Robot-assisted laparoscopic extended right hepatectomy with biliary reconstruction

Revisiting resectability of biliary tract cancers, in the triplet drug therapy era with immune checkpoint inhibitors

Biliary tract cancers (BTCs) include intrahepatic, perihilar, distal cholangiocarcinoma, gallbladder cancer, and sometimes papillary Vater cancer. The incidence of BTCs varies worldwide (0.3-85.0/100,000 population). In Japan, the incidence is lowest, but it is increasing (22,000 cases/ year). The 5-year overall survival (OS) in patients with localized BTC is approximately 60%, which is better than that in liver or pancreatic cancer, but is < 5% in patients with metastatic cancers. Surgery requires liver and pancreas surgery with vascular reconstruction, and is associated with a high perioperative mortality rate (> 2%) relative to other cancer surgeries (< 1%). As an adjuvant therapy, fluorouracil prodrugs are effective for improving OS (hazard ratio [HR] 0.69-0.81); however, in patients who receive major hepatectomy, the completion rate is reportedly low (60%). Since 2010, gemcitabine + cisplatin (GC) has become the first-line therapy for unresectable lesions. Subsequently, in 2023-2024 three triplet regimens were reported: GC + S-1(tegafur-gimeracil-oteracil), GC + durvalumab (an anti-PD-L1 antibody), and GC + pembrolizumab (an anti-PD-1 antibody). HRs for OS were 0.79-0.83, objective response rates were 27-42% (GC, 15-29%), and tumor control rates were 75-85% (GC, 62-83%) with small increases in adverse events. In this review, considering the eligibility criteria of currently ongoing neoadjuvant studies, we report two borderline resectable cases with a discussion on resectability. Owing to the high-risk nature of the surgery and to avoid early recurrence due to subclinical metastasis during postoperative recovery, these three triplet regimens for unresectable tumors may change the concept of resectability in BTC.

Robotic surgery for perihilar cholangiocarcinoma: a concise systematic review

BACKGROUND

Perihilar cholangiocarcinoma (PHC) is a challenging malignancy with a poor prognosis, and the role of robotic surgery in its management remains debated. This systematic review aims to assess the feasibility of robotic surgery for PHC.

METHODS

A systematic literature search was conducted following PRISMA guidelines in Medline, Cochrane Library, and Web of Science for English-language studies on robotic surgery for PHC between 2000 and 2024.

RESULTS

Of the initial 405 manuscripts identified, five studies comprising 110 patients met the inclusion criteria. Pooled analysis showed that operative time ranged from 276 (170-500) to 840 (770-890) minutes, with intraoperative blood loss between 125 (50-425) and 700 (600-800) ml. The rates of overall and major morbidity were 50.0% and 13.6%, respectively. The 30-day and 90-day postoperative mortality rates were 1.8% and 1.9%, respectively. R0 resections were achieved in 78.2% of patients, with a median lymph node retrieval of 7 (8 ± 6.6) to 11 (6-31). Follow-up duration ranged from 7.5 (8.3 ± 2.3) to 15 (19 ± 16) months, recurrence was observed in 14.3% (6/42) of patients.

CONCLUSIONS

Robotic surgery for PHC demonstrates promising perioperative outcomes; however, further studies are needed to assess its long-term oncological efficacy compared with traditional approaches.

The Current Role of Single-Site Robotic Approach in Liver Resection: A Systematic Review

BACKGROUND

Liver resection is a critical surgical procedure for treating various hepatic pathologies. Minimally invasive approaches have gradually gained importance, and, in recent years, the introduction of robotic surgery has transformed the surgical landscape, providing potential advantages such as enhanced precision and stable ergonomic vision. Among robotic techniques, the single-site approach has garnered increasing attention due to its potential to minimize surgical trauma and improve cosmetic outcomes. However, the full extent of its utility and efficacy in liver resection has yet to be thoroughly explored.

METHODS

We conducted a comprehensive systematic review to evaluate the current role of the single-site robotic approach in liver resection. A detailed search of PubMed was performed to identify relevant studies published up to January 2024. Eligible studies were critically appraised, and data concerning surgical outcomes, perioperative parameters, and post-operative complications were extracted and analyzed.

RESULTS

Our review synthesizes evidence from six studies, encompassing a total of seven cases undergoing robotic single-site hepatic resection (SSHR) using various versions of the da Vinci© system. Specifically, the procedures included five left lateral segmentectomy, one right hepatectomy, and one caudate lobe resection. We provide a summary of the surgical techniques, indications, selection criteria, and outcomes associated with this approach.

CONCLUSION

The single-site robotic approach represents an option among the minimally invasive approaches in liver surgery. However, although the feasibility has been demonstrated, further studies are needed to elucidate its optimal utilization, long-term outcomes, and comparative effectiveness against the other techniques. This systematic review provides valuable insights into the current state of single-site robotic liver resection and underscores the need for continued research in this rapidly evolving field.

Evaluation of the outcomes of biliary-enteric reconstruction in robotic radical resection of hilar cholangiocarcinoma: a single-center propensity score matching analysis

Although robotic radical resection for hilar cholangiocarcinoma (HCCA) has been reported in some large hepatobiliary centers, biliary-enteric reconstruction (BER) remains a critical step that hampers the operation's success. This study aimed to evaluate the feasibility and quality of BER in robotic radical resection of HCCA and propose technical recommendations. A retrospective study was conducted on patients with HCCA who underwent minimally invasive radical resection at Zhejiang Provincial People's Hospital between January 2016 and July 2023. A 1:2 propensity score matching (PSM), widely used to reduce selection bias, was performed to evaluate the outcomes, especially BER-related data, between the robotic and laparoscopic surgery. Forty-six patients with HCCA were enrolled; ten underwent robotic-assisted resection, while the others underwent laparoscopic surgery. After PSM at a ratio of 1:2, 10 and 20 patients were assigned to the robot-assisted and laparoscopic groups, respectively. The baseline characteristics of both groups were generally well-balanced. The average liver resection time was longer in the robotic group than in the laparoscopic group (139.5 ± 38.8 vs 108.1 ± 35.8 min, P = 0.036). However, the former had less intraoperative blood loss [200 (50-500) vs 310 (100-850) ml], despite no statistical difference (P = 0.109). The number of residual bile ducts was 2.6 ± 1.3 and 2.7 ± 1.2 (P = 0.795), and anastomoses were both 1.6 ± 0.7 in the two groups (P = 0.965). The time of BER was 38.4 ± 13.6 and 59.1 ± 25.5 min (P = 0.024), accounting for 9.9 ± 2.8% and 15.4 ± 4.8% of the total operation time (P = 0.001). Although postoperative bile leakage incidence in laparoscopic group (40%) was higher than that in robotic group (10%), there was no significant difference between the two groups (P = 0.204); 6.7 ± 4.4 and 12.1 ± 11.7 days were observed for tube drawing (P = 0.019); anastomosis stenosis and calculus rate was 10% and 30% (P = 0.372), 0% and 15% (P = 0.532), respectively. Neither group had hemorrhage- or bile leakage-related deaths. Robotic radical resection for HCCA may offer perioperative outcomes comparable to conventional laparoscopic procedures and tends to be advantageous in terms of anastomosis time and quality. We are optimistic about its wide application in the future with the improvement of surgical techniques and experience.

