Parenchymal transection in robotic liver resection: results of 70 resections using the Vessel Sealer

Aim: There is no standard technique for transection of the hepatic parenchyma during robotic liver resection. The aim of this study was to describe the outcomes of robotic liver resections using the Vessel Sealer for parenchymal transection.Methods: This is a post hoc analysis of a prospective database. All consecutive patients who underwent robotic liver resection in the Regional Academic Cancer Centre, Utrecht, Netherlands, between August 2015 and January 2019 were included.Results: A total of 70 robotic liver resections were performed, including 60 minor resections (86%) and ten hemihepatectomies (14%). Five procedures (7%) were converted. Mean parenchymal transection time was 43 ± 26 min. Median blood loss was 150 mL (interquartile range 40-300). Ten patients (14%) suffered from a major complication, and three patients (4%) had bile leakage postoperatively. One patient died from post-hepatectomy liver failure.Conclusion: Based on the results of this series, consisting of 60 minor liver resections and 10 hemihepatectomies, we conclude that the use of the Vessel Sealer during the parenchymal transection in liver resection is feasible and safe

Robotic Developments in Cancer Surgery

Indications for robotic surgery have been rapidly expanding since the first introduction of the robotic surgical system in the US market in 2000. As the robotic systems have become more sophisticated over the past decades, there has been an expansion in indications. Many new tools have been added with the aim of optimizing outcomes after oncologic surgery. Complex abdominal cancers are increasingly operated on using robot-assisted laparoscopy and with acceptable outcomes. In this article, the authors discuss robotic developments, from the past and the future, with an emphasis on cancer surgery

Robotic Versus Open Minor Liver Resections of the Posterosuperior Segments : A Multinational, Propensity Score-Matched Study

BACKGROUND: Minor liver resections of posterosuperior segments (1, 4A, 7, 8) are challenging to perform laparoscopically and are mainly performed using an open approach. We determined the feasibility of robotic resections of posterosuperior segments and compared short-term outcomes with the open approach. METHODS: Data on open and robotic minor (≤ 3 segments) liver resections including the posterosuperior segments, performed between 2009 and 2016, were collected retrospectively from four hospitals. Robotic and open liver resections were compared, before and after propensity score matching. RESULTS: In total, 51 robotic and 145 open resections were included. After matching, 31 robotic resections were compared with 31 open resections. Median hospital stay was 4 days (interquartile range [IQR] 3-7) for the robotic group, versus 8 days (IQR 6-10) for the open group (p  0.99). There was no mortality in either group. CONCLUSION: Minor robotic liver resections of the posterosuperior segments are safe and feasible and display a shorter length of stay than open resections in selected patients at expert centers

Pan-European survey on the implementation of robotic and laparoscopic minimally invasive liver surgery

Background: Laparoscopic and robotic minimally invasive liver surgery (MILS) is gaining popularity. Recent data and views on the implementation of laparoscopic and robotic MILS throughout Europe are lacking. Methods: An anonymous survey consisting of 46 questions was sent to all members of the EuropeanAfrican Hepato-Pancreato-Biliary Association. Results: The survey was completed by 120 surgeons from 103 centers in 24 countries. Median annual center volume of liver resection was 100 [IQR 50-140]. The median annual volume of MILS per center was 30 [IQR 16-40]. For minor resections, laparoscopic MILS was used by 80 (67%) surgeons and robotic MILS by 35 (29%) surgeons. For major resections, laparoscopic MILS was used by 74 (62%) surgeons and robotic MILS by 33 (28%) surgeons. The majority of the surgeons stated that minimum annual volume of MILS per center should be around 21-30 procedures/year. Of the surgeons performing robotic surgery, 28 (70%) felt they missed specific equipment, such as a robotic-CUSA. Seventy (66%) surgeons provided a formal MILS training to residents and fellows. In 5 years' time, 106 (88%) surgeons felt that MILS would have superior value as compared to open liver surgery. Conclusion: In the participating European liver centers, MILS comprised about one third of all liver resections and is expected to increase further. Laparoscopic MILS is still twice as common as robotic MILS. Development of specific instruments for robotic liver parenchymal transection might further increase its adoption

