Edited by: Robert Grützmann, University Hospital Dresden, Germany
Reviewed by: Christoph W. Michalski, University Hospital Heidelberg, Germany; Premkumar Balachandran, Fortis Hospital, India; Duilio Pagano, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, Italy; Stephan Kersting, RKK Klinikum, Germany
Specialty section: This article was submitted to Visceral Surgery, a section of the journal Frontiers in Surgery
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Minimally invasive liver surgery is growing worldwide with obvious benefits for the treated patients. These procedures maybe improved by robotic techniques, which add several innovative features. In Germany, we were the first surgical department implementing robotic assisted minimally invasive liver resections.
Between June 2013 and March 2015, we performed robotic based minimally invasive liver resections in nine patients with malignant liver disease. Five off these patients suffered from primary and four from secondary liver malignancies. We retrospectively analyzed the perioperative variables of these patients and the oncological follow up.
Mean age of the patients was 63 years (range 45–71). One patient suffered from intrahepatic cholangiocellular, four from hepatocellular carcinoma, and four patients from colorectal liver metastases. In six patients, left lateral liver resection, in two cases single segment resection, and in one case minimally invasive guided liver ablation were performed. Five patients underwent previous abdominal surgery. Mean operation time was 312 min (range 115–458 min). Mean weight of the liver specimens was 182 g (range 62–260 g) and mean estimated blood loss was 251 ml (range 10–650 ml). The mean tumor size was 4.4 cm (range 3.5–5.5 cm). In all cases, R0 status was confirmed with a mean margin of 0.6 cm (range 0.1–1.5 cm). One patient developed small bowel fistula on postoperative day 5, which could be treated conservatively. No patient died. Mean hospital stay of the patients was 6 days (range 3–10 days). During a mean follow up of 12 months (range 1–21 months), two patients developed tumor recurrence.
Robotic-based liver surgery is feasible in patients with primary and secondary liver malignancies. To achieve perioperative parameters comparable to open settings, the learning curve must be passed. Minor liver resections are good candidates to start this technique. But the huge benefits of robotic-based liver resections should be expected in extended procedures beyond minor liver resections with the currently available technology.
Minimally invasive liver surgery is growing worldwide. Initially recommended for smaller benign lesions only, recent meta-analysis demonstrates the value for malignant tumors as well. No differences in the long-term survival and tumor recurrence for patients between open and laparoscopic procedures were observed. But the blood loss and postoperative complication rates seem to be lower in minimally invasive procedures (
Between June 2013 and March 2015, nine patients with malignant liver tumors were operated with robotic-based minimally invasive surgery. One of these patients suffered from intrahepatic cholangiocellular carcinoma (CCC), four patients from hepatocellular carcinoma (HCC), and four patients from metachronous colorectal liver metastases (CRC). Only patients with ≤2 unilateral lesions identified by preoperative imaging techniques (CT-scan, MRI) were selected. The mean tumor size was 4.4 cm (range 3.5–5.5 cm). Two patients with CRC underwent previous laparoscopic rectum resection, one patient robotic-based rectum resection and one patient open rectum extirpation. One patient with HCC was treated with laparoscopic sigmoid resection for diverticulitis prior to liver resection. Patient demographics are listed in Table
Patient | Age (years) | Tumor | Tumor size (cm) | R-status | Surgery | Operation time (min) | Previous abdominal surgery | Liver fibrosis (Ishak-scoring) | Hepatic steatosis | Postop. morbidity | Discharge (postop. day) |
---|---|---|---|---|---|---|---|---|---|---|---|
1 | 71 | CCC | 5.5 | 0 | Left lateral | 458 | None | n.d. | 20–40% | None | 7 |
2 | 45 | CRC | 3.5 | 0 | Left lateral | 368 | Robotic sigmoid | 0 | None | None | 6 |
3 | 75 | CRC | 4.5 | 0 | Left lateral | 314 | Lap. rectum | 0 | 5% | None | 5 |
4 | 66 | HCC | 5 | 0 | Left lateral, gallblader | 405 | Open sigmoid | 2 | 5% | None | 9 |
5 | 64 | HCC | 3.1 | 0 | Segment III | 138 | None | n.d. | n.d. | None | 6 |
6 | 58 | HCC | 5 | 0 | Ablation segment II/III and IV | 115 | None | 4–5 | n.d. | None | 3 |
7 | 69 | CRC | 4.1 | 0 | Left lateral | 228 | Open rectum extirpation | 1 | 5–10% | Small bowel fistula | 10 |
8 | 62 | HCC | 5 | 0 | Left lateral | 403 | None | 6 | 20–30% | None | 6 |
9 | 57 | CRC | 3.5 | 0 | Segment V, gallblader | 375 | Lap. rectum | 1 | n.d. | None | 6 |
For robotic-based liver resection, we used the Da Vinci Si System (Intuitive Surgical, Inc., CA, USA). Patients were placed in a reverse Trendelenburg position. The screen was located at the head end of the patient. The robot cart moved over the right shoulder. The anesthesia was positioned at the left, the assisting nurse at the right and the assisting surgeon between the legs of the patient (Figure
In one case (case 6, Table
Six patients had undergone prior surgery and suffered from adhesions, which were less in the minimally invasive pre-operated cases. In six patients, a left lateral resection and in two cases a single segmental resection were performed. In two cases, the gallbladder was removed for stones or tumor adhesion. Initially, in one patient (case 6, Table
In histopathology, in one case CCC, in three cases HCC, and in four cases CRC were confirmed. The mean weight of the resected liver specimens was 182 g (range 62–260). In all resected cases, R0 status was confirmed by histopathology. The men resection margin was 0.6 cm (range 0.1–1.5 cm). Five percent hepatic steatosis was identified in two patients, 5–10% in one patient, and >20% in two patients. Severe liver fibrosis (Ishak 4–6) was present in two cases and less liver fibrosis (Ishak 1–2) in three patients. Steatosis and severe fibrosis was mainly present in patients with primary liver malignancies.
Postoperative morbidity (≤30 days postoperative) occurred in one patient. One patient (patient 7, Table
During a mean follow up of 12 months (range 1–21 months), two patients developed tumor recurrence. One patient (patient 1, Table
Our experience demonstrates that robotic-based minimally invasive surgery is feasible for primary and secondary liver malignancies. Complete and oncological adequate removal of the tumors is possible. Liver parenchymal disorders like steatosis or fibrosis are no limitations for this technique but correlate with increased operation time. In these cases, the identification for intrahepatic structures is more time consuming. Even adhesions after prior surgery are no contraindications for robotic-based procedures. In case of expected relevant adhesions, the situation can be clarified by explorative laparoscopy via a 5-mm trocar in the left upper abdomen after inducing the pneumoperitoneum. If necessary, laparoscopic mobilization of adherent tissue to the ventral abdomen can be performed. Still operation time is longer and blood loss slightly higher than in open procedures. But even in series of minor resections beyond 25 cases, a mean operation time of 4 h for conventional laparoscopic liver surgery was described (
The robot really adds helpful tools for minimally invasive liver resections. But it cannot show its real benefits in minimally invasive segmental resections, which can be carried out even by conventional laparoscopy. These operations are good for starting these procedures and overcoming a learning curve. The highly innovative robotic technique is available and it will stay. The real benefits of robotic based minimally invasive liver resections should be expected in major procedures beyond minor resections with the currently available technology. It remains the surgeons’ preference to identify adequate candidates and indications.
Informed consent was obtained from all patients and the study was carried out in accordance with institutional and national guidelines and regulations.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.