State of the art of robotic surgery in the liver

Gian Luca Grazi
Hepato-Biliary-Pancreatic Surgery
National Cancer Institute Regina Elena
Rome
State of the art of robotic surgery in the liver

Leung U, Hepatobiliary Surg Nutr 2014;3(5):288-294
Robotic Liver Resections
Some of the major technical challenges in liver surgery include the difficult
access to the vena cava and major hepatic veins, precision required for
dissection at the hilum, and propensity for the liver to bleed.
These are made more difficult with laparoscopy due to the limitations in depth
perception, restricted movement by rigid instruments and fixed fulcrum at the
ports, unnatural ergonomics, and difficult suturing particularly in presence of
hemorrhage.
There is a steep learning curve making its practice outside high-volume centers
difficult.
Laparoscopic liver surgery

Bhogal H R. IntechOpen Chapter 2019, DOI: 10.5772/intechopen.87995
• There is a common misconception that robotic liver surgery evolved
from laparoscopic liver surgery but robotic surgery has developed in
tandem with the former.
• Computer Motion Inc. and Intuitive Surgical Inc. independently
developed robotic surgical systems in the 1990s.
• Computer Motion Inc based in California. They were contracted by NASA
to develop the AESOP, a voice-activated camera control system that was
compatible with standard 5 and 10 mm endoscopes.
• In 1999, Intuitive Surgical released the da Vinci robot in Europe.
• In 2003, Intuitive Surgical and Computer Motion were merged.

Leung U, Hepatobiliary Surg Nutr 2014;3(5):288-294
• The second generation da Vinci S was released in 2006
• In 2009, the third generation Si model was released with dual console
capability and improved vision.
• In 2014, the fourth generation da Vinci Xi robot was approved by the
FDA, with a redesigned surgical arm cart, smaller, longer arms, and
new camera system to allow more flexibility in cart position and port
placement
Robotic liver surgery

Surgery. 2011;149:29-39. doi: 10.1016/j.surg.2010.04.002

Sucandy I, Surg Endosc 2022, Online ahead of print, doi.org/10.1007/s00464-021-08948-3

Machado MAC, Arq Gastroenterol. 2021;58(4):514-9
Absence of specific
instruments for this
complex procedure in the
field of liver surgery

Liu R. World J Gastroenterol 2019; 25(12): 1432-1444

Zhao Z, Updates Surg 2021, 73(3): 977-9877

Meta-analysis forest plot depicting the operative parameters
Operation time
Open/Robot
Operation time
Laparo/Robot
Blood Loss
Open/Robot
Blood Loss
Laparo/Robot
Transfusion Rate
Open/Robot
Transfusion Rate
Laparo/Robot
Longer Longer
Higher
Higher
Higher

Meta-analysis forest plot
Pringle
Open/Robot
Pringle
Laparo/Robot
Conversion
Laparo/Robot
Conversion
Laparo/Robot
Hospital Stay
Open/Robot
Hospital Stay
Laparo/Robot
Higher
Higher

Meta-analysis forest plot depicting complications
Complications
Open/Robot
Complications
Laparo/Robot
Severe
Complications
Open/Robot
Severe
Complications
Laparo/Robot
Bile Leak
Open/Robot
Bile Leak
Laparo/Robot
Higher

Conclusions
• No prospective randomized study (all retrospective)
• Heterogenity
• No data on long term for cancer
• Robotic surgery may have some technical advantages in
extensive hepatectomy or posterosuperior sectionectomy
of the liver compared to laparoscopic surgery

Sucandy I, Surg Endosc 2022, Online ahead of print, doi.org/10.1007/s00464-021-08948-3

International consensus statement on robotic hepatectomy surgery in 2018
Recommendation 1 - OPEN Level of evidence Level of recommendation
Robotic hepatectomy is as safe and feasible as traditional open hepatectomy.
Robotic hepatectomy has
• longer operative time,
• less intraoperative blood loss,
• less length of hospital stays,
• lower complication rate and
• lower severe complication rate.
The intraoperative blood loss of robotic hepatectomy is comparable to that of
open hepatectomy.
Low Weak (Grade 2C)
Recommendation 2 - MALIGNANCY Level of evidence Level of recommendation
Robotic hepatectomy has similar effectiveness for liver malignancy lesion
compared to open hepatectomy.
Regarding the oncological outcome there is no significant difference in the radical
resection rate, overall survival rate and recurrence rate between robotic
hepatectomy and open hepatectomy.
Very low Weak (Grade 2D)

