In the field of minimally invasive surgery, robotic surgery (RS) was introduced to overcome drawbacks in laparoscopic surgery. However, its clinical application in hepatobiliary surgery is not yet standardized. This review analyzed the results of RS to clarify the benefits of robotic liver surgery in comparison with standard laparoscopy. Among 112 publications found in the literature, the 72 most relevant were selected and the following data were extracted: patients characteristics, operative procedures, histopathology, short-term and long-term outcomes, and costs. Twenty-nine articles on robotic liver resections, published in the last five years (2015-2020) and including 1831 patients, were analyzed. Twenty-five comparative studies between robotic and laparoscopic surgery were evaluated to underline the differences in operative outcomes. Eventually, 4 sub-group analyses were conducted on hepatocellular carcinoma, gallbladder cancer, hilar cholangiocarcinoma, and colorectal liver metastases. Almost all the authors reported data on safety, feasibility and oncologic effectiveness of RS reaching comparable results with laparoscopy. However, even if robotic surgery showed longer operative time and higher costs, in selected cases it allowed to increase the rate of minimally invasive approach when compared with laparoscopy. Thus, both open and minimally invasive surgery should be provided in a modern hepatobiliary center, including the robotic approach particularly to complex cases, otherwise very demanding by laparoscopy. In conclusion, different techniques should be tailored to each patient, choosing the minimally invasive approach when possible, enhancing patients’ recovery after surgery, especially in cirrhotic livers and in the context of liver transplantation. Although many centers experienced robotic liver surgery, more and larger studies are necessary to define its real benefits relative to laparoscopy, in order to standardize patient selection criteria and techniques.
Since its introduction, robotic surgery (RS) has received great interest from scientific societies. In the era of minimally invasive surgery (MIS) it represents an advanced technique able to overcome some limitations of laparoscopy. Nevertheless, its use is not standardized in hepatobiliary surgery. Although single surgeons and centers have published their experiences demonstrating the safety and feasibility of the technique, large international studies are limited and few publications reported long-term outcomes. The advantages of RS are several: it provides increased surgical dexterity and enhanced suturing ability, thanks to a magnified three-dimensional view of the operative field, hand tremor filtration and articulating instruments with seven-degrees of freedom. Furthermore, this approach reduces significantly surgeons’ fatigue, improving performances for long operations[
A search of the current literature on robotic liver surgery was conducted in PubMed, Medline, PMC and Google Scholar databases. The research terms adopted were: robotic/robot-assisted liver surgery/resection, hepatic robotic surgery/resection, robotic/robot-assisted hepatectomies. Only articles published in English were selected. Further reports were retrieved from those listed in the articles’ references and from the manual search on specific additional topics, such as robotic surgery for hepatocellular carcinoma, cholangiocarcinoma, gallbladder cancer, colorectal liver metastases, lesions located in postero-superior liver segments, comparison between laparoscopic and robotic hepatic resections.
