Robotic Liver Resections: Application of Difficulty Score Systems to an Initial Experience. Is a Specific Robotic Difficulty Score Necessary?

Abstract

Background: Recently, the minimally invasive surgical approach has been available for performing liver resections (LRs) with laparoscopic and robotic techniques. The robotic approach for LRs seems to overcome several laparoscopic limitations, which is a valid alternative when performed in high volume and specialized centers. Laparoscopic difficulty score systems (DSSs) should serve to guide the surgeon's choice in the best surgical approach to adopt for every single patient, giving the possibility to switch to the open approach when needed. To this day, no specific robotic difficulty scores exist. The aim of our study was to verify the feasibility of applying these scores and related updates on robotic LRs performed in our Institute. Materials and Methods: Out of a total of 683 LRs performed from June 2010 to July 2019, 60 were performed through using a mini invasive approach and of these 18 were performed robotically. The Ban DSS and subsequently the modified Iwate DSS were applied to our cases. Results: Based on our findings, applying the DSS we divided our series into two groups: a low difficulty level group (1-3) made up of 5 patients, and an intermediate difficulty level group (4-6) consisting of 13 patients. Average Ban DSS and subsequently updated score system results were 4.6 -1.5 points (range 2-6) for both scores. Conclusions: Difficulties were encountered in applying the score when simultaneous multiple wedge resections were performed. The laparoscopic DSS is applicable to robotic LRs with some limitations due to the peculiarity of the two different minimally invasive approaches. A specific robotic difficulty rating score could be necessary to include these elements.

Robot‐assisted versus conventional laparoscopic major hepatectomies: Systematic review with meta‐analysis

“…Of note, as for surgical procedures, the use of MIS is predominantly still limited to minor surgeries, mostly in the context of wedge resection or isolated segmentectomy of anterolateral segments and left lateral sectionectomy 3,9,10,29–31 . In this scenario, the use of robotic platforms has been proposed to overcome some of the technical limitations of conventional laparoscopy and widen the application of MIS for liver surgery 3,6,28,31–38 . The difficulties in liver exposition, parenchymal frailty, the risk of bleeding limited laparoscopy application in liver surgery to selected patients.…”

“…3,9,10,[29][30][31] In this scenario, the use of robotic platforms has been proposed to overcome some of the technical limitations of conventional laparoscopy and widen the application of MIS for liver surgery. 3,6,28,[31][32][33][34][35][36][37][38] The difficulties in liver exposition, parenchymal frailty, the risk of bleeding limited laparoscopy application in liver surgery to selected patients. Robotic technology has made it possible to overcome many of the limitations of laparoscopic surgery, which include a reduction in tremors, magnifying images with three-dimensional technology, an increase in the effectiveness of surgical gestures through tools with several degrees of freedom and an improvement in fatigue in relation to the continuation of surgery.…”

Systematic review and meta‐analysis of difficulty scoring systems for laparoscopic and robotic liver resections

“…[44][45][46] Two articles were excluded by virtue of them being review articles with no unique datasets 10,46 and one article was found to be a duplicate, 19 and the remaining 37 articles were included in the qualitative analysis. 3,[6][7][8][9][11][12][13][14]17,18,…”

“…Twelve studies in the literature had supporting data for the Iwate DSS for MILR. [11][12][13]18,32,[33][34][35][36][37][38][39] Notably, the Iwate DSS was not formulated based on any data but as a modification of the Ban DSS based on expert opinion. Ten studies had supporting data for Iwate DSS for LLR against various outcome measures, 11,12,18,[32][33][34][35][36]38,39 of which eight studies 11,12,18,21,[32][33][34][35][36] published data that was amenable to pooling (Table 3).…”

“…At present, several studies have sought to validate the major DSS in LLR 10 and compare between them. 11,12 Several studies also attempted to validate the DSS for various subgroups such as in robotic-assisted liver resection (RLR) 13 or in LLR for colorectal metastasis (CRLM). 14 The aim of the present study is to perform a systematic review and metanalysis to summarize the existing literature pertaining to the formulation, supporting data for the system (data for formulation and external validation), and comparison of DSS for minimally invasive liver resection (MILR) including LLR and RLR.…”