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

Midline Incision Living Donor Liver Transplantation as a Step Toward Minimally Invasive Liver Transplantation: A Propensity Score Matched Analysis

BACKGROUND

Performing the living donor liver transplant (LDLT) recipient operation via a midline incision (MILT) may reduce perioperative morbidity and postoperative wound related issues. Also, it is likely to bear significance in the current era of minimally invasive recipient surgery (MIRS) as competence in performing an MILT is likely to be the stepping-stone toward and importantly, the safety net in performing a safe MIRS. We present our series of MILT, highlighting the evolution and its technical modifications.

METHODS

Propensity score matched analysis (based on MELD, GRWR, and etiology) of MILT versus standard LDLT (reverse L incision) (SILT) with a 1:2 ratio was performed from a prospectively collected database. All perioperative recipient data including postoperative morbidity and mortality were compared.

RESULTS

Among 75 MILT and 150 SILT patients, there were no significant differences between the groups with regards to operative time (520 ± 73 vs. 522 ± 120 min, p = 0.89) and cold ischemia time (110 ± 45 vs. 118 ± 60 min, p = 0.31). The warm ischemia time was significantly longer in the MILT group (52 ± 24 min vs. 46 ± 14 min, p = 0.02). While the mean blood loss was comparable between the groups (1675 ± 850 vs. 1550 ± 1150 mL, p = 0.41), blood transfusion requirements including packed red cells (5 (IQR:3-7) vs. 3 (IQR:1-6), p = 0.03) and fresh frozen plasma (3 (IQR:2-4) vs. 2 (IQR:0-3), p = 0.02) were significantly higher in MILT patients. There was no difference between the groups with regards to major 90-day morbidity (18.6% vs. 15.3%, p = 0.53), duration of hospital stay (15 (IQR:10-18) vs. 14 (IQR: 12-18) days, p = 0.06), and 1-year (92% vs. 95.3%) and 3-year mortality (92% vs. 91.4%) (p = 0.89).

CONCLUSION

We present the feasibility and safety of MILT in LDLT. In the current milieu of MIRS, competence in performing a safe MILT may become an essential component of the recipient surgeon's armamentarium.

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.

Chinese guidelines for minimally invasive donor hepatectomy in living donor liver transplantation (2024 edition)

Background

Minimally invasive surgeries are increasingly central to modern medicine, particularly in liver transplantation. These techniques, which offer reduced trauma, precise operations, minimal bleeding, and swift recovery, are, however, unevenly adopted across China. Only a limited number of centers routinely perform minimally invasive donor hepatectomies, indicating a significant imbalance in the development and application of these advanced procedures. Additionally, there lacks a set of standardized guidelines that are tailored to meet China's unique healthcare challenges and conditions.

Methods

In August 2023, the Branch of Organ Transplant of Chinese Medical Association and the Branch of Organ Transplant Physicians of Chinese Medical Doctor Association convened a group of national liver transplantation experts to establish a guideline development committee. This committee conducted a thorough review of relevant literature, evaluated existing guidelines and consensus, and assessed factors such as the evidence base, patient preferences, and the cost-effectiveness of interventions within China. After multiple rounds of discussions, both online and offline, the committee finalized the guidelines.

Results

This collaborative effort led to the creation of the "Chinese guidelines for minimally invasive donor hepatectomy in living donor liver transplantation (2024 edition)". These guidelines address crucial aspects such as the safety and advantages of minimally invasive surgery for living donor liver transplantation, donor selection criteria, anesthesia strategies, surgical technical details, and learning curves associated with these procedures, resulting in a comprehensive set of 26 recommendations.

Conclusions

The formulation of these guidelines represents a significant advancement towards standardizing minimally invasive liver transplantation surgeries in China. They are designed to enhance outcomes for both donors and recipients by synthesizing expert consensus with contemporary research and clinical practices. Moreover, they serve as a crucial reference for surgeons and medical institutions, promoting the refinement and adoption of minimally invasive surgical techniques in liver transplantation.

Revolutionizing Organ Transplantation With Robotic Surgery

OBJECTIVE

The aim of this study was to evaluate the impact of robotic techniques on organ transplantation outcomes.

BACKGROUND

The evolution of organ transplantation is becoming influenced by the adoption of minimally invasive techniques, transitioning from laparoscopic to robotic methods. Robotic surgery has emerged as a significant advancement, providing superior precision and outcomes compared with traditional approaches.

METHODS

This perspective includes a systematic review of the literature, original data from a high-volume center, as well as an international survey focusing on perceptions related to robotic versus laparoscopic and open approaches.