Current Status of Robotic Hepatobiliary and Pancreatic Surgery

Laparoscopic surgery is performed worldwide and has clear economic and social benefits in terms of patient recovery time. It is used for most gastrointestinal surgical procedures, but laparoscopic surgery for more complex procedures in the esophageal, hepatobiliary, and pancreatic regions remains challenging. Minimally invasive surgery that results in accurate tumor dissection is vital in surgical oncology, and development of surgical systems and instruments plays a key role in assisting surgeons to achieve this. A notable advance in the latter half of the 1990s was the da Vinci Surgical System, which involves master-slave surgical support robots. Featuring high-resolution three-dimensional (3D) imaging with magnification capabilities and forceps with multi-joint function, anti-shake function, and motion scaling, the system compensates for the drawbacks of conventional laparoscopic surgery. It is expected to be particularly useful in the field of hepato-biliary-pancreatic surgery, which requires delicate reconstruction involving complex liver anatomy with diverse vascular and biliary systems and anastomosis of the biliary tract, pancreas, and intestines. The learning curve is said to be short, and it is hoped that robotic surgery will be standardized in the near future. There is also a need for a standardized robotic surgery training system for young surgeons that can later be adapted to a wider range of surgeries. This systematic review describes trends and future prospects for robotic surgery in the hepatobiliary-pancreatic region.

Robotic Hepatectomy plus Biliary Reconstruction for Bismuth Type III and Type IV Hilar Cholangiocarcinoma: State of the Art and Literature Review

BACKGROUND

In Bismuth type III and IV Hilar Cholangiocarcinoma (III-IV HC), surgical resection is the only chance for long-term survival. As the surgical procedure is complex and Robotic-Assisted Surgery (RAS) may be particularly suitable in this setting, the aim of this study is to evaluate the potential benefits of RAS in III-IV HC in terms of post-operative outcomes.

METHODS

We conducted a systematic review using the PRISMA checklist for article selection. We searched the PubMed database and included only studies with clinical data about the treatment of III-IV HC using RAS.

RESULTS

A total of 12 papers involving 50 patients were included. All cases were Bismuth IIIa (n = 18), IIIb (n = 27) or IV type (n = 5) and underwent hepatectomy with biliary confluence resection and reconstruction. The mean operative time was 500 minutes with a conversion rate of 4%. The mean hospital stay was 12.2 days, and the morbidity and 30-day mortality rate were 61.9% and 2%, respectively. Over a mean follow up period of 10.1 months, 9/18 cases experienced recurrence (50%).

CONCLUSIONS

RAS for III-IV HC is safe and feasible, at least if performed by experienced surgeons on selected cases. The oncological outcomes appear acceptable, given the aggressiveness of this pathology, but further studies are needed to fully elucidate the exact role of robotics in this setting.

Robotic approach for perihilar cholangiocarcinoma: from Bismuth 1 to vascular resection

BACKGROUND

Implementation of minimally invasive surgical approaches for perihilar cholangiocarcinoma (pCCA) has been relatively slow compared to other indications. This is due to the complexity of the disease and the need of advanced skills for the reconstructive phase. The robot may contribute to close the gap between open and minimally invasive surgery in patients with Klastkin tumors.

STUDY DESIGN

We report details of our experience with robotic approach in patients affected by pCCA. In particular selection criteria, ERAS management, technical tips and robotic setup are discussed. Finally, results from our cohort are reported. A video clip of a patient that underwent left hepatectomy with en-bloc caudatectomy and portal vein resection at the confluence with end-to-end reconstruction for a pCCA 3-b according to Bismuth-Corlette classification with full robotic approach is enclosed.

RESULTS

Fourteen patients underwent robotic resection of pCCA over the three-year interval with a median follow-up interval of 18.7 months. The pre-operative Bismuth-Corlette classification was 1 for two patients (14.2%) and 2 for one patient (7.1%), 3-a for three (21.4%) patients, 3-b for four (28.6%) patients and 4 for four (28.6%) patients. Median estimated blood loss was 150 ml (range 50-800 ml) and median operative time was 490 min (range 390-750 min). The median length of hospital stay after the index operation was 6 days (range 3-91). Final histology revealed a median of 19 (range 11-40) lymph nodes retrieved, with 92.9% R0 resections. 90-days mortality was nihil and 3-year survival exceeds 50%.

CONCLUSION

With adequate preparation, outcomes of robotic approach to pCCA can be safe and in line with the current international benchmark outcomes, as showed in this study, when performed in expert high volume centers for complex major hepatectomy and robotic HPB.

Laparoscopic Resection of Perihilar Cholangiocarcinoma Type IIIb: A Video Demonstration of No-Touch En-Block Technique and Radical Lymphadenectomy

BACKGROUND

Minimally invasive surgery for perihilar cholangiocarcinoma (pCCA) is in an exploratory phase by now and is only recommended for carefully selected patients.

PATIENTS AND METHODS

Our team performed total laparoscopic hepatectomy in a 64-year-old woman with perihilar cholangiocarcinoma type IIIb. Laparoscopic left hepatectomy and caudate lobectomy were performed involving a no-touch en-block technique. Meanwhile, extrahepatic bile duct resection, radical lymphadenectomy with skeletonization, and biliary reconstruction were performed.

RESULTS

Laparoscopic left hepatectomy and caudate lobectomy were successfully performed in 320 min with 100 ml of blood loss. The histological grading was T2bN0M0 (stage II). The patient was discharged on the 5th day without postoperative complications. Following the operation, the patient received single-drug capecitabine chemotherapy. There was no recurrence after 16 months of follow-up.

CONCLUSION

Our experience is that, in selected patients with pCCA type IIIb or type IIIa, laparoscopic resection can reach comparable outcome to open surgery with standardized lymph node dissection by skeletonization, use of no-touch en-block technique, and proper digestive tract reconstruction.

Minimally Invasive Surgery for Perihilar Cholangiocarcinoma: A Systematic Review of the Short- and Long-Term Results

Surgery and postoperative systemic chemotherapy represent the standard treatment for patients with perihilar cholangiocarcinoma (PHC). Minimally Invasive Surgery (MIS) for hepatobiliary procedures has spread worldwide in the last two decades. Since resections for PHC are technically demanding, the role of MIS in this field is yet to be established. This study aimed to systematically review the existing literature on MIS for PHC, to evaluate its safety and its surgical and oncological outcomes. A systematic literature review on PubMed and SCOPUS was performed according to the PRISMA guidelines. Overall, a total of 18 studies reporting 372 MIS procedures for PHC were included in our analysis. A progressive increase in the available literature was observed over the years. A total of 310 laparoscopic and 62 robotic resections were performed. A pooled analysis showed an operative time ranging from 205.3 ± 23.9 and 840 (770-890) minutes, and intraoperative bleeding between 101.1 ± 13.6 and 1360 ± 809 mL. Minor and major morbidity rates were 43.9% and 12.7%, respectively, with a 5.6% mortality rate. R0 resections were achieved in 80.6% of patients and the number of retrieved lymph nodes ranged between 4 (3-12) and 12 (8-16). This systematic review shows that MIS for PHC is feasible, with safe postoperative and oncological outcomes. Recent data has shown encouraging results and more reports are being published. Future studies should address differences between robotic and laparoscopic approaches. Given the management and technical challenges, MIS for PHC should be performed by experienced surgeons, in high-volume centers, on selected patients.