Among the 112 publications analyzed, the most significant were selected according to the following factors: quality of data reported and of statistical analysis adopted, relevance in scientific literature, date of publication. In case of overlapping studies with the same first author, the most recent was chosen. Once reviews, meta-analyses and studies reporting incomplete or unclear information were excluded, the following data were extracted from the 72 remaining publications: patient characteristics (number of patients, age, sex, body mass index, ASA score, comorbidities, previous chemotherapy and abdominal surgery), operative procedure (type of resection, use of Pringle maneuver, additional simultaneous procedures, intraoperative drain placement, estimated blood loss, operation time, conversion rate), histopathology (nature of the lesion, median tumor size, number of lesions, margin status, lymphadenectomy), short-term outcomes (overall morbidity, major complications, perioperative blood transfusions, admission to intensive care units, length of hospital stay, surgery-related readmission, reoperation within 30 days, 30- and 90-days mortality), long-term outcomes (disease free survival, overall survival), costs
Selection of articles
Minor and major resections were defined according to the Brisbane 2000 Terminology of Liver Anatomy and Resections[
Twenty-nine articles, published in the last five years (2015-2020) including a number of patients greater than or equal to 20, were analyzed
Robotic liver surgery
Authors | Cases | Age | Location | Major/minor | EBL | Time | Conversion | Malignant | R0 | LoS | Overall/Major complications |
---|---|---|---|---|---|---|---|---|---|---|---|
Chong |
91 | 58.7 | LS, Sg1 | 19/72 | 274.6* | 259.3* | 7.7 | 100 | 98.9 | 4.8 | 9.9/3.3 |
Montalti |
36 | 62 | PS | 0/36 | 415* | 306* | 13.9 | 69.4 | 89 | 6* | 19.4/11.1 |
Marino |
40 | 69.4 | LS | 18/22 | 260 | 305 | 2.5 | 100 | 100 | 7.4 | 20/12.5 |
Pesi |
51 | 63 | LS, PS | 13/38 | 100 | 300 | 2 | 100 | 100 | 5 | 18/9.8 |
Magistri |
22 | 60.8 | LS | 2/20 | 400 | 318* | 0 | 100 | 95.5 | 5.1 | 68.2/9 |
Nota |
51 | 59 | PS | 0/51 | 180 | 198 | 8 | 88.2 | 84 | 4 | -/6 |
Daskalaki |
67 | 52.5 | LS | 29/39 | 438* | 293.4* | 8.8 | 55.8 | - | 6.8* | 22/4.4 |
Hu |
58 | 52.2 | LS | 0/58 | 80.1* | 107* | 0 | 62 | 100 | 4.3 | 1.7/- |
Lee |
70 | 58 | LS | 14/56 | 100 | 251.5 | 5.7 | 74.2 | 98.2 | 5 | 11.4/- |
Felli |
20 | 64.6 | LS, PS | 2/18 | 50 | 141.5* | 0 | 85 | - | - | - |
Lai |
95 | 62.1 | LS, PS | 27/75 | 334.6* | 207.4 | 4 | 100 | 96 | 7.3* | 14/1 |
Li |
48 | 62.4 | LS, Sg1 | 48/0 | 150 | 276 | - | 100 | 72.9 | 9 | 58.3/10.4 |
Guerra |
59 | 64 | LS, PS | 4/78 | 200 | 210 | 12 | 100 | 92 | 6.7 | 27/5 |
Goel |
27 | 54 | LS | 0/27 | 200 | 295 | 14.8 | 100 | 100 | 4 | 3.7/3.7 |
Khan |
61 | 66 | LS | 8/53 | 100 | 240 | 11.5 | 100 | 85.2 | 5 | 37.7/11.4 |
Efanov |
40 | 45 | PS | 2/49 | 465* | 407 | 0 | 28 | - | 11 | 20/- |
Choi |
69 | 53 | LS | 64/16 | 170 | 491 | 9.1 | 76.8 | 100 | 8 | 43.5/10.6 |
Sham |
71 | 54.8 | LS, Sg1 | 17/54 | 495* | 284* | 5.7 | 98.6 | - | 3.9* | 14.3/4.3 |
Fruscione |
57 | 58.1 | LS | 57/0 | 250 | 194 | - | 64.9 | 91.9 | 4 | 28.1/25.1 |
Lim |
61 | 66 | LS, PS | 9/52 | - | 277 | 0 | 100 | 89 | 9 | 25/2 |
Beard |
115 | 61 | LS, PS | 17/98 | - | 272* | 5.2 | 93.9 | 73.7 | 5 | 31.3/10.4 |
Quijano |
