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Kong X, Niu Z, Wang H, Liu M, Ma C, Lu J, Zhou X, Zhu H. Left-lateral decubitus jackknife position for laparoscopic resection of right posterior liver tumors: A safe and effective approach. Langenbecks Arch Surg 2025; 410:25. [PMID: 39755910 DOI: 10.1007/s00423-024-03595-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2024] [Accepted: 12/22/2024] [Indexed: 01/06/2025]
Abstract
PURPOSE To compare outcomes of LLR in VI/VII of the liver in Left-lateral Decubitus Jackknife Position (LDJP) and traditional Supine Position (SP). We used propensity score matching (PSM) to analyze clinical outcomes. PATIENTS & METHODS This study retrospectively analyzed patients undergoing LLR for liver tumors in segments VI and/or VII at Shandong Provincial Hospital from 2018 to 2023. A total of 218 cases were included (LDJP, n = 94; SP, n = 124). Matched 1:1 PSM groups were created and clinical indicators compared between groups. RESULTS 218 LLR patients, 94 LDJP and 124 supine. After 1:1 PSM, each group had 62 patients. No significant differences in clinical or laboratory parameters. All surgeries were successful, 1 LDJP conversion to open resection and 4 SP conversions (P = 0.375). LDJP average surgery duration: 220.6 ± 29.9 min, supine position: 262.6 ± 35.6 min (P < 0.001). LDJP perioperative blood loss: 169.0 ± 74.4 mL, supine position: 231.6 ± 84.6 mL (P < 0.001). Four LDJP patients required intraoperative blood transfusion compared to 16 supine position patients (P = 0.012). All cases had negative margins postoperatively. No significant differences in postoperative complications (8 LDJP vs 9 supine, P = 0.675) or length of hospital stay (25 LDJP vs 26 supine, ≥ 7 days) (P = 1.000). CONCLUSION Laparoscopic partial hepatectomy in LDJP for hepatic VI/VII tumor safe and feasible. Reduces operative time, blood loss, transfusion requirement, improving outcomes.
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Affiliation(s)
- Xiaohan Kong
- Department of Hepatobiliary Surgery, Shandong Provincial Hospital, Shandong First Medical University, 324 Jingwuweiqi Road, Jinan, 250021, China
| | - Zheyu Niu
- Department of Hepatobiliary Surgery, Shandong Provincial Hospital, Shandong First Medical University, 324 Jingwuweiqi Road, Jinan, 250021, China
- Department of Clinical Research, Qilu Synva Pharmaceutical Co. Ltd, Dezhou, China
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Heng Wang
- Department of Hepatobiliary Surgery, Shandong Provincial Hospital, Shandong University, Jinan, 250021, China
| | - Meng Liu
- Department of Hepatobiliary Surgery, Shandong Provincial Hospital, Shandong First Medical University, 324 Jingwuweiqi Road, Jinan, 250021, China
| | - Chaoqun Ma
- Department of Hepatobiliary Surgery, Shandong Provincial Hospital, Shandong First Medical University, 324 Jingwuweiqi Road, Jinan, 250021, China
| | - Jun Lu
- Department of Hepatobiliary Surgery, Shandong Provincial Hospital, Shandong First Medical University, 324 Jingwuweiqi Road, Jinan, 250021, China
- Department of Hepatobiliary Surgery, Shandong Provincial Hospital, Shandong University, Jinan, 250021, China
| | - Xu Zhou
- Department of Hepatobiliary Surgery, Shandong Provincial Hospital, Shandong First Medical University, 324 Jingwuweiqi Road, Jinan, 250021, China
- Department of Hepatobiliary Surgery, Shandong Provincial Hospital, Shandong University, Jinan, 250021, China
| | - Huaqiang Zhu
- Department of Hepatobiliary Surgery, Shandong Provincial Hospital, Shandong First Medical University, 324 Jingwuweiqi Road, Jinan, 250021, China.
- Department of Hepatobiliary Surgery, Shandong Provincial Hospital, Shandong University, Jinan, 250021, China.
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O'Connell R, Bucheeri M, Quidwai O, Bourke M, Gallagher TK, Hoti E. Robotic, laparoscopic, and open liver resection for hepatocellular carcinoma: A propensity score matched analysis of perioperative outcomes. SURGERY IN PRACTICE AND SCIENCE 2023; 14:100196. [PMID: 39845844 PMCID: PMC11750000 DOI: 10.1016/j.sipas.2023.100196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/26/2023] [Accepted: 06/27/2023] [Indexed: 01/24/2025] Open
Abstract
Introduction Minimally invasive surgery may confer perioperative benefit to patients with resectable Hepatocellular Carcinoma (HCC) but published data are limited. Robotic resection for HCC has recently been introduced in our institution, and the goal of this study is to benchmark patient outcomes against open and laparoscopic surgery. Methods A retrospective evaluation was performed of all patients undergoing liver resection for HCC in our institution between September 2012 and November 2022 using a prospectively maintained database. Data were collected relating to demographics, pre-operative staging, co-morbidities, type of resection, operative time, surgical technique, histology, length of stay, and post-operative complications. A propensity score matched analysis was performed to compare outcomes for open, laparoscopic, and robotic surgery. Results 106 patients were identified. 66 (62%) had open, 26 (25%) laparoscopic, and 14 (13%) had a robotic resection. Using propensity matched analysis, robotic liver resections for HCC were associated with a non-significantly lower risk of ICU admission than open surgery (0 v 21%, p = 0.16). A lower risk of conversion to open than laparoscopic surgery was seen within the unmatched cohort (0 v 23%, p = 0.07), albeit there was a significantly longer median operative times than open or laparoscopic resection (285 min v 192 and 147 respectively, p<0.001). Conclusion Our data show that robotic hepatectomy is a safe alternative to open and laparoscopic resection for HCC in terms of perioperative outcomes despite increased operative times. Longer-term data will be needed to confirm the oncological safety of this approach.