Initial experience with robotic liver resection: Audit of 120 consecutive cases at a single center and comparison with open and laparoscopic approaches

BACKGROUND/PURPOSE

Surgical outcomes and utility of robotic liver resection (RLR) are undefined.

METHODS

We retrospectively studied perioperative and long-term outcomes of the single-center 120 RLRs including non-anatomic (NAR, n = 58) and anatomic (AR, n = 62) resections. To evaluate the feasibility and safety of RLR, perioperative outcomes of RLR (n = 103) were compared to those of open (OLR, n = 495) or laparoscopic (LLR, n = 451) resection in liver-only resections without reconstruction, using 1:1 propensity score matching (PSM). The changing trends from the earlier to the later RLR cases were assessed. Long-term outcomes were compared between RLR and LLR.

RESULTS

Various types of RLR with different surgical difficulties were performed, with mostly comparable postoperative morbidity between AR and NAR, or among AR subtypes. In segmentectomy and sectionectomy cases, perioperative outcomes significantly improved in the later period. In comparison between PSM-selected OLR and RLR cases (87:87), RLR had significantly longer operative time, less blood loss, and shorter hospital stay. PSM-selected LLR and RLR cases (91:91) showed comparable perioperative outcomes. Overall and recurrence-free survivals after RLR for newly diagnosed hepatocellular carcinoma and colorectal metastasis were comparable to those after LLR.

CONCLUSIONS

RLR is applicable to various types of liver resection with acceptable perioperative and long-term outcomes in select patients.

The role of robotic surgery for the treatment of hilar cholangiocarcinoma: A systematic review

Background

The role of robotic surgery (RS) for hilar cholangiocarcinoma (HC) is under investigation. Surgical resection is the only curative modality of treatment but extremely complex and high risk of morbidity and mortality may occur. The aim of this study is to perform a systematic review of perioperative and oncological outcomes of RS for HC, across a comprehensive range of outcomes reported in recent literature.

Materials and Methods

PRISMA checklist was used as a basis for writing the systematic review and studies’ selection. Literature documenting RS for HC was analyzed by searching PubMed and Cochrane Library from 2009 to May 2022. The search terms, either independently or in combination, were used according to PICOT framework. The target population are patients treated with robotic surgical approach for HC.

Results

12 studies with 109 patients were included after screening process. The Bismuth classification in all series except one was: 21 type I, 7 type II, 12 type IIIa, 26 type IIIb and 4 type IV. Mean operative time for a total of 21 patients was 644 minutes. Other two case series reported a median operative time of 375 with a console time of 276 minutes. Mean blood loss for case reports and two case series was 662 milliliters. Blood transfusion rate for all operation was 33.3%. Overall Conversion rate was 2.8%. Pooled post operative morbidity and mortality was 39.8% and 1.8% respectively. Mean LOS for case reports and one case series for a total of 17 patients was 16 days. R0 resection rate for the 11 papers was 74.3%. Seven out of 12 studies reported on the oncological follow up: median observation time ranged from 5 to 60 months, recurrence rate was 52.6% (range 0-90%) reported only in 19 patients (10/19).

Conclusions

RS for HC was feasible and safe. However, although this systematic review could not be conclusive in most of the analyzed items, RS for the treatment of HC could represent the best tool for a future meticulous and precision surgery. The review’s results certainly indicate that further research in urgently is required on this field.

Robotic Surgery for Biliary Tract Cancer

Biliary tract cancer consists of cholangiocarcinoma (CC) and gallbladder cancer (GBC). When resectable, surgery provides the best chance at long-term survival. Unfortunately, surgery for these tumors is associated with long operative times, high morbidities, and prolonged hospital stays. Minimally invasive surgery has been shown to impact selected outcomes, including length of stay, in other diseases, and robotic surgery may offer additional advantages compared to laparoscopic surgery in treating bile duct cancers. This is a systematic review of robotic surgery for biliary tract cancer. Predetermined selection criteria were used to appraise the literature. The PRISMA guidelines were followed. In total, 20 unique articles with a total of 259 patients with biliary tract cancer undergoing robotic surgery met the inclusion criteria. For CC and GBC, respectively, the weighted average operative time was 401 and 277 min, the estimated blood loss was 348 and 260 mL, the conversion rate to open was 7 and 3.5%, the all-cause morbidity was 52 and 9.7%, the major morbidity was 12 and 4.4%, the perioperative mortality was 1.4 and 0%, the length of stay was 15 and 4.8 days, the positive margin rate was 27 and 9%, and the number of lymph nodes retrieved was 4.2 and 8. Robotic surgery for biliary tract cancer appears non-inferior to open surgery when compared to the published contemporary data. However, the current literature on the topic is of low quality, and future prospective/randomized studies are needed.

Current Surgical Management of Peri-Hilar and Intra-Hepatic Cholangiocarcinoma

Cholangiocarcinoma accounts for approximately 10% of all hepatobiliary tumors and represents 3% of all new-diagnosed malignancies worldwide. Intrahepatic cholangiocarcinoma (i-CCA) accounts for 10% of all cases, perihilar (h-CCA) cholangiocarcinoma represents two-thirds of the cases, while distal cholangiocarcinoma accounts for the remaining quarter. Originally described by Klatskin in 1965, h-CCA represents one of the most challenging tumors for hepatobiliary surgeons, mainly because of the anatomical vascular relationships of the biliary confluence at the hepatic hilum. Surgery is the only curative option, with the goal of a radical, margin-negative (R0) tumor resection. Continuous efforts have been made by hepatobiliary surgeons in order to achieve R0 resections, leading to the progressive development of aggressive approaches that include extended hepatectomies, associating liver partition, and portal vein ligation for staged hepatectomy, pre-operative portal vein embolization, and vascular resections. i-CCA is an aggressive biliary cancer that arises from the biliary epithelium proximal to the second-degree bile ducts. The incidence of i-CCA is dramatically increasing worldwide, and surgical resection is the only potentially curative therapy. An aggressive surgical approach, including extended liver resection and vascular reconstruction, and a greater application of systemic therapy and locoregional treatments could lead to an increase in the resection rate and the overall survival in selected i-CCA patients. Improvements achieved over the last two decades and the encouraging results recently reported have led to liver transplantation now being considered an appropriate indication for CCA patients.

