Can robotic liver resection compensate for weaknesses of the laparoscopic approach?

Robotic-Assisted Surgery for Primary Hepatobiliary Tumors-Possibilities and Limitations

Simple Summary

Primary liver malignancies are some of the most common and fatal tumors today. Robotic-assisted liver surgery is becoming increasingly interesting for both patients and surgeons alike. Up to date, prospective comparative studies around the topic are scarce. This leads us to an ever existing controversy about the efficacy, safety, and economic benefits of robotic surgery as an extension of traditional minimally invasive surgery over open liver surgery. However, there is evidence that robotic-assisted surgery is, after passing the learning curve, equivalent in terms of feasibility and safety, and in some cases superior to traditional laparoscopic hepatic resection. With this work, we want to provide an overview of the latest and most significant reviews and meta-analyses focusing on robotic hepatectomy in primary liver malignancies. We outline the technical aspects of robotic-assisted surgery and place them into the context of technical, surgical, and oncological outcomes compared with laparoscopic and open resection. When chosen per case individually, any hepatic resection can be performed robotically to overcome limitations of laparoscopic surgery by an experienced team. In this paper, we propose that prospective studies are needed to prove efficacy for robotic-assisted resection in liver malignancy.

Abstract

Hepatocellular and cholangiocellular carcinoma are fatal primary hepatic tumors demanding extensive liver resection. Liver surgery is technically challenging due to the complex liver anatomy, with an intensive and variant vascular and biliary system. Therefore, major hepatectomies in particular are often performed by open resection and minor hepatectomies are often performed minimally invasively. More centers have adopted robotic-assisted surgery, intending to improve the laparoscopic surgical limits, as it offers some technical benefits such as seven degrees of freedom and 3D visualization. The da Vinci^® Surgical System has dominated the surgical robot market since 2000 and has shown surgical feasibility, but there is still much controversy about its economic benefits and real benefits for the patient over the gold standard. The currently available retrospective case studies are difficult to compare, and larger, prospective studies and randomized trials are still urgently missing. Therefore, here we summarize the technical, surgical, and economic outcomes of robotic versus open and laparoscopic hepatectomies for primary liver tumors found in the latest literature reviews and meta-analyses. We conclude that complex robotic liver resections (RLR) are safe and feasible after the steep learning curve of the surgical team has plateaued. The financial burden is lower in high volume centers and is expected to decrease soon as new surgical systems will enter the market.

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

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

Case Report: Successful DaVinci-Assisted Major Liver Resection for Alveolar Echinococcosis

We report a case of successful robot-assisted major liver resection in a patient with liver alveolar echinococcosis (AE). A 62-year-old male patient was incidentally diagnosed with a large infiltrative lesion in the right liver lobe suspicious for AE. A radical surgical resection as a right-sided hemihepatectomy was indicated. The operation was carried out via a robotic-assisted procedure using the DaVinci Xi Surgical System. The tumor measured 12.4 × 8.8 cm and was successfully resected through a suprapubic incision of 13 cm. The patient was free of pain after the second post-operative day. A fluid collection near the resection plate was easily drained without bile leakage. The patient had no surgical complications. Radical resection is inevitable for adequate curative therapy of AE and provides clear margins. Robotic surgery is a relatively new and safe option for curative resection of AE lesions, with remarkable advantages for patients and surgeons.

[Possibilities and limits of robotic liver surgery - Current status 2020]

BACKGROUND

Minimally invasive liver surgery is now the standard procedure at experienced centers, whereby the techniques and strategies are continuously evolving.

MATERIAL AND METHODS

An analysis of English language literature on minimally invasive and robotic liver surgery was performed. The current scientific status was summarized and evaluated on the basis of experience at our own center.

RESULTS

The advantages of the minimally invasive technique compared to the conventional open technique are shown in liver surgery by improved perioperative results. Concerns about intraoperative complications and possible compromises in oncological radicality have been addressed in a number of publications. First reports on the robot-assisted technique seem to confirm the known advantages of laparoscopic liver surgery. The data available on robot-assisted liver surgery are still limited due to the short period of experience of a few centers and do not yet allow final conclusions; however, an increase in intraoperative safety and an expansion of the surgical spectrum towards highly complex liver resections seems likely.

CONCLUSION

Even during the learning curve the known advantages of laparoscopic liver surgery seem to be confirmed also for robot-assisted liver surgery. According to the center's own experience, minimally invasive liver surgery will in future be meaningfully supplemented by robotic technology. In particular, technically highly complex resections with reconstruction are made possible.