Improving Outcomes Defending Patient Safety: The Learning Journey in Robotic Liver Resections

Learning curve analysis of 100 consecutive robotic liver resections

BACKGROUND

Robotic liver surgery, as part of minimally invasive liver surgery (MILS), offers advantages like enhanced dexterity and stable camera and instrument control. However, the learning curve - particularly the number of cases required for proficiency - remains underexplored. This study analyzes 100 consecutive robotic liver resections performed by a single surgeon to assess the learning curve and outcomes.

PATIENTS AND METHODS

This retrospective analysis reviewed data from the Magdeburg registry of minimally invasive liver surgery (MD-MILS) from June 2013 to July 2024, to identify surgeons who performed at least 100 robotic liver resections. Operation time and Iwate difficulty score were used as indicators of surgical proficiency and learning progression.

RESULTS

One surgeon fulfilled the inclusion criteria of performing 100 robotic liver resections. Of these, 41 (41%) were major and 59 (59%) were minor liver resections. A significant reduction in average operation time was observed across the series, decreasing from an initial average of 450 min to approximately 300 min by the 100th operation. Similarly, the Iwate difficulty score showed a significant upward trend, reflecting the increasing technical challenges of the procedures. The learning curve was divided into four distinct phases: Competency (Cases 1-20), Proficiency (Cases 21-30), Early Mastery (Cases 31-65), and Full Mastery (Cases 66-100), highlighting the progression in skill acquisition and case complexity. Major complications (21%), such as bile leak, bilioma, and pulmonary embolism, were observed during the study period.

CONCLUSION

Over 100 robotic liver resections, significant learning curve progression was evident, with marked improvements in operation time and handling of complex cases. The results suggest that approximately 65 cases are needed for a surgeon experienced in open and laparoscopic liver surgery to achieve consistent proficiency in robotic liver resections. These findings underscore the importance of standardized training protocols to support the learning curve in robotic liver surgery.

Learning curve in robotic liver surgery: easily achievable, evolving from laparoscopic background and team-based

BACKGROUND

Limited and heterogeneous literature data necessitate a focused examination of the learning curve in robotic liver resections. This study aims to assess the learning curve of two surgeons from the same team with differing laparoscopic backgrounds.

METHODS

Since February 2021, San Raffaele Hospital in Milan has implemented a robotic liver surgery program, performing 250 resections by three trained console surgeons. Using cumulative sum (CUSUM) analysis, the learning curve was evaluated for a Pioneer Surgeon (PS) with around 1200 laparoscopic cases and a New Generation Surgeon (NGS) with approximately 100 laparoscopic cases. Cases were stratified by complexity (38 low, 74 intermediate, 85 high).

RESULTS

Both PS and NGS demonstrated a learning curve for operative time after 15 low-complexity and 10 intermediate-complexity cases, with high-complexity learning curves apparent after 10 cases for PS and 18 cases for NGS. Conversion rates remained unaffected, and neither surgeon experienced increased blood loss or postoperative complications. A "team learning curve" effect in terms of operative time emerged after 12 cases, suggesting the importance of a cohesive surgical team.

CONCLUSION

The robotic platform facilitated a relatively brief learning curve for low and intermediate complexity cases, irrespective of laparoscopic background, underscoring the benefits of team collaboration.

Learning curve analysis after 500 robotic hepatectomies

BACKGROUND

The robotic platform is growing in popularity for hepatobiliary resections. Although the learning curve for basic competency has been reported, this is the first study to analyze the learning curve to achieve long-term mastery on a decade of experience with more than 500 robotic hepatectomies.

METHODS

After institutional review board approval, 500 consecutive robotic hepatectomies from 2013 to 2023 were analyzed. Cumulative sum (CUSUM) analysis using operative duration was used to determine the learning curves.

RESULTS

A total of 500 patients were included in this study: composed of 230 men (46.0 %) and 270 women (54.0 %), aged 63.0 (61.0 ± 14.6) years, with a body mass index of 28.0 (29.0 ± 8.0) kg/m2, a Model for End-Stage Liver Disease score of 7 (8 ± 3.0), an albumin-bilirubin score of -3.0 (-3.0 ± 0.6), and a Child-Pugh score of 5.0 (5.0 ± 0.7). Operative duration was 235.0 (260.1 ± 131.9) minutes, estimated blood loss was 100.0 (165.0 ± 208.1) mL, tumor size was 4.0 (5.0 ± 3.5) cm, and 94.0 % of patients achieved R0 margins. The length of hospital stay was 3.0 (4.0 ± 3.7) days, with 4.0 % of patient having major complications. Of note, 30-day readmission was 17.0 %, 30-day mortality was 2.0 %, and 90-day mortality was 3.0 %. On CUSUM analysis, the learning curve for minor resection (n = 215) was 75 cases, major resection (n = 154) was 100 cases, and technically challenging minor resection (n = 131) was 57 cases. Gaining more experience in performing surgical procedures resulted in shorter operative duration, lower blood loss, higher R0 resections, and lower major postoperative complications.

