Short-Term Outcomes After Robotic Versus Open Liver Resection: A Systematic Review and Meta-analysis

Robotic versus laparoscopic liver resection for difficult posterosuperior segments: a systematic review with a meta-analysis of propensity-score matched studies

BACKGROUND

The outcomes of minimally invasive liver surgery for posterosuperior segments (PS) are still debated. Since the results of ongoing trials focusing on the results of laparoscopic liver resection (LLR) and robotic liver resection (RLR) in this setting are still awaited, the best evidence currently comes from retrospective propensity-score matched (PSM) studies. The aim of this meta-analysis was to assess the outcomes of RLR for difficult located lesions and to provide evidence for its use in clinical practice.

METHODS

A systematic review with meta-analysis was conducted to evaluate the safety and efficacy of LLR and RLR for PS segments. The Medline, Embase and Web of Science Library electronic databases were searched to identify available research published up to June 2024.

RESULTS

Five studies with a total of 2907 patients (RLR: n = 1084; LLR: n = 1823) were included in the meta-analysis. The RLR group had less estimated blood loss (EBL) (MD: - 88.3, 95% CI - 144.2-- 32.3; p = 0.012), fewer blood transfusions (OR 0.70, 95% CI 0.39-0.80, p = 0.033), and a shorter operative time (MD - 27.3, 95% CI - 49.4-- 5.1; p = 0.027). No differences in postoperative morbidity, mortality and R1 resection rates were observed.

CONCLUSION

RLR for lesions in the PS segments are safe and effective, and may have superior surgical outcomes than LLR.

A Systematic Review of Current Practices, Challenges, and Future Directions for the Use of Robotic Surgery in Otolaryngology in Greece

Robotic surgery is increasingly used in otolaryngology (ENT), particularly for complex head and neck procedures. It offers various advantages, including limited postoperative pain, excellent aesthetic results, better visualization in the surgical field, enhanced dexterity due to movement adjustment by the robotic system, and minimal complications and hospital stay. However, robotic systems' higher cost and limited availability are a burden for clinical applications. This systematic review is a detailed assessment that looks at the existing situation, problems, and prospects for robotic ENT surgery in Greece. It is based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The included studies were chosen based on specific criteria after a thorough inspection of electronic databases of clinical trials and medical journals (PubMed, Scopus, Web of Science). Despite steady adoption, Greece needs to catch up with other European countries in deploying robotic surgery technology. Various possible reasons may cause the small number of ENT robotic-assisted surgeries, including the high cost and the availability of robotic systems, mainly in large private or public hospitals in the main cities of Greece (Athens and Thessaloniki). Training on robotic systems is also very limited for surgery residents and young surgeons, while the learning curve of robotic-assisted surgeries in ENT is big. Peer-reviewed literature was analyzed to compare it with other European nations and investigate the economic, training, and geographic aspects that may be a burden for the rise of robotic surgery in Greece. Through the review scope, this study also provided recommendations concerning the implementation of robotic surgery in daily practice among surgeons in Greece and the difficulties that may arise regarding robotic surgery training in resource-limited countries.

Robotic-Assisted Versus Open Hemi-Hepatectomy: A Propensity Score Analysis

INTRODUCTION

The robotic-assisted surgical system has been widely used in hepatectomy. However, the effectiveness and feasibility of robotic-assisted hemi-hepatectomy (RH) has not been well-documented.

METHODS

Patients who underwent RH or open hemi-hepatectomy (OH) performed by a single surgeon at our hospital between January 2010 and August 2023 were included in this study. A stabilized inverse probability of treatment weighting adjusted analysis was performed.

RESULTS

Of the 163 consecutive patients identified, 60 underwent RH, and 103 underwent OH. After stabilized inverse probability of treatment weighting adjustment, RH demonstrated less blood loss than OH. In subgroup analyses, robotic-assisted left hemi-hepatectomy was associated with a shorter postoperative stay, a lower postoperative complication rate, and less blood loss compared with open left hemi-hepatectomy. While robotic-assisted right hemi-hepatectomy (RRH) was associated with less blood loss and a lower intraoperative blood transfusion rate, but a longer operation time compared with open right hemi-hepatectomy.