21 | 59.3 | LS, PS | 4/17 | - | 262* | 4.75 | 65 | - | 12* | 19/4.7 |
Chen |
183 | 60.8 | LS, PS | 92/91 | 249 | 361 | 1.6 | 67.2 | - | 7.5 | 4.4/2.1 |
Kingham |
64 | 64 | LS | 6/65 | 100 | 163 | 6.3 | 78.2 | - | - | 10.9/4.4 |
Sucandy |
75 | 64 | LS | 25/50 | 125 | 227 | 0 | 81 | - | 3 | 11/- |
Wang |
92 | 54.1 | LS | 92/0 | 243* | 195.5* | 1 | 66.3 | - | 7.4* | 13/1.1 |
Melstrom |
97 | 62 | LS, PS | 13/84 | 144* | 197* | 9.7 | 85.5 | - | - | 9.7/- |
Ceccarelli |
70 | 67 | LS, PS | 2/89 | 25 | 115* | 10 | 70 | 94.3 | 3 | 10.1/1.4 |
Guadagni |
20 | 66 | LS | 0/20 | 250* | 198.5* | 0 | 20 | 100 | 4.7 | 25/0 |
Cases: number of patients. Lesions’ location: PS: postero-superior segments; LS: laparoscopic segments different from the postero-superiors; LLS: left-lateral sectionectomy. Major/minor resections: number of major/minor, according to the description of the authors or calculated from the data supplied. EBL: milliliters (median/*mean). Operative time: minutes (median/*mean). Conversion rate: percentage of procedures converted to open surgery. Malignant: percentage of malignant lesions. R0: percentage of negative margin status. LoS: days (median/*mean). Overall/major complications: percentage of all complications/major complications. “-”: not reported
Referring to the type of resections, 1328 (69.5%) were minor, and 584 (30.5%) were major resections. The number of “technically major resections”[
Among the 29 studies collected, the median value of EBL was 200 mL (range 25-495) and the median operative time was 260.65 min (range 107-491). Chong
Only 10 articles reported data about the use of the Pringle maneuver and the median rate of its application was 23.6% (range 0-55.6). The agreement in the literature on this topic is limited and some authors considered pedicle clamping unnecessary in most cases during RS[
Conversion to open surgery occurred with a median of 5.45% (range 0-14.8). Four authors reported that higher conversions rates (greater than 10%) were related to bleeding, adhesions, technical difficulty, advanced oncological diseases and the requirement of adequate oncologic margins[
Among the indications for RS of the 29 articles reviewed, malignancies were the 84% of the cases, in particular the most frequent indication was HCC (40%), followed by CRLM (21%), other metastases (14%), cholangiocarcinoma (CCC) (9%), GBC (3%) and other malignancies (13%). The median tumor size was 33 mm (range 17.8-73). Efanov
Interestingly, Khan
In conclusion, despite the lack of long-term results available in literature, RS is considered feasible and effective in the treatment of malignant diseases.
ICU admission rate was described in 6 studies reporting a median frequency of 27.9% of patients requiring ICU postoperative care (range 0-83.8). Daskalaki
The median rate of overall complications of the 29 reports reviewed was 18.5% (range 1.7-68.2), with a median rate of major complications (Clavien-Dindo grade 3 or greater) of 4.7% (range 0-25). Choi
The median LOS was 5.05 days (range 3-12). In particular, 16 studies reporting an operative time longer than 250 min revealed greater LOS, overall and major complications. Among these 16 articles, the median operative time was 294.2 min (range 251.5-491) and the corresponding median LOS was 6.4 days (range 3.9-12), overall complications rate was 9% (range 1-36) and major complications rate was 3.5 % (range 1-12).