CONCLUSION

The minimum number of robotic hepatectomies to overcome the learning curves for mastery of minor, major, and technically challenging minor resections was significant. Our study can help guide surgeons in their early experience to optimize patient safety and outcomes.

Towards a Standardization of Learning Curve Assessment in Minimally Invasive Liver Surgery

OBJECTIVE

The aim was to analyze the learning curves of minimal invasive liver surgery(MILS) and propose a standardized reporting.

SUMMARY BACKGROUND DATA

MILS offers benefits compared to open resections. For a safe introduction along the learning curve, formal training is recommended. However, definitions of learning curves and methods to assess it lack standardization.

METHODS

A systematic review of PubMed, Web of Science, and CENTRAL databases identified studies on learning curves in MILS. The primary outcome was the number needed to overcome the learning curve. Secondary outcomes included endpoints defining learning curves, and characterization of different learning phases(competency, proficiency and mastery).

RESULTS

60 articles with 12'241 patients and 102 learning curve analyses were included. The laparoscopic and robotic approach was evaluated in 71 and 18 analyses and both approaches combined in 13 analyses. Sixty-one analyses (60%) based the learning curve on statistical calculations. The most often used parameters to define learning curves were operative time (n=64), blood loss (n=54), conversion (n=42) and postoperative complications (n=38). Overall competency, proficiency and mastery were reached after 34 (IQR 19-56), 50 (IQR 24-74), 58 (IQR 24-100) procedures respectively. Intraoperative parameters improved earlier (operative time: competency to proficiency to mastery: -13%, 2%; blood loss: competency to proficiency to mastery: -33%, 0%; conversion rate (competency to proficiency to mastery; -21%, -29%), whereas postoperative complications improved later (competency to proficiency to mastery: -25%, -41%).

CONCLUSIONS

This review summarizes the highest evidence on learning curves in MILS taking into account different definitions and confounding factors. A standardized three-phase reporting of learning phases (competency, proficiency, mastery) is proposed and should be followed.

The Role of Robotics in Meeting Institutional Goals: A Unified Strategy to Facilitate Program Excellence

PURPOSE

The rapid expansion of robotic surgical equipment necessitates a review of the needs and challenges faced by hospitals introducing robots for the first time to compete with experienced institutions. The aim of this study was to analyze the impact of robotic surgery on our hospital compared to open and laparoscopic surgery, examine internal transformations, and assess regional, domestic, and international implications.

METHODS

A retrospective review was conducted of electronic medical records (EMRs) from 2019 to 2022 at Inha University Hospital, including patients who underwent common robotic procedures and equivalent open and laparoscopic operations. The study investigated clinical and operational performance changes in the hospital after the introduction of robotic technology. It also evaluated the operational effectiveness of robot implementation in local, national, and international contexts. To facilitate comparison with other hospitals, the data were transmitted to Intuitive Surgical, Inc. for analysis. The study was conducted in compliance with domestic personal information regulations and received approval from our Institutional Review Board.

RESULTS

We analyzed EMR data from 3,147 patients who underwent surgical treatment. Over a period of 3.5 years, the adoption of robotic technology in a hospital setting significantly enhanced the technical skills of all professors involved. The introduction of robotic systems led to increased patient utilization of conventional surgical techniques, as well as a rise in the number of patients choosing robotic surgery. This collective trend contributed to an overall increase in patient numbers. This favorable evaluation of the operational effectiveness of our hospital's robot implementation in the context of local, national, and global factors is expected to positively influence policy changes.

CONCLUSION

Stakeholders should embrace data science and evidence-based techniques to generate valuable insights from objective data, assess the health of robot-assisted surgery programs, and identify opportunities for improvement and excellence.

Tampa Difficulty Score: a novel scoring system for difficulty of robotic hepatectomy

BACKGROUND

Difficulty scoring system (DSS) has been established for laparoscopic hepatectomy and serves as useful tools to predict difficulty and guide preoperative planning. Despite increased adoption of robotics and its unique technical characteristics compared with laparoscopy, no DSS currently exists for robotic hepatectomy. We aimed to introduce a new DSS for robotic hepatectomy.

METHODS

A total of 328 patients undergoing a robotic hepatectomy were identified. After removing the first 24 major and 30 minor hepatectomies using cumulative-sum analysis, 274 patients were included in this study. Relevant clinical variables underwent linear regression using operative time and/or estimated blood loss (EBL) as markers for operative difficulty. Score distribution was analyzed to develop a difficulty-level grouping system.

