Hepatectomy, cholecystectomy, and biliary reconstruction

Indications and contraindications for robotic hepatobiliary surgery

The patient must have the cardiopulmonary resilience to tolerate a 4- to 8-hour operation under pneumoperitoneum. Tumor invasion into a major hepatic vein is not a contraindication, as long as negative margins are attainable with resection. Vascular reconstruction with a patch or interposition conduit for inferior vena cava (IVC) involvement is an indication for an open approach. If R0 resection is attainable with a side bite of a major hepatic vein without narrowing the lumen significantly, the resection can proceed robotically as long as adequate experience and technical expertise are available. The presence of nodal disease beyond the tumor’s expected lymphatic drainage basin (N2) or metastatic disease (M1) is considered a contraindication to resection. In addition, an adequate future liver remnant must be preserved (>20% in normal liver, >30% in postchemotherapeutic liver, and >40% in cirrhotic liver) to avoid posthepatectomy liver failure (PHLF). Alternatively, two-staged hepatectomy with portal venous occlusion and embolization can be employed to achieve interval liver hypertrophy, making the operation safer. A set of guidelines is available in Table 57.1 .

Preoperative assessment

Our preferred imaging modality is a triple phase 1 mm cut computed tomography (CT) of the abdomen and pelvis, with regular CT of the chest to complete staging. This is especially important for defining vascular anatomy and potential vascular invasion by the tumor. An MRI with adequate arterial, portal, and systemic venous phases is an acceptable alternative for intrahepatic lesions, particularly in the presence of renal disease to avoid contrast nephropathy. A tissue diagnosis of the liver lesion is often unnecessary; by synthesizing the data from the patient’s demographics, symptomatology, presence of cirrhosis, lesion morphology, and contrast enhancement patterns, we are able to forgo the need for preoperative liver biopsy in greater than 95% of cases, thereby avoiding needle tract seeding which can be a source of cancer recurrence.

We utilize a well-reconstructed thin-cut CT scan to permit 3D liver reconstruction with volumetric analysis to prevent PHLF, a devastating and often fatal complication. A detailed discussion on preventing PHLF is beyond the scope of this chapter; however, along Makuuchi’s decisional algorithm, we are very selective in performing a major hepatectomy in a patient with a total bilirubin greater than 1 mg/dL or evidence of significant portal hypertension (ascites, platelet count <100,000 per microliter or large abdominal varices). In patients with an obstructive cholangiocarcinoma, we preoperatively decompress the future liver remnant side by endoscopic retrograde cholangioscopic (ERC) stenting or interventional radiologic (IR) guided external percutaneous transhepatic biliary (PTB) drainage to reach the goal of total bilirubin less than 3 mg/dL.

In cases of liver lesions smaller than 3 cm in size at a favorable location, we will offer upfront robotic resection over ablation, despite more recent data suggesting that ablation approaches resection in terms of tumor recurrence risk. We are more confident in attaining cure by acquiring pathologic confirmation via negative margins (as opposed to via ablation), conforming to the current recommendations for liver cancer treatment. We utilize ablative methods for patients who cannot tolerate loss of any parenchyma or a prolonged operation under pneumoperitoneum. This often includes patients with background liver cirrhosis in the Child-Pugh Class B category. Additionally, lesions less than 3 cm in a deep, unfavorable location, particularly in those who require maximal parenchymal salvation, should be best treated with ablation. Selection criteria are not absolute but must be applied on a case-by-case basis ( Table 57.2 ). Cardiopulmonary risk stratification and optimization considering patient age, frailty, and extent of resection are very important preoperative steps to ensure safe overall outcomes ( Table 57.3 ).

Patient preparation and positioning

Starting from 2016, we began to utilize the Intuitive Surgical Inc. da Vinci robotic platform (Intuitive Surgical, Sunnyvale, CA) to undertake minimally invasive hepatobiliary resections. We have previously published our operative setup and initial outcomes from our tertiary hepatobiliary center, but the following is a more detailed explanation.

Patients are positioned supine on the operating table and induced with general endotracheal anesthesia. A central venous catheter and a radial arterial line are placed to facilitate central venous pressure (CVP) monitoring during liver parenchymal transection (<5 mm Hg) and to guide intraoperative resuscitation, which includes judicious fluid administration to prevent excessive hepatic venous bleeding. We also ask anesthesia to eliminate the postexpiratory positive pressure (PEEP) to further reduce the hepatic venous pressure, thus achieving optimized hemostasis during parenchymal transection.