Recent advances in the surgical management of hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) is increasing, despite effective antiviral treatment for hepatitis B (HBV) and C virus infection and the application of preventive measures such as vaccination at birth against HBV infection. This is mainly due to the increase in metabolic syndrome and its hepatic components, nonalcoholic fatty liver disease and steatohepatitis. Liver resection and transplantation are the main treatment options, offering long-term survival and potential cure. In this review, the recent advances in the surgical management of HCC are presented. More specifically, the role of liver resection in the intermediate and advanced stages, according to the Barcelona Clinic Liver Cancer classification, is analyzed. In addition, the roles of minimally invasive surgery and of living-related liver transplantation in the management of patients with HCC are discussed. Finally, recent data on the role of molecular markers in the early diagnosis and recurrence of HCC are presented. The management of HCC is complex, as there are several options for each stage of the disease. In order for, each patient to get the maximum benefit, an individualized approach is suggested, in specialized liver units, where cases are discussed in multidisciplinary tumor boards.

Robotic hepatectomy and biliary reconstruction for perihilar cholangiocarcinoma: a pioneer western case series

Open surgery is the standard of care for perihilar cholangiocarcinoma (pCCA). With the aim of oncologic radicality, it requires a complex major hepatectomy with biliary reconstruction. The postoperative course is consequently often complicated, with severe morbidity and mortality rates of up to 27.5–54% and 18%, respectively. Robotic liver surgery is emerging as a safe, minimally-invasive technique with huge potential for pCCA management. After the first case described by Giulianotti in 2010, here we present the first western series of robot-assisted liver resections with biliary reconstruction for pCCA with the aim to preliminarily assess the feasibility and repeatability of the procedure. At our high-volume teaching hospital center dedicated to HPB surgery, 128 pCCA patients have been surgically treated in the last 15 years whereas more than 800 laparoscopic liver resections have been performed. Since the Da Vinci Xi Robotic platform was introduced in late 2018, 6 major robotic liver resections with biliary reconstruction have been performed, 4 of which were for pCCA. All 4 cases involved a left hepatectomy with caudate lobectomy. The median operating time was 840 min, with a median blood loss of 700 ml. One case was converted to open surgery during the reconstruction due to a short mesentery preventing the hepatico-jejunostomy. None of the patients experienced major complications, while minor complications occurred in 3 out of 4 cases. One biliary leak was managed conservatively. The median postoperative stay was 9 days. Negative biliary margins were achieved in 3 of the 4 cases. An included video clip shows the most relevant technical details. This preliminary series demonstrates that robot-assisted liver resection for pCCA is feasible. We speculate that the da Vinci platform has a relevant potential in pCCA surgery with particular reference to the multi-duct biliary reconstruction. Further studies are needed to better clarify the role of this high-cost technology in the minimally-invasive treatment of pCCA.

Robotic liver surgery: literature review and future perspectives

INTRODUCTION

Minimally invasive liver resections (MILR) have been gaining popularity over the last decades. MILR provides superior peri-operative outcome. Despite these advantages, the penetrance of MILR in the clinical setting has been limited, and it was slowed down, among other factors, also by the laparoscopic technological limitations.

EVIDENCE ACQUISITION

A literature review has been carried out (Pubmed, Embase and Scopus platforms) focusing on the role of robotic surgery in MILR.

EVIDENCE SYNTHESIS

The literature review results are presented and our additional remarks on the topic are discussed.

CONCLUSIONS

Robotic MILR has been helping to expand the penetrance of MIS in liver surgery by making possible increasingly more challenging procedures. Minor resections still represent most of the robotic liver surgery data currently available. Robotic liver surgery is safe and effective, and it shows perioperative outcomes comparable with laparoscopic and open surgery. The oncological efficacy, within the limitations of the current level of evidence (mostly retrospective studies and literature heterogeneity), seems to show promising result. High quality prospective randomized studies, the use of prospective registry data, and multi-institutional efforts are needed.

Systematic review of perioperative and oncologic outcomes of minimally-invasive surgery for hilar cholangiocarcinoma

Most surgeons have traditionally been reluctant toward minimally-invasive surgery for bile duct tumors. This study aimed to perform a systematic literature review on perioperative and oncologic results of pure laparoscopic and robotic curative-intent surgery for hilar cholangiocarcinoma. According to the PRISMA statement, a systematic review was conducted into Pubmed, EMBASE and Cochrane. A critical appraisal of study was performed according to the Joanna Briggs Institute tools. Nineteen studies (12 on pure laparoscopy and 7 on robotics) were included: 7 case reports, 9 case series, 3 case-control (193 patients). The pooled conversion, morbidity, biliary leak and mortality rates were 5.5%, 43%, 16.4% and 4%. The weighted mean of operative time, blood loss and postoperative stay were 388 min, 446 mL and 14 days. For pure laparoscopy, the pooled R0 rate was 86%; overall survival and disease-free survival rates ranged from 85 to 100% and from 80 to 100% (median observation time 6-18 months). For robotic surgeries, the pooled R0 rate was 69% and overall survival rates ranged from 90 to 100% (median observation time 5-15 months). Case reports were overall of high quality, case series of moderate / high-quality, case-control studies ranged from low to high quality. In selected patients, minimally-invasive surgery for Klatskin tumors appears feasible, safe, satisfactory for perioperative outcomes and adequate for oncologic results. However, the results are based on few studies, limited in patient numbers and with allocation criteria more restrictive than open, reporting short follow-up and mainly with non-comparative design: evidence of higher quality is recommended.

Minimally invasive versus open radical resection surgery for hilar cholangiocarcinoma: Comparable outcomes associated with advantages of minimal invasiveness

Background

Minimally invasive surgery (MIS) provides a new approach for patients with hilar cholangiocarcinoma (HCCA). However, whether it can achieve similar outcomes to traditional open surgery (OS) remains controversial.

Methods

To assess the safety and feasibility of MIS for HCCA, a systematic review and meta-analysis was performed to compare the outcomes of MIS with OS. Seventeen outcomes were assessed.

Results

Nine studies involving 382 patients were included. MIS was comparable in blood transfusion rate, R0 resection rate, lymph nodes received, overall morbidity, severe morbidity (Clavien–Dindo classification > = 3), bile leakage rate, wound infection rate, intra-abdominal infection rate, days until oral feeding, 1-year overall survival, 2-year overall survival and postoperative mortality with OS. Although operation time was longer (mean difference (MD) = 93.51, 95% confidence interval (CI) = 64.10 to 122.91, P < 0.00001) and hospital cost (MD = 0.68, 95% CI = 0.03 to 1.33, P = 0.04) was higher in MIS, MIS was associated with advantages of minimal invasiveness, that was less blood loss (MD = -81.85, 95% CI = -92.09 to -71.62, P < 0.00001), less postoperative pain (MD = -1.21, 95% CI = -1.63 to -0.79, P < 0.00001), and shorter hospital stay (MD = -4.22, 95% CI = -5.65 to -2.80, P < 0.00001).

Conclusions

The safety and feasibility of MIS for HCCA is acceptable in selected patients. MIS is a remarkable alternative to OS for providing comparable outcomes associated with a benefit of minimal invasiveness and its application should be considered more.