RESULTS

Of the 274 patients, neoadjuvant chemotherapy; tumor location, size, and type; the extent of parenchymal resection; the need for portal lymphadenectomy; and the need for biliary resection with hepaticojejunostomy were significantly associated with operative time and/or EBL. They were used to develop the difficulty scores from 1 to 49. Grouping system results were group 1 (less demanding/beginner), 1 to 8 (n = 39); group 2 (intermediate), 9 to 24 (n = 208); group 3 (more demanding/advanced), 25 to 32 (n = 17); and group 4 (most demanding/expert), 33 to 49 (n = 10). When stratified by group, age, previous abdominal operation, Child-Pugh score, operative duration, EBL, major resection, 30-day mortality, 90-day mortality, and length of stay were significantly different among the groups.

CONCLUSION

In addition to established variables in laparoscopic systems, new factors such as the need for portal lymphadenectomy and biliary resection specific to the robotic approach have been identified in this new robotic DSS. Internal and external validations are the next steps in maturing this robotic DSS.

Robotic versus open resection for colorectal liver metastases in a "referral centre Hub&Spoke learning program". A multicenter propensity score matching analysis of perioperative outcomes

Background

Surgical resection is still considered the optimal treatment for colorectal liver metastasis (CRLM). Although laparoscopic and robotic surgery demonstrated their reliability especially in referral centers, the comparison between perioperative outcomes of robotic liver resection (RLR) and open (OLR) liver resection are still debated when performed in referral centers for robotic surgery, not dedicated to HPB. Our study aimed to verify the efficacy and safety of perioperative outcomes after RLR and OLR for CRLM in an HUB&Spoke learning program (H&S) between a high volume center for liver surgery and high volume center for robotic surgery.

Methods

We analyzed prospective databases of Pineta Grande Hospital (Castel Volturno) and Robotic Surgical Units (Foligno-Spoleto and Arezzo) from 2011 to 2021. A 1:1 propensity score matching (PSM) was performed according to baseline characteristics of patients, solitary/multiple CRLM, anterolateral/posterosuperior location.

Results

383 patients accepted to be part of the study (268 ORL and 115 RLR). After PSM, 45 patients from each group were included. Conversion rate was 8.89 %. RLR group had a significantly lower blood loss (226 vs. 321 ml; p=0.0001), and fewer major complications (13.33 % vs. 17.78 %; p=0.7722). R0 resection was obtained in 100% of OLR (vs.95.55%, p =0.4944. Hospital stay was 8.8 days in RLR (vs. 15; p=0.0001).Conclusion: H&S represents a safe and effective program to train general surgeons also in Hepatobiliary surgery providing R0 resection rate, blood loss volume and morbidity rate superimposable to referral centers. Furthermore, H&S allow a reduction of health mobility with consequent money saving for patients and institutions.

Concomitant training in robotic and laparoscopic liver resections of low-to-intermediate difficulty score: a retrospective analysis of the learning curve

In the setting of minimally invasive liver surgery (MILS), training in robotic liver resections (RLR) usually follows previous experience in laparoscopic liver resections (LLR). The aim of our study was to assess the learning curve of RLR in case of concomitant training with LLR. We analyzed consecutive RLRs and LLRs by a surgeon trained simultaneously in both techniques (Surg1); while a second surgeon trained only in LLRs was used as control (Surg2). A regression model was used to adjust for confounders and a Cumulative Sum (CUSUM) analysis was carried out to assess the learning phases according to operative time and difficulty of the procedures (IWATE score). Two-hundred-forty-five procedures were identified (RobSurg1, n = 75, LapSurg1, n = 102, LapSurg2, n = 68). Mean IWATE was 4.0, 4.3 and 5.8 (p < 0.001) in each group. The CUSUM analysis of the adjusted operative times estimated the learning phase in 40 cases (RobSurg1), 40 cases (LapSurg1), 48 cases (LapSurg2); for IWATE score it was 38 cases (RobSurg1), 33 cases (LapSurg1), 38 cases (LapSurg2) respectively. Our preliminary experience showed a similar learning curve of 40 cases for low and intermediate difficulty RLR and LLR. Concomitant training in both techniques was safe and may be a practical option for starting a MILS program.

10 years, 100 robotic major hepatectomies: a single-center experience

INTRODUCTION

Adoption of robotic liver resections has been gradually increasing throughout the HPB surgical community over the past decade. Currently there is limited literature which demonstrates a significant benefit of robotic surgery for major hepatectomies over open or laparoscopic. As one of the first centers to develop a robotic HPB program, we have experienced improved outcomes over time with increasing utilization of robotics. Herein, we present our 10-year experience and outcomes for major robotic liver resections.

METHODS

From 2012 to 2022, 361 robotic liver procedures were performed, including 100 major hepatectomies. A retrospective data review of the electronic medical record was performed evaluating outcomes after robotic major hepatectomy. Outcomes for the first 50 cases (Group A) and second 50 cases (Group B) were compared to identify any improvements in practice. Demographic and clinical outcome variables were analyzed. Data were assessed for normality, and Wilcoxon rank-sum, χ2 tests, and a logistic regression model were performed appropriate for the data. Stata v.17 was utilized, and significance was set as p < .05.