Many studies documented the costs of robotic liver resections, which were higher than laparoscopy, but lower than open surgery. Daskalaki
Twenty-five comparative studies between robotic and laparoscopic liver surgery, including 1,043 cases (range 3-115) and 1,385 cases (range 5-223) respectively, were reviewed
Robotic
Authors | Cases | Location | Major/minor | EBL | Time | Conversion | LoS | Overall/major complications | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
R | L | R | L | R | L | R | L | R | L | R | L | R | L | R | L | |
Chong |
91 | 92 | LS, Sg1 | LS, Sg1 | 19/72 | 4/88 | 275* | 212* | 259*,# | 217*,# | 7.7 | 12 | 4.8 | 4.9 | 9.8/3.3 | 5.4/0 |
Montalti |
36 | 72 | PS | PS | 0/36 | 0/72 | 415* | 437* | 306* | 295* | 14 | 9.7 | 6* | 4.9* | 19.4/11.1 | 19.4/6.9 |
Magistri |
22 | 24 | LS, PS | LS, PS | 2/20 | 0/24 | 400 | 328 | 318*,# | 211*,# | 0# | 16.7# | 5.1 | 6.2 | 68.1/9 | 100/12.5 |
Hu |
58 | 54 | LLS | LLS | 0/58 | 0/54 | 80* | 109* | 107* | 96* | 0 | 1.9 | 4.3 | 4.4 | 1.7/- | 3.7/- |
Lee |
70 | 66 | LS | LS | 14/70 | 2/66 | 100 | 100 | 251# | 215# | 5.7 | 12.1 | 5 | 5 | 11.4/- | 4.5/- |
Lai |
95 | 35 | LS, PS | LS | 27/75 | 1/34 | 335 | 336 | 207*,# | 134*,# | 4 | 5.7 | 7.3* | 7.1* | 14.7/1 | 20/- |
Efanov |
40 | 91 | LS, PS | LS, PS | 2/40 | 11/91 | 465 | 302 | 407# | 296# | 0 | 0 | 11# | 9# | 20/- | 16.4/- |
Fruscione |
57 | 116 | LS | LS | 57/0 | 116/0 | 250 | 400 | 194 | 204 | - | - | 4 | 5 | 28/7 | 35.3/9.4 |
Lim |
55 | 55 | LS, PS | LS, PS | 4/51 | 8/47 | - | - | 254 | 257 | 0 | 0 | 9 | 7 | 21.8/1.8 | 12.7/0 |
Beard |
115 | 115 | LS, PS | LS, PS | 97/18 | 94/21 | - | - | 272* | 253* | 5.2# | 12# | 5 | 4 | 31.3/10.4 | 27.8/14.7 |
Wang |
92 | 48 | LS | LS | 92/0 | 48/0 | 243*,# | 346*,# | 195* | 199* | 1# | 10.4# | 7.4* | 7* | 13/1 | 10.4/0 |
Spampinato |
25 | 25 | LS | LS | 25/0 | 25/0 | 250 | 400 | 430 | 360 | 4 | 4 | 8 | 7 | 16/4 | 48/12 |
Kim |
12 | 31 | LLS | LLS | 0/12 | 0/31 | 225 | 150 | 404# | 246# | - | 1 | 7 | 7 | -/16.6 | -/9.6 |
Packiam |
11 | 18 | LLS | LLS | 0/11 | 0/18 | 30 | 30 | 175 | 188 | 0 | 0 | 4# | 3# | 27.2/0 | 0 |
Salloum |
14 | 14 | LLS | LLS | 0/14 | 0/14 | 265* | 121* | 203*,# | 140*,# | 14 | 0 | 6* | 6* | 7.1/0 | 7.1/21.4 |
Croner |
10 | 19 | LS | LS | 0/10 | - | 306 | 356 | 321 | 242 | - | - | 7 | 8 | 10/0 | 15.7/5.2 |
Ji |
13 | 20 | LS, Sg1 | LS | 9/4 | 4/16 | 280 | 350 | 338 | 130 | 0 | 10 | 6.7 | 5.2 | 7.7/- | 10/- |
Wu |
52 | 69 | LS | LS | 20/52 | 10/69 | 325°,*,# | 173°,*,# | 380°,# | 227°,# | 5° | 12° | 7.9° | 7.2° | 5.7/0° | 5.7/-° |
Troisi |
40 | 223 | LS, PS | LS, PS | 0/40 | 82/223 | 330# | 174# | 271 | 262 | 20 | 7.6 | 6.1 | 5.9 | 12.5/10 | 12.5/8.9 |
Tsung |
57 | 114 | LS | LS | 21/36 | 42/72 | 200 | 100 | 253# | 198# | 7 | 8.8 | 4 | 4 | 19.2/1.7 | 25.4/0.8 |
Tranchart |
28 | 28 | LS, PS | LS, PS | 0/28 | 0/28 | 200 | 150 | 210# | 176# | 14 | 7.1 | 6 | 5.5 | 17.8/10.7 | 17.8/10.7 |
Berber |
9 | 23 | LLS | LLS | 0/9 | 0/12 | 136* | 155* | 258* | 234* | 1 | 0 | - | - | 11/- | 17/- |
Yu |
13 | 17 | LS | LS | 3/10 | 11/6 | 388 | 343 | 291 | 241 | 0 | 0 | 7.8* | 9.5* | 0 | 11.7/- |
Zeng |
3 | 5 | LS | LS | 0/3 | 0/5 | 316* | 290* | 370* | 249* | 0 | 20 | 3 | 5 | - | - |
Lin |
25 | 11 | LS | LS | 3/25 | 2/11 | 271 | 295 | 319 | 315 | - | - | 7.5 | 7 | 24/- | 27.2/- |
