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Multivisceral Resection in Robotic Liver Surgery: Comparison
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Please note this is a comparison between Version 2 by Vicky Zhou and Version 4 by Vicky Zhou.

Minimally invasive surgery techniques are expanding in utilization in liver resections and now include robotic approaches. Robotic liver resection has been demonstrated to have several benefits, including surgeon ergonomics, wrist articulation, and 3D visualization. Similarly, for multivisceral liver resections, the use of minimally invasive techniques has evolved and expanded from laparoscopy to robotics.

  • minimally invasive surgery
  • robotic
  • liver surgery
  • liver resection
  • hepatectomy

1. Introduction

With the wide adoption of minimally invasive surgery (MIS) for various operations, the utilization of laparoscopic and, eventually, robotic approaches has steadily increased in liver surgery. Compared to open liver surgery, MIS approaches have been demonstrated to have a faster recovery time with fewer short-term complications [1][2]. Importantly, these advantages in recovery over open surgery are not gained at the expense of oncologic outcomes, which remain similar for robotic surgery of both primary and metastatic liver tumors [3]. While initial perioperative costs are greater for robotic surgery, the total cost for robotic surgery is similar or decreased compared to open surgery [4][5]. When comparing MIS approaches, robotic liver surgery has been demonstrated as feasible and safe compared to laparoscopy [6]. Long-term oncological outcomes, including overall and disease-free survival for primary hepatobiliary malignancies and metastatic colorectal cancer (CRC), are comparable when a robotic approach is used versus both open and laparoscopic techniques [7][8]. While maintaining similar benefits of reduced hospital length of stay and short-term complications to laparoscopy as an MIS technique, notably, robotic surgery has several advantages over laparoscopy including surgeon ergonomics, three-dimensional visualization with the robotic camera, and the ability to articulate wrists using robotic equipment.

2. Combined Hepatic and Colorectal Resection for Synchronous Colorectal Liver Metastases

A common indication for hepatectomy is CRC metastatic to the liver. Once considered only for palliative chemotherapy, patients with CRC liver metastases (CRCLM) undergoing resection of metastatic lesions now experience a 5-year survival of about 25–51% and a 10-year survival of 17–36% [9]. Many of the patients treated by hepatectomy are cured. Simultaneous open operative resection of synchronous CRCLM with a primary CRC tumor has been demonstrated to be safe and feasible in select patients and have favorable outcomes than staged operations [10][11]. Analysis of the LiverMetSurvey demonstrated that simultaneous resection of liver metastases and the CRC primary tumor has similar morbidity and survival for low-complexity hepatic resections, while a liver-first approach had a survival advantage only when the hepatic metastases were multiple and bilobar [10]. A randomized trial (METASYNC) of simultaneous versus delayed resection of liver metastases after resection of CRC showed improved 2-year survival in the simultaneous resection group without statistically significant differences in complication rate [11]. Synchronous colorectal and liver resection has also been demonstrated to be safe and feasible in well-selected patients via a laparoscopic MIS approach [12]. Oncologic outcomes included one positive R1 margin, and median OS was 27.5 months. Overall, the published data (summarized in Table 1) on combined colorectal and liver resections using robotic techniques demonstrate an acceptable operative time and estimated blood loss (EBL) with minimal severe complications and a low mortality rate.
Table 1. Summary of simultaneous robotic hepatic and colorectal resections for synchronous CRCLM.
Study Cases Liver Resection Colorectal Resection Operative Time (min) EBL (mL) length of stay (LOS) (Days) Conversions Complications Other
Choi (2008) [13] 1 Segment 3 LAR 360 300 6 0 0  
Calin (2016) [24] NET NR DP, splenectomy 369 100 NR NR  
Sunil (2017) [14] 1
Bhat (2020) [25] NETSegment 4a/8 Recto-sigmoid 390 Non-anatomic resection 2 lesions, ablation of multiple lesions DP, splenectomy, gastrectomy, cholecystectomy300 6 0 0 420pT3N1bM1a
400 4 None R1 resection Morelli (2017) [15] 3 NR AR
Villano (2020) [26360–480 200 6 0 0  
] ACC Non-anatomic segment 6 DP, splenectomy NR NR 2 None Disease free at 6-month follow up Eu (2018) [16] 1 Segment 2/3
Konstantindis (2020) [22] PDALAR 300 10 Partial segment 3 DP, splenectomy2 0 0  
NR NR 5 None Negative margins Dwyer (2018) [17] 6 4 multiple Seg 3 LAR,