RESULTS

There was no difference in median operative time (258 vs 256 min), EBL (500 vs 500 mL), median LOS (5 vs 3.5 days), 90-day readmission (14% vs 24%), major complications (14% vs 20%), and 90-day mortality (6% vs 4%) between early and late cases, respectively. ICU admissions and conversion rates were significantly lower in group B (14.0% vs 48.0%), while expert level difficulty indices were higher (82% vs 58%).

CONCLUSION

Development of a robotic liver program with good outcomes is feasible over time. Our data suggest that our institutional learning curve for robotic major hepatectomy plateaued at approximately 50 cases.

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.

Robotic versus laparoscopic liver resections: propensity-matched comparison of two-center experience

BACKGROUND

The advantages of the robotic approach in minimally invasive liver surgery (MILS) are still debated. This study compares the short-term outcomes between laparoscopic (LLR) and robotic (RLR) liver resections in propensity score matched cohorts.

METHODS

Data regarding minimally invasive liver resections in two liver surgery units were retrospectively reviewed. A propensity score matched analysis (1:1 ratio) identified two groups of patients with similar characteristics. Intra- and post-operative outcomes were then compared. The difficulty of MILS was based on the IWATE criteria.

RESULTS

Two hundred sixty-nine patients underwent MILS between January 2014 and December 2021 (LLR = 192; RLR = 77). Propensity score matching identified 148 cases (LLR = 74; RLR = 74) consisting of compensated cirrhotic patients (100%) underwent non-anatomic resection of IWATE 1-2 class (90.5%) for a solitary tumor < 5 cm in diameter (93.2%). In such patients, RLRs had shorter operative time (227 vs. 250 min, p = 0.002), shorter Pringle's cumulative time (12 vs. 28 min, p < 0.0001), and less blood loss (137 vs. 209 cc, p = 0.006) vs. LLRs. Conversion rate was nihil (both groups). In RLRs compared to LLRs, R0 rate (93 vs. 96%, p > 0.71) and major morbidity (4.1 vs. 5.4%, p > 0.999) were similar, without post-operative mortality. Hospital stay was shorter in the robotic group (6.2 vs. 6.6, p = 0.0001).

CONCLUSION

This study supports the non-inferiority of RLR over LLR. In compensated cirrhotic patients underwent resection of low-to-intermediate difficulty for a solitary nodule < 5 cm, RLR was faster, with less blood loss despite the shorter hilar clamping, and required shorter hospitalization compared to LLR.

Robotic versus laparoscopic liver resection in posterosuperior region: a retrospective study of consecutive cases

BACKGROUND

Minimally invasive liver resection of the posterosuperior region is considered a challenging procedure due to poor exposure and difficult bleeding control. A robotic approach is supposed to be advantageous in posterosuperior segmentectomy. Its benefits over laparoscopic liver resection (LLR) remain undetermined. This study compared robotic liver resection (RLR) and LLR in the posterosuperior region performed by a single surgeon.

MATERIALS AND METHODS

We retrospectively analyzed consecutive RLR and LLR performed by a single surgeon between December 2020 and March 2022. Patient characteristics and perioperative variables were compared. A 1:1 propensity score matched (PSM) analysis was performed between both groups.

RESULTS

The analysis included 48 RLR and 57 LLR procedures in the posterosuperior region. After PSM analysis, 41 cases of both groups were retained. In pre-PSM cohort, the operative time in the RLR group was significantly shorter than in the LLR group (160 vs. 208 min, P = 0.001), especially in radical resection of malignant tumors (176 vs. 231 min, P = 0.004). The total Pringle maneuver duration was also markedly shorter (40 vs. 51 min, P = 0.047), and the estimated blood loss in the RLR group was lower (92 vs. 150 mL, P = 0.005). The postoperative hospital stay (POHS) in the RLR group was significantly shorter (5.4 vs. 7.5 days, P = 0.048). In PSM cohort, operative time in the RLR group was also significantly shorter (163 vs. 193 min, P = 0.036), and the estimated blood loss was lower (92 vs. 144 mL, P = 0.024). However, the total Pringle maneuver duration and POHS showed no significant difference. The complications were similar between two groups in both pre-PSM and PSM cohorts.

CONCLUSION

RLR in the posterosuperior region was as safe and feasible as LLR. RLR was associated with reduced operative time and blood loss than LLR.

Safety and Efficacy of Robotic vs Open Liver Resection for Hepatocellular Carcinoma

Importance

Long-term oncologic outcomes of robotic surgery remain a hotly debated topic in surgical oncology, but sparse data have been published thus far.