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Affiliation(s)
- R.M. O'Connell
- Department of Hepatobiliary and Transplant Surgery, Saint Vincent's University Hospital, Dublin, Ireland
| | - M. Bucheeri
- Department of Hepatobiliary and Transplant Surgery, Saint Vincent's University Hospital, Dublin, Ireland
| | - O. Quidwai
- Department of Hepatobiliary and Transplant Surgery, Saint Vincent's University Hospital, Dublin, Ireland
| | - M. Bourke
- Department of Hepatology, Saint Vincent's University Hospital, Dublin, Ireland
| | - TK Gallagher
- Department of Hepatobiliary and Transplant Surgery, Saint Vincent's University Hospital, Dublin, Ireland
| | - E Hoti
- Department of Hepatobiliary and Transplant Surgery, Saint Vincent's University Hospital, Dublin, Ireland
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Based on the IWATE criteria: to investigate the influence of different surgical approaches on the perioperative outcomes of hepatectomy. Surg Endosc 2023; 37:1044-1052. [PMID: 36109356 DOI: 10.1007/s00464-022-09563-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 08/12/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND In terms of perioperative outcomes, compared with traditional open surgery and laparoscopic surgery, studies of robotic liver resection have been limited and must be further clarified. METHODS Clinical data from 465 patients who underwent liver resection were collected in this retrospective study, and the IWATE criteria were used to evaluate the difficulty level of each operation. We compared perioperative outcomes of open, laparoscopic, or robotic approaches for patients with uncomplicated and complex hepatectomy according to different IWATE scores. Among patients with uncomplicated hepatectomy, the median operation time was significantly longer in the robotic liver resection (RLR) group than in the open liver resection (OLR) and laparoscopic liver resection (LLR) groups; however, the RLR group had the shortest hospital stay. There were no significant differences in intraoperative blood loss, conversion rate, total complication rate, or serious complication rate among the three groups. RESULTS Among patients with complex hepatectomy, the RLR group had the smallest intraoperative blood loss and shortest mean length of stay. The cases converted to open hepatectomy were lower in the RLR group than in the laparoscopic group, mainly based on the IWATE score of expert hepatectomy. The incidence of general and serious postoperative complications in the RLR group was significantly lower than that in the OLR and LLR groups. CONCLUSIONS Robotic liver resection is a safe and feasible surgical method that is more advantageous than laparoscopic and open liver resection, especially in complex liver surgery.
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Long-Term Outcomes of Laparoscopic Liver Resection for Centrally Located Hepatocellular Carcinoma. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58060737. [PMID: 35744000 PMCID: PMC9230051 DOI: 10.3390/medicina58060737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 05/24/2022] [Accepted: 05/26/2022] [Indexed: 12/07/2022]
Abstract
Background and Objectives: The feasibility of laparoscopic liver resection (LLR) for centrally located hepatocellular carcinoma (cHCC 1 cm of the hilum, major hepatic veins, and inferior vena cava) is still controversial. This study aims to evaluate the feasibility and safety of LLR for cHCC and compare the perioperative outcomes with those of open liver resection (OLR). Materials and Methods: This retrospective study included 110 patients who underwent LLR (n = 59) or open liver resection (OLR) (n = 51) for cHCC between January 2004 and September 2018. LLR group was divided into the following two subgroups according to the date of operation: Group 1 (n = 19) and Group 2 (n = 40), to account for the advancement in the laparoscopic techniques. Results: No mortality within 3 months was observed. There were no significant differences in operation time (285 vs. 280 min; p = 0.938) and postoperative complication rate (22.0% vs. 27.5%; p = 0.510) between both groups. However, intraoperative blood loss (500 vs. 700 mL; p < 0.001), transfusion rate (10.2% vs. 31.4%; p = 0.006), and hospital stay (6 vs. 10 days; p < 0.001) were significantly lower in the LLR group than in the OLR group. In the LLR group, Group 2, showed a shorter hospital stay than Group 1 (6 vs. 8 days; p = 0.006). There were improvements in the operation time (280 vs. 360 min; p = 0.036) and less intraoperative blood loss (455 vs. 500 mL; p = 0.075) in Group 2. Conclusions: We demonstrated that LLR can be safely performed in highly selected patients with cHCC.