Robot-assisted and open resections for perihilar cholangiocarcinoma. Comparative analysis of the immediate outcomes

Background. Minimally invasive radical surgery for perihilar cholangiocarcinoma is in its early stages. Aim. A comparative analysis of the initial experience of robot-assisted and open resections for perihilar cholangiocarcinoma. Material and methods. The single-center experience, accumulated over the period from 2014 to 2018, is analyzed. Robot-assisted procedures included major liver resection and caudate lobectomy with extrahepatic bile duct resection and lymphadenectomy. The need for vascular reconstruction was considered a contraindication to surgery. Results. Thirteen robot-assisted resections were performed. The perihilar cholangiocarcinoma was confirmed by pathologic examination in 10 patients. The immediate outcomes were compared with that in 88 open procedures. There were no significant differences in blood loss, the rate of severe morbidity, mortality, and hospital stay. The duration of the robot-assisted surgical resections was significantly longer. Conclusion. Analysis of initial experience justifies the robotic approach for radical resection in highly selected patients.

Minimally invasive surgery for hilar cholangiocarcinoma: a multicenter retrospective analysis of 158 patients

BACKGROUND

Curative resection of hilar cholangiocarcinoma (HC) is typically carried out using open surgery. In the present study, we examined the safety (postoperative complication) and effectiveness (resection margin status and patient survival) of minimally invasive surgery (MIS) for HC.

METHODS

This retrospective analysis included 158 patients receiving MIS for HC at 10 participating centers between December 2013 and November 2019. Patient demographics, surgical outcomes, and oncological outcomes were retrospectively analyzed.

RESULTS

Clinical information obtained from 10 different clinical centers did not show any evident cohort-bias clustering. One hundred and twenty-six (79.7%) patients underwent LRHC, 12 (7.6%) patients underwent RARHC, conversion to an open procedure occurred in 20 (12.7%) patients. The operation time and estimated blood loss were 410.8 ± 128.9 min and 477.8 ± 706.3 mL, respectively. The surgical radicality of the 158 patients was R0, 129 (81.6%); R1, 20 (18.4%) and R2, 9 (5.7%). Grades I-II complications was occurred in 68 (43.0%) patients. Severe morbidity (grade III-V) occurred in 14 (8.7%) patients. The median overall survival in whole cohort was 25.4 months. The overall survival rate was 67.6% at year 1, 28.8% at year 3, and 19.2% at year 5. Comparing the first half of MISHC performed by each center with the following cases, the operation time and postoperative hospital stay does not decrease with the increasing cases. On literature review, MISHC is non-inferior to open surgery at least in perioperative period.

CONCLUSIONS

In this Chinese MIS for HC multicenter study, the largest to date, long-term overall survival rates after MIS appear comparable to those reported in current open series. Further randomized controlled trials are necessary to assess the global impact of MISHC.

Robotic liver resection: Hurdles and beyond

Laparoscopy is currently considered the standard of care for certain procedures such as left-lateral sectionectomies and wedge resections of anterior segments. The role of robotic liver surgery is still under debate, especially with regards to oncological outcomes. The purpose of this review is to describe how the field of robotic liver surgery has expanded, and to identify current limitations and future perspectives of the technology. Available evidences suggest that oncologic results after robotic liver resection are comparable to open and laparoscopic approaches for hepatocellular carcinoma and colorectal liver metastases, with identifiable advantages for cirrhotic patients and patients undergoing repeat resections. Excellent outcomes and optimal patient safety can be only achieved with specific hepato-biliary and general minimally invasive training to overcome the learning curve.

Current Advances in Minimally Invasive Surgical Management of Perihilar Cholangiocarcinoma

BACKGROUND

While the safety of minimally invasive surgery (MIS) has been reported for several liver malignancies, the role of MIS in the management of perihilar cholangiocarcinoma (pCCA) has been poorly defined.

METHODS

A systematic review of the literature was performed utilizing MEDLINE/PubMed and Web of Science databases up to January 2020 to assess the safety and feasibility of MIS in the management of patients with pCCA.

RESULTS

Limited data exist on the MIS approach to treat pCCA. Staging laparoscopy carries a low diagnostic yield and typically is used only in select patients with high suspicion of metastatic disease. Data on the use of MIS approach for resection of pCCA have largely been limited to case reports or small case series. A MIS approach to pCCA resection has been demonstrated to be feasible and safe, yet in most series the surgeon failed to include resection of the caudate lobe. Given that caudate lobe involvement occurs in 31-98% of patients with pCCA, incomplete resection of the caudate lobe may be associated with higher local recurrence. More recently, several surgeons have reported complete R0 surgical with removal of the caudate lobe using a MIS approach. While patients may have a shorter length-of-stay, the true benefit of the MIS approach for pCCA needs to be better defined.

CONCLUSIONS

MIS may be a safe and feasible approach at high-volume centers with robust expertise in the management of patients with pCCA. Further studies with larger number of patients are required prior to universal application of MIS for pCCA.

Complete laparoscopic radical resection of hilar cholangiocarcinoma: technical aspects and long-term results from a single center

Introduction

The landscape of surgical treatments for hepatobiliary disease was significantly changed after the advent of laparoscopy. Many kinds of complex laparoscopic procedures can be routinely performed at present, but radical resection of hilar cholangiocarcinoma (HC) by laparoscopy is still highly contentious.

Aim

To describe our primary experience with laparoscopic radical resection for HC and determine the safety and feasibility of this procedure.

Material and methods

Between December 2015 and November 2019, 32 patients planned to undergo curative-intent laparoscopic resection of HC in our department. The perioperative and long-term outcomes of these patients were retrospectively analyzed.

Results

Laparoscopic surgery with radical resection was ultimately performed in 24 (75.0%) patients; 3 (9.3%) patients were found to be unresectable at the preliminary exploration stage, and 5 (15.7%) patients converted from laparoscopy to laparotomy. The operation time and blood loss were 476.95 ±133.89 min and 568.75 ±324.01 ml, respectively. A negative margin was achieved in 19 (79.1%) of the laparoscopy patients. Three (12.5%) patients were identified with microscopic positive margins, and 2 (8.4%) patients underwent macroscopic residual tumor resection (R2). The length of postoperative stay was 23.3 ±11.7 days. Severe morbidity occurred in 4 (16.6%) patients. The actuarial 3-year overall survival and disease-free survival for patients who underwent laparoscopic surgery were 49.1% and 47.0%, respectively.

Conclusions

Laparoscopic radical resection for HC is safe and feasible in experienced hands for highly selected patients but is still in its initial stages. When adequate oncologic resection is performed, the laparoscopic approach does not adversely influence the prognosis of the patient.

Laparoscopic surgery and robotic surgery for hilar cholangiocarcinoma: an updated systematic review

BACKGROUND

The role of laparoscopic surgery (Lap) and robotic surgery (Rob) for radical resection of hilar cholangiocarcinoma (HC) is not clear. We summarized the safety and feasibility of Lap and Rob for HC.

METHODS

A search of all HC studies in English published on PubMed up to April 2020 was conducted. References from retrieved articles were reviewed to broaden the search.

