performed using an open approach. Robotic hepatectomy has been suggested as a safe and effective approach for hepatocellular carcinoma; however, studies regarding oncological and surgical outcomes are still limited. Accordingly, we performed this study to compare the surgical and oncological outcomes between robotic and open approaches. METHODS Between June, 2013 and July, 2016, a total of 63 HCC patients undergoing robotic hepatectomy, and 177 patients undergoing open hepatectomy were included in this study to assess the surgical and oncological outcomes after hepatectomy. The data of demographic, clinical features, hepatitis profile, tumor characters, TNM stage, surgical type, pathological outcomes, and postoperative results were collected prospectively and analyzed retrospectively. RESULTS The demographic and clinical features of patients with HCC in both groups were statistically comparable. The robotic group had longer operative times (296 ± 84 vs. 182 ± 51 min, p = 0.032). The postoperative complications rate was slightly lower in the robotic group (11.1 vs. 15.3%, p = 0.418). The rate of Ro resection was similar in both groups (93.7 vs. 96%, p = 0.56). The length of hospital stay was significantly shorter in the robotic group (6.21 ± 2.06 vs. 8.18 ± 6.99 days, p = 0.001). The overall recurrence rate of HCC was lower in the robotic group (27 vs. 37.3%, p = 0.140). The 1, 2, 3 year disease-free survival rates were 72.5, 64.3, and 61.6%, respectively, for the open group, while they were 77.8, 71.9, and 71.9%, respectively, for the robotic group, (p = 0.325). The 1, 2, 3 year overall survival rates were 95.4, 92.3, and 92.3%, respectively, for the open group, while they were 100, 97.7, and 97.7%, respectively, for the robotic group (p = 0.137). CONCLUSION Robotic surgery is a safe and feasible procedure for liver resection in selected patients. The oncological and surgical outcomes of robotic hepatectomy were comparable to open surgery. The robotic hepatectomy carried significantly shorter length of hospital stay.
Collapse
Affiliation(s)
- Wen-Hsiuan Wang
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzy-you 1st Rd, Kaohsiung, 807, Taiwan
| | - Kung-Kai Kuo
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzy-you 1st Rd, Kaohsiung, 807, Taiwan
| | - Shen-Nien Wang
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzy-you 1st Rd, Kaohsiung, 807, Taiwan
| | - King-Teh Lee
- Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzy-you 1st Rd, Kaohsiung, 807, Taiwan.
| |
Collapse
|
41
|
Robotic-Assisted Versus Laparoscopic Left Lateral Sectionectomy: Analysis of Surgical Outcomes and Costs by a Propensity Score Matched Cohort Study. World J Surg 2017; 41:516-524. [PMID: 27743071 DOI: 10.1007/s00268-016-3736-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND After comparing with open approach, left lateral sectionectomy (LLS) has become standard in terms of short-term outcomes without jeopardizing long-term survival when performed for malignancy. The aim of this study was to compare the short-term and economic outcomes of laparoscopic (L-LLS) and robotic (R-LLS) LLS. METHODS All consecutive patients who underwent L-LLS or R-LLS from 1997 to 2014 were analyzed. Short-term and economic outcomes were compared between the two groups using a propensity score matching (PSM). RESULTS Ninety-six consecutive cases of LLS were performed using the laparoscopic (80 cases; 83 %) or robotic (16 cases; 17 %) approach. The two groups were similar for operative and surgical outcomes. Operation time was similar in the R-LLS compared to the L-LLS group (190 vs. 162 min; p = 0.10). Perioperative costs were higher (1457 € vs. 576 €; p < 0.0001) in the R-LLS group than in the L-LLS group; however, postoperative costs were similar between the two groups (4065 € in the R-LLS group vs. 5459 € in the L-LLS group; p = 0.30). Total costs were similar between the two groups (5522 € in the R-LLS group vs. 6035€ in the L-LLS group; p = 0.70). The PSM included 14 patients for each group. Surgical and economic outcomes remained similar after PSM, except for total operating time which was significantly longer in the R-LLS group than in the L-LLS group. CONCLUSIONS Even if feasible and safe, the robotic approach does not seem so far to offer additional benefit in terms of intra- and postoperative outcomes over the laparoscopic approach in patients requiring LLS. Total costs associated with the R-LLS group are not greater than that associated with the L-LLS group, which is the standard of care so far.
Collapse
|
42
|
Nota CL, Rinkes IHB, Hagendoorn J. Setting up a robotic hepatectomy program: a Western-European experience and perspective. Hepatobiliary Surg Nutr 2017; 6:239-245. [PMID: 28848746 DOI: 10.21037/hbsn.2016.12.05] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Currently the majority of liver resections are performed via open resection. Nevertheless, minimally invasive liver surgery is gaining ground and conventional laparoscopy has proven to be beneficial in different fields of liver surgery compared to open resections. Still, conventional laparoscopy has a few downsides, from which straight instruments, 2-dimensional view and awkward ergonomics are the most obvious. The robotic surgical system is developed to overcome these limitations. It offers several advantages over conventional laparoscopy to optimize conditions in minimally invasive surgery: instruments are wristed with a wide range of motion and the view is 3-dimensional and magnified. With instruments with a greater range of motion than in laparoscopic surgery, the use of a robotic system potentially broadens indications for minimally invasive liver resection. Here, we discuss the steps of setting up a robotic hepatectomy program against the background of the initial experience at our institution.