Objective

To analyze short- and long-term outcomes of robotic liver resection (RLR) for hepatocellular carcinoma (HCC) from Western high-volume centers to assess the safety, reproducibility, and oncologic efficacy of this technique.

Design, Setting, and Participants

This cohort study evaluated the outcomes of patients receiving RLR vs open liver resection (OLR) for HCC between 2010 and 2020 in 5 high-volume centers. After 1:1 propensity score matching, a group of patients who underwent RLR was compared with a validation cohort of OLR patients from a high-volume center that did not perform RLR.

Main Outcomes and Measures

A retrospective analysis was performed of prospectively maintained databases at 2 European and 2 US institutions of patients who underwent RLR for HCC between January 1, 2010, and September 30, 2020. The main outcomes were safety and feasibility of RLR for HCC and its oncologic outcomes compared with a European OLR validation cohort. A 2-sided P < .05 was considered significant.

Results

The study included 398 patients (RLR group: 125 men, 33 women, median [IQR] age, 66 [58-71] years; OLR group: 315 men, 83 women; median [IQR] age, 70 [64-74] years), and 106 RLR patients were compared with 106 OLR patients after propensity score matching. The RLR patients had a significantly longer operative time (median [IQR], 295 [190-370] minutes vs 200 [165-255] minutes, including docking; P < .001) but a significantly shorter hospital length of stay (median [IQR], 4 [3-6] days vs 10 [7-13] days; P < .001) and a lower number of admissions to the intensive care unit (7 [6.6%] vs 21 [19.8%]; P = .002). Incidence of posthepatectomy liver failure was significantly lower in the RLR group (8 [7.5%] vs 30 [28.3%]; P = .001), with no cases of grade C failure. The 90-day overall survival rate was comparable between the 2 groups (RLR, 99.1% [95% CI, 93.5%-99.9%]; OLR, 97.1% [95% CI, 91.3%-99.1%]), as was the cumulative incidence of death related to tumor recurrence (RLR, 8.8% [95% CI, 3.1%-18.3%]; OLR, 10.2% [95% CI, 4.9%-17.7%]).

Conclusions and Relevance

This study represents the largest Western experience to date of full RLR for HCC. Compared with OLR, RLR performed in tertiary centers represents a safe treatment strategy for patients with HCC and those with compromised liver function while achieving oncologic efficacy.

Trends of the Extra-Hepatic Biliary Cancer and Its Surgical Management: A Cross-Sectional Study From the National Cancer Database

Introduction

Biliary cancers are rare cancers with poor prognoses. In this study, we aimed to evaluate trends in early detection and surgical treatment and approaches in extra-hepatic biliary tract cancers (EBCs) over 13 years in the US.

Methods

The most recent data on patients diagnosed with EBC between 2004 and 2016 were extracted from the National Cancer Database (NCDB). The patients’ demographics (sex, age, race), primary tumor sites, tumor grades and stages, staging modalities, diagnostic confirmation, surgical treatment modalities and approaches, and 90-day mortality were analyzed to determine trends.

Results

Biopsy was the most common staging modality in 63.9% of total 60,291 patients. The bile duct was the primary tumor site (55.0%). Histologic examination was the most common confirmatory diagnostic modality (77.5%). The most common stage was stage II (23%). The most common surgical treatment modality was radical surgery (13.88%). The open surgical approach was used in 27.1% of patients, followed by a laparoscopic approach (4.3%).

Conclusion

EBC showed no significant change in the trends of the stage at diagnosis, treatment modality, and extent of surgical procedures despite advances in surgical diagnostic and therapeutic modalities; however, the total number of cases slightly increased between 2004 and 2016.

Robotic vs. laparoscopic liver surgery: a single-center analysis of 600 consecutive patients in 6 years

Background

While laparoscopic liver surgery has become a standard procedure, experience with robotic liver surgery is still limited. The aim of this prospective study was to evaluate safety and feasibility of robotic liver surgery and compare outcomes with conventional laparoscopy.

Methods

We here report the results of a single-center, prospective, post-marketing observational study (DRKS00017229) investigating the safety and feasibility of robotic liver surgery. Baseline characteristics, surgical complexity (using the IWATE score), and postoperative outcomes were then compared to laparoscopic liver resections performed at our center between January 2015 and December 2020. A propensity score-based matching (PSM) was applied to control for selection bias.

Results

One hundred twenty nine robotic liver resections were performed using the da Vinci Xi surgical system (Intuitive) in this prospective study and were compared to 471 consecutive laparoscopic liver resections. After PSM, both groups comprised 129 cases with similar baseline characteristics and surgical complexity. There were no significant differences in intraoperative variables, such as need for red blood cell transfusion, duration of surgery, or conversion to open surgery. Postoperative complications were comparable after robotic and laparoscopic surgery (Clavien–Dindo ≥ 3a: 23% vs. 19%, p = 0.625); however, there were more bile leakages grade B–C in the robotic group (17% vs. 7%, p = 0.006). Length of stay and oncological short-term outcomes were comparable.

