Robotic Liver Surgery
PC Giulianotti, MD, FACS
Professor and Chief
Division of General, Minimally Invasive and Robotic Surgery
University of Illinois Medical Center at Chicago
Robotic Surgery
The UIC program
Robotic Surgery
The UIC program
Robotic Liver Surgery
Backgrounds
1. Lesion size: No limits. Exclusion of sub-capsular extension and major vessels
infiltration.
2. Location: All the segments except segment I. (Posterior segment when a major
hepatectomy is required).
3. Extension:
Left lateral Sectionectomy, Segmentectomy,
Bisegmentectomy, Major Hepatectomies, Extended Hepatectomy
4. Pathology: Benign lesions (selected),
Malignant lesions: -HCC
- CRLM/ NCRLM
- Hilar malignancy
5. Pediatric and Adult Living donor: limited experience
6. Contraindications: Subcapsular extension, Invasion of Major Hepatic Vessels,
(Portal vein resection).
Laparoscopic Liver Surgery
Backgrounds
1992
First laparoscopic liver resection
Gagner et al. Surg Endosc 1992; 6: 99.
1996
First anatomic laparoscopic liver resection
Azagra et al. Surg Endosc 1996; 10: 758-761.
1997
First laparoscopic major liver resection
Huscher et al. J R Coll Surg Edinb 1997; 42: 219-225.
Laparoscopic Liver Surgery
Consensus
• Currently acceptable indications: solitary lesions, 5 cm or less, located in liver
segments 2 to 6
• Major liver resections should be reserved for experienced surgeons
• Conversion should not be considered as a failure
• Utilization of a hand assist or hybrid technique may be faster and safer
• Laparoscopic liver surgery has not been tested by controlled trials for
efficacy or safety
• A prospective randomized trial appears to be logistically prohibitive
• An international registry should be initiated to document the role and
safety of laparoscopic liver resection.
Laparoscopic Liver Surgery
Limitations
• Surgical skills
• Previous laparotomy
• Tools and instruments (suturing, retraction…)
• Location of the lesions (posterior segments)
• Extension of resection (major resections)
• Complex resections and reconstruction (hilar
cholangiocarcinoma)
Robotic Liver Surgery
Robotic Liver Surgery: Backgrounds
background
 In the current literature, only few small robotic series
 Good clinical results
 Robotic facilitate liver resection
 Especially for procedures that require a small operating field
 Left lateral sectionectomy is the first step in the learning curve
Giulianotti PC et al. Arch Surg 2003;138:777-84.
Patriti A et al. J Hepatobiliary Pancreat Surg 2009;16:450-7.
Tomulescu V et al. Chirurgia (Bucur) 2009;104:141-50.
Vasile S et al. Chirurgia (Bucur) 2008;103:401-5.
Choi SB et al. Yonsei Med J 2008;49:632-8.
Robotic Liver Surgery
Robotic Liver Surgery: Backgrounds
background
Surgery 2010; June 4
Robotic Liver Surgery
Our technique
Right Resections
Or setup
Assistant surgeons at
patient side:
•Suctioning
•Stapling
•Clipping
•Changing instruments
•Laparoscopic
Ultrasonography
Left Resections
Robotic Liver Surgery
Our technique
OR setup
Right Resections
Trocar Positioning
REVERSE TRENDELEMBURG
Patient Positioning
Robotic Liver Surgery
Our technique
Trocar Positioning
4
2
3
1
4
3
2
1
Right Resections
Left Resections
Robotic Liver Surgery
Intraoperative ultrasound
Our technique
Robotic Liver Surgery
Standardized technique
Our technique
Robotic Liver Surgery
Robotic Liver Surgery
Standardized Technique: 3 steps
1st step:
Hilum dissection
2nd step:
Dissection of the vena cava
3rd step:
Parenchymal transection
Robotic Liver Surgery
R
obotic Liver Surgery
Robotic
Phase 1: Hilum dissection
ADVANTAGES
• Retraction and exposure
(4th arm)
Left
• Stability
• Magnification