RESULTS

The systematic review and meta-analysis revealed lower morbidity with robotic donor nephrectomy, recipient kidney transplant and donor hepatectomy. Our center's experience, with over 3000 minimally invasive transplant procedures (kidney, liver, donor, and recipient), supports the superiority of robotic transplant surgery (RTS). The global survey confirms this shift, revealing a preference for robotic approaches due to their reduced morbidity, despite challenges such as access to the robotic system and cost.

CONCLUSIONS

This comprehensive overview including a systematic review, original data, and perceptions derived from the international survey demonstrate the superiority of robotic transplant surgery (RTS) across a range of organ transplantations, for both donors and recipients. The future of RTS depends on the efforts of the surgical community in addressing challenges such as economic implications, the need for specialized surgical training for numerous surgeons, as well as wide access to robotic systems worldwide.

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.

Clinical effectiveness of robotic versus laparoscopic and open surgery: an overview of systematic reviews

OBJECTIVE

To undertake a review of systematic reviews on the clinical outcomes of robotic-assisted surgery across a mix of intracavity procedures, using evidence mapping to inform the decision makers on the best utilisation of robotic-assisted surgery.

ELIGIBILITY CRITERIA

We included systematic reviews with randomised controlled trials and non-randomised controlled trials describing any clinical outcomes.

DATA SOURCES

Ovid Medline, Embase and Cochrane Library from 2017 to 2023.

DATA EXTRACTION AND SYNTHESIS

We first presented the number of systematic reviews distributed in different specialties. We then mapped the body of evidence across selected procedures and synthesised major findings of clinical outcomes. We used a measurement tool to assess systematic reviews to evaluate the quality of systematic reviews. The overlap of primary studies was managed by the corrected covered area method.

RESULTS

Our search identified 165 systematic reviews published addressing clinical evidence of robotic-assisted surgery. We found that for all outcomes except operative time, the evidence was largely positive or neutral for robotic-assisted surgery versus both open and laparoscopic alternatives. Evidence was more positive versus open. The evidence for the operative time was mostly negative. We found that most systematic reviews were of low quality due to a failure to deal with the inherent bias in observational evidence.

CONCLUSION

Robotic surgery has a strong clinical effectiveness evidence base to support the expanded use of robotic-assisted surgery in six common intracavity procedures, which may provide an opportunity to increase the proportion of minimally invasive surgeries. Given the high incremental cost of robotic-assisted surgery and longer operative time, future economic studies are required to determine the optimal use of robotic-assisted surgery capacity.

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.

Indications and results of right-lobe living donor liver transplantation

The shortage of deceased liver donor organs over the years has always posed the need to expand the donor pool. A viable alternative to deceased donors is that of the living donor. Indeed, the living donor in liver transplantation, initially in pediatric transplantation, but for several years now also in adult transplantation, is a more than viable alternative to deceased liver donation. In fact, right liver lobe donation has proven to be a surgical procedure with low impact on the donor's life in terms of morbidity and mortality, with excellent results in recipients of such organs. In recent years, an increasing number of studies have been published that show excellent results in right-lobe living donor liver transplantation, encouraging this practice not only in countries that have historically had a shortage of deceased donor organs, such as Asian countries, but making it a practice of increasing use in Western countries as well. In addition, thanks to improvements in surgical technique and the experience of high-volume centers, this surgery has also begun to be performed using minimally invasive surgical techniques, allowing us to envision ever better outcomes for both donor and recipient in the coming years.

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.

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.

Management of Colorectal Cancer Liver Metastases

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Application of robotics in abdominal organ transplantation: A bibliometric analysis

BACKGROUND

Robotic transplant surgery has garnered worldwide attention since 2002. Discussions on this issue have led to more publications over the past decade. This study assessed global robotic organ transplantation studies using bibliometric analysis.

METHOD

The study sample was robotic technique use in organ transplantation publications from 2002 to 2021 in the Web of Science database. We analysed top-cited authors, countries, institutions, journals, and keywords. Citations were used to visualise and analyse target literature in VOSviewer.

RESULTS

160 articles were included in the bibliometric study. Among the nations that are presently involved in the use of robotics in organ transplantation research, the United States of America leads robotic organ transplantation studies. The American Journal of Transplantation published the most articles overall.

CONCLUSION

Based on publication and citation numbers, robotic organ transplantation techniques are becoming more global attention. This robotic abdominal organ transplant surgery bibliometric analysis review covers research output and hotspots.

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.