Conclusions

We propose robotic liver resection as a safe and feasible alternative to established laparoscopic techniques. The object of future studies must be to define interventions where robotic techniques are superior to conventional laparoscopy.

Understanding the surgeon's behaviour during robot-assisted surgery: protocol for the qualitative Behav'Robot study

INTRODUCTION

Robot-assisted surgery is spreading worldwide, accounting for more than 1.2 million procedures in 2019. Data are sparse in the literature regarding the surgeon's mechanisms that mediate risk-taking during a procedure, especially robot-assisted. This study aims to describe and understand the behaviour of the surgeons during robot-assisted surgery and the change in their behaviour with increasing experience in using the robot.

METHODS AND ANALYSIS

This is a qualitative study using semistructured interviews with surgeons who perform robot-assisted surgery. An interview guide comprising open questions will be used to ensure that the points to be discussed are systematically addressed during each interview (ie, (1) difference in behaviour and preparation of the surgeon between a standard procedure and a robot-assisted procedure; (2) the influence of proprioceptive modifications, gain in stability and cognitive biases, inherent in the use of a surgical robot and (3) the intrinsic effect of the learning curve on the behaviour of the surgeons. After transcription, interviews will be analysed with the help of NVivo software, using thematic analysis.

ETHICS AND DISSEMINATION

Since this project examines professional practices in the field of social and human sciences, ethics committee was not required in accordance with current French legislation (Decree no 2017-884, 9 May 2017). Consent from the surgeons is implied by the fact that the interviews are voluntary. Surgeons will nonetheless be informed that they are free to interrupt the interview at any time.Results will be presented in peer-reviewed national and international congresses and submitted to peer-reviewed journals for publication. The communication and publication of the results will be placed under the responsibility of the principal investigator and publications will be prepared in compliance with the ICMJE uniform requirements for manuscripts.

TRIAL REGISTRATION NUMBER

NCT04869995.

Pan-European survey on the implementation of robotic and laparoscopic minimally invasive liver surgery

BACKGROUND

Laparoscopic and robotic minimally invasive liver surgery (MILS) is gaining popularity. Recent data and views on the implementation of laparoscopic and robotic MILS throughout Europe are lacking.

METHODS

An anonymous survey consisting of 46 questions was sent to all members of the European-African Hepato-Pancreato-Biliary Association.

RESULTS

The survey was completed by 120 surgeons from 103 centers in 24 countries. Median annual center volume of liver resection was 100 [IQR 50-140]. The median annual volume of MILS per center was 30 [IQR 16-40]. For minor resections, laparoscopic MILS was used by 80 (67%) surgeons and robotic MILS by 35 (29%) surgeons. For major resections, laparoscopic MILS was used by 74 (62%) surgeons and robotic MILS by 33 (28%) surgeons. The majority of the surgeons stated that minimum annual volume of MILS per center should be around 21-30 procedures/year. Of the surgeons performing robotic surgery, 28 (70%) felt they missed specific equipment, such as a robotic-CUSA. Seventy (66%) surgeons provided a formal MILS training to residents and fellows. In 5 years' time, 106 (88%) surgeons felt that MILS would have superior value as compared to open liver surgery.

CONCLUSION

In the participating European liver centers, MILS comprised about one third of all liver resections and is expected to increase further. Laparoscopic MILS is still twice as common as robotic MILS. Development of specific instruments for robotic liver parenchymal transection might further increase its adoption.

Robotic-Assisted Surgery for Primary Hepatobiliary Tumors-Possibilities and Limitations

Simple Summary

Primary liver malignancies are some of the most common and fatal tumors today. Robotic-assisted liver surgery is becoming increasingly interesting for both patients and surgeons alike. Up to date, prospective comparative studies around the topic are scarce. This leads us to an ever existing controversy about the efficacy, safety, and economic benefits of robotic surgery as an extension of traditional minimally invasive surgery over open liver surgery. However, there is evidence that robotic-assisted surgery is, after passing the learning curve, equivalent in terms of feasibility and safety, and in some cases superior to traditional laparoscopic hepatic resection. With this work, we want to provide an overview of the latest and most significant reviews and meta-analyses focusing on robotic hepatectomy in primary liver malignancies. We outline the technical aspects of robotic-assisted surgery and place them into the context of technical, surgical, and oncological outcomes compared with laparoscopic and open resection. When chosen per case individually, any hepatic resection can be performed robotically to overcome limitations of laparoscopic surgery by an experienced team. In this paper, we propose that prospective studies are needed to prove efficacy for robotic-assisted resection in liver malignancy.

