Outcomes of Robotic Living Donor Right Hepatectomy From 52 Consecutive Cases: Comparison With Open and Laparoscopy-assisted Donor Hepatectomy

COMPLEX DONOR ANATOMY DOES NOT INFLUENCE EARLY DONOR OR RECIPIENT OUTCOMES AFTER ROBOTIC DONOR HEPATECTOMY AT A HIGH VOLUME CENTER

INTRODUCTION

With evolving expertise, criteria to select donors for robotic living donor hepatectomy (RDH) have expanded. We studied the comparative donor and recipient outcomes in RDH with standard grafts and complex grafts.

METHODS

We have performed 360 right lobe RDH (RRDH) out of 4296 LDLT, with 280 having over 6 months follow-up. First 53 cases were excluded as we used a different (cut-suture) technique for hepatic duct division. Subsequent 227 RRDH were then divided into donors with standard (group S, n=76) and complex grafts (group C, n=151).

RESULTS

Three donors in each group were converted to open midline incision. In Groups S and C, 1(1.3%) and 3(1.9%) donors developed biliary complications (p=0.741). Both recipient groups had similar early and late post-operative complications. Group C recipients had non-significantly higher incidence of late biliary complications [3(3.9%) vs 17(11.2%); OR 3.09, 95% CI 0.88-10.88, p=0.067]. Early (< 30days) recipient mortality was similar with 4(6.6%) in group S, and 11(7.3%) in group C (p=0.755), all sepsis related.

CONCLUSION

The outcomes were similar among donors and recipients with both standard and complex grafts. With experience, RDH can be safely offered to "all comer" donors and has the potential to become standard of care.

[Status of Robotics in Living Donor Liver and Kidney Transplantation - Review of the Literature and Results of a Survey among German Transplant Centres]

The advantages of minimally invasive surgical techniques are undisputed. With the introduction of robotic assistance systems, classic laparoscopy has been further developed and is now also being utilized in transplant surgery, which was previously mainly characterised by open surgical procedures, particularly in living donor liver and kidney donations. In order to assess the current implementation status of robotic assistance systems in transplant surgery, international studies in this field were summarized and correlated with a national survey on the use of robotic assistance systems in living donation.First, a narrative summary of the MEDLINE-listed publications on robotic living kidney and liver donation was carried out. In addition, an online survey was conducted among German transplant centres with ten questions on the utilization of robotic techniques in Germany.Retrospective cohort studies at a small number of transplant centres worldwide report particular advantages of robotics, especially regarding blood loss, patient comfort and length of hospital stay. One-third of German transplant centres already perform living kidney donations with robotic assistance, and one-fifth of centres even use this technique in over 90% of cases. In contrast, living liver donations are only performed in one German transplant centre using robotic assistance for left lateral liver resection of the donor.In the context of living donation, advocates of robotics emphasise technical advantages, greater patient comfort and a steeper learning curve. A persistent and significant point of criticism regarding robotic surgical techniques remains the prolonged warm ischemia time, especially during learning curves. The survey results presented here demonstrate that there is still a substantial need for discussion on this current topic. However, there is a lack of prospective randomised controlled studies.

Robotic versus laparoscopic hepatectomy: meta-analysis of propensity-score matched studies

BACKGROUND

Robotic techniques can theoretically overcome the limitations of laparoscopic liver resection and are currently recognized as safe options; however, it is not known which approach is better. The purpose of this study was to compare the advantages of robotic hepatectomy and laparoscopic hepatectomy.

METHODS

Electronic databases (the Cochrane Library, PubMed (MEDLINE), Embase and Web of Science) were systematically searched from January 2000 to August 2023 for eligible studies that compared robotic hepatectomy and laparoscopic hepatectomy. Studies that met the inclusion criteria were then reviewed systematically. The reported data were aggregated statistically using RevMan 5.4 software. The parameters of interest included intraoperative, postoperative, survival and financial outcomes. Subgroup analysis was performed according to the type and difficulty level of hepatectomy and the study setting.

RESULTS

A total of 26 propensity-score matching comparative trials met the inclusion criteria, which comprised 9355 participants (robotic hepatectomy versus laparoscopic hepatectomy: 3938 versus 5417) in the meta-analysis. For surgical outcomes, lower blood loss, lower open conversion rate and higher R0 resection rate were observed in the robotic hepatectomy group compared with the laparoscopic hepatectomy group (mean difference (MD) -86.22, 95% c.i. -116.49 to -55.95, I² = 87%, P < 0.001; OR 0.51, 95% c.i. 0.38 to 0.69, I² = 40%, P < 0.001; OR 1.31, 95% c.i. 1.03 to 1.67, I² = 0%, P = 0.030 respectively). The lower blood loss (major hepatectomy group: MD -56.88, 95% c.i. -109.09 to -4.28, I² = 76%, P = 0.030; IWATE score (advanced/expert more than 80%) group: MD -0.61, 95% c.i. -1.14 to -0.08, I² = 95%, P < 0.001) and lower open conversion rate (major hepatectomy group: OR 0.41, 95% c.i. 0.30 to 0.56, I² = 0%, P < 0.001; IWATE score (advanced/expert less than 80%) group: OR 0.52, 95% c.i. 0.36 to 0.75, I² = 0%, P = 0.659) advantage persisted across subgroup analyses.

CONCLUSION

The robotic approach had advantages to laparoscopic in terms of lower blood loss and reduced rates of open conversion, especially in difficult hepatectomies.

Early outcomes of robotic vs open living donor right hepatectomy in a US Center

BACKGROUND

Robotic living donor hepatectomy offers potential advantages but has been limited to high-volume centers, primarily in Asia and the Middle East. We report our experience establishing a robotic living donor right hepatectomy program in a U.S. center with low LDLT volume and no prior laparoscopic donor hepatectomy experience and analyze early outcomes.