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Delvecchio A, Inchingolo R, Laforgia R, Ratti F, Gelli M, Anelli MF, Laurent A, Vitali G, Magistri P, Assirati G, Felli E, Wakabayashi T, Pessaux P, Piardi T, di Benedetto F, de'Angelis N, Briceño J, Rampoldi A, Adam R, Cherqui D, Aldrighetti LA, Memeo R. Liver resection vs radiofrequency ablation in single hepatocellular carcinoma of posterosuperior segments in elderly patients. World J Gastrointest Surg 2021; 13:1696-1707. [PMID: 35070074 PMCID: PMC8727180 DOI: 10.4240/wjgs.v13.i12.1696] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/30/2021] [Accepted: 11/01/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Liver resection and radiofrequency ablation are considered curative options for hepatocellular carcinoma. The choice between these techniques is still controversial especially in cases of hepatocellular carcinoma affecting posterosuperior segments in elderly patients. AIM To compare post-operative outcomes between liver resection and radiofrequency ablation in elderly with single hepatocellular carcinoma located in posterosuperior segments. METHODS A retrospective multicentric study was performed enrolling 77 patients age ≥ 70-years-old with single hepatocellular carcinoma (≤ 30 mm), located in posterosuperior segments (4a, 7, 8). Patients were divided into liver resection and radiofrequency ablation groups and preoperative, peri-operative and long-term outcomes were retrospectively analyzed and compared using a 1:1 propensity score matching. RESULTS After propensity score matching, twenty-six patients were included in each group. Operative time and overall postoperative complications were higher in the resection group compared to the ablation group (165 min vs 20 min, P < 0.01; 54% vs 19% P = 0.02 respectively). A median hospital stay was significantly longer in the resection group than in the ablation group (7.5 d vs 3 d, P < 0.01). Ninety-day mortality was comparable between the two groups. There were no significant differences between resection and ablation group in terms of overall survival and disease free survival at 1, 3, and 5 years. CONCLUSION Radiofrequency ablation in posterosuperior segments in elderly is safe and feasible and ensures a short hospital stay, better quality of life and does not modify the overall and disease-free survival.
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Affiliation(s)
- Antonella Delvecchio
- Unit of General Surgery, "A. Perrino" Hospital, Ceglie Messapica 70124, Bari, Italy
| | - Riccardo Inchingolo
- Interventional Radiology Unit, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 75100, Italy
| | - Rita Laforgia
- Unit of Laparoscopic Surgery, University of Bari, Bary 70124, Italy
| | - Francesca Ratti
- Unit of Hepato-Pancreatic-Biliary Surgery, University Vita Salute San Raffaele, Milan 20132, Italy
| | - Maximiliano Gelli
- Department of Surgical Oncology, Gustave Roussy Cancer Campus Grand Paris, Villejuif 94800, France
| | | | - Alexis Laurent
- Department of Digestive and Hepatobiliary Surgery, Henry Mondor University Hospital, Creteil 94000, France
| | - Giulio Vitali
- Division of Transplantation, Geneva University Hospital, Geneva 44041, Switzerland
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena 42121, Italy
| | - Giacomo Assirati
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena 42121, Italy
| | - Emanuele Felli
- Department of Digestive Surgery, Strasbourg University Hospital, Strasbourg 67000, France
| | - Taiga Wakabayashi
- Department of Digestive Surgery, Strasbourg University Hospital, Strasbourg 67000, France
| | - Patrick Pessaux
- Department of Digestive Surgery, Strasbourg University Hospital, Strasbourg 67000, France
| | - Tullio Piardi
- Department of Digestive and Hepatobiliary Surgery, Robert Debrè University Hospital, Reims 51100, France
| | - Fabrizio di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena 42121, Italy
| | - Nicola de'Angelis
- Unit of Minimally Invasive and Robotic Digestive Surgery, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70124, Italy
| | - Javier Briceño
- Department of General Surgery, Reina Sofia University Hospital, Cordoba 14004, Spain
| | - Antonio Rampoldi
- Interventional Radiology Unit, Niguarda Hospital, Milan 20162, Italy
| | - Renè Adam
- Department of Hepatobiliary Surgery, Paul Brousse University Hospital, Villejuif 94800, France
| | - Daniel Cherqui
- Department of Hepatobiliary Surgery, Paul Brousse University Hospital, Villejuif 94800, France
| | | | - Riccardo Memeo
- Unit of Hepato-Pancreatic-Biliary Surgery, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70124, Italy
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Laparoscopic posterior segmental resections: How I do it: Tips and pitfalls. Int J Surg 2020; 82S:178-186. [DOI: 10.1016/j.ijsu.2020.06.052] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 06/01/2020] [Accepted: 06/29/2020] [Indexed: 02/08/2023]
