Robotic hepatectomy

Introduction

The evolution of minimally invasive techniques, starting from laparoscopy to the more recent robotic platform, have allowed for greater consistency in the applicability of advanced surgical techniques. The widespread adoption of robotic surgery has stimulated expansion of the robotic platform into complex hepatobiliary procedures.

The goal of any new technique is to improve outcomes, and robotic hepatectomies have shown promise in that regard. In 2018, the first international consensus statement regarding robotic hepatectomy was formulated. Although outcomes data on robotic hepatectomy are preliminary because of the relative rarity of these procedures being performed, it was considered to be as safe and feasible as open or laparoscopic hepatectomy. The overall complication rate was found to be lower for robotic hepatectomy than for open hepatectomy but was similar to that for the laparoscopic approach. One can postulate that the outcomes data would continue to improve as surgeons develop more expertise and overcome their learning curves for robotic liver surgery, as seen in other types of surgeries. As robotic surgery continues to mature, there is significant promise in the field of robotic liver surgery.

Indications

In general, indications for robotic hepatectomy should be similar to those for laparoscopic or open hepatectomy, provided the resection is technically feasible by this route. Common indications include primary or metastatic malignant liver tumors, benign tumors such as hepatic adenomas that meet the criteria, or, occasionally, tumors with diagnostic uncertainty. As with other surgeries, it is the responsibility of the surgeon to first determine if the patient’s condition is amenable to operative intervention and then select the best route of intervention for that patient. Specific to liver surgery, one must take into consideration the primary tumor characteristics, baseline liver condition, patient comorbidities, and surgeon’s operative experience. Appropriate patient selection can directly impact outcomes. For example, large centrally located tumors (>5 cm) or multiple tumors may increase the difficulty of surgery due to the limited working space available in a closed environment. Similarly, close proximity of a tumor to the major blood vessels or bile ducts, a tumor in difficult hepatic segments (such as posterior-superior), and intrinsic liver disease can increase the complexity of liver surgery.

Preparation

Baseline laboratory evaluation usually includes a complete blood count, coagulation factors, metabolic panel, and liver function tests. An objective evaluation of underlying intrinsic liver disease, such as the model for end-stage liver disease scores, should also help guide operative decision-making. Finally, a comprehensive evaluation of the patient’s functional and cardiopulmonary status may determine their physiologic fitness and ability to tolerate major surgery.

Thorough anatomic evaluation of the liver should be completed preoperatively, with either a high-quality computed tomography scan with triphasic liver protocol or contrast-enhanced magnetic resonance imaging. These studies provide excellent delineation of the tumor location, including the relation to the major blood vessels as well as the background hepatic architecture and presence of cirrhosis. Volumetric analysis of the functional liver remnant (FLR) should be considered when major hepatectomies are planned. The decision for preoperative portal vein embolization should be made based on the extent of hepatectomy along with the quality and size of FLR, similar to open and laparoscopic techniques.

Operating room setup and patient positioning

As with all liver resections, the patient should have appropriate intravenous access and monitoring devices. It is important to have appropriate communication with the anesthesiologist to maintain the low central venous pressure intraoperatively to limit blood loss. A urinary catheter should be inserted, and the urine output carefully monitored. Sequential compression devices should be used to minimize venous stasis.

The optimal operating room setup should be streamlined to accommodate any equipment that may be required during the surgery. Preparation for possible complications should be undertaken, and it is prudent to ensure that equipment for conversion to an open procedure is available and accessible, should it be required.

The positioning and port placement described in this chapter are for the da Vinci Xi platform (Intuitive Surgical, Sunnyvale, CA, USA). We prefer to maintain the supine position for almost all robotic hepatectomies. This minimizes the possibility of arm collisions when allowing access to critical hepatic anatomic landmarks. A bean bag can be employed to maintain secure and safe positioning. Care should be taken to position and pad the patient appropriately to avoid inadvertent positional injury.

Operative steps

Port placement

Initial abdominal entry can be obtained via either open or closed techniques. We prefer a limited 2–3 cm Pfannenstiel incision with open entry into the peritoneal cavity. Next, a GelPOINT mini (Applied Medical, Rancho Santa Margarita, CA) is placed through the incision and a 12-mm AirSeal (Conmed, Utica, NY) device is placed through it. In our experience, the Airseal device (or any similar high-flow cannula) is essential to robotic hepatectomies as it allows for excellent smoke evacuation while maintaining an adequate pneumoperitoneum. In our practice, it also serves as the only assist port for the case. The 12-mm port allows for exchange of gauze sponges and sutures while maintaining the ability to be used as an active assist arm. Four ports are then placed across the mid-abdomen, each spaced 8–10 cm apart, approximately at, or just above, the level of the umbilicus. The distance from the costal margin can be more reliable in obese patients.

In our routine port placement ( Fig. 29.1 ), Arm #1 is an 8-mm port in the right anterior axillary line. We utilize a bipolar grasper through this port. Arm #2 is also an 8-mm port that serves as the camera port and is in the right paramedian location. Arm #3 is a 12-mm port that can be used as a stapler port and is placed in the left paramedian position. Arm #4 is an 8-mm port and is placed around the left anterior axillary line, slightly closer to the costal margin. This is used as an active robotic retractor arm and we prefer to use the tip-up grasper, as its long atraumatic jaws are ideal for gentle retraction and maneuvering of the liver during the case.

The da Vinci Xi surgical robot can approach and dock from either side depending on the accommodations of the operating room. The operating table is then moved to a 10–15-degree reverse Trendelenburg position. A lateral tilt can also be used if needed.