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Pioneering Robotic Liver Surgery in Germany: First Experiences with Liver Malignancies.

Croner RS, Perrakis A, Brunner M, Matzel KE, Hohenberger W - Front Surg (2015)

Bottom Line: Minimally invasive liver surgery is growing worldwide with obvious benefits for the treated patients.These procedures maybe improved by robotic techniques, which add several innovative features.To achieve perioperative parameters comparable to open settings, the learning curve must be passed.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery and Liver Center, University Hospital Erlangen , Erlangen , Germany.

ABSTRACT

Background: Minimally invasive liver surgery is growing worldwide with obvious benefits for the treated patients. These procedures maybe improved by robotic techniques, which add several innovative features. In Germany, we were the first surgical department implementing robotic assisted minimally invasive liver resections.

Material and methods: Between June 2013 and March 2015, we performed robotic based minimally invasive liver resections in nine patients with malignant liver disease. Five off these patients suffered from primary and four from secondary liver malignancies. We retrospectively analyzed the perioperative variables of these patients and the oncological follow up.

Results: Mean age of the patients was 63 years (range 45-71). One patient suffered from intrahepatic cholangiocellular, four from hepatocellular carcinoma, and four patients from colorectal liver metastases. In six patients, left lateral liver resection, in two cases single segment resection, and in one case minimally invasive guided liver ablation were performed. Five patients underwent previous abdominal surgery. Mean operation time was 312 min (range 115-458 min). Mean weight of the liver specimens was 182 g (range 62-260 g) and mean estimated blood loss was 251 ml (range 10-650 ml). The mean tumor size was 4.4 cm (range 3.5-5.5 cm). In all cases, R0 status was confirmed with a mean margin of 0.6 cm (range 0.1-1.5 cm). One patient developed small bowel fistula on postoperative day 5, which could be treated conservatively. No patient died. Mean hospital stay of the patients was 6 days (range 3-10 days). During a mean follow up of 12 months (range 1-21 months), two patients developed tumor recurrence.

Conclusion: Robotic-based liver surgery is feasible in patients with primary and secondary liver malignancies. To achieve perioperative parameters comparable to open settings, the learning curve must be passed. Minor liver resections are good candidates to start this technique. But the huge benefits of robotic-based liver resections should be expected in extended procedures beyond minor liver resections with the currently available technology.

No MeSH data available.


Related in: MedlinePlus

Laparoscopic ultrasound to identify resection margin. Red arrows indicate the tumor margin, yellow arrow indicates a shadow induced by an incision of the liver capsular.
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Figure 3: Laparoscopic ultrasound to identify resection margin. Red arrows indicate the tumor margin, yellow arrow indicates a shadow induced by an incision of the liver capsular.

Mentions: For robotic-based liver resection, we used the Da Vinci Si System (Intuitive Surgical, Inc., CA, USA). Patients were placed in a reverse Trendelenburg position. The screen was located at the head end of the patient. The robot cart moved over the right shoulder. The anesthesia was positioned at the left, the assisting nurse at the right and the assisting surgeon between the legs of the patient (Figure 1). A pneumoperitoneum was achieved puncturing the abdomen with a veress needle in the left upper abdomen. In case of adhesions resulting from prior surgery pneumoperitoneum and explorative laparoscopy can be initiated via a 5 mm port in the same position. The camera of the robot was positioned right above the umbilicus via a 10-mm trocar. If necessary, a 10-mm trocar can be placed below the umbilicus for pringle maneuver. To the left side of the umbilicus, a 10-mm trocar for laparoscopic assistance was inserted. The robotic arm 1 was positioned in the left middle abdomen, the robotic arm 2 in the right upper, and the robotic arm 3 in the left upper abdomen (Figure 2A). Arm 3 was mainly used for liver exposure while via arm 1 and 2 a bipolar forceps and monopolar scissors were placed for tissue preparation (Figure 2B). Liver parenchymal dissection was carried out with harmonic scalpel, which can be inserted via each robotic arm needed. Via the assistant port a laparoscopic succor was placed to reduce smoke exposure or to maintain visualization in case of bleeding. Vessel clipping was performed by using robotic clips, which we prefer for bigger vessels or via the assistant port with laparoscopic clips. The portal or liver vein can be divided by a stapler via the assistant port. Usually, we started the preparation by defining the resection margins with laparoscopic ultrasound. After incising the liver capsular, a shadow can be identified, this shadow marks the distance between liver lesion and resection margin (Figure 3). In a next step, and if necessary, the liver side containing the tumor was mobilized and extrahepatic vessels were dissected. Then, the parenchyma dissection started. Intrahepatic vessels and bile ducts were clipped or stitched. The resected specimens were inserted in a bag and removed via a pfannenstiel incision or in case of prior open surgery using preexisting scars (Figure 4A). Usually, a drain was placed which was removed on postoperative day 2. The fascia was stitched and skin incisions were glued.