Recommendation 3 - LAPAROSCOPY Level of evidence Level of recommendation
As a minimally invasive surgery, robotic hepatectomy is as safe and feasible as
traditional laparoscopic hepatectomy.
Robotic hepatectomy has longer operative time, more intraoperative blood loss,
and higher cost.
Robotic hepatectomy has similar overall complication rate and length of hospital
stays compared to open hepatectomy.
Conversion rate of robotic hepatectomy would decrease with the experience
accumulation.
Recommendation 4 - MALIGNANCY Level of evidence Level of recommendation
As minimally invasive surgery, robotic hepatectomy has similar effectiveness for
liver malignancy disease compared to laparoscopic hepatectomy.
Regarding the oncological outcome there is no significant difference in the radical
resection rate, overall survival rate and recurrence rate between robotic
hepatectomy and laparoscopic hepatectomy.

Garden OJ, Gut 2006;55 (Suppl III): iii1–iii8
Recommendation 5 – MINOR HEPATECTOMY Level of evidence Level of recommendation
For minor hepatectomy, robotic hepatectomy as safe and feasible as laparoscopic
hepatectomy and open hepatectomy.
Robotic hepatectomy has longer operative time than laparoscopic hepatectomy
for minor hepatectomy.
The intraoperative blood loss, overall postoperative complication rate and overall
cost of robotic minor hepatectomy are comparable to that of laparoscopic minor
hepatectomy.
Recommendation 6 – MAJOR HEPATECTOMY Level of evidence Level of recommendation
For major hepatectomy, robotic hepatectomy as safe and feasible as laparoscopic
hepatectomy and open hepatectomy. Robotic hepatectomy has longer operative
time than laparoscopic hepatectomy for major hepatectomy.
The intraoperative blood loss, overall postoperative complication rate and overall
cost of robotic major hepatectomy are comparable to that of laparoscopic major
hepatectomy.
There is no significant difference in the operative time, intraoperative blood loss
and complication rate between robotic hepatectomy and open hepatectomy for
minor hepatectomy.

Recommendation 7 – DONOR HEPATECTOMY Level of evidence Level of recommendation
Robotic liver donor hepatectomy could be an alternative.
The procedure should only be performed by experienced surgeons, and the true
benefits of robotic donor hepatectomy need further investigation in the future.

Ruzzunente A. Mini-invasive Surg 2020;4:91
Robotic liver surgery: literature review and current evidence
Laparoscopic Robotic
Actually the standard of care Perioperative outcomes are similar
Costs are markedly higher
Complex cases (lesions located in
postero-superior segments) could
take advantages from RS, thus
increasing the rate of MIS
Easier management of major
intraoperative complications, such as
bleeding

Dalsgaard T, Ann Surg. 2020;271(1):106-113

Dalsgaard T, Ann Surg. 2020;271(1):106-113
• Compared with LS, RALS is less physically demanding and feels less strenuous for the surgeons,
due to several factors.
• the muscular workload in the shoulder and the neck regions is significantly reduced,
• the number of gaps (or ‘‘micropauses’’) is higher,
• the rating of perceived exertion is lower, especially for the legs, and
• there is an asymmetric static muscle activity between the dominant and nondominant
sides during LS.
• For both types of surgeries, there still is room for improvement of working conditions.
• To further optimize these, we advice using our recommendation and regularly observe and
advise the surgeons and analyze whether it could be indicated to invest in accessory
equipment.
• Compared with the price of buying and running a robotic system, and to the high value that the
staff in the operating room represents, these investments would be minor.
Conclusions

Learning curve
Difficulty

Ahmad J, HPB. 2021;S1365-182X(21)01709-3. doi: 10.1016/j.hpb.2021.11.014.

J Laparoendosc Adv Surg Tech A. 2020;30(11):1177-1182

Future of Robotic Liver Resections
Specific
Possible development of
specific instruments for
liver surgery

Specific
Possible development of
specific instruments for
liver surgery
Independent
New surgical robots

J&J Ottava Robotic-Assisted Surgical Solution

Medtronic Hugo™ - Robotic-Assisted Surgery

Versius Surgical Robotic System

Gian Luca Grazi
Hepato Biliary Pancreatic Surgery
National Cancer Institute “Regina Elena”, Rome, Italy
gianluca.grazi@ifo.it
www.chirurgiadelfegato.it

State of the art of robotic surgery in the liver

State of the art of robotic surgery in the liver

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