METHODS

This retrospective cohort study analyzed 37 living donor right hepatectomies (13 robotic [including one open conversion], 24 open) performed between June 2022 and February 2024.

RESULTS

The robotic group had longer operative times (median [range], 451 [374-568] minutes vs 368 [276-421] minutes; P < 0.001) but less blood loss (median [range], 200 [50-700] mL vs 900 [300-2500] mL; P < 0.001). One case required unplanned open conversion due to gas embolism. Two hematomas/bleeding (Clavien-Dindo grade IIIB) occurred in the robotic group, but no biliary complications. Comprehensive Complication Index, liver function tests, and hospital stays were similar between the two groups, with no 90-day graft failure/mortality.

CONCLUSION

With extensive surgical experience in both open donor hepatectomy and robotic surgery, along with meticulous preparation as a team, U.S. centers with lower LDLT volume and no laparoscopic experience can safely implement robotic living donor right hepatectomy, achieving comparable short-term outcomes to the open approach. Further research on long-term outcomes and donor quality of life is necessary.

Propensity Score-matched Donor and Recipient Outcomes: Robotic Versus Laparoscopic Donor Right Hepatectomy

BACKGROUND

Few studies have examined the long-term outcomes of recipients in minimally invasive donor hepatectomies, particularly comparing robotic and laparoscopic donor procedures. Understanding these outcomes is crucial for optimizing surgical approaches and improving the overall success of living donor liver transplantation. This study aimed to compare the feasibility and safety of robotic donor right hepatectomy (RDRH) and laparoscopic donor right hepatectomy (LDRH) by evaluating total follow-up patient outcomes.

METHODS

This retrospective, single-center study included 117 and 118 donors who underwent RDRH and LDRH between March 2016 and June 2023, respectively. After performing 1:1 propensity score matching, 71 donor-recipient pairs were included in each group. Donor and recipient complications were divided into early (within 90 d) and late (after 90 d) biliary and vascular complications.

RESULTS

In the matched cohort, major complication rates of donors were similar in both groups. Bile duct (BD) variation was not significantly different; however, the rates of multiple BD openings (26.8% versus 54.9%; P  =   0.001) and major biliary complications in recipients were higher in the LDRH group (22.5% versus 42.3%; P  =   0.012). The cumulative biliary complication rate was significantly higher in the LDRH group. Early biliary complications were not significantly different; however, the rate of late biliary complications was higher in the LDRH group (11.3% versus 23.9%; P  =   0.047).

CONCLUSIONS

RDRH demonstrated comparable postoperative complications to LDRH in donors but showed fewer recipient biliary complications. This could be attributed to the precision of robotic dissection and BD division, resulting in fewer multiple BD openings.

The learning curve for robotic living donor right hepatectomy: Analysis of outcomes in 2 specialized centers

Robotic surgery is an emerging minimally invasive option for living donor hepatectomy. Currently, there are no studies on the learning curve of robotic donor hepatectomy. Thus, we evaluated the learning curve for robotic donor right hepatectomy. We retrospectively reviewed prospectively collected data from consecutive living donors who underwent robotic hepatectomy at 2 specialized centers between 2016 and 2022. We estimated the number of cases required to achieve stable operating times for robotic donor right hepatectomy using cumulative sum (CUSUM) analysis. The complication rates were similar between the 2 centers (22.8% vs. 26.7%; p = 0.74). Most complications were graded as minor (70.4%). Analysis of the total operative time demonstrated that the learning curves reached a peak at the 17th case in center 1 and the 9th case in center 2. The average operation times for cases 1-17 versus 18-99 in center 1 were 603 versus 438 minutes ( p < 0.001), and cases 1-9 versus 10-15 in center 2 were 532 versus 418 minutes ( p = 0.002). Complication rates were lower after the learning curves were achieved, although this did not reach statistical significance. A comparison of outcomes between centers suggests that a standardized approach to this complex operation can be successfully transferred.

Recommendations on Robotic Hepato-Pancreato-Biliary Surgery. The Paris Jury-Based Consensus Conference

OBJECTIVE

To establish the first consensus guidelines on the safety and indications of robotics in Hepato-Pancreatic-Biliary (HPB) surgery. The secondary aim was to identify priorities for future research.

BACKGROUND

HPB robotic surgery is reaching the IDEAL 2b exploration phase for innovative technology. An objective assessment endorsed by the HPB community is timely and needed.

METHODS

The ROBOT4HPB conference developed consensus guidelines using the Zurich-Danish model. An impartial and multidisciplinary jury produced unbiased guidelines based on the work of 10 expert panels answering predefined key questions and considering the best-quality evidence retrieved after a systematic review. The recommendations conformed with the GRADE and SIGN50 methodologies.

RESULTS

Sixty-four experts from 20 countries considered 285 studies, and the conference included an audience of 220 attendees. The jury (n=10) produced recommendations or statements covering 5 sections of robotic HPB surgery: technology, training and expertise, outcome assessment, and liver and pancreatic procedures. The recommendations supported the feasibility of robotics for most HPB procedures and its potential value in extending minimally invasive indications, emphasizing, however, the importance of expertise to ensure safety. The concept of expertise was defined broadly, encompassing requirements for credentialing HPB robotics at a given center. The jury prioritized relevant questions for future trials and emphasized the need for prospective registries, including validated outcome metrics for the forthcoming assessment of HPB robotics.

CONCLUSIONS

The ROBOT4HPB consensus represents a collaborative and multidisciplinary initiative, defining state-of-the-art expertise in HPB robotics procedures. It produced the first guidelines to encourage their safe use and promotion.