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Zhu P, Liao W, Ding ZY, Chen L, Zhang WG, Zhang BX, Chen XP. Learning Curve in Robot-Assisted Laparoscopic Liver Resection. J Gastrointest Surg 2019; 23:1778-1787. [PMID: 30406576 DOI: 10.1007/s11605-018-3689-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/08/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The objective of this study was to evaluate the learning curve effect on the safety and feasibility of robot-assisted liver resection (RALR). METHODS In 140 consecutive cases, all data about demographic, surgical procedure, postoperative course were collected prospectively and analyzed. Risk-adjusted cumulative sum model was used for determining the learning curve based on the need for conversion. RESULTS Among all 140 patients, no patients suffered from any organ dysfunction postoperatively and the operative mortality was 0%. The CUSUM analysis showed that at the 30th consecutive patient, the open conversion rate reached to the average value, and it further improved thereafter. In the last 70 patients, only 3 patients (4.3%) required conversion and 7 patients (10%) needed blood transfusion. Only 1 patient (1.3%) out of 79 patients with HCC had a positive resection margin. Univariate analyses showed the following risk factors associated with significantly higher risks of conversion (P < 0.05): tumor number > 1, lesions in segments 1/4a/7/8, right posterior sectionectomy, and lesions which were beyond the indications of the Louisville statement. Multivariate logistic analysis revealed that both tumor number > 1 (OR: 2.10, P < 0.05) and right posterior sectionectomy (OR: 11.19, P < 0.01) were risk factors of conversion. CONCLUSIONS The robotic approach for hepatectomy is safe and feasible. A learning curve effect was demonstrated in this study after the 30th consecutive patient. The long-term oncological outcomes of robotic hepatectomy still need further investigation.
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Affiliation(s)
- Peng Zhu
- Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Liao
- Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ze-Yang Ding
- Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lin Chen
- Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wan-Guang Zhang
- Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bi-Xiang Zhang
- Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Xiao-Ping Chen
- Department of Surgery, Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Laparoscopic Versus Open Liver Resection for Centrally Located Hepatocellular Carcinoma in Patients With Cirrhosis: A Propensity Score-matching Analysis. Surg Laparosc Endosc Percutan Tech 2019; 28:394-400. [PMID: 30180138 DOI: 10.1097/sle.0000000000000569] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This study aimed to compare the surgical and oncological outcomes of laparoscopic liver resection (LLR) and open liver resection (OLR) for centrally located hepatocellular carcinoma in patients with cirrhosis. Between May 2013 and December 2015, 26 patients underwent pure LLR (14 underwent laparoscopic right anterior sectionectomy and 12 underwent laparoscopic central bisectionectomy). In total, 18 patients in the laparoscopic group and 36 patients in the open group were matched. When the LLR and OLR groups were compared, the operation time was found to be longer in the LLR group. However, LLR was associated with less blood loss, a shorter hospital stay, and earlier time to diet resumption. In this study, we confirmed that LLR for centrally located hepatocellular carcinoma can be safely performed in selected patients with cirrhosis despite a longer operation time.
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Zhu P, Liao W, Ding ZY, Luo HC, Zhang BH, Zhang WG, Zhang W, Zhang ZG, Zhang BX, Chen XP. Intraoperative ultrasonography of robot-assisted laparoscopic hepatectomy: initial experiences from 110 consecutive cases. Surg Endosc 2018; 32:4071-4077. [PMID: 30151749 DOI: 10.1007/s00464-017-5854-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Accepted: 08/22/2017] [Indexed: 01/29/2023]
Abstract
BACKGROUND To evaluate the safety and efficacy of IOUS in robotic liver surgery and propose a standard protocol of IOUS for safe robot-assisted hepatectomy. METHODS Between February 2015 and December 2016, liver resection was performed in 110 patients with robotic approach in Tongji Hospital. In these patients, IOUS was routinely performed. All data about demographic, surgical procedure, postoperative course were collected prospectively and analyzed. RESULTS A four steps IOUS protocol in robotic liver surgery was proposed, including exploration, verification, guidance, and confirmation. A total of 11 additional lesions in 11 patients were detected and 7 patients accepted strategic surgical modification. No patient suffered from any single or multiple organ dysfunctions, and there were no mortalities observed. CONCLUSION IOUS is indispensable to understand lesions and vessels in robotic liver surgery. A four-step standard protocol of IOUS is essential for safe robot-assisted hepatectomy.
