Three-Device (3D) Technique for Liver Parenchyma Dissection in Robotic Liver Surgery

Abstract

Background: The implementation of robotics in liver surgery offers several advantages compared to conventional open and laparoscopic techniques. One major advantage is the enhanced degree of freedom at the tip of the robotic tools compared to laparoscopic instruments. This enables excellent vessel control during inflow and outflow dissection of the liver. Parenchymal transection remains the most challenging part during robotic liver resection because currently available robotic instruments for parenchymal transection have several limitations and there is no standardized technique as of yet. We established a new strategy and share our experience. Methods: We present a novel technique for the transection of liver parenchyma during robotic surgery, using three devices (3D) simultaneously: monopolar scissors and bipolar Maryland forceps of the robot and laparoscopic-guided waterjet. We collected the perioperative data of twenty-eight patients who underwent this procedure for minor and major liver resections between February 2019 and December 2020 from the Magdeburg Registry of minimally invasive liver surgery (MD-MILS). Results: Twenty-eight patients underwent robotic-assisted 3D parenchyma dissection within the investigation period. Twelve cases of major and sixteen cases of minor hepatectomy for malignant and non-malignant cases were performed. Operative time for major liver resections (≥ 3 liver segments) was 381.7 (SD 80.6) min vs. 252.0 (70.4) min for minor resections (p < 0.01). Intraoperative measured blood loss was 495.8 (SD 508.8) ml for major and 256.3 (170.2) ml for minor liver resections (p = 0.090). The mean postoperative stay was 13.3 (SD 11.1) days for all cases. Liver surgery-related morbidity was 10.7%, no mortalities occurred. We achieved an R0 resection in all malignant cases. Conclusions: The 3D technique for parenchyma dissection in robotic liver surgery is a safe and feasible procedure. This novel method offers an advanced locally controlled preparation of intrahepatic vessels and bile ducts. The combination of precise extrahepatic vessel handling with the 3D technique of parenchyma dissection is a fundamental step forward to the standardization of robotic liver surgery for teaching purposing and the wider adoption of robotic hepatectomy into routine patient care.

Does Robotic Liver Surgery Enhance R0 Results in Liver Malignancies during Minimally Invasive Liver Surgery?—A Systematic Review and Meta-Analysis

“…Higher freedom of movement, stable three-dimensional visualization, the possibility of using a third arm and the absence of a physiological tremor are the advantages of robotic over conventional laparoscopic surgery. These advantages of robotics enable us to operate safely and precisely in the tight areas and difficult-to-access localizations of the liver [ 21 , 22 , 23 ]. One of the modern approaches in robot-assisted liver resection is image-guided surgery.…”

“…Stable three-dimensional visualization, absence of physiological tremor, higher freedom of movement, better ergonomics for the surgeon and the possibility of using a third arm are the advantages of robots compared to conventional laparoscopic surgery [ 21 , 22 , 23 ]. Perhaps these advantages of robotics are also beneficial in achieving R0 resection.…”

Laparoscopic and Robot-Assisted Hepatic Surgery: An Historical Review

“…Some of the issues with robot-assisted hepatic surgery have been mentioned above, including the difficulties associated with parenchymal transection, due to limitations of instrumentation. Perrakis and colleagues have developed a novel approach to parenchymal transection using three devices, including the monopolar scissors and bipolar Maryland forceps of the robot and a laparoscopic guided waterjet [ 61 ]. They reported a series of 28 patients who underwent this procedure for major (n = 12) and minor (n = 16) liver resections and referred to this method as a “3D parenchymal transection”.…”

“…The combination of precise extrahepatic vessel handling with this novel technique of parenchyma dissection is a fundamental step forward for the standardization of robot-assisted hepatic surgery. This may be a significant contribution to teaching leading to wider adoption of robot-assisted hepatectomy [ 61 ].…”

Auswirkungen der COVID-19-Pandemie auf die robotische Viszeralchirurgie in Deutschland

“…Dies ermöglicht es, im Verlauf komplexere Eingriffe auf Basis der erworbenen Erfahrung durchzuführen. Besonders bei Eingriffen am hepatobiliären System helfen dabei spezifische Modifikationen der chirurgischen Techniken [ 21 ]. In diesem Zusammenhang ist ergänzend zu erwähnen, dass über die letzten Jahre der Anteil robotischer Eingriffe der einzelnen Kliniken am Gesamtkollektiv der viszeralchirurgischen Operationen (4,6 ± 4,6 %) sehr niedrig war.…”