Hepatic Duct Division During Robotic Living Donor Hepatectomy: A Comparison Between the Novel Triple C (Clip-Clamp-Cut) and the Cut-Suture Techniques

Background: In robotic donor hepatectomy (RDH), hepatic duct division (HDD) and its stump closure technique are of paramount importance in avoiding postoperative biliary complications in both donors and recipients. We describe our novel triple C ("clip-clamp-cut") technique of HDD. Methods: Out of 4016 living donor liver transplant (LDLT) (2004-October 2023), we have performed 208 RDH cases since December 2019. This study is a retrospective analysis of the first 160 RDH cases. After excluding the first 20 RDH cases (learning curve) and 3 left-sided RDH cases, 137 cases with no exclusion criteria were included. We divided these 137 donors into the "cut and suture" (CS) group (n = 33) and the "triple C" technique group (n = 104). We compared intraoperative details and postoperative outcomes. Results: All 137 robotic donors and 128/137 recipients are currently well. Donor biliary leak rate was significantly lower among the triple C group (n = 3, 2.9%) compared to the CS group (n = 5, 15.2%) (p=0.009). No other differences in postdonation morbidity were observed among the two groups. Recipient biliary complication rate was lower in the triple C group than in the CS group although not statistically significant (10.6% vs. 15.1%; p=0.537), despite more multiple biliary anastomoses in the former. No significant differences in post-transplant recipient morbidity and mortality were observed. Conclusions: Our simple yet novel triple C technique enables clean, precise, bloodless HDD resulting in lower donor and potentially recipient biliary complication rates. The ease and reproducibility make it ideal for widespread adoption.

Robotic surgery in the aspect of liver transplantation

Introduction. Almost 60 years have passed since the first liver transplant performed by Thomas Starzl. During this time, medical technologies have gradually improved, which has made it possible to use more and more new methods and approaches in this type of medical care. One of the new techniques of recent decades is robotic surgery, which is gradually being introduced into medical practice, including in the field of transplant medicine.

Objective. The purpose of writing this review was to summarize knowledge and describe the current status of development of robotic surgery in the aspect of liver transplantation, namely: liver resection in donors, as well as graft implantation in the recipient.

Material and methods. The review includes foreign and domestic publications on minimally invasive donor liver surgery. Publications on the topic of robotic liver resection in the aspect of liver transplantation were also processed.

Conclusion. Robotic surgery using advanced robotic systems represents the next step in the development of minimally invasive technologies in liver transplantation. Robotic systems provide more precise and dexterous control of instruments, allowing surgeons to perform complex procedures with greater precision and less risk to patients. However, the robotic approach is still very limited in geographical distribution and requires much more experience than laparoscopy. The upcoming introduction of new robotic systems that support haptic feedback or cavitronic ultrasonic surgical aspirators will further promote a widespread adoption of robotic liver resection in liver donors and liver recipients.

The future of liver transplantation

Over the last 50 years, liver transplantation has evolved into a procedure routinely performed in many countries worldwide. Those able to access this therapy frequently experience a miraculous risk-benefit ratio, particularly if they face the imminently life-threatening disease. Over the decades, the success of liver transplantation, with dramatic improvements in early posttransplant survival, has aggressively driven demand. However, despite the emergence of living donors to augment deceased donors as a source of organs, supply has lagged far behind demand. As a result, rationing has been an unfortunate focus in recent decades. Recent shifts in the epidemiology of liver disease combined with transformative innovations in liver preservation suggest that the underlying premise of organ shortage may erode in the foreseeable future. The focus will sharpen on improving equitable access while mitigating constraints related to workforce training, infrastructure for organ recovery and rehabilitation, and their associated costs. Research efforts in liver preservation will undoubtedly blossom with the aim of optimizing both the timing and conditions of transplantation. Coupled with advances in genetic engineering, regenerative biology, and cellular therapies, the portfolio of innovation, both broad and deep, offers the promise that, in the future, liver transplantation will not only be broadly available to those in need but also represent a highly durable life-saving therapy.

Trends of liver transplantation in Asia

Liver transplantation (LT) in Asia started comparatively early in 1964, just 1 year after Starzl's trail-blazing first attempt. Despite the quick start, LT was slow to develop in this region. Limited access to universal healthcare, lack of public understanding and support as well as the absence of strong legislation, on a backdrop of a wide range of diverse social, religious, economic and cultural background are all contributory factors. Through strong administrative efforts, the number of DDLTs in selected Asian countries has been slowly rising in recent years. However, Asians are generally still less likely to donate organs than Caucasians after death. The strong demand for LT with limited access to deceased organs has, therefore, led to constant need for innovation in LT this region, with the pioneering of various LDLT techniques and safe expansion of donor pool being driven primarily by Asian centers. Familiarity and the development of technical expertise in donor surgery have also resulted in Asian centers repeatedly pushing the boundaries on minimally invasive donor and recipient surgery. In this article, we focus on the past and present states of LT in Asia and explore the future trends of LT in this region.

The aim of donor safety: surgical approaches and current results

Living liver donation (LLD) has been suggested as a potential solution to reduce the waitlist mortality for liver transplantation (LT) recipients by facilitating living donor liver transplantation (LDLT). Ensuring both donor and recipient safety is a critical aspect of LDLT. An accurate understanding of the complexity and extend of safety outcomes of the donor is imperative to maintain the high-quality standard this medical program requires. This review seeks to outline safety outcome parameters of interest for donors. Early postoperative mortality is very low with no significant differences comparing left lobe to right lobe LLD. Complications most commonly are biliary (leakage or strictures), bleeding, respiratory or pulmonary, gastrointestinal or infectious. Return to full-time work and quality of life are essential parameters in the mid and long term. As evidence continues to accumulate, outcomes may evolve with the expansion of minimal invasive surgery practice and currently laparoscopic approach is recommended in large experienced centers. By offering safer operations that require fewer incisions or liver resections, living liver donations can be further encouraged, and the perception of the procedure can be improved. Rational consideration of the safety of the donor and in-depth discussion and evaluation with the patient is of utmost importance.

