Atlanta—Use of the robotic platform for minor and major liver resections appears to be safe and feasible, and may open minimally invasive hepatectomy to more patients, according to the findings of a recent study.
Despite the significant development of minimally invasive surgery over the last few decades, three-fourths of liver resections are still open procedures, mainly due to the complexity of the intrahepatic anatomy, the need for rapid bleeding control and the minimally invasive skills required to perform laparoscopic procedures, said Harel Jacoby, MD, an advanced gastrointestinal and hepatobiliary surgical fellow under Iswanto Sucandy, MD, the director of robotic surgery at Advent Health Tampa, in Florida.
“Robotic liver surgery overcomes several limitations of conventional laparoscopy, as it offers 3D visualization, improved articulation, precise vascular dissection, the ability to suture with both hands and better ergonomics,” he said, presenting the research at the 2021 Southeastern Surgical Congress.
Furthermore, in 2019, the international consensus statement on robotic hepatectomy reported equivalent peri- and postoperative outcomes compared with laparoscopy.
To investigate the safety and feasibility of robotic liver resection, surgeons at Advent Health Tampa prospectively followed consecutive patients undergoing robotic minor or major hepatectomy for any indication between 2016 and 2020. They defined minor hepatectomy as a liver resection with two or fewer contiguous Couinaud segments, and major hepatectomy as the resection of three or more.
Ultimately, the study included 220 patients, 82 of whom (37%) had minor hepatectomy and 138 (63%) who underwent major hepatectomy.
“Demographically, there were no statistically significant differences between major and minor hepatectomy patients; however, it’s worth noting that more than 50% patients had previous abdominal operation, but this didn’t affect our ability to complete the procedure using the robotic platform,” Dr. Jacoby said.
The most common indications for hepatectomy were colorectal metastasis and hepatocellular carcinoma. Patients with hepatocellular carcinoma were more likely to undergo a major hepatectomy, while patients with benign lesions were more likely to undergo a minor hepatectomy.
The operative duration for minor hepatectomy was about four hours, and five hours for major hepatectomy. Estimated blood loss for minor and major hepatectomy was 100 and 200 mL, respectively. There was one interoperative complication requiring conversion to open in a patient who had a previous right hepatectomy.
“However, the postoperative course for this patient went well, and he was able to be discharged home on post-op day 4,” Dr. Jacoby said. The average length of stay was three days for minor hepatectomy patients and four days for major hepatectomy patients.
Nine patients had postoperative complications, most of which were seen, somewhat surprisingly, in the minor hepatectomy group; and two patients died related to cardiopulmonary events.
“We were able to maintain excellent oncologic outcomes, as 97% of our patients had an R0 resection; no patients had an R2 resection,” Dr. Jacoby said.
“We found minor and major robotic hepatectomy to be safe and feasible, associated with excellent short-term outcomes, and we believe that the robotic approach will play a wider role in hepato-pancreato-biliary [HPB] surgery,” he said. The Advent Health group expects to make further data on robotic major hepatectomy available to the scientific public.
Laura Enomoto, MD, MSc, a surgical oncologist and an assistant professor of surgery at the University of Tennessee Medical Center, in Knoxville, applauded the researchers for contributing to the growing body of literature reporting the safety and efficacy of robotic hepatectomy.
“Your rate of conversion to open is low, and your complication rate is low as well,” she said. But she questioned why they didn’t compare robotic hepatectomy with laparoscopic or open hepatectomy, which is a more standard study design for investigating new technologies or techniques.
“Also, many institutions are just starting their robotic experience. Do you have any advice or lessons learned that you could share?” Dr. Enomoto asked.
Dr. Jacoby was unsure about the first question, as his institution switched fully to robotic programs for all but the most minor procedures in recent years. Dr. Sucandy told General Surgery News that in their program, comparisons of robotic, laparoscopic and open procedures are now being performed using a propensity score matching method.
“A prospective randomization is near impossible to achieve, since most patients come specifically for the robotic minimally invasive liver surgery,” he said.
But Dr. Jacoby was able to describe the learning curve, which for robotic major hepatectomy is 60 to 80 cases.
“We started with minor procedures such as peripheral segmentectomy and gradually reached the most challenging procedures, such as extended hepatectomy and Klatskin tumor resection,” Dr. Jacoby said.
Further advice came from Sharona Ross, MD, an advanced foregut and HPB surgeon with Advent Health and a professor of surgery at the University of Central Florida College of Medicine in Tampa, who was also involved in the research.
“My suggestion is to start with easy cases that you’re very comfortable with and learn the technology before you apply it to the harder cases; that’s what we did here.”
This article is from the November 2021 print issue.
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