Minimally Invasive Robotic Liver Resection

In the early 1980s, liver resection was associated with high morbidity and mortality (approximacalltoy 25%). Major intraoperative bleeding was the most feared untoward event by the operating surgeon and excessive bleeding was responsible for the high mortality.  However, outcomes of liver resection have significantly evolved over the years with a better understanding of liver anatomy, advancement in surgical instrumentation, and improved perioperative care.  Mortality after liver resection is now < 1%.  Consequently, more patients including the elderly become a candidate for curative intent liver resection.

Surgical extirpation via liver resection is widely performed for both symptomatic benign and malignant liver masses. Liver resection with the goal of achieving negative margins is considered the gold standard curative treatment for primary (hepatocellular carcinoma with preserved liver function and intrahepatic cholangiocarcinoma) and metastatic liver tumors (colorectal cancer, neuroendocrine tumor, sarcoma, ovarian tumor, etc that give metastasis to the liver). Specifically for the colorectal liver metastasis, patients who do not undergo treatment, survival rates are poor (<2% at 5 years) [1]. On the contrary, patients who undergo liver resection and systemic chemotherapy achieve 3-year and 5-year overall survival of 88% and 84%, respectively [3]. Other treatment modalities such as radiofrequency ablation and microwave ablationare considered a second-line option after liver resection due to higher rate of local recurrence/failure, especially for lesions >3cm [1].  A combination of ablation for lesion > 3cm and liver resection is commonly done intraoperatively by surgeons to achieve a tumor-free state while adhering to the parenchymal-sparing liver surgery principal.  Alternative treatments such as bland embolization, chemo-embolization, radio-embolization Y-90 are considered palliative in nature.

In the early 1990s, laparoscopy gained popularity in the field of general surgery, marked by the rapid adoption of 4-small-incision laparoscopic cholecystectomy.  Very quickly, laparoscopic cholecystectomy replaced open cholecystectomy as the standard of care, not just in America but throughout the world.  As more experience is gained with minimally invasive technique, laparoscopic liver resection then became a new alternative approach in liver surgery. Minimally Invasive Robotic Liver Resection can be offered as long as adequate future liver remnant volume (±25% of total liver volume) can be preserved. The number of lesions and evidence of bilateral tumors is no longer contraindications for resection. An important principle of minimally invasive liver surgery is that the indications for resection are similar to those for open liver resection.

Since 2008, indications and feasibility of minimally invasive liver resection are expanding in terms of tumor size, tumor location, number of the lesion, the extent of liver resection, level of technical difficulty, and degree of background liver cirrhosis [2-3].  This is mainly driven by known advantages of minimally invasive surgery, which include less intraoperative blood loss, reduced postoperative pain, reduced narcotic requirements, shorter hospital stay, significantly lower risk for perioperative complications, fewer days till resumption of oral intake, and faster overall recovery. Most patients require 7-10 days in the hospital after open liver resection.  On the contrary, patients only require 2-4 days in the hospital after a Minimally Invasive Robotic Liver Resection.   Postoperative chemotherapy can also be started much earlier after Minimally Invasive Robotic Liver Resection. Oncological outcomes are similar when compared to the traditional open operation [4].

In the world of Minimally Invasive Robotic Liver Resection, there are inherent limitations of the laparoscopic approach, which include limited range of motion, two-dimensional view, amplification of physiologic tremors, and a steep learning curve. The robotic surgical system provides a solution to these technical limitations by providing a magnified three-dimensional view, articulating instruments with seven degrees of freedom, and intuitive hand control movements. A single-institution study by Tsung et al. showed only 49.1% of all laparoscopic liver resection were completed in a purely minimally invasive approach (i.e without the need to make a larger incision), compared to 93% completed in a purely minimally invasive manner if performed using the robotic technology [5]. Control of intraoperative bleeding, one of the most difficult aspects in minimally invasive liver surgery, can be facilitated via the robotic approach at any point during the operation, mostly due to a greater degree of instrument movement and ease of suturing even in difficult areas.

Since 2013, we have undertaken 140 liver resections in our hepatobiliary program. The most common indications for the robotic liver resection included hepatocellular carcinoma (22%), metastatic colorectal cancer to the liver (20%), and symptomatic benign lesions (30%). Forty-seven percent of patients underwent left-sided liver resection, 48% underwent right-sided liver resection, while the remainder underwent central liver resection (mostly for gallbladder cancer). Major hepatic resection (resection of more than 2 liver segments) was done in 70% of patients.  Median operative time is 220 minutes, typical blood loss is less than 125 mL and an average hospital stay is 3 days.  Advanced gastrointestinal endoscopic service, interventional radiology, hepatology, medical oncology, and radiation oncology are pertinent parts of a successful hepatobiliary program.  Complex hepatobiliary cases are discussed at biweekly multidisciplinary tumor board in a collaborative manner.  All hepatobiliary patients are managed in a dedicated hepatobiliary surgical unit by specially trained providers.  Enhanced recovery after surgery program also contributes to better perioperative outcomes.  In 2018, our program has become the busiest robotic liver and pancreas program in the country, serving patients from throughout the state of Florida.
References

1. Groeschl RT, Pilgrim CH, Hanna EM, Simo KA, Swan RZ, Sindram D, et al. Microwave ablation for hepatic malignancies: a multiinstitutional analysis. Ann Surg. 2014 Jun;259(6):1195-200.
2. Wagner JS, Adson MA, Van Heerden JA, Adson MH, Ilstrup DM. The natural history of hepatic metastases from colorectal cancer. A comparison with resective treatment. Ann Surg. 1984 May;199(5):502-8.
3. Allard MA, Cunha AS, Gayet B, Adam R, Goere D, Bachellier P, et al. Early and Long-term Oncological Outcomes After Laparoscopic Resection for Colorectal Liver Metastases: A Propensity Score-based Analysis. Ann Surg. 2015 Nov;262(5):794-802.
4. van Vledder MG, Pawlik TM, Munireddy S, Hamper U, de Jong MC, Choti MA. Factors determining the sensitivity of intraoperative ultrasonography in detecting colorectal liver metastases in the modern era. Ann Surg Oncol. 2010 Oct;17(10):2756-63
5. Tsung A, Geller DA. Reply to Letter: “Does the robot provide an advantage over laparoscopic liver resection?” Ann Surg. 2015 Aug;262(2):e70-1.

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