Robotic and laparoscopic right lobe living donation compared to the open approach: A multicenter study on 1194 donor hepatectomies

Due to the success of minimally invasive liver surgery, laparoscopic and robotic minimally invasive donor hepatectomies (MIDH) are increasingly performed worldwide. We conducted a retrospective, multicentre, propensity score-matched analysis on right lobe MIDH by comparing the robotic, laparoscopic, and open approaches to assess the feasibility, safety, and early outcomes of MIDHs. From January 2016 until December 2020, 1194 donors underwent a right donor hepatectomy performed with a robotic (n = 92), laparoscopic (n = 306), and open approach (n = 796) at 6 high-volume centers. Donor and recipients were matched for different variables using propensity score matching (1:1:2). Donor outcomes were recorded, and postoperative pain was measured through a visual analog scale. Recipients' outcomes were also analyzed. Ninety-two donors undergoing robotic surgery were matched and compared to 92 and 184 donors undergoing laparoscopic and open surgery, respectively. Conversions to open surgery occurred during 1 (1.1%) robotic and 2 (2.2%) laparoscopic procedures. Robotic procedures had a longer operative time (493 ± 96 min) compared to laparoscopic and open procedures (347 ± 120 and 358 ± 95 min; p < 0.001) but were associated with reduced donor blood losses ( p < 0.001). No differences were observed in overall and major complications (≥ IIIa). Robotic hepatectomy donors had significantly less pain compared to the 2 other groups ( p < 0.001). Fifty recipients of robotic-procured grafts were matched to 50 and 100 recipients of laparoscopic and open surgery procured grafts, respectively. No differences were observed in terms of postoperative complications, and recipients' survival was similar ( p =0.455). In very few high-volume centers, robotic right lobe procurement has shown to be a safe procedure. Despite an increased operative and the first warm ischemia times, this approach is associated with reduced intraoperative blood losses and pain compared to the laparoscopic and open approaches. Further data are needed to confirm it as a valuable option for the laparoscopic approach in MIDH.

Asian Pacific Association for the Study of the Liver clinical practice guidelines on liver transplantation

Liver transplantation is a highly complex and challenging field of clinical practice. Although it was originally developed in western countries, it has been further advanced in Asian countries through the use of living donor liver transplantation. This method of transplantation is the only available option in many countries in the Asia-Pacific region due to the lack of deceased organ donation. As a result of this clinical situation, there is a growing need for guidelines that are specific to the Asia-Pacific region. These guidelines provide comprehensive recommendations for evidence-based management throughout the entire process of liver transplantation, covering both deceased and living donor liver transplantation. In addition, the development of these guidelines has been a collaborative effort between medical professionals from various countries in the region. This has allowed for the inclusion of diverse perspectives and experiences, leading to a more comprehensive and effective set of guidelines.

Surgical techniques for robotic right donor hepatectomy, part 2: robotic parenchymal transection and bile duct division

Robotic surgery is emerging as a feasible minimally invasive approach for donor hepatectomy at specialized centers. The aim of this article is to systematically describe the surgical techniques for robotic parenchymal transection and bile duct division in right donor hepatectomy. The setup of the robotic arms, methods of parenchymal transection using robotic instruments, and right hepatic duct division with the aid of indocyanine green dye are detailed, along with the pearls and pitfalls of these two parts of the operation.

Surgical techniques for robotic right donor hepatectomy, part 1: robotic hilar dissection and right lobe mobilization

Robotic surgery is emerging as a feasible minimally invasive approach for donor hepatectomy at specialized centers. The aim of this article is to systematically describe the surgical techniques for robotic hilar dissection and right lobe mobilization in right donor hepatectomy. The setup of the robotic arms, the dissection of inflow vessels and retrohepatic inferior vena cava, and the pearls and pitfalls of these two parts of the operation are detailed.

Minimally Invasive Surgery in Liver Transplantation: From Living Liver Donation to Graft Implantation

Since the end of the 20th century and the establishment of minimally invasive techniques, they have become the preferred operative method by many surgeons. These techniques were applied to liver surgery for the first time in 1991, while as far as transplantation is concerned their application was limited to the living donor procedure. We performed a review of the literature by searching in Pubmed and Scopus using the following keywords: Liver transplantation, Minimally invasive surgery(MIS) living liver donor surgery. Applications of MIS are recorded in surgeries involving the donor and the recipient. Regarding the recipient surgeries, the reports are limited to 25 patients, including combinations of laparoscopic, robotic and open techniques, while in the living donor surgery, the reports are much more numerous and with larger series of patients. Shorter hospitalization times and less blood loss are recorded, especially in centers with experience in a large number of cases. Regarding the living donor surgery, MIS follows the same principles as a conventional hepatectomy and is already the method of choice in many specialized centers. Regarding the recipient surgery, significant questions arise mainly concerning the safe handling of the liver graft.

Comparison of short-term outcomes between robotic and laparoscopic liver resection: a meta-analysis of propensity score-matched studies

OBJECTIVE

This meta-analysis aimed to compare short-term outcomes between robotic liver resection (RLR) and laparoscopic liver resection (LLR) using data collected from propensity score-matched studies.

METHODS

The PubMed, Cochrane Library, and Embase databases were searched to collect propensity score-matched studies comparing RLR and LLR. Relevant data were extracted and analyzed. Odds ratios (ORs) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated using fixed-effect or random-effect models. Meta-regression analysis was performed for primary outcome measures. Subgroup analyses and sensitivity analyses were performed for outcomes exhibiting high heterogeneity. Quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluation framework.

