Robotic resections in hepatobiliary oncology - initial experience with Xi da Vinci system in India

Implementation of robotic and laparoscopic hepatopancreatobiliary surgery in low- and middle-income settings: a systematic review and meta-analysis

BACKGROUND

Despite numerous barriers, the application of minimally invasive surgery (MIS) for hepatopancreatobiliary (HPB) conditions has been increasing globally. This study aims to review the current status of HPB MIS in LMICs.

METHODS

Relevant databases were searched, identifying 3452 publications, 38 of which met the inclusion criteria. Meta-analysis of outcomes was carried out using "R" statistical software.

RESULTS

This study reviewed reports of application of MIS for HPB conditions in LMICs, analyzing a total of 3272 procedures. India (66.87 %) and Egypt (20.11 %) contributed majorly to the procedures reviewed. Others were from Indonesia (8.68 %), Colombia (3.06 %), Pakistan (0.67 %), Sri Lanka (0.34 %), Trinidad and Tobago (0.18 %), and Nigeria (0.09 %). India was the only LMIC with robotic HPB MIS. The majority of the procedures were biliary (74.88 %). Basic procedures accounted for 55.63 %, while 44.37 % were advanced. The overall conversion rate and prevalence of morbidity were 8 % [95 % CI: 5; 13], and 15 % [95 % CI: 9; 22], respectively. Robotics was associated with higher conversion (14 % vs 6 %, p < 0.01) but lower morbidity (10 % vs 16 %, p = 0.91), compared to laparoscopic surgery. There were 5 cases of mortality from laparoscopy.

CONCLUSION

The outcomes in this systematic review, compared to findings in other settings indicate successful implementation of HPB MIS in LMICs.

Liver Resection for Hepatocellular Carcinoma: Recent Advances

Hepatocellular carcinoma (HCC) represents a significant global health burden. Surgery remains a cornerstone in the curative treatment of HCC, and recent years have witnessed notable advancements aimed at refining surgical techniques and improving patient outcomes. This review presents a detailed examination of the recent innovations in HCC surgery, highlighting key developments in both surgical approaches and adjunctive therapies. Advanced imaging technologies have revolutionized preoperative assessment, enabling precise tumour localization and delineation of vascular anatomy. The use of three-dimensional rendering has significantly augmented surgical planning, facilitating more accurate and margin-free resections. The advent of laparoscopic and robotic-assisted surgical techniques has ushered in an era of minimal access surgery, offering patients the benefits of shorter hospital stays and faster recovery times, while enabling equivalent oncological outcomes. Intraoperative innovations such as intraoperative ultrasound (IOUS) and fluorescence-guided surgery have emerged as valuable adjuncts, allowing real-time assessment of tumour extent and aiding in parenchyma preservation. The integration of multimodal therapies, including neoadjuvant and adjuvant strategies, has allowed for 'bio-selection' and shown the potential to optimize patient outcomes. With the advent of augmented reality and artificial intelligence (AI), the future holds immense potential and may represent significant strides towards optimizing patient outcomes and refining the standard of care.

Gallbladder cancer: surgical treatment, immunotherapy, and targeted therapy

Gallbladder cancer is a common type of biliary tract tumor. Optimal management for early stage cases typically involves radical excision as the primary treatment modality. Various surgical techniques, including laparoscopic, robotic, and navigational surgery, have demonstrated favorable clinical outcomes in radical gallbladder excision. Unfortunately, most patients are ineligible for surgical intervention because of the advanced stage of the disease upon diagnosis. Consequently, non-surgical interventions, such as chemotherapy, radiotherapy, immunotherapy, and targeted therapy, have become the mainstay of treatment for patients in advanced stages. This review focuses on elucidating various surgical techniques as well as advancements in immunotherapy and targeted therapy in the context of recent advancements in gallbladder cancer research.

Robotic Resection of Gallbladder Cancer: A Single-Center Retrospective Comparative Study to Open Resection

BACKGROUND

Minimally invasive surgery is gaining support for resection of gallbladder cancer (GBC). This study aims to compare operative and early outcomes of robotic resection (RR) to open resection (OR) from a single institution performing a high volume of robotic HPB surgery.

METHODS

Twenty patients with GBC underwent RR from January 2013 to August 2019. Outcomes were compared to a historical control of 23 patients with OR. Radical cholecystectomy for suspected GBC and completion operations for incidental GBC after routine cholecystectomy were both included.