In case of PSM, only its data were reported. R: robotic surgery; L: laparoscopic surgery. °: referred to the sub-group of HCC. Cases: number of patients. Lesions location: PS:postero-superior segments; LS: laparoscopic segments different from the postero-superiors; LLS: left-lateral sectionectomy. Major/minor resections: number of major/minor, according to the description of the authors or calculated from the data supplied. EBL: milliliters (median/*mean). Operative time: minutes (median/*mean). Conversion rate: percentage of procedures converted to open surgery. LoS: days (median/*mean). Overall/major complications: percentage of all complications/major complications. Statistically significant results (
Left lateral sectionectomy (LLS) is currently performed with laparoscopy as a standard of care. Five studies focused on robotic and laparoscopic LLS, including 106 (range 9-58) and 206 (range 18-80) cases, respectively. Most of the articles reported similar perioperative outcomes between laparoscopy and RS. Many authors concluded that laparoscopic LLS remains the gold standard, since RS did not add any significant benefit, but increased the costs[
Among the 25 articles reviewed, the numbers of major and minor robotic resections included were 395 and 694 (63.7% and 36.3%) respectively, while laparoscopic cases were 460 and 1,002 (68.5% and 31.5%), respectively.
Three papers focused on only major hepatectomies (174 robotic
Many authors focused on the ability of RS to overcome laparoscopic drawbacks, particularly simplifying hilar and hepatocaval dissection, suturing and anastomosis, precise vessel dissection or advanced sewing. However, the numbers of complex parenchymal sparing resections involving postero-superior segments or caudate lobe were similar for RS and laparoscopy, 112 (10.7%)
In complex cases many comparative studies demonstrated similar safety, feasibility and postoperative outcomes, but RS was preferred over laparoscopy, especially when several and multiplanar transection lines were necessary, resulting in safe surgical margins and increasing the rate of MIS resections[
Considering the 25 articles reviewed, the median EBL for RS and laparoscopy were 261 mL
Referring to the use of the Pringle maneuver, Montalti
The median operative time for RS and laparoscopy was 271 min (range 107-430) and 227 min (range 96-360), respectively. Ten studies reported statistically significant longer duration with RS compared to laparoscopy, with a mean additional time of 68 min (range 34-153)[
In 18 articles the median operative time was longer than 250 min for RS and/or laparoscopy. In these studies, although the frequency of minor resections (69.6%
The reported use of hand-port in RS is lower than in laparoscopy. The reason for this observation could be the distance of the first surgeon from the patient and from the operative field that is mainly occupied by the robotic arms. Moreover, the second surgeon at the operative table could not have enough surgical skills to manage unexpected events. This statement could explain also the lower rate of conversion to hybrid robotic procedures in case of unexpected events. However, many studies reported an easier robotic management of adhesions and major intraoperative complications as bleeding than in laparoscopy, that could explain the lower rate of conversion to open surgery for RS.