RESULTS

Twenty-two propensity score-matched studies were included to comprise 5272 patients (RLR group, 2422 cases; LLR group, 2850 cases). Intraoperative blood loss (SMD=-0.31 ml, 95% CI -0.48 to -0.14; P =0.0005), open conversion (OR=0.46, 95% CI 0.37-0.58; P <0.0001), and severe complications (OR=0.76, 95% CI 0.61-0.95; P =0.02) were significantly lower in the RLR group. Operation time, odds of use, and duration of Pringle maneuver, length of hospital stay, and odds of intraoperative blood transfusion, overall complications, R0 resection, reoperation, 30-day readmission, 30-day mortality, and 90-day mortality did not significantly differ between the groups. Further subgroup and sensitivity analyses suggested that the results were stable. Meta-regression analysis did not suggest a correlation between primary outcomes and study characteristics. The quality of evidence for the primary outcomes was medium or low, while that for the secondary outcomes was medium, low, or very low.

CONCLUSION

Although some short-term outcomes are similar between RLR and LLR, RLR is superior in terms of less blood loss and lower odds of open conversion and severe complications. In the future, RLR may become a safe and effective replacement for LLR.

Systematic review and meta-analysis of open versus laparoscopy-assisted versus pure laparoscopic versus robotic living donor hepatectomy

The value of minimally invasive approaches for living donor hepatectomy remains unclear. Our aim was to compare the donor outcomes after open versus laparoscopy-assisted versus pure laparoscopic versus robotic living donor hepatectomy (OLDH vs. LALDH vs. PLLDH vs. RLDH). A systematic literature review of the MEDLINE, Cochrane Library, Embase, and Scopus databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement (up to December 8, 2021). Random-effects meta-analyses were performed separately for minor and major living donor hepatectomy. The risk of bias in nonrandomized studies was assessed using the Newcastle-Ottawa Scale. A total of 31 studies were included. There was no difference in donor outcomes after OLDH versus LALDH for major hepatectomy. However, PLLDH was associated with decreased estimated blood loss, length of stay (LOS), and overall complications versus OLDH for minor and major hepatectomy, but also with increased operative time for major hepatectomy. PLLDH was associated with decreased LOS versus LALDH for major hepatectomy. RLDH was associated with decreased LOS but with increased operative time versus OLDH for major hepatectomy. The scarcity of studies comparing RLDH versus LALDH/PLLDH did not allow us to meta-analyze donor outcomes for that comparison. There seems to be a marginal benefit in estimated blood loss and/or LOS in favor of PLLDH and RLDH. The complexity of these procedures limits them to transplant centers with high volume and experience. Future studies should investigate self-reported donor experience and the associated economic costs of these approaches.

International experts consensus guidelines on robotic liver resection in 2023

The robotic liver resection (RLR) has been increasingly applied in recent years and its benefits shown in some aspects owing to the technical advancement of robotic surgical system, however, controversies still exist. Based on the foundation of the previous consensus statement, this new consensus document aimed to update clinical recommendations and provide guidance to improve the outcomes of RLR clinical practice. The guideline steering group and guideline expert group were formed by 29 international experts of liver surgery and evidence-based medicine (EBM). Relevant literature was reviewed and analyzed by the evidence evaluation group. According to the WHO Handbook for Guideline Development, the Guidance Principles of Development and Amendment of the Guidelines for Clinical Diagnosis and Treatment in China 2022, a total of 14 recommendations were generated. Among them were 8 recommendations formulated by the GRADE method, and the remaining 6 recommendations were formulated based on literature review and experts' opinion due to insufficient EBM results. This international experts consensus guideline offered guidance for the safe and effective clinical practice and the research direction of RLR in future.

Major hepatectomy in elderly patients: possible benefit from robotic platform utilization

INTRODUCTION

Robotic surgery has been increasingly utilized, yet its application for hepato-pancreato-biliary (HPB) procedures remains low due to technical complexity, perceived financial burden, and unproven clinical benefits. We hypothesized that the robotic approach would be associated with improved clinical outcomes following major hepatectomy compared with the laparoscopic approach among elderly patients who would benefit from the advantages of minimally invasive surgery.

METHODS

A retrospective review of consecutive patients who underwent major hepatectomy between January 2010 and December 2021 at Carolinas Medical Center was performed. Inclusion criteria were age ≥ 65 years and major hepatectomy of three segments or more. Patients who underwent multiple liver resections, vascular/biliary reconstruction, or concomitant extrahepatic procedures (except cholecystectomy) were excluded. Categorical variables were compared using Chi-square or Fisher's exact test when more than 20% of cells had expected frequencies less than five, and Wilcoxon two-sample or Kruskal-Wallis tests were used for continuous or ordinal variables. Results are described as median and interquartile range (IQR). Multivariate analyses were used on postoperative admission days.

RESULTS

There were 399 major hepatectomies performed during this time period, of which 125 met the criteria and were included. There were no differences in perioperative demographics among patients who underwent robotic hepatectomy (RH, n = 39) and laparoscopic hepatectomy (LH, n = 32). There was no difference in operative time, blood loss, or major complication rates. However, RH had lower rates of conversion to an open procedure (2.6% versus 31.3%, p = 0.002), shorter length of hospital stay [LOS, 4 (3-7) versus 6 (4-8.5) days, p ≤ 0.0001], cumulative LOS [4 (3-7) versus 6 (4.5-9) days, p ≤ 0.0001], and lower rates of intensive care unit (ICU) admission (7.7% versus 75%, p ≤ 0.001), with a trend toward fewer rehabilitation requirements.

CONCLUSIONS

Robot major hepatectomy shows clinical advantages in elderly patients, including shorter hospital and ICU stays. These advantages, as well as reduced rehabilitation requirements associated with minimally invasive surgery, could overcome the current perceived financial disadvantages of robotic hepatectomy.

