Q5 Recommendations
The 2nd International Consensus Conference on
Laparoscopic Liver Resection
Question 5 (Q5):
What is the role for robotic hepatectomy?
Q 5 Working group:
Coordinator
Allan Tsung
Literature Review
Mohammad Khreiss
Working group
Gi Hong Choi
Chung-Ngai Tang
Conference Chairman
Go Wakabayashi
Methods:
This document is based on a comprehensive review of the literature as of 08/20/14.
This review is summarized in the accompanied tables.
No randomized trials are available. All data have been reported as case series, case–
control studies and reviews.
17 major series (minimum of 7 patients that included outcome data) were included in
this analysis. 6 of these articles included comparisons between robotic versus
laparoscopic liver resections. Among the series reviewed 9 reported on the experience
with major and minor robotic liver resections. 6 series reported on minor resections only.
1
General features of reported cases:
1. Numbers: 452 robotic live resections were identified in this review. Efforts were
made to avoid reporting of duplicate patients (ie. Patients reported in series from
the same institutions or from the same authors). 6 comparative series included
197 robotic cases and 454 laparoscopic cases
2. Indications: indications for robotic liver resections were similar to those of
laparoscopic or open liver resections. 70 % of cases were performed for
malignant disease with CRLM and HCC being the most common disease
malignant disease entities.
3. Types of resection : the most common procedures performed were wedge
resections 81(18%), segmentectomy 63 (14%), right hepatectomy 63(14%), and
left lateral sectionectomy 60 (13%). Other procedures performed included left
hepatectomy 43 (10%), bisegmentectomy 49 (11%), extended right hepatectomy
3(1%), and extended left hepatectomy 2(1%).
Comparative short term outcomes:
1. Mortality : there was no mortality in the robotic liver resection groups reported
2. Morbidity: morbidity rate ranged from 4 to 46.7% in the series reported. The most
common complication reported was bile leak post resection. Other complications
included intra-abdominal collections, wound infections, deep vein thrombosis,
postoperative bleeding and ileus.
3. Estimated blood loss: estimated blood loss ranged between 50 and 412 cc in the
series reported. In the comparative series only one series reported a significant
difference in estimated blood loss favoring laparoscopic liver resection.
4. Operative time: the operative time in the series reported ranged from 61 to 507
min. In the comparative series, two series showed a significantly less operative
time in the laparoscopic liver resection group. One series reported on improved
operative time in the robotic liver resection group with increased experience.
2
5. Conversion rate: the conversion rate in all series reported ranged between 0 and
20%. In the series that compared robotic liver resection to laparoscopic liver
resection, there was no difference in conversion rates.
6. Length of hospital stay: the length of hospital stay ranged between 2 and 11
days. There was no difference in LOS in the series that compared laparoscopic
to robotic resections
7. Oncologic outcomes: Data on oncologic outcomes were very limited in the series
reported. Long term follow up was not present in most of the series and disease
free and overall survival was not reported. When reported, tumor size ranged
from 1.5 to 6.5 cm. margins ranged from 1 to 11 mm. R0 resection rates ranged
between 92 and 100 %. In the series that compared robotic liver resection to
laparoscopic liver resections, there were no significant differences in the rate of
R0 resections.
8. Two studies demonstrated a greater proportion of major hepatectomies
completed in a totally minimally invasive manner with the robot compared to
laparoscopic approach with many consisting of hand-assist and hybrid
techniques. However, there were no significant benefits over laparoscopic in
operative outcomes. Another study showed more resections of tumors located in
the postero-superior segments with the robotic approach.