RESULTS

In total, 23 reports were enrolled: 15 involving Lap, seven using Rob and one study reporting a minimally invasive approach (Lap or Rob, not specified). A total of 205 cases of HC were documented (Lap/Rob/not specified, 99/101/5): 37 cases of Bismuth type-I (Lap/Rob, 17/20), 22 cases of Bismuth type-II (Lap/Rob, 15/7), 68 cases of type-III (Lap/Rob, 39/29) and 13 cases of type-IV (Lap/Rob, 9/4). The pooled prevalence of R0 resection was 80.1% (Lap/Rob, 85.9%/71.0%). The weighted mean for operative time, blood loss and post-operative hospital stay was 458.4 min (Lap/Rob, 423.3/660.8 min), 615.3 mL (Lap/Rob, 521.0/1188.5 mL) and 14.0 days (Lap/Rob, 14.0/13.7 days), respectively. The pooled prevalence of conversion to open surgery, post-operative complications, and perioperative mortality was 9.1% (Lap/Rob, 12.2%/3.8%), 47.2% (Lap/Rob, 38.4%/61.3%) and 3.0% (Lap/Rob, 4.0%/2.0%), respectively.

CONCLUSION

With innovations in technology and gradual accumulation of surgical experience, the feasibility and safety of performing Lap and Rob for HC will improve.

Robotic Resection of Hilar Cholangiocarcinoma

BACKGROUND

Hilar cholangiocarcinoma is the most common malignant neoplasm of the biliary tract. Surgical resection is the only curative modality of treatment. The aim of this video is to present a robotic left hepatectomy extended to caudate lobe, combined with bile duct resection, lymphadenectomy, and Roux-en-Y biliary reconstruction.

METHODS

A 76-year-old female presented with progressive jaundice due to hilar cholangiocarcinoma. She underwent chemoradiation and after 5 months of treatment was referred for second opinion; imaging reevaluation showed objective response and no arterial invasion. Multidisciplinary team decided for radical treatment, which consisted in robotic left hepatectomy, caudate lobe resection, resection of bile duct, lymphadenectomy, and hepaticojejunostomy.

RESULTS

Operative time was 8 h. Estimated blood loss was 740 mL (received 2 U). The patient's recovery was complicated by drainage clogging resulting in fever and perihepatic fluid collection, successfully treated by change of drainage. Pathology confirmed cholangiocarcinoma with free surgical margins (T1aN0). The patient is well, with no signs of disease 5 months after the procedure.

CONCLUSIONS

Robotic resection of hilar cholangiocarcinoma is feasible and safe. The robotic approach has some technical advantages over laparoscopic approach. This video may help oncological surgeons to perform this complex procedure.

Robotic radical surgery for hilar cholangiocarcinoma: A single-centre case series

BACKGROUND

Radical resection for hilar cholangiocarcinoma is considered one of the most complicated abdominal operations. We report our initial experience with robotic radical resection for hilar cholangiocarcinoma.

METHODS

Between March 2017 and February 2019, the perioperative outcomes of 48 patients were analysed. In addition, there were two techniques for hepaticojejunostomy in the robotic approach. Comparison of the conventional and novel methods for hepaticojejunostomy was also performed to assess the efficacy of the technique.

RESULTS

The operative duration and intraoperative blood loss volume was 276 minutes and 150 mL, respectively. The overall morbidity was 58.3% and the major morbidity was 10.4%. The overall mortality was 0%. No significant differences in the perioperative outcomes of hepaticojejunostomy were found between the 2 groups.

CONCLUSION

Robotic resection is a potential alternative to open surgery for appropriately selected patients with hilar cholangiocarcinoma. Further studies are required to detect the long-term outcomes of this procedure.

The role of minimally invasive hepatectomy for hilar and intrahepatic cholangiocarcinoma: A systematic review of the literature

Despite the fact laparoscopic liver resections (LLR) for cholangiocarcinoma is still limited, this systematic review addressed surgical and oncological outcomes of LLR to treat both perihilar cholangiocarcinoma (pCCA) and intrahepatic cholangiocarcinoma (iCCA). Five comparative and 20 noncomparative studies were found. Regarding iCCA, LLR had lower blood loss and less need for Pringle maneuver. However, open liver resections (OLR) were performed more for major hepatectomies, with better lymphadenectomy rates and higher number of harvested lymph nodes. High heterogeneity and selection bias were suggested for iCCA studies.

Minimally invasive surgery for perihilar cholangiocarcinoma: a systematic review

Minimally invasive surgery (MIS) is quickly becoming mainstream in hepato-pancreato-biliary surgery because of presumed advantages. Surgery for perihilar cholangiocarcinoma (PHC) is highly demanding which may hamper the feasibility and safety of MIS in this setting. This study aimed to systematically review the existing literature on MIS for PHC. A systematic literature review was performed according to the PRISMA statement. The PubMed and EMBASE databases were searched and all studies describing MIS in patients with PHC were included. Data extraction and risk of bias were assessed by two independent researchers. Overall, 21 studies reporting on a total of 142 MIS procedures for PHC were included. These included 82 laparoscopic, 59 robot-assisted and 1 hybrid procedure(s). Risk of bias was deemed substantial. Pooled conversion rate was 7/142 (4.9%), pooled morbidity 30/126 (23.8%), and pooled mortality rate 4/126 (3.2%). The only comparative study, comparing 10 robot-assisted procedures to 32 open procedures, reported a significant increased operative time and higher morbidity rate with MIS. The available evidence on MIS for PHC is limited and generally of poor quality. This systematic review shows that the implementation of MIS for patients with PHC is still in its infancy.

Treatment of metastatic colorectal cancer: innovations in surgical techniques

Liver metastases and peritoneal carcinomatosis are a particular focus of surgeons in improving survival in stage IV colorectal cancer patients, with laparotomy long being the means to undertake these operations. The Louisville statement published in 2008 was the first international consensus on indications for minimally invasive liver resection. Herein we review the progress in innovative surgical techniques, including minimally invasive liver resection, robot-assisted hepatectomy, and we also describe initial reports in pressurized intraperitoneal aerosol chemotherapy.

Minimally invasive surgery for hilar cholangiocarcinoma: state of art and future perspectives

BACKGROUND

Hilar cholangiocarcinoma (HCCA) occurs in the core section of the biliary system and has a strong tendency to broadly invade the surrounding vascular system, perineural tissue and major liver parenchyma. Thus, minimally invasive resection can only be achieved in limited cases. This article reviews the current laparoscopic and robotic surgery techniques for HCCA and analyses the difficulties and limitations of the current minimally invasive surgical techniques for HCCA.

METHODS

A systematic literature search was conducted using multiple electronic databases. All studies involving minimally invasive resections of HCCA were included (up to November 2017).

RESULTS

Twelve studies were included, of which eight concerned laparoscopic surgery of HCCA and four involved robotic surgery for HCCA. For laparoscopic surgery, most of the surgical procedures were limited to partial hepatectomy or even bile duct resection; the post-operative morbidity rate was approximately 38.9% (range 0-100%); those with fewer complications were mostly restricted to Bismuth type I or type II carcinomas. For robotic surgery, only one study concerned caudate lobectomy of HCCA, with a reported median operative time of 703 min and post-operative morbidity of 90%.