RESULTS

Robotic resection had lower blood loss compared to OR (150 vs 350 mL, P = .002) and shorter postoperative length of stay (2.5 vs 6 days, P < .001), while median operative time was similar (193 vs 208 min, P = .604). There were no statistical differences in 30-day major complications or readmissions. No 30-day mortalities occurred. There was no statistical difference in survival trend (P = .438) or median lymph node harvest (5 vs 3, P = .189) for RR compared to OR.

CONCLUSION

Robotic resection of GBC is safe and efficient, with lower length of hospital stay and blood loss compared to OR. Technical benefits of robotic-assisted surgery may prove advantageous though larger studies are still needed.

Current status and future perspectives of minimally invasive surgery in gallbladder carcinoma

BACKGROUND

Gallbladder carcinoma (GBC) is the most common biliary tract malignancy, which is characterized by easy local invasion, lymph nodes metastasis, local vascular invasion. Hence, minimally invasive surgery (MIS) can be performed in a limited number of patients. In our study, we reviewed the current studies on laparoscopic surgery (LS) and robotic surgery (RS) for GBC and analysed the limitations and difficulties of MIS for GBC.

METHODS

Multiple electronic databases were used for a systematic literature retrieval. All studies involving MIS of GBC were included (up to August 2019).

RESULTS

A total of 24 studies were included, of which 18 studies involved LS for GBC and six studies concerned RS of GBC. For LS, 16 studies contained relevant information of T stage, and 323 patients (98.8%) had T3 or lower stage; the average rate of R0 resection, conversion, postoperative complications and mortality was 95.3% (range 80.5-100%), 1.9% (range 0-16.7%), 13.4% (range 0-33.3%) and 1.0% (range 0-10%), respectively. For RS, four studies contained relevant information of T stage, and all patients were T3 or lower stage; the average rate of R0 resection, conversion and postoperative complications was 96.8% (range 81.8-100%), 5.5% (range 0-14.8%) and11.9% (range 0-36.4%), respectively. In addition, no patient had perioperative mortality.

CONCLUSIONS

MIS for GBC is limited to highly selected patients and is considered to be technically feasible in experienced surgeons. However, improvements in technical and instrumental are needed to reduce the associated postoperative complications and implantation metastasis, and to promote MIS in the treatment of GBC.

Progress in hepatectomy for hepatocellular carcinoma and peri-operation management

The global incidence of liver cancer continues to grow. Liver cancer, especially hepatocellular carcinoma, has high recurrence and mortality rates. Here, we review the past decade's diagnostic, therapeutic, and management strategies for hepatocellular carcinoma, and summarize new patient management approaches, including enhanced recovery after surgery, targeted therapy, and immunotherapy. We compare traditional and innovative management methods, which comprise developments in precision medicine, and consider their limitations. Ongoing innovation and technological advances enable surgeons to gain deeper understandings of the multidimensionality of hepatocellular carcinoma, thereby promoting the continuous development of precision therapy.

Robotic Biliary Surgery

Robotic cholecystectomy is safe and feasible approach and can be combined with common bile duct exploration to address complicated pathology in a single setting. This article summarizes reported outcomes after robotic biliary surgery. A technical overview of robotic multiport and single port cholecystectomy is provided. Last, the approach to benign bile duct disease during robotic cholecystectomy, including reconstruction of the biliary tree, is described.

Outcome of Robot-Assisted Radical Cholecystectomy in a High-Volume Tertiary Cancer Center in India

Introduction: Minimally invasive radical cholecystectomy is a complex laparoscopy. Robotic surgery is now an option to complete a radical cholecystectomy because of its high definition, magnified three-dimensional view of the operative field, and articulating instrumentation.^1–3 Robotic surgery enables a safe dissection in otherwise difficult to access areas such as the porta hepatis. This video reviews the role of robotic surgery in the management of gall bladder (GB) malignancy.

Methods: A 28-year-old lady, with no comorbidities, presented with abdominal pain and underwent an evaluation with a contrast-enhanced CT scan of chest and abdomen. The CT scan revealed a mass in the GB with no evidence of distant metastases. Liver function tests were normal and a CA19-9 was 898 U/mL. A robotic radical cholecystectomy using five ports (four robotic and one assistant port) was performed. The procedure started by clearing the hepatoduodenal ligament nodes (stations 8, 12, and 13 with interaortocaval node sampling). The triangle of Calot was then dissected and secured with clips. Next a wide excision of segments 4b and 5 was performed including the GB. The complete specimen was extracted in a bag from a small incision at the assistant port.