CONCLUSIONS

RH is a safe and effective technique. In addition to less blood loss, robotic-assisted left hemi-hepatectomy had advantages in postoperative complications and postoperative stay, while RRH had advantages in intraoperative blood transfusions. However, operation time was longer for RRH than for open right hemi-hepatectomy.

Essential updates 2022/2023: A review of current topics in robotic hepatectomy

The liver requires careful handling intra-operatively owing to its vital functions and complexity. Traditional open hepatectomy, while standard, is invasive and requires long recovery periods. Laparoscopic hepatectomy is a less invasive option, with its own challenges. The rise of robotic surgery, such as the da Vinci® system, improves precision and control, addressing the limitations of conventional methods, but brings new concerns, such as costs and training. This review focuses on the latest advancements in robotic hepatectomy from 2022/23 articles, delving into topics like "robotic surgery in liver transplantation," "robotic hepatectomy for hilar cholangiocarcinoma," "robotic vascular reconstruction following hepatectomy," "robotic repeat hepatectomy," and "prospective trials in robotic hepatectomy." To retrieve articles, a focused literature search was conducted using PubMed for articles from 2022/23 with a 5-year filter, excluding reviews. Initially, abstracts were screened, and relevant articles on robotic surgery were examined in full for inclusion in this review. Although all the above items are cutting-edge, and many of the references are necessarily at the level of case reports, recent articles are still accompanied by surgical videos, which are useful to readers, especially surgeons who are considering imitating the procedures. In summary, we examined the recent advancements in robotic liver resection. The inclusion of videos that present new techniques aids in knowledge transfer. We anticipate the continued growth of this field of research.

3D visualization systems improve operator efficiency during difficult laparoscopic cholecystectomy: a retrospective blinded review of surgical videos

BACKGROUND

3D visualization systems in laparoscopic surgery have been proposed to improve manual task handling compared to 2D, however, few studies have compared the intra-operative efficacy in laparoscopic cholecystectomy (LC). The aim of this study is to determine if there is a benefit in intra-operative efficiency when using a 3D visualization system in difficult LC compared to traditional 2D visualization systems.

METHODS

Retrospective analysis of 'difficult' LCs (Grades 3 or 4) was completed. The assessor was blinded as all cases were recorded and viewed in 2D only. Variables collected included time to complete steps, missed hook diathermy attempts, failed grasp attempts, missed clip attempts and preparation steps for intra-operative cholangiogram (IOC). Multiple linear regression was undertaken for time variables, Poisson regression or negative binomial regression was completed for continuous variables.

RESULTS

Fifty-two operative videos of 'difficult' LC were reviewed. 3D systems were associated with reduced operative times, although this was not statistically significant (CI: -2.93-14.93, P-value = 0.183). Dissection of the anterior fold to achieve the critical view of safety was significantly faster by 3.55 min (CI: 1.215-9.206, P-value = 0.002), and with considerably fewer errors when using 3D systems. Fewer IOC preparation errors were observed with a 3D system compared with a 2D system.

CONCLUSIONS

3D systems appear to enhance operator efficiency, allowing faster completion of critical steps with fewer errors. This pilot study underscores the utility of video annotation for intra-operative assessment and suggests that, in larger multi-centre studies, 3D systems may demonstrate superior intra-operative efficiency over 2D systems during a 'difficult' LC.

Comparative study of operative expenses: robotic vs. laparoscopic vs. open liver resections at a university hospital in the UK