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Affiliation(s)
- Peng Zhu
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Liao
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ze-Yang Ding
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong-Chang Luo
- Medical Ultrasound Department, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bin-Hao Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wan-Guang Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhan-Guo Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bi-Xiang Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Xiao-Ping Chen
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Robotic-assisted right posterior segmentectomies for liver lesions: single-center experience of an evolutional method in left semi-lateral position. J Robot Surg 2018; 13:231-237. [PMID: 29995223 DOI: 10.1007/s11701-018-0842-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 07/04/2018] [Indexed: 12/12/2022]
Abstract
Despite the popularity of minimally invasive surgery (MIS) for hepatectomy, limitations in the approach of the right posterior section of the liver remain. Although skills and approach techniques have been developed for hepatectomy of lesions in the posterior segments of the liver, most are performed laparoscopically and are limited to few experienced hands using rigid laparoscopic instruments. In this study, we tried a different approach area via the aid of a flexible robotic system. Since 2012, we have successfully completed more than 200 robotic hepatectomy procedures in our institution. Two different patient settings have been applied for right posterior segment lesions, including supine position as general setting in early cases and left semi-lateral decubitus setting in our later cases. The demographic data and perioperative outcomes between the two groups were analyzed in regard to different positioning. A total of 25 patients with right posterior segment lesions underwent robotic-assisted resection, 13 were placed in supine position and 12 in left semi-lateral position. The left semi-lateral group had significantly shorter operation time (306.0 versus 416.8 min, p = 0.023), less blood loss (203.9 versus 1092.3 mL, p = 0.030), and lower transfusion rates (0 versus 46.2%, p = 0.015). We described an evolutionary technique for robotic right posterior segmentectomies with the patient placed in left semi-lateral position. This method can be applied for most patients easily and is demonstrated as a safe and feasible approach in selected patients owing to its ability to overcome the difficulty of MIS hepatectomy for right posterior lesions.
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Kim WJ, Kim KH, Shin MH, Yoon YI, Lee SG. Totally laparoscopic anatomical liver resection for centrally located tumors: A single center experience. Medicine (Baltimore) 2017; 96:e5560. [PMID: 28121916 PMCID: PMC5287940 DOI: 10.1097/md.0000000000005560] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Laparoscopic major hepatectomy is a common procedure that has been reported frequently; however, laparoscopic resection of centrally located tumors involving segments 4, 5, and 8 remains a technically difficult procedure because it requires 2 transection planes and dissection of numerous branches of the hepatic vein and glissonean capsule compared to hemi-hepatectomy. Here, we present 7 cases of totally laparoscopic right anterior sectionectomy (Lap-RAS) and 3 cases of totally laparoscopic central bisectionectomy (Lap-CBS).Between May 2013 and January 2015, 10 totally laparoscopic anatomical resections of centrally located tumors were performed in our institution. The median age of the patients was 54.2 (38-72) years and the median ICG-R15 was 10.4 (3.9-17.4). There were 8 patients with hepatocellular carcinoma (HCC) and 2 with metastatic colorectal cancer. All the HCC patients has the liver function impairment on the degree of Child-Pugh score A.The mean operation time was 330 ± 92.7 minutes with an estimated blood loss of 325 ± 234.5 mL. Only 1 patient required transfusion during surgery. Mean postoperative hospital stay was 9.5 ± 3.4 day and postop complication was reported only 1 case that has the fluid collection at the resection margin of the liver. Mean resection margin was 8.5 ± 6.1 mm and tumor size was 2.9 ± 1.9 cm.Totally lap-RAS and lap-CBS are feasible operative procedures in patients with centrally located tumor of the liver and particularly in patients with limited liver function such as those with cirrhosis.
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Hepatobilio-pancreatic robotic surgery: initial experience from a single center institute. J Robot Surg 2016; 11:355-365. [PMID: 28039607 DOI: 10.1007/s11701-016-0663-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Accepted: 12/04/2016] [Indexed: 02/07/2023]
Abstract
The use of robotic surgery in the hepatobilio-pancreatic (HBP) field is still limited. Our aim is to present our early experience of robotic liver resection. A retrospective review of robotic pancreatic and liver resection was performed at Sanchinarro University hospital from October 2010 to April 2016. Since the beginning of the robotic program in our center, 22 hepatic procedures and 45 pancreatic robotic procedures have been performed. Of the 21 patients subjected to liver resection, 13 (65%) were for malignancy. There were two left hepatectomies, one right hepatectomy, one associated liver partition and portal vein ligation staged procedure (both steps by robotic approach), three bisegmentectomies and three segmentectomies, eight wedge resections, and three pericystectomies. The mean operating time was 282 min. The overall conversion rate and postoperative complication rate were 4.7 and 19%, respectively. The mean length of hospital stay was 13.4 days (range 4-64 days). Of the 45 patients subjected to pancreatic resection, 22 were male and 23 female. The average age of all patients was 62 years (range 31-82 years). The mean operating room (OR) time was 370 min (120-780 min). Among the procedures performed were 15 pancreatico-duodenectomies, 19 distal pancreatectomies, and 11 enucleations. All procedures in the HBP area were R0. Our early experience shows that robotic surgery is a safe and feasible procedure in the HBP area. The complication and mortality rates are comparable to those of open surgery, but with the advantages of minimally invasive surgery.