• Microsurgical capabilities
Right
Robotic Liver Surgery
R
obotic Liver Surgery
Robotic
Phase 2: Hepatocaval dissection
ADVANTAGES
• Retraction and lifting of the
liver (4th arm)
• Stability
• Magnification
• Ability to work in a very
deep and narrow field
Robotic Liver Surgery
R
obotic Liver Surgery
Robotic
Phase 3: Parenchymal transection
ADVANTAGES
• Retraction (stay sutures / 4th arm)
• Stability
• Magnification
• Precise energy delivery
to tissue (Harmonic)
• Ability to microsuture
Cortical and
Intermediate Aspect
Deep Part
(stapler)
Robotic Liver Surgery
Phase 3: Parenchymal transection
Bleeding-Management
Robotic Liver Surgery
obotic
Liver
Surgery
RoboticRLiver
Surgery:
ourOur
experience
experience
100 Robotic Liver resections
49 males and 51 females
Mean age 56.2 yrs (range 20 – 84)
Hepatic lesions localization
22
VII
VIII
II
6
1
VI
23
V
10
IV
4
2
III
14
18
Robotic Liver Surgery
Robotic
Surgery:
personal
experience
RLiver
obotic
Liver
Surgery
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Surgery:
ourOur
experience
experience
Major Hepatectomies:
38
Right hepatectomy
Left hepatectomy
Right trisectionectomy + Biliary reconstruction
29 pts
7 pts
2 pts
Minor Resections:
62
Segmentectomy
Bisegmentectomy
Left lateral sectionectomy
Non Anatomical
19 pts
18 pts
11 pts
14 pts
Adapted from Giulianotti PC et al. Surgery 2010; Jun 4.
Robotic Liver Surgery
Robotic
Surgery:
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experience
RLiver
obotic
Liver
Surgery
RoboticLiver
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experience
RESULTS
MAJOR HEPATECTOMIES
Mean Operative time: 377.2 min (175-840)
MINOR RESECTIONS
Mean Operative time: 221.3 min (45-579)
Mortality: NO MORTALITY
Conversion: 11%
Transfusions: 10% (majority cirrhotic patients)
Only one Pringle maneuver
Morbidity: 16%
Length of stay: 7 days (5 days in US)
Robotic Liver Surgery
Robotic
Surgery:
personal
experience
RLiver
obotic
Liver
Surgery
RoboticLiver
Surgery:
ourOur
experience
experience
US experience: follow up
Median follow up: 16 months (1-31)
Alive without
recurrence
Alive with
recurrence
Died
Hepatocellular
carcinoma
80%
10%
10%
Metastasis
100%
0
0
0
0
100%
Hilar
Cholangiocarcinoma
Robotic Liver Surgery
Robotic
Surgery:
experience
RLiver
obotic
Liver
Surgery
RoboticLiver
Surgery:
our
experience
Topersonal
expand
the limits
 Extended hepatectomy with biliary reconstruction
 Preliminary experience with vascular resection
 Preliminary experience with posterior lesions
Robotic Liver Surgery
Robotic
Surgery:
personal
experience
RLiver
obotic
Liver
RoboticLiver
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To
expand
the limits
Conclusions
 Robotic surgery is safe and feasible in experienced hands
 The technical abilities of the robotic system might improve the
critical steps of minimally invasive major liver resections
 Only robotics make feasible complex minimally invasive liver
resections
 Robotic surgery may expand the indications for minimally
invasive liver surgery
Conclusions
 For oncology, robotic surgery is one of the tool to extend the limit
of minimally invasive surgery in the field of liver resections
 Probably achieves the same oncological results as open approach
 Achieves low morbidity and mortality rate
 Reopens the possibilities of minimally invasive surgery
The Robotic Training Lab
The Bruno and Tony Pasquinelli Lab
Procedures performed at UIC and
offered for training include:
• Splenectomy
• Total gastrectomy
• Lung lobectomy
• Colorectal surgery
• Thyroidectomy
• Adrenalectomy
• Esophagectomy
• Major hepatectomies
• CBD Procedures
• Whipple