Robotic liver resections (RLR) are increasingly being performed and has previously been considered more costly. The aim is to explore the cost of RLR compared with laparoscopic and open liver resection in a single National Health Service (NHS) hospital. A retrospective review of patients who underwent RLR, LLR, and OLR from April 2014 to December 2022 was conducted. The primary outcomes were the cost of consumables and median income, and the secondary outcomes were the overall length of stay and mortality at 90 days. Overall, 332 patients underwent liver resections. There were 204 males (61.4%) and 128 females (38.6%), with a median age of 62 years (IQR: 51-77 years). Of these, 60 patients (18.1%) underwent RLR, 21 patients (6.3%) underwent LLR, and 251 patients (75.6%) underwent OLR. Median consumables cost per case was £3863 (IQR: £3458-£5061) for RLR, £4326 (IQR: £4273-£4473) for LLR, and £4,084 (IQR: £3799-£5549) for the OLR cohort (p = 0.140). Median income per case was £7999 (IQR: £4509-£10,777) for RLR, £7497 (IQR: £2407-£14,576) for LLR, and £7493 (IQR: £2542-£14,121) for OLR. The median length of stay (LOS) for RLR was 3 days (IQR: 2-4.7 days) compared to 5 days for LLR (IQR: 4.5-7 days) and 6 days for OLR (IQR: 5-8 days, p < 0.001). Within the NHS, RLR has consumable costs comparable to OLR and LLR. It is also linked with a shorter LOS and generates similar income for patients undergoing OLR and LLR.

Prince and princesses: The current status of robotic surgery in surgical oncology

Robotic surgery has experienced a dramatic increase in utilization across general surgery over the last two decades, including in surgical oncology. Although urologists and gynecologists were the first to show that this technology could be utilized in cancer surgery, the robot is now a powerful tool in the treatment of gastrointestinal, hepato-pancreatico-biliary, colorectal, endocrine, and soft tissue malignancies. While long-term outcomes are still pending, short-term outcomes have showed promise for this technologic advancement of cancer surgery.

Robotic hepatectomy: current evidence and future directions

Minimally invasive hepatectomy continues to gain popularity and acceptance for treatment of benign and malignant liver disease. Robotic hepatectomy offers potential advantages over open and conventional laparoscopic approaches. Review of the literature on robotic hepatectomy was performed. Search terms included "robotic hepatectomy" and "minimally invasive hepatectomy." Search was further customized to include articles related to robotic surgical technology. Across many parameters in liver surgery, robotic liver resection appears to have comparable outcomes with respect to laparoscopic resection. The benefits over open resection are largely related to less morbidity and faster recovery times. There is evidence that the robotic approach may have a shorter learning curve and enable more difficult resections to be performed minimally invasively. The robotic platform may have the potential to achieve superior margin status or parenchymal sparing resection in oncologic resections, but numerous obstacles remain. The robotic platform has not been applied to liver surgery to the same extent as either laparoscopic or open surgery. Robotic surgical technology will need to continue developing to deliver on its potential advantages.

Implementation of a patient blood management in an Italian City Hospital: is it effective in reducing the use of red blood cells?

To evaluate the effect of patient blood management (PBM) since its introduction, we analyzed the need for transfusion and the outcomes in patients undergoing abdominal surgery for different types of tumor pre- and post-PBM. Patients undergoing elective gastric, liver, pancreatic, and colorectal surgery between 2017 and 2020 were included. The implementation of the PBM program was completed on May 1, 2018. The patients were grouped as follows: those who underwent surgery before the implementation of the program (pre-PBM) versus after the implementation (post-PBM). A total of 1302 patients were included in the analysis (445 pre-PBM vs. 857 post-PBM). The number of transfused patients per year decreased significantly after the introduction of PBM. A strong tendency for a decreased incidence of transfusion was evident in gastric and pancreatic surgery and a similar decrease was statistically significant in liver surgery. With regard to gastric surgery, a single-unit transfusion scheme was used more frequently in the post-PBM group (7.7% vs. 55% after PBM; p = 0.049); this was similar in liver surgery (17.6% vs. 58.3% after PBM; p = 0.04). Within the subgroup of patients undergoing liver surgery, a significant reduction in the use of blood transfusion (20.5% vs. 6.7%; p = 0.002) and a decrease in the Hb trigger for transfusion (8.5, 8.2-9.5 vs. 8.2, 7.7-8.4 g/dl; p = 0.039) was reported after the PBM introduction. After the implementation of a PBM protocol, a significant reduction in the number of patients receiving blood transfusion was demonstrated, with a strong tendency to minimize the use of blood products for most types of oncologic surgery.