Robot Facilitates Less Invasive Approach To More Liver Resections, Study Suggests

By MONICA J. SMITH

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. y mics,” he said, presentSouthterment portstoperwith d h wed g n ned resection ith t oor

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 p resection,” Dr. Jacoby said. resection,” Dr. Jacoby sa “We found minor and major robotic hep“We found atectomy to be safe and feasible, associatatectomy to ed with excellent short-term outcomes, ed with and we believe that the robotand w ic approach will play a wider role in ic app hepato-pancreato-biliary [HPB] he surgery,” he said. The Advent s Health group expects to make H further data on robotic major fu hepatectomy available to the scihep entific public. ent Laura Enomoto, MD, MSc, a surgical oncologist and an assissu tant professor of surgery at the ta University of Tennessee Medical U Center, in Knoxville, applauded Ce the researchers for contributing to the theres 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.

Dr. Jacoby was unsure as his institution switched fully to robotic programs for all but the most minor procedures in recent years. Dr. Sucandy told OR Management 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. ■