CONCLUSIONS

Minimally invasive surgery for HCCA is restricted to highly selected cases and is deemed technically achievable in experienced hands. However, technical and instrumental improvement is needed to reduce the relevant morbidity and popularize the use of minimally invasive surgery to treat HCCA.

[Robotic approach to hepatobiliary surgery. German version]

Robot-assisted hepatobiliary surgery has been steadily growing in recent years. It represents an alternative to the open and laparoscopic approaches in selected patients. Endowristed instruments and enhanced visualization provide important advantages in terms of selective bleeding control, microsuturing, and dissection. Cholecystectomies and minor hepatectomies are being performed with comparable results to open and laparoscopic surgery. Even complex procedures, such as major and extended hepatectomies, can have excellent outcomes, in expert hands. The addition of indocyanine green fluorescence provides an additional advantage for recognition of the vascular and biliary anatomy. Future innovations will allow for expanding its use and indications. Robotic surgery has become a very important component of modern minimally invasive surgery and the development of new robotic technology will facilitate a broader adoption of this technique.

The role of minimally invasive surgery in the treatment of cholangiocarcinoma

Cholangiocarcinoma (CC) is the second most common type of primary liver cancer after hepatocellular carcinoma. Surgical resection is considered the only curative treatment for CC. In general, laparoscopic liver surgery (LLS) is associated with improved short-term outcomes without compromising the long-term oncological outcome. However, the role of LLS in the treatment of CC is not yet well established. In addition, CC may arise in any tract of the biliary tree, thus requiring different types of treatment, including pancreatectomies and extrahepatic bile duct resections. This review presents and discusses the state of the art in the laparoscopic and robotic surgical treatment of all types of CC. An electronic search was performed to identify all studies dealing with laparoscopic or robotic surgery and cholangiocarcinoma. Laparoscopic resection in patients with intrahepatic CC (ICC) is feasible and safe. Regarding oncologic adequacy, as R0 resections, depth of margins, and long-term overall and disease-free survival, laparoscopy is comparable to open procedures for ICC. An adequate patient selection is required to obtain optimal results. Use of laparoscopy in perihilar CC (PHC) has not gained popularity. Further studies are still needed to confirm the benefit of this approach over conventional surgery for PHC. Laparoscopic pancreaticoduodenectomy for distal CC (DCC) represents one of the most advanced abdominal operations owing to the necessity of a complex dissection and reconstruction and has also had small widespread so far. Minimally invasive surgery seems feasible and safe especially for ICC. Laparoscopy for PHC is technically challenging notably for the caudate lobectomy. Not least as for the LLR, the robotic approach for DCC appears technically achievable in selected patients.

Financial Impact of the Robotic Approach in Liver Surgery: A Comparative Study of Clinical Outcomes and Costs Between the Robotic and Open Technique in a Single Institution

BACKGROUND

One of the perceived major drawbacks of minimally invasive techniques has always been its cost. This is especially true for the robotic approach and is one of the main reasons that has prevented its wider acceptance among hospitals and surgeons. The aim of our study was to evaluate the clinical outcomes and economic impact of robotic and open liver surgery in a single institution.

METHODS

Sixty-eight robotic and 55 open hepatectomies were performed at our institution between January 1, 2009 and December 31, 2013. Demographics, perioperative data, and postoperative outcomes were collected and compared between the two groups. An independent company performed the financial analysis. The economic parameters comprised direct variable costs, direct fixed costs, and indirect costs.

RESULTS

Mean estimated blood loss was significantly less in the robotic group (438 versus 727.8 mL; P = .038). Overall morbidity was significantly lower in the robotic group (22% versus 40%; P = .047). Clavien III/IV complications were also lower, with 4.4% in the robotic versus 16.3% in the open group (P = .043). The length of stay in the intensive care unit (ICU) was shorter for patients who underwent a robotic procedure (2.1 versus 3.3 days; P = .004). The average total cost, including readmissions, was $37,518 for robotic surgery and $41,948 for open technique.

CONCLUSIONS

Robotic liver resections had less overall morbidity, ICU, and hospital stay. This translates into decreased average costs for robotic surgery. These procedures are financially comparable to open resections and do not represent a financial burden to the hospital.

Robotic versus open liver resections: A case-matched comparison

BACKGROUND

Most hepatic resections are currently performed using an open approach. Robotic surgery might enable the transition of these procedures to minimally invasive surgery.

METHODS

Pre-, peri- and post-operative data of all patients who underwent a liver resection from 2009/2012 to 2001/2015, were collected prospectively. All robotic resection patients were matched 1:1 to patients who underwent open surgery. Pre- and perioperative data, up to 30 days, were analyzed.

RESULTS

Sixteen robotic and open hepatic resections were identified. Fewer complication events and shorter lengths of stay (LOS, 7.9 versus 11 days, P = 0.0603) were observed for robotic resections. Length of stay in the intermediate care unit (IMC) was shorter after the robotic procedure (10 h vs 16.6 h, P = 0.0699). Operating room (OR) time was significantly longer in the robotic resection cohort (352.8 vs 239.6 min, P = 0.0215). All tumor margins were negative.

CONCLUSIONS

This preliminary comparison demonstrates the general feasibility of minor robotic liver resection in selected cases.

Robotic Liver Surgery: Early Experience From a Single Surgical Center

INTRODUCTION

The use of robotic surgery in liver resection is still limited. Our aim is to present our early experience of robotic liver resection.

MATERIALS AND METHODS

It is a retrospective review of Sanchinarro University hospital experience of robotic liver resection performed from 2011 to 2014. Clinicopathologic characteristics, and perioperative and postoperative outcomes were recorded and analyzed.

RESULTS

Twenty-one procedures have been performed and 13 (65%) of them were for malignancy. There were 2 left hepatectomies, 1 right hepatectomy, 1 associated liver partition and portal vein ligation staged procedure (both steps by robotic approach), 1 bisegmentectomy and 3 segmentectomies, 9 wedge resections, and 3 pericystectomies. The mean operating time was 282 minutes (range, 90 to 540 min). 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 to 64 d).

CONCLUSION

From our early experience, robotic liver surgery is a safe and feasible procedure, especially for major hepatectomies.

Robotic liver surgery: technical aspects and review of the literature

Minimally invasive surgery for liver resections has a defined role and represents an accepted alternative to open techniques for selected cases. Robotic technology can overcome some of the disadvantages of the laparoscopic technique, mainly in the most complex cases. Precise dissection and microsuturing is possible, even in narrow operative fields, allowing for a better dissection of the hepatic hilum, fine lymphadenectomy, and biliary reconstruction even with small bile ducts and easier bleeding control. This technique has the potential to allow for a greater number of major resections and difficult segmentectomies to be performed in a minimally invasive fashion. The implementation of near-infrared fluorescence with indocyanine green (ICG) also allows for a more accurate recognition of vascular and biliary anatomy. The perspectives of this kind of virtually implemented imaging are very promising and may be reflected in better outcomes. The overall data present in current literature suggests that robotic liver resections are at least comparable to both open and laparoscopic surgery in terms of perioperative and postoperative outcomes. This article provides technical details of robotic liver resections and a review of the current literature.