The median rates of conversion for RS and laparoscopy were 4%
The median rates of overall robotic and laparoscopic complications were 17.7%
The median LOS for RS and laparoscopy were 6 days
Many authors confirmed the major costs of robotic resections, although the annual service fees could be cushioned by the utilization of the robot in other surgical specialties at the same institution. Kim
The majority of the publications in the literature report cumulative results, without differentiation between benign and malignant diseases. However, in future probably more specific analyses of RS outcomes for each of the most relevant hepatobiliary malignancies could help in the definition of the standard of care for each one.
Robotic resections for HCC are feasible, safe, and demonstrated adequate oncologic outcomes. Six retrospective papers, including 294 patients, analyzed the results of RS for HCC
Robotic surgery for hepatocellular carcinoma
Authors | Cases | Age | Location | Major/minor | EBL | Time | Conversion | Cirrhosis | R0 | LoS | Overall/major complications | DFS/OS |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Magistri |
22 | 60.8 | LS, PS | 2/20 | 400 | 318* | 0 | 68 | 95 | 5.1 | 68/9 | - |
Lai |
95 | 62.1 | LS, PS | 27/75 | 335 | 207 | 4 | 84 | 96 | 7.3* | 14/1 | 5-year: 42/65 |
Lim |
42 | - | - | - | - | - | 0 | - | 97 | - | - | 3-year: 64/98 |
Chen |
81 | - | - | 34/47 | 282 | 343 | - | 46 | 97 | 7.5 | 5/0 | 3-year: 72/93 |
Wu |
38 | 60.9 | LS | - | - | 380 | 5 | - | - | 7.9 | 8/- | - |
Han |
16 | 54.5 | LS | 10/16 | 389 | 285 | 0 | 53 | 100 | 8.4 | - | - |
Cases: number of patients. Lesions’ location: PS: postero-superior segments; LS: laparoscopic segments different from the postero-superiors. OS: overall survival; DFS: disease free survival. Major/minor resections: number of major/minor, according to the description of the authors or calculated from the data supplied. EBL: milliliters (median/*mean). Operative time: minutes (median/*mean). Conversion rate: percentage of procedures converted to open surgery. R0: percentage of negative margin status. LoS: days (median/*mean). Overall/major complications: percentage of all complications/major complications. DFS and OS: percentage at 3-/5-year. “-”: not reported
In this field the superiority of robotic MIS over open surgery was confirmed by Chen
Likewise, Han
RS seems particularly advantageous in the treatment of GBC, overcoming the difficulties related to the laparoscopic approach. Focusing on this field, 4 articles including 51 patients were reviewed
Robotic surgery for gallbladder cancer
Authors | Cases | Age | EBL | Time | Conversion | Lymph nodes | Extension | R0 | LoS | Overall/major complications |
---|---|---|---|---|---|---|---|---|---|---|
Goel |
27 | 54 | 200 | 295 | 14.8 | 10/- | pT2-3 | 100 | 4 | 3.7/3.7 |
Zeng |
3 | - | 316* | 370* | 0 | 6.3/- | pT2-3 | - | 3 | - |
Byun |
16 | 64.3 | 295 | 198.3* | - | 7.2/3 | - | 100 | 7 | 6.3/6.3 |
Shen |
5 | 57.4 | 210* | 200* | 0 | 9/1,3 | - | - | 7.4* | 0 |
Cases: number of patients. Major/minor resections: number of major/minor, according to the description of the authors or calculated from the data supplied. EBL: milliliters (median/*mean). Operative time: minutes (median/*mean). Conversion rate: percentage of procedures converted to open surgery. Lymph nodes: mean number of nodes obtained/mean number of positive nodes. R0: percentage of negative margin status. LoS: days (median/*mean). Overall/major complications: percentage of all complications/major complications. “-”: not reported
