Resection of Tumors in Difficult Locations Using Robotic Approach. Development of Tampa Score for Robotic Liver Resections
Difficulty in performing liver resection are not universal for each liver tumors. Some operations are harder or easier than others to complete using the robotic approach. Tumors that are larger, close to major vascular structures, cirrhotic liver background, or deep locations are more difficult to resection. The more difficult the liver resection is, the higher the chance that the operation needs to be converted to open and the longer the hospitalization/recovery will be. These differences are well known to liver surgeons making liver resection is so variable between one from the others. Not every surgeons can do the difficult robotic liver resections, depending on their previous training and experience.
The Japanese and European societies of hepatobiliary surgery had come up with a difficulty scoring system for laparoscopic liver surgery but none for robotic liver surgery. In the past years, Dr Sucandy and his research team had compared all three major laparoscopic scoring system to see if they work well in robotic liver resections. They are known as Iwate score, Southampton sore and Institut Mutualiste Mountsouris -IMM score. Generally, all of those scores work for robotic liver surgery but they are not perfect because many complex liver surgeries were not commonly performed by laparoscopy. In order to overcome this limitation, a dedicated scoring system to determine difficulty of robotic liver resection is needed. Off a side note, in 2016 Dr Sucandy went to learn laparoscopic liver surgery at IMM in Paris-France following completion of his fellowship from the University of Pittsburgh under the guidance of Professor Brice Gayet, a world pioneer in minimally invasive liver surgery. To date, Professor Gayet has retired from clinical practice.
Since Dr. Sucandy and his team lead the largest robotic liver surgery program in North America with the most number of robotic liver resections at a single institution, they had decided to come with with a novel robotic liver surgery difficulty scoring system which is known as “Tampa Score”. This scoring system had been published on the Journal of Gastrointestinal Surgery [1] and it has an online calculator which can be used to predict case difficulty prior to liver surgery (www.roboticliverresectionscore.com). This study was further later validated and published on Surgical Endoscopy [2] another leading journal in minimally invasive surgery subspecialty.
In this “Tampa Score”, the use of chemotherapy before surgery, tumor location, tumor type, tumor size, extent of liver resection, need for lymphadenectomy and biliary resection are all important factors that determine the level of difficulty. Livers that had undergone extensive chemotherapy prior to surgery are generally more friable to mechanical handling and tend to have more blood loss. Tumors located in the dorsal (far deep) aspects of the liver are much more difficult to access. These cases after need a complete liver mobilization, which requires additional skills to do it. Benign tumors are easier to remove so are small tumors less than 3cm in diameter. Finally, liver resections that require lymph node dissection and biliary reconstruction are also more difficult to perform due to the need for delicate dissections and fine suturing. The Tampa score helps surgeons gauge case difficulty and avoid miscalculations. Technically very difficult cases within the ‘expert level’ category should be referred to a highly specialized center with high expertise in robotic liver surgery. In Florida, these kinds of difficult cases are generally referred to Dr Sucandy with the most experience in Robotic liver resections, either through second opinion or regular referral routes.