Role of laparoscopy in hepatobiliary malignancies

The many benefits of laparoscopy, including smaller incision, reduced length of hospital stay and more rapid return to normal function, have seen its popularity grow in recent years. With concurrent improvements in non-surgical cancer management the importance of accurate staging is becoming increasingly important. There are two main applications of laparoscopic surgery in managing hepato-pancreatico-biliary (HPB) malignancy: accurate staging of disease and resection. We aim to summarize the use of laparoscopy in these contexts. The role of staging laparoscopy has become routine in certain cancers, in particular T[2] staged, locally advanced gastric cancer, hilar cholangiocarcinoma and non-Hodgkin's lymphoma. For other cancers, in particular colorectal, laparoscopy has now become the gold standard management for resection such that there is no role for stand-alone staging laparoscopy. In HPB cancers, although staging laparoscopy may play a role, with ever improving radiology, its role remains controversial.

Robot-assisted versus open liver resection in the right posterior section

BACKGROUND

Open liver resection is the current standard of care for lesions in the right posterior liver section. The objective of this study was to determine the safety of robot-assisted liver resection for lesions located in segments 6 and 7 in comparison with open surgery.

METHODS

Demographics, comorbidities, clinicopathologic characteristics, surgical treatments, and outcomes from patients who underwent open and robot-assisted liver resection at 2 centers for lesions in the right posterior section between January 2007 and June 2012 were reviewed. A 1:3 matched analysis was performed by individually matching patients in the robotic cohort to patients in the open cohort on the basis of demographics, comorbidities, performance status, tumor stage, and location.

RESULTS

Matched patients undergoing robotic and open liver resections displayed no significant differences in postoperative outcomes as measured by blood loss, transfusion rate, hospital stay, overall complication rate (15.8% vs 13%), R0 negative margin rate, and mortality. Patients undergoing robotic liver surgery had significantly longer operative time (mean, 303 vs 233 minutes) and inflow occlusion time (mean, 75 vs 29 minutes) compared with their open counterparts.

CONCLUSIONS

Robotic and open liver resections in the right posterior section display similar safety and feasibility.

Laparoscopic and robot-assisted laparoscopic digestive surgery: Present and future directions

Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissen's fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated.

Laparoscopic resection of hilar cholangiocarcinoma

Laparoscopic resection of hilar cholangiocarcinoma is technically challenging because it involves complicated laparoscopic procedures that include laparoscopic hepatoduodenal lymphadenectomy, hemihepatectomy with caudate lobectomy, and hepaticojejunostomy. There are currently very few reports describing this type of surgery. Between August 2014 and December 2014, 5 patients underwent total laparoscopic or laparoscopic-assisted surgery for hilar cholangiocarcinoma. Two patients with type I or II hilar cholangiocarcinoma underwent radical hilar resection. Three patients with type IIIa or IIIb cholangiocarcinoma underwent extended hemihepatectomy together with caudate lobectomy. The median (range) age, operation time, blood loss, and length of hospital stay were 63 years (43-76 years), 610 minutes (410-665 minutes), 650 mL (450-1,300 mL), and 12 days (9-21 days), respectively. Four patients had a negative margin, but 1 patient was diagnosed with high-grade dysplasia on the proximal resection margin. The median tumor size was 3.0 cm. One patient experienced postoperative biliary leakage, which resolved spontaneously. Laparoscopic resection is a feasible surgical approach in selected patients with hilar cholangiocarcinoma.

Laparoscopic Management of Hilar Cholangiocarcinoma: a Case Report

The only option for cure of Klatskin's tumour is surgical excision. The radicality of the procedure is determined by the extent of the tumour and functional parameters of the patient. Complete laparoscopic resection of hilar cholangiocarcinoma with biliary reconstruction is a challenging procedure. The main aim is to achieve pathological negative margins, complete lymph node retrieval and enterobiliary bypass. We present a case report of a patient with hilar cholangiocarcinoma managed laparoscopically. The nodal yield was nine. On 6-month follow-up, the patient was symptom free. The main aim is to study the feasibility of performing this complex procedure completely laparoscopically.

Outcomes of robotic vs laparoscopic hepatectomy: A systematic review and meta-analysis

AIM

To perform a systematic review and meta-analysis on robotic-assisted vs laparoscopic liver resections.

METHODS

A systematic literature search was performed using PubMed, Scopus and the Cochrane Library Central. Participants of any age and sex, who underwent robotic or laparoscopic liver resection were considered following these criteria: (1) studies comparing robotic and laparoscopic liver resection; (2) studies reporting at least one perioperative outcome; and (3) if more than one study was reported by the same institute, only the most recent was included. The primary outcome measures were set for estimated blood loss, operative time, conversion rate, R1 resection rate, morbidity and mortality rates, hospital stay and major hepatectomy rates.

RESULTS

A total of 7 articles, published between 2010 and 2014, fulfilled the selection criteria. The laparoscopic approach was associated with a significant reduction in blood loss and lower operative time (MD = 83.96, 95%CI: 10.51-157.41, P = 0.03; MD = 68.43, 95%CI: 39.22-97.65, P < 0.00001, respectively). No differences were found with respect to conversion rate, R1 resection rate, morbidity and hospital stay.

CONCLUSION

Laparoscopic liver resection resulted in reduced blood loss and shorter surgical times compared to robotic liver resections. There was no difference in conversion rate, R1 resection rate, morbidity and length of postoperative stay.

Italian experience in minimally invasive liver surgery: a national survey

This survey provides an overview about current spread of Minimally Invasive Liver Resection (MILR) in Italy. Primary endpoint was to assess evolution of MILR in recent years and its degree of application among centres with different experience in laparoscopic and hepatic surgery. A questionnaire with items describing activity MILR was sent to Italian surgical centers. Diagnosis, technical approaches, resection extent, devices and vascular control, reasons for conversion, morbidity and mortality were recorded. Level of expertise per centre was analysed in terms of learning curve acquisition and relationship with hepatobiliary background. 1497 MILRs from 39 centers (median 27 patients/center, range 1-145, period 1995-2012) were collected. Conversion rate was 10.7% (180 patients out of 1677, excluded from subsequent analysis), with bleeding representing most frequent cause of conversion (34.4%). Eleven centers completed learning curve, performing >60 MILR. Benign lesions were 27.5% and malignant 72.5%, with hepatocellular carcinoma being the most frequent indication. 92.6% of cases were performed with a totally laparoscopic technique (1.3% were hand-assisted, 1.9% single-port and 4.2% robotic). Minor resections accounted for 92.9% (left lateral sectionectomy resulted the most frequent procedure; 23.8%), while major resections represented 7.1%. Overall mortality was 0.2% (3 of 1497 patients) and morbidity 22.8%. Mean length of stay was 5 days. Correlation between MILR activity and a hepatobiliary background was not clear comparing MILR cases and liver resection volumes per center. MILR has been significantly widespread in Italy in recent years, with several centers having definitely completed the learning curve as attested by clinical results consistent with major series from the Western and Eastern countries. MILR programs in Italy seem to arise from both centers with specific hepatobiliary expertise and centers performing advanced general laparoscopic surgery.