In conclusion, in selected cases RS for GBC is considered safe, feasible and effective, even during the initial learning curve, allowing sufficient lymph node dissection and enhancing recovery[
Even if the advantages of the robotic technique for procedures that require extreme precision and microanastomosis are clear, the scientific literature is lacking in reports about robotic treatment of this disease. Probably further implementation in surgeon expertise and robotic tools are necessary to reach encouraging results that could increase its use. Two articles were selected and their data tabulated
Robotic surgery for hilar cholangiocarcinoma
Authors | Cases | Age | Pre-op. procedures | Type of resection | EBL | Operative time | Conversion | R0 | LoS | Overall/major complications | Biliary leak |
---|---|---|---|---|---|---|---|---|---|---|---|
Li |
48 | 62.4 | PTBD 41.7 | RH/LH + Sg1 | 150 | 276 | - | 72.9 | 9 | 58.3/10.4 | 4.2 |
Xu |
10 | 54 | PVE 10, PTBD 60 | LH/RH + Sg1(9)
|
1360 | 703 | 0 | - | 16 | 90/30 | 40 |
Cases: number of patients. PTBD: percentage of percutaneous trans-hepatic biliary drainage; PVE: percentage of portal vein embolization; RH/LH: right/left hepatectomy; ERH: number of extended right hepatectomies; EBL: milliliters (median/*mean). Operative time: minutes (median/*mean). Conversion rate: percentage of procedures converted to open surgery. R0: percentage of negative margin status. LoS: days (median/*mean). Overall/major complications: percentage of all complications/major complications. Biliary leak: percentage. “-“: not reported
Li
Many hepatobiliary surgeons encouraged the robotic approach to CRLM, achieving good surgical and oncological outcomes. Seven articles were reviewed, including 242 patients
Robotic surgery for colorectal liver metastases
First Author | Cases | Age | Location | Major/minor | Simultaneous | EBL | Time | Conversion | R0 | LoS | Overall/major complications | DFS/OS |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Guerra |
59 | 64 | LS, PS | 4/78 | 4 | 200 | 210 | 12 | 92 | 6.7 | 27/5 | 3-year: 41.9/66.1 |
Beard |
115 | 61 | LS, PS | 97/18 | - | - | 272* | 5.2 | 73.7 | 5 | 31.3/10.4 | 5-year: 38/61 |
Guadagni |
20 | 66 | LS | 0/20 | 3 | 250* | 198* | 0 | 100 | 4.7 | 25/0 | 3-year: 35.8/- |
Lin |
25 | 58.5 | LS | 3/22 | 25 | 271 | 319 | - | 100 | 7.5 | 24/- | - |
Araujo |
5 | 59 | PS | 0/5 | - | 160* | 294* | 0 | 100 | 4 | 20/0 | - |
Dwyer |
6 | 59.3 | - | 0/6 | 6 | 316 | 401 | 0 | 100 | 4.5 | 33.3/- | - |
Navarro |
12 | 59 | LS, Sg1 | 4/8 | 16 | 274 | 449 | 0 | 100 | 12 | 41/16.6 | - |
Cases: number of patients. Lesions’ location: PS: postero-superior segments; LS: laparoscopic segments different from the postero-superiors. Major/minor resections: number of major/minor, according to the description of the Authors or calculated from the data supplied. Simultaneous: resection of the primary and secondary tumors simultaneously. EBL: milliliters (median/*mean). Operative time: minutes (median/*mean). Conversion rate: percentage of procedures converted to open surgery. R0: percentage of negative margin status. LoS: days (median/*mean). Overall/major complications: percentage of all complications/major complications. DFS and OS: percentage at 3-/5-year. “-”: not reported
Araujo
Fifty-four simultaneous resections of the primary tumor and liver metastases were included. In these cases, RS added additional safety and effectiveness in the management of multiple metastases, improving short-term outcomes such as EBL, bowel function return time and LOS, with the exception of operative time, reaching excellent R0 resection rates[
In conclusion, these outcomes could support the use of RS, despite the high operative time and costs.