Results: The procedure was performed in 330 minutes with a blood loss of 200 mL. There were no perioperative complications and the postoperative stay was 3 days. Final histopathology report revealed moderately differentiated adenocarcinoma of GB invading serosa (pT3) with negative margins and 4 out of 14 lymph nodes showed presence of metastases. The overall cohort shows 22 robotic radical cholecystectomies for GB malignancy. The median age was 53 years. The average duration of surgery was 270 minutes with a median blood loss of 120 mL. The median postoperative stay was 4 days and the median nodal yield for radical cholecystectomy was 8. The overall median survival at 18 months was 100% with one recurrent hepatic lesion.

Discussion: Robotic radical cholecystectomy may offer technical superiority over laparoscopic surgery and is an oncologically acceptable approach with good short-term oncologic outcomes. This type of surgery may require a highly specialized center with adequate experience in hepatopancreatobiliary surgery.

No competing financial interests exist.

Runtime of video: 9 mins 5 secs

Robotic hepatic surgery in malignancy: review of the current literature

The use of minimally invasive liver surgery, such as laparoscopic and robotic surgery, is increasing worldwide. Robot-assisted laparoscopy is a new surgical technique that improves surgical handling. The advantage of this technique is improved dexterity, which leads to increased surgical precision and no tremor or fatigue. Comparable oncological results were documented for laparoscopic and open surgery. Currently, "conventional" laparoscopic liver surgery has limitations with respect to the treatment of lesions in the posterior-superior segments, and there are limited technical features for the reconstruction steps. These limitations might be overcome with the use of robotic surgery. The use of robotic surgery for hepatic procedures originated because of the technical potential to overcome several of the major technical limitations known from conventional laparoscopy and the possibility of performing more extended liver resections. Additionally, there is increasing evidence indicating that robotic hepatic surgery is feasible and safe in resections of the posterior segments. Studies showed that using the robotic technique is associated with a decreased or at least equal amount of intraoperative blood loss compared to that of the conventional laparoscopic or open technique. There is increasing evidence that robotic liver surgery might be as safe as conventional laparoscopic procedures in cancer cases in terms of resection margins, disease-free and overall survival. Furthermore, robotic surgery might be more favorable with respect to postoperative patient recovery. Despite promising results, still large, multicenter, randomized and prospective studies are needed to analyze the exact value of robotic liver surgery in patients with malignant liver tumors.

Robotic Surgery for Malignant Liver Disease: a Systematic Review of Oncological and Surgical Outcomes

Robot-assisted laparoscopic surgery is yet another modification of minimally invasive liver surgery. It is described as feasible and safe from the surgical point of view; however, oncological outcomes need to be adequately analysed to justify the use of this technique when resecting malignant liver tumours. We reviewed existing English medical literature on robot-assisted laparoscopic liver surgery. We analysed surgical outcomes and oncological outcomes. We analysed operative parameters including operative time, type of hepatectomy, blood loss, conversion rate, morbidity and mortality rates and length of stay. We also analysed oncological outcomes including completeness of resection (R status), recurrence, survival and follow-up data. A total of 582 patients undergoing robot-assisted laparoscopic liver surgery were analysed from 17 eligible publications. Only 5 publications reported survival data. The overall morbidity was 19% with 0.2% reported mortality. R0 resection was achieved in 96% of patients. Robotic liver surgery is feasible and safe with acceptable morbidity and oncological outcomes including resection margins. However, well-designed trials are required to provide evidence in terms of survival and disease-free intervals when performed for malignancy.

Robotic surgery for gallbladder cancer: Operative technique and early outcomes

BACKGROUND

The objective was to elucidate the operative technique of robotic radical cholecystectomy (RRC) and to compare the early outcomes of RRC with open radical cholecystectomy (ORC) for gallbladder cancer (GBC).

METHODS

Patients who underwent RRC for suspected or incidental GBC between July 2015 and August 2018 were analyzed. Patients who underwent ORC during the same period and fulfilled the study criteria formed the control group.

RESULTS

During the study period, 27 patients who underwent RRC formed the study group (group A) and 70 matched patients who underwent ORC formed the control group (group B). Median surgical time was higher in group A (295 vs 200 minutes, P < 0.001). However, median blood loss (200 vs 600 mL, P < 0.001), postoperative hospital stay (4 vs 5 days, P = 0.046) and postoperative morbidity (1 vs 15 patients, P = 0.035) were lower in group A. Median lymph node yield was 10 (range = 2-21) for group A and 9 (range = 2-25) for group B, and was comparable (P = 0.408). During a median follow up of 9 (1-46) months, two patients in group A developed recurrence (no port site recurrence).

CONCLUSION

RRC is safe and feasible and the short-term results are compared with ORC.