Table 1: Major robotic series with postoperative outcomes
STUDY
Patie
nts
(N)
Malignant
(N, %)
EBL
(ml)
Blood
transfusion
(% )
Conversion
(%)
Morbidity
(%)
LOS
(dys)
42 (60)
Major
Time
Resectio (min)
n (≥3
segment
s; N, %)
27 (39)
270
Giulianotti et al
(2011)
Tsung et al
(2013)
Wu et al (2014)
Lai et al (2013)
Troisi (2013)
Choi et al
(2012)
Tranchart et al
(2014)
Chan et al
(2011)
Spampinato et
al (2014)
70
262
15.0
5.7
22.9
7
57
38 (66)
21 (37)
253
200
3.8
7.0
19.3
4
52
43
40
30
39 (75)
43 (100)
28 (70)
21 (70)
20 (38)
10 (23)
0 (0)
20 (67)
380
229
271
507
325
412
330
343
NR
7.3
NR
13.3
5.0
7.3
20.0
6.6
8.0
17.1
22.5
46.7
NR
6
6
11
28
15 (54)
0 (0)
210
200
14.0
14.0
18.0
6
27
21 (78)
1 (4)
200
50
NR
3.7
7.0
6
25
17 (68)
25 (100)
430
250
44.0
4.0
4.0
8
3
Casciola et al
23
19 (83)
0 (0)
280
245 NR
8.7
39.0
(2011)
Ji et al (2012)
13
8 (62)
9 (69)
338
280 0.0
0.0
7.8
Geneva et al
11
7 (64)
0 (0)
329
200 9.1
0.0
27.3
(2014)
Berber et al
9
9 (100)
0 (0)
258
136 NR
11.1
11.1
(2010)
Kandil et al
7
4 (57)
1 (14)
61
100 NR
0.0
0.0
(2013)
Tomulescu et
7
NA
0 (0)
137
NR
NR
0.0
0.0
al (2009)
Patriti et
5
5 (100)
0 (0)
334
660 NR
0.0
0.0
al*(2009)
Wakabayashi
4
3 (75)
0 (0)
272
min 0
0.0
0.0
et al (2011)
*= data reported for synchronous resection of colon and liver. 2 pts were totally laparoscopic
Min=minimal
9
7
9
NR
2
11
8.1
NR
Table 2: Oncologic outcomes of malignant tumors of major robotic series
STUDY
Type of Tumor (N)
Resection (%)
Margin (mm)
CRM
16
HCC
13
Other
13
R0
100
R1
0
18
Tsung et al (2013)
21
7
10
100
0
NR
Wu et al (2014)
0
38
1
NR
NR
NR
Lai et al (2013)
0
41
0
93
7
NR
Troisi et al (2013)
24
3
3
92
8
NR
Choi et al (2012)
4
13
4
NR
NR
21
NR
NR
NR
NR
NR
NR
Chan et al (2011)
7
13
1
NR
NR
NR
Spampinato et al (2014)
11
2
3
100
0
NR
Casciola et al (2011)
14
3
2
NR
NR
14.6
Ji et al (2012)
0
6
2
100
0
NR
Giulianotti et al (2011)
Tranchart et al (2014)
4
Geneva et al (2014)
1
6
0
100
0
8.8
Berber et al (2010)
4
3
2
100
0
11
Kandil et al (2013)
1
1
2
NR
NR
NR
NA
NA
NA
NA
NA
NA
Patriti et al(2009)
5
0
0
100
0
NR
Wakabayashi et al (2011)
0
3
0
NR
NR
NR
Tomulescu et al (2009)
NR=Not Reported
Table 3: Series comparing laparoscopic (lap) and robotic (R) outcomes
(NR=Not Reported, NS=Not Significant)
Tsung et al
Tranchart et al
Berber et al
R
P
Lap
R
p
Lap
R
Lap
R
P
Lap
R
P
42
21
1.0
0
0
1.0
0
0
1.0
37
0
0.011
10
20
NR
25
25
1.0
Minor resection
(N)
72
36
1.0
28
28
1.0
23
9
NS
186
40
NR
59
32
NR
0
0
1.0
Operative time
(min)
EBL (ml)
198
253
0.001
176
210
0.12
233
258
NS
262
271
0.67
227
380
0.04
360
430
0.07
100
200
0.097
150
200
0.19
155
136
NS
174
330
0.001
173
325
0.03
400
250
0.95
Transfusion (%)
7.4
3.8
0.37
3.5
14.0
0.35
NR
Conversion (%)
8.8
7.0
0.67
7.0
14.0
0.67
NR
12.2
5
Morbidity (%)
26.0
19.3
0.34
18.0
18.0
Mortality (%)
0.9
0.0
0.48
3.5
0.0
1.0
NR
LOS (dys)
4.0
4.0
0.10
5.5
6.0
0.52
NR
5.9
6.1
0.78
R0 resection (%)
92
95
0.44
NR
94.6
92.5
0.71
NR
11.0
P
p
Spampinato et al
Lap
17.0
R
Wu et al
Major resection
(N)
1.0
Lap
Troisi et al
NR
NS
NR
7.6
20
0.034
12.6
12.5
1.0
10
0
0
1.0
0
16
44
0.03
NS
4
4
1.0
8
NS
36
16
0.2
0
NS
1
0
NR
NR
7
8
0.48
NR
91
100
0.49
Recommendations:
1. All data comes from cases series, case-control studies and reviews.
2. Only a small proportion of minimally invasive hepatectomies are completed
with the robotic approach.
3. Feasibility and safety has been demonstrated with minor/major resections,
variety of tumor types, and various locations in the liver with trained
surgeons and appropriate patient selection.
4. Robotic approach may have a role in tumors at difficult segments and
facilitate portal dissection resulting in a higher rate of major hepatectomy
in some centers.
5. Although robotic technology has theoretical advantages to surpass
limitations of laparoscopic surgery, comparative studies with
laparosocopic hepatectomies currently do not show significant differences
in operative and post-operative outcomes.
5
6. The oncological outcomes are not clear yet and requires more data and
longer follow up.
7. Potential increased costs with robotic hepatectomies, training/competency
requirements, and continually advancing robotic technology/instruments
require further analysis.
References
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