Abstract

Hepatocellular and cholangiocellular carcinoma are fatal primary hepatic tumors demanding extensive liver resection. Liver surgery is technically challenging due to the complex liver anatomy, with an intensive and variant vascular and biliary system. Therefore, major hepatectomies in particular are often performed by open resection and minor hepatectomies are often performed minimally invasively. More centers have adopted robotic-assisted surgery, intending to improve the laparoscopic surgical limits, as it offers some technical benefits such as seven degrees of freedom and 3D visualization. The da Vinci^® Surgical System has dominated the surgical robot market since 2000 and has shown surgical feasibility, but there is still much controversy about its economic benefits and real benefits for the patient over the gold standard. The currently available retrospective case studies are difficult to compare, and larger, prospective studies and randomized trials are still urgently missing. Therefore, here we summarize the technical, surgical, and economic outcomes of robotic versus open and laparoscopic hepatectomies for primary liver tumors found in the latest literature reviews and meta-analyses. We conclude that complex robotic liver resections (RLR) are safe and feasible after the steep learning curve of the surgical team has plateaued. The financial burden is lower in high volume centers and is expected to decrease soon as new surgical systems will enter the market.

Implementing a robotic liver resection program does not always require prior laparoscopic experience

Background

Preliminary experience in laparoscopic liver surgery is usually suggested prior to implementation of a robotic liver resection program.

Methods

This was a retrospective cohort analysis of patients undergoing robotic (RLR) versus laparoscopic liver resection (LLR) for hepatocellular carcinoma at a center with concomitant initiation of robotic and laparoscopic programs

Results

A total of 92 consecutive patients operated on between May 2014 and February 2019 were included: 40 RLR versus 52 LLR. Median age (69 vs. 67; p = 0.74), male sex (62.5% vs. 59.6%; p = 0.96), incidence of chronic liver disease (97.5% vs.98.1%; p = 0.85), median model for end-stage liver disease (MELD) score (8 vs. 9; p = 0.92), and median largest nodule size (22 vs. 24 mm) were similar between RLR and LLR. In the LLR group, there was a numerically higher incidence of nodules located in segment 4 (20.0% vs. 16.6%; p = 0.79); a numerically higher use of Pringle’s maneuver (32.7% vs. 20%; p = 0.23), and a shorter duration of surgery (median of 165.5 vs. 217.5 min; p = 0.04). Incidence of complications (25% vs.32.7%; p = 0.49), blood transfusions (2.5% vs.9.6%; p = 0.21), and median length of stay (6 vs. 5; p = 0.54) were similar between RLR and LLR. The overall (OS) and recurrence-free (RFS) survival rates at 1 and 5 years were 100 and 79 and 95 and 26% for RLR versus 96.2 and 76.9 and 84.6 and 26.9% for LLR (log-rank p = 0.65 for OS and 0.72 for RFS).

Conclusions

Based on our results, concurrent implementation of a robotic and laparoscopic liver resection program appears feasible and safe, and is associated with similar oncologic long-term outcomes.

National Trends and Perioperative Outcomes of Robotic-assisted Hepatectomy in the USA: A Propensity-score Matched Analysis from the National Cancer Database

BACKGROUND

A paucity of data exists on the national use of robotic hepatectomy. We assessed national trends and perioperative outcomes of robotic hepatectomy in the USA. In addition, factors associated with use of the robotic approach were analyzed.

METHODS

The National Cancer Database (NCDB) was queried for patients undergoing hepatectomy from 2010 to 2016. Patients undergoing total hepatectomy for transplant were excluded. Factors associated with the use of the robotic approach were assessed using logistic regression multivariable analysis. Propensity-score analysis was performed (robotic vs. laparoscopic and robotic vs. open approaches), and perioperative outcomes were compared between the matched groups.

RESULTS

The robotic approach was used in 287 patients (110 hospitals). Utilization of the robotic approach increased significantly on the national level from 0.8% in 2010 to 4.1% in 2016 (P<0.001). The number of hospitals performing a minimum of one robotic hepatectomy per year increased from 8 in 2010 to 35 in 2016. The median hospital length of stay was 4 days (IQR 3-6), 30-day readmission rate was 5%, and 30-day/90-day mortality rates were 3%/4%. Factors associated with using robotic approach were African-American race (95% CI 1.02-2.11), recent year of surgery (95% CI 1.11-1.32), HCC histology (95% CI 1.01-52.03), tumor size (95% CI 0.87-0.96), and early-stage tumor (Stage I-II, 95% CI 1.27-3.99). On propensity-matched analysis, there were no differences between robotic and open approaches (n=184 each group) in 30-day readmission (5% vs. 7%, P=0.651), 30-day mortality (2% vs. 4%, P=0.106), 90-day mortality (3% vs. 7%, P=0.080), or 5-year overall survival (58% vs. 43%, P=0.211). However, the robotic approach was associated with a significantly shorter hospital stay (median: 4 vs. 6 days, P<0.001). There were no differences between matched groups of patients undergoing robotic and laparoscopic approaches (n=182 in each group) in perioperative outcomes or length of hospital stay.