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Coelho FF, Kruger JAP, Fonseca GM, Araújo RLC, Jeismann VB, Perini MV, Lupinacci RM, Cecconello I, Herman P. Laparoscopic liver resection: Experience based guidelines. World J Gastrointest Surg 2016; 8:5-26. [PMID: 26843910 PMCID: PMC4724587 DOI: 10.4240/wjgs.v8.i1.5] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 09/07/2015] [Accepted: 11/25/2015] [Indexed: 02/06/2023] Open
Abstract
Laparoscopic liver resection (LLR) has been progressively developed along the past two decades. Despite initial skepticism, improved operative results made laparoscopic approach incorporated to surgical practice and operations increased in frequency and complexity. Evidence supporting LLR comes from case-series, comparative studies and meta-analysis. Despite lack of level 1 evidence, the body of literature is stronger and existing data confirms the safety, feasibility and benefits of laparoscopic approach when compared to open resection. Indications for LLR do not differ from those for open surgery. They include benign and malignant (both primary and metastatic) tumors and living donor liver harvesting. Currently, resection of lesions located on anterolateral segments and left lateral sectionectomy are performed systematically by laparoscopy in hepatobiliary specialized centers. Resection of lesions located on posterosuperior segments (1, 4a, 7, 8) and major liver resections were shown to be feasible but remain technically demanding procedures, which should be reserved to experienced surgeons. Hand-assisted and laparoscopy-assisted procedures appeared to increase the indications of minimally invasive liver surgery and are useful strategies applied to difficult and major resections. LLR proved to be safe for malignant lesions and offers some short-term advantages over open resection. Oncological results including resection margin status and long-term survival were not inferior to open resection. At present, surgical community expects high quality studies to base the already perceived better outcomes achieved by laparoscopy in major centers’ practice. Continuous surgical training, as well as new technologies should augment the application of laparoscopic liver surgery. Future applicability of new technologies such as robot assistance and image-guided surgery is still under investigation.
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The superficial precoagulation, sealing, and transection method: a "bloodless" and "ecofriendly" laparoscopic liver transection technique. Surg Laparosc Endosc Percutan Tech 2015; 25:e33-e36. [PMID: 24752166 PMCID: PMC4311999 DOI: 10.1097/sle.0000000000000051] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Minimizing blood loss is an important aspect of laparoscopic liver resection. Liver transection is the most challenging part of liver resection, but no standard method is available for this step at present. Herein, we have introduced the superficial precoagulation, sealing, and transection (SPST) method, a potentially “bloodless” and “ecofriendly” laparoscopic liver transection technique involving reusable devices: the VIO soft-coagulation system; VIO BiClamp (bipolar electrosurgical coagulation); Olympus SonoSurg (ultrasonic surgical system); and CUSA (ultrasonic aspirator). Furthermore, we have reported the short-term outcomes of laparoscopic liver transection with the SPST method. Methods: The study included 14 consecutive patients who underwent laparoscopic partial liver resection with the SPST method at a single institution between August 2008 and June 2010. Results: The median operative time was 201 minutes (range, 97 to 332 min) and the median blood loss was 5 mL (range, 5 to 250 mL). There was no requirement for blood transfusion, no intraoperative complications, and no cases of conversion to open laparotomy. There were no liver transection-related complications such as postoperative bile leakage, bleeding, or infection. All surgical margins were negative, with a mean margin of 4.6 mm, and no local recurrence was observed at an average follow-up of 37.6 months. Conclusions: The SPST method is a simple, efficient, and cost-effective surgical technique for laparoscopic liver resection. It is associated with low intraoperative blood loss and good short-term outcomes. We recommend that the SPST method should be used as a standard technique for laparoscopic liver transection (Supplemental Digital Content 1, http://links.lww.com/SLE/A103).
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Abstract
Supplemental Digital Content is available in the text. Laparoscopic liver resection is gaining popularity because of the availability of new laparoscopic instruments and advanced techniques. Laparoscopic liver mobilization is not only necessary for pure laparoscopic liver resection but also for laparoscopy-assisted hepatectomy. Laparoscopy-assisted hepatectomy significantly reduces the length of the laparotomy incision, and it is a good educational transition to the more advanced laparoscopic liver resection. Laparoscopic liver mobilization is a simple and easy procedure if surgeons know what challenges to expect. Here, the technique of liver mobilization is summarized, along with those challenges.
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Single-port and multi-port laparoscopic left lateral liver sectionectomy for treating benign liver diseases: a prospective, randomized, controlled study. World J Surg 2015; 38:2668-73. [PMID: 24867469 DOI: 10.1007/s00268-014-2610-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The use of single-port laparoscopy for left-lateral liver sectionectomy (LLLS) has been reported in the literature, but the effectiveness and safety of LLLS has not been validated in randomized, controlled trials. This prospective randomized controlled trial compared the effectiveness and safety of single-port and multi-port laparoscopic LLLS for the surgical treatment of benign liver disease. METHODS Altogether, 38 patients aged 17-65 years (16 men, 22 women) with benign liver diseases were hospitalized for elective laparoscopic LLLS between January 2010 and December 2012. Patients were randomly assigned to either single-port (n = 19) or multi-port (n = 19) laparoscopic LLLS. Main outcome measures were operative time, volume of intraoperative blood loss, complication rates, and postoperative hospitalization. RESULTS Baseline characteristics of the two groups were comparable. Single-port and multi-port laparoscopies were successfully completed in all but one patient (1/19, 5.3 %) who required conversion from a single-port to a multi-port procedure. The two groups had similar mean operative times and volumes of intraoperative blood loss. There were no clinically significant postoperative complications or deaths. The single-port group had a significantly shorter postoperative hospitalization than the multi-port group (2.5 ± 1.7 vs. 4.0 ± 2.1 days; p < 0.05). CONCLUSIONS Single-port laparoscopic LLLS is a technically feasible, effective, safe alternative to multi-port laparoscopy for the treatment of benign liver diseases in cautiously selected patients.