Collapse
Affiliation(s)
- Carolijn L Nota
- Department of Surgical Specialties, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Inne H Borel Rinkes
- Department of Surgical Specialties, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen Hagendoorn
- Department of Surgical Specialties, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| |
Collapse
|
43
|
Araujo RLC, de Castro LA, Fellipe FEC, Burgardt D, Wohnrath DR. Robotic left lateral sectionectomy as stepwise approach for cirrhotic liver. J Robot Surg 2017; 12:549-552. [PMID: 28733780 DOI: 10.1007/s11701-017-0730-0] [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: 04/19/2017] [Accepted: 07/15/2017] [Indexed: 12/07/2022]
Abstract
Laparoscopy is considered the gold standard approach to perform left lateral sectionectomy (LLS). Furthermore, laparoscopy for cirrhotic patients can reduce intraoperative bleeding and postoperative morbidity when compared to open surgery. Although robotic surgery is feasible for both minor and major liver resections, it remains a work in progress and only few series reported this approach for cirrhotic patients. We reported two cases of 62-year-old men, both with hepatitis C virus and alcoholic cirrhosis, but with compensated liver functions (MELD 9-10 and Child-Pugh A5-A6). The patients were diagnosed with a single lesion in the left lobe. Robotic LLS was performed using intraoperative ultrasound to confirm findings of pre-operative image, and linear staplers were used to control left lobe inflow and outflow. The specimens were removed through Pfannenstiel incision in both patients. Both procedures followed the same standardization. The total operative time was 250 and 151 min with estimated blood loss of 100 and 70 ml, respectively, for cases 1 and 2. The procedures were made without Pringle maneuver and postoperative course was uneventful with hospital discharge at third and fourth postoperative day, respectively. The pathology examination confirmed a 2.5- and 4.5-cm hepatocellular carcinoma, respectively; both presented negative margins and cirrhosis. Robotic LLS seems to be as feasible as conventional laparoscopic approach as a stepwise procedure in a robotic learning curve for liver resection. Its benefits can also be offered to selected cirrhotic patients.
Collapse
Affiliation(s)
- Raphael L C Araujo
- Department of Upper Gastrointestinal and Hepato-pancreato-biliary Surgery, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, SP, CEP 14784-400, Brazil.
| | | | - Fernando E C Fellipe
- Department of Upper Gastrointestinal and Hepato-pancreato-biliary Surgery, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, SP, CEP 14784-400, Brazil
| | - Diego Burgardt
- Department of Upper Gastrointestinal and Hepato-pancreato-biliary Surgery, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, SP, CEP 14784-400, Brazil
| | - Durval R Wohnrath
- Department of Upper Gastrointestinal and Hepato-pancreato-biliary Surgery, Barretos Cancer Hospital, Rua Antenor Duarte Villela, 1331, Barretos, SP, CEP 14784-400, Brazil
| |
Collapse
|
44
|
Yan Y, Cai X, Geller DA. Laparoscopic Liver Resection: A Review of Current Status. J Laparoendosc Adv Surg Tech A 2017; 27:481-486. [DOI: 10.1089/lap.2016.0620] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Yihe Yan
- Division of General Surgery, Department of Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, People's Republic of China
| | - Xiaoyong Cai
- Division of General Surgery, Department of Surgery, The First Affiliated Hospital of Guangxi Medical University, Nanning, People's Republic of China
| | - David A. Geller
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
45
|
|
46
|
Nota CLMA, Molenaar IQ, van Hillegersberg R, Borel Rinkes IHM, Hagendoorn J. Robotic liver resection including the posterosuperior segments: initial experience. J Surg Res 2016; 206:133-138. [PMID: 27916352 DOI: 10.1016/j.jss.2016.06.079] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 06/13/2016] [Accepted: 06/27/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND Robot-assisted laparoscopy has been introduced to overcome the limitations of conventional laparoscopy. This technique has potential advantages over laparoscopy, such as increased dexterity, three-dimensional view, and a magnified view of the operative field. Therefore, improved dexterity may make a robotic system particularly suited for liver resections, which require nonlinear manipulation, such as curved parenchymal transection, hilar dissection, and resection of posterosuperior segments. METHODS Between August 2014 and March 2016, 16 patients underwent robot-assisted laparoscopic liver resection at University Medical Center Utrecht. RESULTS Fifteen robot-assisted laparoscopic liver resections were performed in a minimally invasive manner. One procedure was converted. In eight patients, we performed a resection of a posterosuperior segment (segment 7 or 8). Median operating time was 146 (60-265) min, and median blood loss was 150 (5-600) mL. Four patients had a Clavien-Dindo grade III complication. Median length of stay was 4 (1-8) days. There was no mortality. CONCLUSIONS This prospective study reporting on our initial experience with robot-assisted laparoscopic liver resection demonstrates that this technique is easily adopted, safe, and feasible for minor hepatectomies in selected patients. Moreover, it shows that the robotic platform also enables fully laparoscopic resections of the posterior segments.
Collapse
Affiliation(s)
- Carolijn L M A Nota
- Department of Surgical Specialties, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I Quintus Molenaar
- Department of Surgical Specialties, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgical Specialties, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Inne H M Borel Rinkes
- Department of Surgical Specialties, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen Hagendoorn
- Department of Surgical Specialties, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht, The Netherlands.
| |
Collapse
|