Comparison of surgical outcomes and learning curve for robotic versus laparoscopic living donor hepatectomy: A retrospective cohort study

BACKGROUND

Both laparoscopic living donor right hemihepatectomy (LLDRH) and robotic living donor right hemihepatectomy (RLDRH) have been developed for minimally invasive donor hepatectomy (MIDH), although comparative analysis between the two surgical modalities is lacking. This study aims to compare surgical outcomes of LLDRH and RLDRH at a single institution.

MATERIALS AND METHODS

From March 2016 to March 2022, 171 patients who underwent MILH of right liver were enrolled and divided into RLDRH and LLDRH. Two surgeons with experience in both techniques performed all procedures. Clinical characteristics, perioperative outcomes of donor and recipient, and donor anatomic variations were compared between both groups, and learning curves were estimated. Subgroup analysis was also performed, including only donors recruited after 2019, when LLDRH was initiated at our institution.

RESULTS

RLDRH and LLDRH were performed for 102 and 69 patients, respectively. Operative time was significantly longer for RLDRH than LLDRH (464 vs. 407 min, P < 0.001), although estimated blood loss was lower in RLDRH (104 vs. 238 mL, P = 0.002). Incidence of major complications was similar in both groups. After 2019, significantly more RLDRH vs. LLDRH patients had variation in the hepatic artery (14.3% vs. 2.9%, P = 0.020) and portal vein (16.1% vs. 4.3%, P = 0.027). Learning curve for RLDRH was stabilized after approximately the 16th case, whereas that of LLDRH stabilized immediately.

CONCLUSION

RLDRH resulted in less intraoperative bleeding and comparable postoperative outcomes than LLDRH. Moreover, since 2019, RLDRH has been employed more frequently for donors with hilar structure anatomic variations. Based on our single-center experience, we propose that standardized procedures for RLDRH might help set up pure minimally invasive procedures for donor hepatectomy and facilitate safe implementation of laparoscopic approaches.

2022 KLCA-NCC Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

Robotic surgery and liver transplantation: A single-center experience of 501 robotic donor hepatectomies

BACKGROUND

Over the past two decades robotic surgery has been introduced to many areas including liver surgery. Laparoscopic liver surgery is an alternative minimally invasive approach. However, moving on to the complexity of living donor hepatectomies, the advantages of robotic versus laparoscopic approach have convinced us to establish the robotic platform as a standard for living donor hepatectomy.

METHODS

From November 2018 to January 2022, 501 fully robotic donor hepatectomies, including 177 left lateral donor lobes, 112 full left lobes and 212 full right lobes were performed. Grafts were donated to 296 adult recipients and 205 pediatric recipients. Donor age, sex, body weight, body mass index (BMI), graft weight, graft to body weight ratio (GBWR), operative time, blood loss, first warm ischemic time, pain score, length of intensive care unit (ICU) stay and hospital stay, and complications were retrospectively analyzed based on a prospectively kept database. Recipients were evaluated for graft and patient survival, age, sex, BMI, body weight, model of end-stage liver disease score, blood loss, transfusions, operative time, cold ischemic time, length of hospital stay and complications.

RESULTS

There was no donor mortality. Two cases needed to be converted to open surgery. The median blood loss was 60 mL (range 20-800), median donor operative time was 6.77 h (range 2.93-11.53), median length of hospital stay was 4 days (range 2-22). Complication rate in donors classified following Clavien-Dindo was 6.4% (n = 32) with one grade III complication. Three-year actual recipient overall survival was 91.4%; 87.5% for adult recipients and 97.1% for pediatric recipients. Three-year actual graft overall survival was 90.6%; 87.5% for adult recipients and 95.1% for pediatric recipients. In-hospital mortality was 6%, 9.1% (27/296) for adult recipients and 1.4% (3/205) for pediatric recipients. The recipients' morbidity was 19.8% (n = 99). Twenty-eight recipients (5.6%) had biliary and 22 (4.4%) vascular complications. Six (12.0%) recipients needed to be re-transplanted.

CONCLUSIONS

With growing experience it is nowadays possible to perform any donor hepatectomy by robotic approach regardless of anatomical variations and graft size. Donor morbidity and quality for life results are encouraging and should motivate other transplant centers with interest in minimally invasive donor surgery to adopt this robotic technique.

A systematic review and network meta-analysis of outcomes after open, mini-laparotomy, hybrid, totally laparoscopic, and robotic living donor right hepatectomy

BACKGROUND

A systematic review and network meta-analysis was performed to compare outcomes after living donor right hepatectomy via the following techniques: conventional open (Open), mini-laparotomy (Minilap), hybrid (Hybrid), totally laparoscopic (Lap), and robotic living donor right hepatectomy (Robotic).

METHODS

PubMed, EMBASE, Cochrane, and Scopus were searched from inception to August 2021 for comparative studies of patients who underwent living donor right hepatectomy.

RESULTS

Nineteen studies comprising 2,261 patients were included. Operation time was longer in Lap versus Minilap and Open (mean difference 65.09 min, 95% confidence interval 3.40-126.78 and mean difference 34.81 minutes, 95% confidence interval 1.84-67.78), and in Robotic versus Hybrid, Lap, Minilap, and Open (mean difference 144.72 minutes, 95% confidence interval 89.84-199.59, mean difference 113.24 minutes, 95% confidence interval 53.28-173.20, mean difference 178.33 minutes, 95% confidence interval 105.58-251.08 and mean difference 148.05 minutes, 95% confidence interval 97.35-198.74, respectively). Minilap and Open were associated with higher blood loss compared to Lap (mean difference 258.67 mL, 95% confidence interval 107.00-410.33 and mean difference 314.11 mL, 95% confidence interval 143.84-484.37) and Robotic (mean difference 205.60 mL, 95% confidence interval 45.92-365.28 and mean difference 261.04 mL, 95% confidence interval 84.26-437.82). Open was associated with more overall complications compared to Minilap (odds ratio 2.60, 95% confidence interval 1.11-6.08). Recipient biliary complication rate was higher in Minilap and Open versus Hybrid (odds ratio 3.91, 95% confidence interval 1.13-13.55 and odds ratio 11.42, 95% confidence interval 2.27-57.49), and lower in Open versus Minilap (OR 0.07, 95% confidence interval 0.01-0.34).