CONCLUSION

National use of robotic-assisted hepatectomy has increased by fivefold over the seven-year study period. It was associated with a shorter hospital length of stay compared to the open approach without compromising perioperative outcomes or survival.

Major robotic hepatectomies: technical considerations

Robotic approach to the liver may allow to perform difficult resections with a minimally invasive strategy in an easier way as compared to standard laparoscopy. The aim of this study is to review our experience with robotic major hepatectomies, reporting technical considerations, and describing the outcomes of patients that underwent either left (LRH) or right robotic hepatectomy (RRH). Our prospectively maintained database was screened to identify all patients that received a major liver resection for benign or malignant disease. Preoperative data and postoperative short-term and long-term outcomes were reported. 261 robotic procedures were performed in our Center between May 2014 and October 2020. 12 patients underwent robotic left hepatectomy (RLH) and 10 patients were treated by robotic right hepatectomy (RRH). In the RLH group, median operative time (OT) was 383 min, median estimated blood loss (EBL) was 300 ml, and median in-hospital stay was of 3 days. In the RRH group, median OT was 490 min, median EBL 725 ml, and median hospital stay was 5 days. Although one of the advantages of minimally invasive surgery is to obtain radical resections with parenchyma sparing strategies, patients that need a major hepatectomy may benefit of a robotic resection with good postoperative outcomes. Team learning curve and growth instead of personal progression is crucial to expand the limits of novel surgical techniques.

Robotic Liver Resection Versus Percutaneous Ablation for Early HCC: Short- and Long-Term Results

BACKGROUND

The correct approach for early hepatocellular carcinoma (HCC) is debatable, since multiple options are currently available. Percutaneous ablation (PA) is associated in some series to reduced morbidity compared to liver resection (LR); therefore, minimally invasive surgery may play a significant role in this setting.

METHODS

All consecutive patients treated by robotic liver resection (RLR) or PA between January 2014 and October 2019 for a newly diagnosed single HCC, less than 3 cm in size (very early/early stages according to the Barcelona Clinic Liver Cancer (BCLC)) on chronic liver disease or liver cirrhosis, were enrolled in this retrospective study. The aim of this study was to compare short- and long-term outcomes to define the best approach in this specific cohort.

RESULTS

60 patients fulfilled the inclusion criteria: 24 RLR and 36 PA. The two populations were homogeneous in terms of baseline characteristics. There were no statistically significant differences regarding the incidence of postoperative morbidity (RLR 38% vs. PA 19%, p = 0.15). The cumulative incidence of recurrence (CIR) was significantly higher in patients who underwent PA, with the one, two, and three years of CIR being 42%, 69%, and 73% in the PA group and 17%, 27%, and 27% in the RLR group, respectively.

CONCLUSIONS

RLR provides a significantly higher potential of cure and tumor-related free survival in cases of newly diagnosed single HCCs smaller than 3 cm. Therefore, it can be considered as a first-line approach for the treatment of patients with those characteristics in high-volume centers with extensive experience in the field of hepatobiliary surgery and minimally invasive approaches.

Robotic hepatic resection in postero-superior region of liver

OBJECTIVE

Laparoscopic hepatectomy in the posterosuperior hepatic region is technically challenging and demanding. However, minimally invasive procedures carried out using the Da Vinci robot provide potential advantages in complex hepatectomy. This study reported the experience of a single center on robotic hepatectomy in the posterosuperior hepatic region.

METHODS

This retrospective study evaluated the general characteristics and perioperative outcomes of consecutive patients who underwent robotic hepatectomy in the posterosuperior hepatic region at our center from March 2015 to January 2020.

RESULTS

For 100 patients who were included into this study, 53 underwent anatomical segmentectomy or subsegmentectomy and 47 non-anatomical partial hepatectomy. There was no conversion to laparotomy. The R0 resection rate was 100%. The following perioperative outcomes were compared between patients who underwent anatomical segmentectomy/subsegmentectomy versus those who underwent non-anatomical partial hepatectomy: operation times of 160 versus 126 min, intraoperative blood losses of 100 versus 50 ml, intraoperative blood transfusion rates of 7.54% versus 4.26%, postoperative lengths of hospital stay of 5 versus 4 days, Clavien-Dindo Grade I-II complications rates of 15.09% versus 19.15%, Grade III-V complications rates of 3.77% versus 0%, bile leakage rates of 4% versus 7% and pleural effusion rates of also 4% versus 7%, respectively.

CONCLUSION

The results indicated the safety and feasibility of robotic anatomical and non-anatomical liver resections in the posterosuperior hepatic region. The robotic transabdominal approach is an option for hepatectomy in the posterosuperior hepatic region.

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.