Robotic liver surgery: literature review and current evidence

Abstract

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.

Robotic Liver Surgery

“…HCC is the predominant malignancy for which a robotic approach has been utilised, with 40% of the cases published in the literature indicating this as the underlying indication [22]. Three studies have examined the longer term oncological outcomes following robotic hepatectomy in this cohort and found the oncological outcomes to be comparable.…”

“…A recent review of outcomes from 584 major robotic liver resections demonstrated acceptable blood loss, operation time, R0 resection rate, length of hospital stay and post op morbidity. When directly compared to laparoscopy, robotic major hepatectomies demonstrated significantly improved rates of post-operative critical care admission, 90 day re-admission rate and a similar length of stay and complication rate [22]. The robotic approach has also been shown to be feasible for simultaneous resection of a colorectal primary malignancy and the associated liver metastasis.…”

“…Minimally Invasive Surgery utilising a robotic approach should theoretically convey the significant advantages to hilar CCA resections given the necessity of extreme precision and micro-anastomosis formation. However CCA resections form less than 10% of robotic liver surgery in the current literature, likely due to the required tertiary level of surgical expertise and robotic technology [22]. As such, the literature exploring oncolocological outcomes is very limited.…”

Laparoscopic and Robot-Assisted Hepatic Surgery: An Historical Review

“…Robot-assisted hepatic surgery has rapidly become a widely used modality for liver surgery and is being used throughout the world to treat a wide spectrum of hepatic lesions. This advanced technique was introduced to overcome some of the limitations associated with laparoscopic liver surgery, but many of the techniques are not yet standardized [ 57 ]. The purported advantages of robot-assisted hepatic surgery include increased dexterity and enhanced suturing ability, which is in part due to a magnified three-dimensional view of the operative field, hand tremor filtration, and articulating instruments with seven degrees of freedom [ 57 ].…”

“…This advanced technique was introduced to overcome some of the limitations associated with laparoscopic liver surgery, but many of the techniques are not yet standardized [ 57 ]. The purported advantages of robot-assisted hepatic surgery include increased dexterity and enhanced suturing ability, which is in part due to a magnified three-dimensional view of the operative field, hand tremor filtration, and articulating instruments with seven degrees of freedom [ 57 ]. Furthermore, robot-assisted hepatic surgery is felt to significantly reduce surgeon fatigue, with improved performance during long operations.…”