CONCLUSION

Minimally invasive donor right hepatectomy via the various techniques is safe and feasible when performed in high-volume centers, with no major differences in donor complication rates and comparable recipient outcomes once surgeons have mounted the learning curve.

OPEN TO ROBOTIC RIGHT DONOR HEPATECTOMY: A TECTONIC SHIFT IN SURGICAL TECHNIQUE

Robotic right live donor hepatectomy(r-LDRH) has been reported with reduced morbidity compared to open donor right hepatectomy(o-LDRH) in few recent series. Nevertheless, its routine use is debated. We present a large series comparing pure r-LDRH with o-LDRH. Consecutive r-LDRH performed from June 2018 to June 2020 (n = 102) were compared with consecutive donors undergoing o-LDRH (n = 152) from February 2016 to February 2018, a period when r-LDRH was not available at this centre. Propensity score matched (PSM) analysis of 89 case-control pairs was additionally performed. Primary endpoints were length of high dependency unit (HDU) & hospital stay and Clavien-Dindo graded complications among donors. Although r-LDRH took longer to perform (540 versus 462 mins, P<0.001), the post-operative peak transaminases levels(P<0.001), the length of HDU (3 versus 4 days, P<0.001) and hospital stay (8 versus 9 days, P<0.001) were lower in in donors undergoing r-LDRH. Clavien-Dindo graded complications were similar (16.67% in r-LDRH and 13.16% in o-LDRH). The rates of early allograft dysfunction (1.6% versus 3.3%), bile leak (14.7% versus 10.7%), and 1-year mortality (13.7% versus 11.8%) were comparable between r-LDRH and o-LDRH recipients. PSM analysis yielded similar results between the groups. These data support the safety and feasibility of r-LDRH in select donors. This article is protected by copyright. All rights reserved.

The use of nondirected donor organs in living donor liver transplantation: Perspectives and guidance

Interest in anonymous nondirected living organ donation is increasing in the United States and a small number of transplantation centers are accumulating an experience regarding nondirected donation in living donor liver transplantation. Herein, we review current transplant policy, discuss emerging data, draw parallels from nondirected kidney donation, and examine relevant considerations in nondirected living liver donation. We aim to provide a consensus guidance to ensure safe evaluation and selection of nondirected living liver donors and a schema for just allocation of nondirected grafts.

Robotic Living Donor Right Hepatectomy: A Systematic Review and Meta-Analysis

The introduction of robotics in living donor liver transplantation has been revolutionary. We aimed to examine the safety of robotic living donor right hepatectomy (RLDRH) compared to open (ODRH) and laparoscopic (LADRH) approaches. A systematic review was carried out in Medline and six additional databases following PRISMA guidelines. Data on morbidity, postoperative liver function, and pain in donors and recipients were extracted from studies comparing RLDRH, ODRH, and LADRH published up to September 2020; PROSPERO (CRD42020214313). Dichotomous variables were pooled as risk ratios and continuous variables as weighted mean differences. Four studies with a total of 517 patients were included. In living donors, the postoperative total bilirubin level (MD: −0.7 95%CI −1.0, −0.4), length of hospital stay (MD: −0.8 95%CI −1.4, −0.3), Clavien−Dindo complications I−II (RR: 0.5 95%CI 0.2, 0.9), and pain score at day > 3 (MD: −0.6 95%CI −1.6, 0.4) were lower following RLDRH compared to ODRH. Furthermore, the pain score at day > 3 (MD: −0.4 95%CI −0.8, −0.09) was lower after RLDRH when compared to LADRH. In recipients, the postoperative AST level was lower (MD: −0.5 95%CI −0.9, −0.1) following RLDRH compared to ODRH. Moreover, the length of stay (MD: −6.4 95%CI −11.3, −1.5) was lower after RLDRH when compared to LADRH. In summary, we identified low- to unclear-quality evidence that RLDRH seems to be safe and feasible for adult living donor liver transplantation compared to the conventional approaches. No postoperative deaths were reported.

Extended criteria donors for Robotic Right Hepatectomy- A Propensity Score matched Analysis

BACKGROUND

Robotic right donor hepatectomy (RDH) has been reported from experienced centers with reduced morbidity when compared to open RDH. However, outcomes in donors with large grafts/ complex biliovascular anatomy are unknown.

METHODS

Out of 170 robotic RDH, 100 had one or more of the following: graft weight ≥ 800gms, type 2/3 portal vein, >1 bile duct or hepatic artery and inferior hepatic veins >5mm requiring reconstruction (extended criteria donors- ExRDH), while the remaining 70 had standard anatomy (SRDH). After propensity score matching, 66 ExRDH were compared with 66 SRDH. Additionally, all robotic RDH performed were analysed in 3 temporal phases (60, 60 and 50).

RESULTS

Peak AST and ALT were higher among donors and recipients in the ExRDH arm compared to SRDH. Other intraoperative parameters and post-operative complications were similar between the two groups. During the last phase, donors demonstrated reduction in duration of surgery, postoperative complications and hospital stay while recipients showed decreased blood loss and hospital stay.

CONCLUSION

Robotic right hepatectomy performed in donors with extended criteria have similar perioperative outcomes as standard donors. However, a significant learning curve needs to be traversed. Further studies are required before safely recommending robotic RDH for all donors.

Minimally invasive versus open living donors right hepatectomy: A systematic review and meta-analysis

BACKGROUND

Although minimally invasive technology has been widely used in hepatectomy, it remains controversial with regards to liver transplantation, especially in donors right hepatectomy. Herein, we compared the short-term safety and efficacy of minimally invasive donors right hepatectomy (MIDRH) with open donors right hepatectomy (ODRH).