Pioneering Robotic Liver Surgery in Germany: First Experiences with Liver Malignancies.

Croner RS, Perrakis A, Brunner M, Matzel KE, Hohenberger W - Front Surg (2015)

Laparoscopic ultrasound to identify resection margin. Red arrows indicate the tumor margin, yellow arrow indicates a shadow induced by an incision of the liver capsular.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4440394&req=5

Figure 3: Laparoscopic ultrasound to identify resection margin. Red arrows indicate the tumor margin, yellow arrow indicates a shadow induced by an incision of the liver capsular.
Mentions: For robotic-based liver resection, we used the Da Vinci Si System (Intuitive Surgical, Inc., CA, USA). Patients were placed in a reverse Trendelenburg position. The screen was located at the head end of the patient. The robot cart moved over the right shoulder. The anesthesia was positioned at the left, the assisting nurse at the right and the assisting surgeon between the legs of the patient (Figure 1). A pneumoperitoneum was achieved puncturing the abdomen with a veress needle in the left upper abdomen. In case of adhesions resulting from prior surgery pneumoperitoneum and explorative laparoscopy can be initiated via a 5 mm port in the same position. The camera of the robot was positioned right above the umbilicus via a 10-mm trocar. If necessary, a 10-mm trocar can be placed below the umbilicus for pringle maneuver. To the left side of the umbilicus, a 10-mm trocar for laparoscopic assistance was inserted. The robotic arm 1 was positioned in the left middle abdomen, the robotic arm 2 in the right upper, and the robotic arm 3 in the left upper abdomen (Figure 2A). Arm 3 was mainly used for liver exposure while via arm 1 and 2 a bipolar forceps and monopolar scissors were placed for tissue preparation (Figure 2B). Liver parenchymal dissection was carried out with harmonic scalpel, which can be inserted via each robotic arm needed. Via the assistant port a laparoscopic succor was placed to reduce smoke exposure or to maintain visualization in case of bleeding. Vessel clipping was performed by using robotic clips, which we prefer for bigger vessels or via the assistant port with laparoscopic clips. The portal or liver vein can be divided by a stapler via the assistant port. Usually, we started the preparation by defining the resection margins with laparoscopic ultrasound. After incising the liver capsular, a shadow can be identified, this shadow marks the distance between liver lesion and resection margin (Figure 3). In a next step, and if necessary, the liver side containing the tumor was mobilized and extrahepatic vessels were dissected. Then, the parenchyma dissection started. Intrahepatic vessels and bile ducts were clipped or stitched. The resected specimens were inserted in a bag and removed via a pfannenstiel incision or in case of prior open surgery using preexisting scars (Figure 4A). Usually, a drain was placed which was removed on postoperative day 2. The fascia was stitched and skin incisions were glued.

Bottom Line: Minimally invasive liver surgery is growing worldwide with obvious benefits for the treated patients.These procedures maybe improved by robotic techniques, which add several innovative features.To achieve perioperative parameters comparable to open settings, the learning curve must be passed.

View Article: PubMed Central - PubMed

Affiliation: Department of Surgery and Liver Center, University Hospital Erlangen , Erlangen , Germany.

ABSTRACT

Background: Minimally invasive liver surgery is growing worldwide with obvious benefits for the treated patients. These procedures maybe improved by robotic techniques, which add several innovative features. In Germany, we were the first surgical department implementing robotic assisted minimally invasive liver resections.

Material and methods: Between June 2013 and March 2015, we performed robotic based minimally invasive liver resections in nine patients with malignant liver disease. Five off these patients suffered from primary and four from secondary liver malignancies. We retrospectively analyzed the perioperative variables of these patients and the oncological follow up.

Results: Mean age of the patients was 63 years (range 45-71). One patient suffered from intrahepatic cholangiocellular, four from hepatocellular carcinoma, and four patients from colorectal liver metastases. In six patients, left lateral liver resection, in two cases single segment resection, and in one case minimally invasive guided liver ablation were performed. Five patients underwent previous abdominal surgery. Mean operation time was 312 min (range 115-458 min). Mean weight of the liver specimens was 182 g (range 62-260 g) and mean estimated blood loss was 251 ml (range 10-650 ml). The mean tumor size was 4.4 cm (range 3.5-5.5 cm). In all cases, R0 status was confirmed with a mean margin of 0.6 cm (range 0.1-1.5 cm). One patient developed small bowel fistula on postoperative day 5, which could be treated conservatively. No patient died. Mean hospital stay of the patients was 6 days (range 3-10 days). During a mean follow up of 12 months (range 1-21 months), two patients developed tumor recurrence.

Conclusion: Robotic-based liver surgery is feasible in patients with primary and secondary liver malignancies. To achieve perioperative parameters comparable to open settings, the learning curve must be passed. Minor liver resections are good candidates to start this technique. But the huge benefits of robotic-based liver resections should be expected in extended procedures beyond minor liver resections with the currently available technology.

No MeSH data available.


Related in: MedlinePlus