review article robotic liver resection - · pdf file 15 abstract minimally invasive...

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    Minimally invasive liver surgery has continued to evolve over the past few decades since its introduction in the 1990s. Although laparoscopic liver surgery is becoming the standard of care, particularly for favorable minor liver resection, its feasibility in advanced and complexed cases is still limited and it is mostly performed in a few high volume liver centers. The advent of robotic surgery, albeit still in the early phases, has enhanced the capability of surgeons to operate on more complex cases in a minimally invasive manner. Equipped with advantageous instruments (a stable camera offering a 3-dimensional view, wristed instruments, no tremors, and improved ergonomics), robotic surgery allows surgeons to perform major hepatectomies, operate on posteriorly-located tumors (segments 7 and 8), perform liver surgery requiring complex biliary reconstructions, and even perform donor hepatectomies. More importantly, the surgical outcomes of robotic surgery do not compromise the patient's safety, with comparable outcomes or even better outcomes than a laparoscopic approach. Several studies have reported better performance of robotic surgery in terms of perioperative outcomes such as less blood loss, fewer complications, and decreased length of hospital stay compared to laparoscopic surgery. Emergence of new robotic systems in the market will likely decrease the high costs of robotic surgery, which will further expand the population who will benefit from minimally invasive surgery. However, further randomized and multicenter trials need to be undertaken to clearly delineate the advantages of robotic surgery over laparoscopy.

    Keywords: Robotic surgery; Liver resection; Surgical outcomes


    Since Mouret performed the first laparoscopic cholecystectomy in 1987, there has been a dramatic revolution in the surgical arena [1]. With continued technological advances, laparoscopy is now being utilized for various surgical procedures [2]. Although laparoscopic liver resection has been performed since the 1990s, it is still not yet widely used, unlike laparoscopic gastrointestinal procedures. Nevertheless, continued refinement of surgical techniques and the evolution of surgical instruments has resulted in improvement in the clinical outcomes of minimally invasive surgery, and less complex laparoscopic liver resection was standardized in 2008 in Louisville [3]. This procedure was subsequently updated in 2015

    Ann Robot Innov Surg. 2020 Feb;1(1):15-32 pISSN 2635-6678·eISSN 2635-666X

    Review Article

    Received: Oct 10, 2019 Accepted: Jan 7, 2020

    Correspondence to Gi Hong Choi Department of Surgery, Yonsei University College of Medicine, Alffred I. Ludlow Faculty Building, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea. E-mail:

    Copyright © 2020 The Korean Association of Robotic Surgeons This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https:// which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

    ORCID iDs Jonathan Geograpo Navarro Seoung Yoon Rho Gi Hong Choi

    Conflict of Interest The authors have no conflict of interest to declare

    Author Contributions Conceptualization: Navarro JG, Choi GH; Data curation: Rho SY; Investigation: Navarro JG; Methodology: Navarro JG, Rho SY, Choi GH; Supervision: Choi GH; Validation: Choi GH; Visualization: Navarro JG, Choi GH; Writing - original draft: Navarro JG; Writing - review & editing: Navarro JG, Choi GH.

    Jonathan Geograpo Navarro ,1 Seoung Yoon Rho ,2 Gi Hong Choi 2

    1Department of Surgery, Vicente Sotto Memorial Medical Center, Cebu City, Philippines 2Department of Surgery, Yonsei University College of Medicine, Seoul, Korea

    Robotic Liver Resection

  • by Marioka [4] to include more complex and difficult procedures. The advantages of this procedure, such as fewer complications, less blood loss, and decreased length of hospital stay relative to laparoscopic surgery are well documented [5]. However, certain caveats are associated with the propagation of laparoscopic liver surgery. One of these is the innate complexity of the procedure itself in terms of hilar dissection and parenchymal transection, which requires more advanced laparoscopic skills [6]. This sophisticated procedure has a steep learning curve and therefore requires a long surgical experience [7,8]. As such, until recently, laparoscopic liver resection was generally performed only in high volume centers by expert surgeons.

    The inherent limitations of the surgeon's dexterity in laparoscopic surgery and the resulting technical complexity might potentially be overcome by use of robotic surgical systems. Since the first robotic cholecystectomy was successfully performed in 1997 [9] using the da Vinci® Surgical System, this new technology has gradually gained popularity. Its key advantages compared to laparoscopic surgery include an augmented three-dimensional view, stable camera, greater freedom of motion of surgical instruments, no tremors, and improved ergonomics for the operator [10]. These advantages have been demonstrated in subspecialties such as urologic, gynecologic, and rectal procedures where the application of robotic surgery is widely implemented and standardized [11]. Despite these advantages, however, the high costs of robotic surgery remain one of the reasons for the slow penetration of robotic liver surgery in the surgical arena. In terms of cost-effectiveness, its superiority compared to laparoscopic surgery remains unjustified. Although some reports argue that the cost-effectiveness of the robotic system should be evaluated taking into consideration improved perioperative outcomes, including fewer complications and early discharge of patients [12,13], more data is required. Moreover, some scenarios require complex manipulation that are beyond the capabilities of currently available laparoscopic instruments; in this context, robotic endowrist movement is greatly advantageous.

    Evidence to support the superiority of robotic liver resection relative to laparoscopic liver resection is lacking. Therefore, the present review focuses on the feasibility and safety of robotic liver resection and presents some unique advantages of robotic surgery over laparoscopic surgery.

    APPLICATION OF THE DA ROBOTIC SURGICAL SYSTEM FOR PRECISE LIVER RESECTION Minimally invasive liver surgery remains one of the most challenging procedures to perform because of the complex anatomy of the liver, which is a highly vascular organ. However, advancements in preoperative imaging modalities have facilitated better delineation of vascular anatomy, and this together with refinement of surgical laparoscopic instruments and energy devices and continued improvements in perioperative management have made liver surgery safe to perform [3,14]. Since the International Consensus Conference (ICC) held in Louisville in 2008, the growth of laparoscopic liver resection has increased exponentially worldwide, especially among high volume centers in Europe and the United States [15-17]. In line with the second ICC in Marioka, laparoscopic liver resection is continually expanding to encompass a higher degree of complexity, such as superior-posterior segment surgery [18]. Despite this, only 32% of liver resections were performed laparoscopically according to an international survey in which 27 centers worldwide participated; of these liver resections,


    Robotic Liver Surgery

  • 74% were minor operations [19]. Thus, from a technical point of view, laparoscopic liver resection, particularly major resection, remains a challenging procedure that requires a highly trained and experienced surgeon.

    Robotic surgical systems may theoretically be superior to a laparoscopic approach because of the following unique features of robotic systems: 1) a 3-dimensional (3D) view with a stable camera, 2) wristed instruments with no tremors, and 3) improved ergonomics. These key features can potentially allow the surgeon to perform more precise and complex operations [20,21]. Giulianotti et al. [22] demonstrated the key advantages of the da Vinci® Surgical System during hilar and hepatocaval dissection for liver resection. Hilar dissection is facilitated by a stable, magnified, high-quality 3D camera view and fine endowrist movement of the instruments. As such, a robotic surgical system can clearly identify, isolate, and safely handle hilar vascular structures, which require fine and delicate dissection. Choi et al. [23] emphasized that caudate branches from the portal vein can be meticulously isolated and suture ligated using a robotic surgical system; these procedures are difficult to perform laparoscopica

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