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Di Benedetto F, Ballarin R, Tarantino G. Totally robotic isolated caudate-lobe liver resection for hydatid disease: report of a case. Int J Med Robot 2015; 12:254-61. [PMID: 26183233 DOI: 10.1002/rcs.1685] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hepatic caudatectomy has always been considered a challenging procedure, because of the complex anatomy and deep location of this segment. Herein we report the first case of a totally robotic isolated caudate-lobe liver resection ever performed for hydatid disease. METHODS A 55 year-old man was referred to our institution after diagnosis was made of a 5.6 cm hepatic lesion of the caudate lobe. Radiological suspicion was for hydatid disease. The patient underwent robotic-assisted hepatic caudatectomy. RESULTS The operative time was 280 min and the estimated blood loss was 200 ml. The postoperative course was uneventful. The drain was removed on post-operative day 3 and the patient was discharged on post-operative day 6. CONCLUSION Robotic resection of the caudate lobe is a technically feasible procedure, which nevertheless requires high hepato-pancreato-biliary surgery skills, both in open an mini-invasive approaches. It provides several technical advantages in the field of mini-invasive surgery, yet assuring patient safety. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberto Ballarin
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Giuseppe Tarantino
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, Modena, Italy
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Abstract
Hepatobiliary (HB) surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive HB surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant to adopt the approach. Recently development of the robotic platform has provided a tool that can overcome many of the limitations of conventional laparoscopic HB surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon's movements, and high-definition three-dimensional vision provided by the stereoscopic camera combine to allow steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive HB and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted HB surgery.
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Park J, Kim S, Song I, Chun K. Experience of laparoscopic liver resection for various liver diseases. KOREAN JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2014; 18:112-7. [PMID: 26155262 PMCID: PMC4492348 DOI: 10.14701/kjhbps.2014.18.4.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 11/07/2014] [Accepted: 11/16/2014] [Indexed: 12/23/2022]
Abstract
Backgrounds/Aims We present our experience of laparoscopic liver resection for various liver diseases. Methods From April 2008 to August 2012 in Chungnam National University, 68 of 253 liver resections were performed laparoscopically. During the first year, laparoscopy-assisted liver resection was mainly performed and subsequently totally laparoscopic liver resection was the main operative type. Surgery type for treatment purposes was decided preoperatively. Clinical data were collected retrospectively and analyzed. Results Preoperatively, 43 patients (63.2%) were diagnosed with benign disease, 19 patients (27.9%) were malignant liver tumors and 6 patients (8.8%) were indeterminate liver tumor but favorable towards malignancy. Anatomical major liver resection was performed in 58 cases (85.3%) and 10 cases (14.7%) were non-anatomical resection. Left hemihepatectomy was performed in 38 cases (55.8%) followed by left lateral sectionectomy in 18 cases (26.5%), and segment IV and IVa segmentectomy, were each in 1 case. Mean operation time was 235.0 minutes (range, 60-470) and 14 patients (18.6%) had intraoperative transfusion. Mean postoperative hospital stay was 10.2 days (range, 4-32). Mean operation time of laparoscopy-assisted left lobectomy was 317 minutes and totally laparoscopic left lobectomy was 281 minutes, but there was no significant statistical difference between these two operation types. There were 11 episodes of postoperative complications in 8 patients. There was no mortality after laparoscopic liver resection. Conclusions We concluded that laparoscopic liver resection is a feasible operation, but needs to be carefully conducted in malignant tumors.
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Affiliation(s)
- Juhong Park
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Seokhwan Kim
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Insang Song
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
| | - Kwangsik Chun
- Department of Surgery, Chungnam National University Hospital, Daejeon, Korea
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Alkhalili E, Berber E. Laparoscopic liver resection for malignancy: A review of the literature. World J Gastroenterol 2014; 20:13599-13606. [PMID: 25309091 PMCID: PMC4188912 DOI: 10.3748/wjg.v20.i37.13599] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 02/07/2014] [Accepted: 06/05/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To review the published literature about laparoscopic liver resection for malignancy.
METHODS: A PubMed search was performed for original published studies until June 2013 and original series containing at least 30 patients were reviewed.
RESULTS: All forms of hepatic resections have been described ranging from simple wedge resections to extended right or left hepatectomies. The usual approach is pure laparoscopic, but hand-assisted, as well as robotic approaches have been described. Most studies showed comparable results to open resection in terms of operative blood loss, postoperative morbidity and mortality. Many of them showed decreased postoperative pain, shorter hospital stays, and even lower costs. Oncological results including resection margin status and long-term survival were not inferior to open resection.