In the field of hepatobiliary surgery, use of the robotic approach is promising, but not standardized yet. International and multicenter studies are limited, only few publications reported long-term outcomes and no randomized trials are available in literature. In the current literature many authors attempted to reach definitive conclusions about the use of RS publishing many reviews/meta-analyses. In general, almost all of these studies found RS as safe and effective with acceptable morbidity in the treatment of liver malignancies as for laparoscopy[
The majority of the studies reported single center initial experiences and considered the robotic learning curve shorter than the laparoscopic one, especially for surgeons with advanced skills in open liver surgery[
Choi
Interestingly, Lai
In conclusion, in the era of MIS in which surgical innovations are increasing, even if the younger surgeons are more confident with MIS, both open and laparoscopic surgical experiences are necessary in order to shorten the learning curve of robotic liver surgery and all the surgeons should receive specific training for RS.
Even though robotic liver surgery allows attainment of excellent oncologic results with adequate R0 margins, long-term outcomes are still lacking, probably because of the recent introduction of this technique.
Regarding the type of liver resection, robotic LLS is considered inappropriate in comparison with the laparoscopic one, which is actually the standard of care. In fact, while perioperative outcomes are similar, costs are markedly higher for RS. On the contrary, complex cases could take advantages from RS, thus increasing the rate of MIS.
Even for other type of resections, the results available in the current literature encourage the use of robotic surgery in complex cases, for example for lesions located in postero-superior segments. Furthermore, many studies reported easier management of major intraoperative complications, such as bleeding, that could explain the lower rate of conversion compared with laparoscopy.
Among the comparative studies between MIS techniques, many of them reported a greater number of major resections for robotic surgery. Some authors explained these results with the reduced difficulty of robotic major hepatectomies in comparison with laparoscopy, allowing a potential increase of MIS in more complex cases[
One of the most relevant drawbacks of robotic surgery remain higher costs. Almost all the comparative studies confirmed robotic perioperative higher costs with reduced postoperative ones[
It is possible that the increasing spread of robotic surgery and the introduction of new robotic platforms with industry competition could lead to a consistent reduction of these costs.
Regarding the application of the robotic approach in specific diseases, RS for HCC and liver metastases achieved good results, allowing parenchymal sparing resections, even in difficult locations.
Furthermore, the robotic approach to biliary tumors seems to be the most promising application of robotic surgery, because of the need for extensive lymph node dissection and of bilio-enteric anastomoses. Currently, there are discordant opinions regarding hCCC, whereas robotic surgery for GBC can add relevant benefits, increasing the rate of MIS without compromising oncologic results.
In conclusion, different techniques should be tailored to each patient, applying MIS when possible, particularly in cirrhotic patients and in the context of liver transplantation[
In the future the technological innovation could lead to more complete, less expensive and smaller robotic systems with additional devices or software for RS, that could really change the actual scenario of MIS overcoming many of the drawbacks of RS. For example, it could become possible to approach the operation without the second surgeon, the equipment could be smaller, the docking could be easier and quicker and costs reduced thanks to the market competition.
Although a lot of hepatobiliary centers worldwide are already experienced in robotic liver surgery, more and larger studies are necessary to define its real benefits compared with laparoscopy, in order to standardize patient selection criteria and its use.
Designed and performed the research: Ruzzenente A, Alaimo L
Collected the data: Conci S, Bagante F
Analyzed the data: Campagnaro T, Pedrazzani C
Supervised the work: Ruzzenente A, Guglielmi A
Wrote and finally approved the manuscript: Ruzzenente A, Alaimo L, Conci S, Bagante F, Campagnaro T, Pedrazzani C, Guglielmi A
A search of the current literature on robotic liver surgery was conducted in PubMed, Medline, PMC and Google Scholar databases.
None.
All authors declared that there are no conflicts of interest.
Not applicable.
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© The Author(s) 2020.