METHODS

A systematic literature search was carried out using PubMed, Embase, Web of Science and the Cochrane Library database in order to identify comparison studies of MIDRH and ODRH. Next, we obtained the relevant data, and carried out the meta-analysis.

RESULTS

This meta-analysis included 12 studies, which included 1755 cases that underwent donors right hepatectomy. Compared to ODRH, patients that underwent MIDRH had less bleeding (SWD = -0.52, p<0.001), shorter hospital stays (SWD = -0.58, p < 0.001) and lower overall postoperative complications of donors (RR = 0.74, p = 0.008). However, MIDRH was found to be associated with prolonged operative times (SWD = 0.74, p < 0.001), as well as a higher rate of biliary complications in donors (RR = 2.26, p = 0.007) and recipients (RR = 1.69, p < 0.001). There were no statistically significant differences between MIDRH and ODRH in postoperative liver function, rate of major complications and vascular complications of both donors and recipients and overall postoperative complications.

DISCUSSION

MIDRH is superior to ODRH with regards to intraoperative bleeding, postoperative hospital stay and overall donor complications. Although biliary-related complications are higher, it is feasible to develop MIDRH in experienced liver transplant centers. However, higher-quality research is still needed for corroboration.

Application of robots in general surgery

Background: Application of robotic surgery in the field of general surgery has been increasing. This paper is an overview of the current uses and future perspectives of robotic surgery in four major divisions—endocrine, upper gastrointestinal, hepato-biliary-pancreatic (HBP), and colorectal surgery.Current Concepts: In endocrine surgery, cosmetic advantage is the highest priority when selecting a surgical approach for thyroidectomy. Currently, the transaxillary route is the most common approach. The introduction of the single-port system could maximize the advantages of this technique. In upper gastrointestinal surgery, the use of robots has the advantage of better retrieval of lymph nodes, less bleeding, earlier discharge, and less complications than the laparoscopic approach. However, a more prospective comparative trial is required to confirm those findings. In the HBP field, the indications of robotic surgery have expanded, starting with cholecystectomy to more challenging procedures, such as donor hepatectomy and pancreaticoduodenectomy. Meticulous dissection using robots could provide benefits to patients. In colorectal surgery, robotic surgery is an excellent technical tool for minimally invasive surgeries for rectal cancers, especially in male patients with narrow, deep pelvises. However, further studies are required to confirm the impact of robotic surgery on rectal cancers.Discussion and Conclusion: Robots are used to provide optimal surgical outcomes. Investigating new technologies and innovative surgical procedures is the highly important for a surgeon in the era of minimally invasive surgery.

Abdominal Organ Transplantation: Noteworthy Literature in 2020

In 2020, we identified and screened over 490 peer-reviewed publications on pancreatic transplantation, over 500 on intestinal transplantation, and over 5000 on kidney transplantation. The liver transplantation section specially focused on clinical trials and systematic reviews published in 2020 and featured selected articles. This review highlights noteworthy literature pertinent to anesthesiologists and critical care physicians caring for patients undergoing abdominal organ transplantation. We explore a wide range of topics, including COVID-19 and organ transplantation, risk factors and outcomes, pain management, artificial intelligence, robotic donor surgery, and machine perfusion.

Robotic Liver Surgery - Current Standards and Future Perspectives

BACKGROUND

 Robotic liver surgery is emerging as the future of minimal invasive surgery. The robotic surgical system offers a stable camera platform, elimination of physiologic tremor, augmented surgical dexterity as well as improved ergonomics because of a seated operating position. Due to the theoretical advantages of the robotic assisted system, complex liver surgery might be an especially interesting indication for a robotic approach since it demands delicate tissue dissection, precise intracorporeal suturing as well as difficult parenchymal transection with subsequent need for meticulous hemostasis and biliostasis.

MATERIAL AND METHODS

 An analysis of English and German literature on open, laparoscopic and robotic liver surgery was performed and this review provides a general overview of the existing literature along with current standards and aims to specifically point out future directions of robotic liver surgery.

RESULTS

 Robotic liver surgery is safe and feasible compared to open and laparoscopic surgery, with improved short-term postoperative outcomes and at least non-inferior oncological outcomes.

CONCLUSION

 In complex cases including major hepatectomies, extended hepatectomies with biliary reconstruction and difficult segmentectomies of the posterior-superior segments, robotic surgery appears to emerge as a reasonable alternative to open surgery rather than being an alternative to laparoscopic procedures.

Short-term and long-term outcomes in living donors for liver transplantation: Cohort study

BACKGROUND

Although perioperative outcomes following donor hepatectomy (DH) have been reported, little is known about the long-term outcomes in living donors of liver transplantation. The aim of this study was to investigate the short-term and long-term outcomes following DH.

METHODS

A total of 408 living donors who underwent DH between 1996 and 2019 were analyzed in this retrospective study, focusing on short-term outcomes with respect to the operation period (era) and the graft type, as well as long-term outcomes.

RESULTS

The overall incidence of postoperative complications was 40.4%. These included minor (30.4%), major (10.0%), and biliary (14.0%) complications. Short-term outcomes after DH slightly improved over time, and outcomes did not differ significantly between the graft types. With regards to long-term outcomes, the incidence of surgery-related complications such as keloids, incisional hernias, and mechanical bowel obstructions was 6.6% over a median follow-up of 7.2 years. In addition, some donors developed comorbidities such as lifestyle diseases and cancers during the follow-up period.

CONCLUSIONS

Our study confirmed an improvement of perioperative outcomes in living donors. There was no significant association between the graft type and postoperative outcomes. Donors could develop various morbidities during long-term follow-up. Therefore, a careful perioperative management and long-term follow-up should be provided to living donors.