CONCLUSION: In the hands of experienced surgeons, laparoscopic liver resection for malignant lesions is safe and offers some short-term advantages over open resection. Oncologically, similar survival rates have been observed in patients treated with the laparoscopic approach when compared to their open resection counterparts.
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Kirchberg J, Weitz J. [Minimally invasive surgery of primary and secondary liver tumors : indications, techniques and results]. Chirurg 2014; 85:689-95. [PMID: 25052816 DOI: 10.1007/s00104-014-2756-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Initially, mainly superficial liver lesions were resected laparoscopically but now even major resections are performed using a minimally invasive procedure. Careful selection of suitable patients is of key importance. AIMS AND METHODS This article describes the current state of the art in patient selection and choice of the appropriate laparoscopic technique based on a review of the recent literature. Perioperative and oncological outcome parameters of laparoscopic liver resection are presented. RESULTS Laparoscopic liver resection offers significant benefits compared to open liver resection in terms of reduced intraoperative blood loss, reduced overall and liver-specific complications and length of hospital stay without compromising oncological outcomes. CONCLUSION Lesions in the peripheral anterolateral segments (segments 2, 3, 4b, 5 and 6) are particularly suitable for laparoscopic liver resection. Access to the posterosuperior segments 1, 4a, 7 and 8 is more challenging but safe and feasible in experienced centers.
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Affiliation(s)
- J Kirchberg
- Klinik und Poliklinik für Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Deutschland,
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Yuan Z, Tian L, Wang P, Song Y, Dong Y, Zhuang H. Comparative research on the efficacy of CyberKnife® and surgical excision for Stage I hepatocellular carcinoma. Onco Targets Ther 2013; 6:1527-32. [PMID: 24194645 PMCID: PMC3814930 DOI: 10.2147/ott.s51452] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To retrospectively analyze and compare the outcomes of patients with hepatocellular carcinoma treated with either surgical excision or CyberKnife® from September 2006 to August 2011. MATERIALS AND METHODS Local control and toxicity were the primary endpoints, followed by local progression-free survival, progression-free survival, and overall survival as the secondary endpoints. Response Evaluation Criteria In Solid Tumors were the evaluation criteria for efficacy; Common Toxicity Criteria 3.0 were the evaluation criteria for adverse events. Local control was calculated using the direct method (nonactuarial). The survival curves were drawn using the Kaplan-Meier method along with log-rank test analysis. RESULTS The research included 26 patients treated with tumor-free cutting edge (R0) surgical excision and 22 patients treated with CyberKnife treatment. The results showed that the adverse effects of CyberKnife were milder, with 1-, 2-, and 3-year local control rates of 92.9%, 90.0%, and 67.7%, respectively. The overall survival rates of the surgical treatment were 88.5%, 73.1%, and 69.2% for the same periods, while those of CyberKnife treatment were 72.7%, 66.7%, and 57.1%, respectively. In this study, surgical excision appeared to prolong overall survival to a greater extent, but with no statistical significance; no statistical difference was observed in the tumor-specific overall survival and progression-free survival between the two cohorts. CONCLUSION According to this preliminary study, with its mild toxicity, the efficacy of CyberKnife treatment for early hepatocellular carcinoma was on par with that of surgical resection.
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Affiliation(s)
- Zhiyong Yuan
- Department of Radiotherapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin, People's Republic of China
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Milone L, Coratti A, Daskalaki D, Fernandes E, Giulianotti PC. [Robotic hepatobiliary and gastric surgery]. Chirurg 2013; 84:651-64. [PMID: 23942961 DOI: 10.1007/s00104-013-2581-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Hepatobiliary surgery is a challenging surgical subspecialty that requires highly specialized training and an adequate level of experience in order to be performed safely. As a result, minimally invasive hepatobiliary surgery has been met with slower acceptance as compared to other subspecialties, with many surgeons in the field still reluctant about the approach. On the other hand, gastric surgery is a very popular field of surgery with an extensive amount of literature especially regarding open and laparoscopic surgery but not much about the robotic approach especially for oncological disease. Recent development of the robotic platform has provided a tool able to overcome many of the limitations of conventional laparoscopic hepatobiliary surgery. Augmented dexterity enabled by the endowristed movements, software filtration of the surgeon's movements, and high-definition three-dimensional vision provided by the stereoscopic camera, allow for steady and careful dissection of the liver hilum structures, as well as prompt and precise endosuturing in cases of intraoperative bleeding. These advantages have fostered many centers to widen the indications for minimally invasive hepatobiliary and gastric surgery, with encouraging initial results. As one of the surgical groups that has performed the largest number of robot-assisted procedures worldwide, we provide a review of the state of the art in minimally invasive robot-assisted hepatobiliary and gastric surgery.The English full-text version of this article is available at SpringerLink (under supplemental).
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Affiliation(s)
- L Milone
- Department of Surgery, Division of Minimally Invasive and Robotic Surgery, University of Illinois at Chicago, 840 S Wood MC 958 Room 435 E, 60612, Chicago, IL, USA
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