Implementation and Outcome of Robotic Liver Surgery in the Netherlands: A Nationwide Analysis

OBJECTIVE: To determine the nationwide implementation and surgical outcome of minor and major robotic liver surgery (RLS) and assess the first phase of implementation of RLS during the learning curve. SUMMARY BACKGROUND DATA: RLS may be a valuable alternative to laparoscopic liver surgery. Nationwide population-based studies with data on implementation and outcome of RLS are lacking. METHODS: Multicenter retrospective cohort study including consecutive patients who underwent RLS for all indications in nine Dutch centers (August 2014-March 2021). Data on all liver resections were obtained from the mandatory nationwide Dutch Hepato Biliary Audit (DHBA) including data from all 27 centers for liver surgery in the Netherlands. Outcomes were stratified for minor, technically major and anatomically major RLS. Learning curve effect was assessed using cumulative sum (CUSUM) analysis for blood loss. RESULTS: Of 9,437 liver resections, 400 were RLS (4.2%) procedures including 207 minor (52.2%), 141 technically major (35.3%) and 52 anatomically major (13%). The nationwide use of RLS increased from 0.2% in 2014 to 11.9% in 2020. The proportion of RLS among all minimally invasive liver resections increased from 2% to 28%. Median blood loss was 150 mL (IQR 50-350 mL) and the conversion rate 6.3% (n=25). The rate of Clavien-Dindo grade ≥III complications was 7.0% (n=27), median length of hospital stay 4 days (IQR 2-5) and 30-day/in-hospital mortality 0.8% (n=3). The R0 resection rate was 83.2% (n=263). CUSUM analysis for blood loss found a learning curve of at least 33 major RLS procedures. CONCLUSIONS: The nationwide use of RLS in the Netherlands has increased rapidly with currently one-tenth of all liver resections and one-fourth of all minimally invasive liver resections being performed robotically. Although surgical outcomes of RLS in selected patient appear favorable, future prospective studies should determine its added value

Outcomes of a Multicenter Training Program in Robotic Pancreatoduodenectomy (LAELAPS-3)

Objective: To assess feasibility and safety of a multicenter training program in robotic pancreatoduodenectomy (RPD) adhering to the IDEAL framework for implementation of surgical innovation. Background: Good results for RPD have been reported from single center studies. However, data on feasibility and safety of implementation through a multicenter training program in RPD are lacking. Methods: A multicenter training program in RPD was designed together with the University of Pittsburgh Medical Center, including an online video bank, robot simulation exercises, biotissue drills, and on-site proctoring. Benchmark patients were based on the criteria of Clavien. Outcomes were collected prospectively (March 2016-October 2019). Cumulative sum analysis of operative time was performed to distinguish the first and second phase of the learning curve. Outcomes were compared between both phases of the learning curve. Trends in nationwide use of robotic and laparoscopic PD were assessed in the Dutch Pancreatic Cancer Audit. Results: Overall, 275 RPD procedures were performed in seven centers by 15 trained surgeons. The recent benchmark criteria for low-risk PD were met by 125 (45.5%) patients. The conversion rate was 6.5% (n = 18) and median blood loss 250ml [interquartile range (IQR) 150-500]. The rate of Clavien-Dindo grade ≥III complications was 44.4% (n = 122), postoperative pancreatic fistula (grade B/C) rate 23.6% (n = 65), 90-day complication-related mortality 2.5% (n = 7) and 90-day cancer-related mortality 2.2.% (n = 6). Median postoperative hospital stay was 12 days (IQR 8-20). In the subgroup of patients with pancreatic cancer (n = 80), the major complication rate was 31.3% and POPF rate was 10%. Cumulative sum analysis for operative time found a learning curve inflection point at 22 RPDs (IQR 10-35) with similar rates of Clavien-Dindo grade ≥III complications in the first and second phase (43.4% vs 43.8%, P = 0.956, respectively). During the study period the nationwide use of laparoscopic PD reduced from 15% to 1%, whereas the use of RPD increased from 0% to 25%. Conclusions: This multicenter RPD training program in centers with sufficient surgical volume was found to be feasible without a negative impact of the learning curve on clinical outcomes