1 RC,

2 APR		 401 316
Konstantindis (2020) 4.5 [22]0 3 1 anastomotic leak,

2 abscesses
RCC Segment 7 Retroperitoneal mass resection NR NR 3 None Negative margins, BMI 50.4 Soh (2019) [18] 4 NR NR 399 281 9.6 0 NR  
Navarro (2019) [19] 12 1 RH, 1 LH,

1 LLS, 1 CL, 1 ALPPS,

1 Seg,

5 wedge resections		 7 LAR,

2 AR,

2 RC,

1 LC		 449 274 NR 0 5 1 anastomotic leak,

2 abscesses
Giovannetti (2019) [20] 5 1 LLS, multiple Seg of 2, 3, 4, 6, 7 2 LAR, 2 RC, 1 APR 439 150 5 0 3 1 ICU, 1 cellulitis, 1 ileus; All margins negative
Masetti (2020) [21] 1 ALPPS LC NR NR NR 0 NR  
Konstantindis (2020) [22] 1 Segments 5 and 6 partial hepatectomies RC NR 50 8 0 Ileus Negative margins, 0/17 positive LN
Ceccarelli (2021) [23] 28 20 wedge,

5 Seg, 1 LLS, 1 RH, 1 LH		 9 RC,

7 LC,

10 LAR,

1 sigmoid, 1 APR		 332 143 8 2 3 grade III-IV 1 R1 margin

Median OS 27.5 months
NR, not reported; AR, anterior resection; LAR, low anterior resection; RC, right hemicolectomy; LC, left hemicolectomy; APR, abdominoperineal resection; ALPPS, associating liver partition and portal vein ligation for staged hepatectomy; RH, right hepatectomy, LH, left hepatectomy; Seg, segmentectomy; LLS, left lateral sectionectomy; CL, caudate lobectomy.

 

3. Combined Hepatic and Other Abdominal Solid Organ Resection

With growing experience and adoption of robotic distal pancreatectomy, several authors have published combined pancreatectomy and hepatectomy. Calin et al. [24] published the first case report of a combined robotic distal pancreatectomy and hepatectomy for neuroendocrine tumor (NET) metastatic to the liver. The operative time for this combined procedure was 369 min with an EBL of 100 mL. In 2020, Bhat et al. [25] also reported a robotic distal pancreatectomy, splenectomy, sleeve gastrectomy, cholecystectomy, and resection plus ablation of multiple liver lesions for well-differentiated NET with a 4-day hospital LOS. Villano et al. [26] also report a patient with acinar cell carcinoma of the pancreas who underwent neoadjuvant chemotherapy followed by robotic distal pancreatectomy, splenectomy, and non-anatomic resection of segment 6. The LOS following the operation was 2 days with no complications, and pathology revealed negative margins. TheOur group has performed a combined distal pancreatectomy, splenectomy, and partial segment 3 resection for pancreatic ductal adenocarcinoma [22]. The pathology from this tumor was pT2N0 with negative margins, 12 negative lymph nodes, and no viable cancer in the liver lesion. The patient had no readmissions or other complications at 13 months of follow-up.
In addition to pancreatectomy, theour group has performed multivisceral resection, which may be indicated for other primary cancer, such as renal cell carcinoma (RCC). HereinWe have also reported a combined robotic debulking and resection of multiple intraabdominal and retroperitoneal masses with a segment seven resection and cholecystectomy for recurrent, metastatic RCC [16]. The patient’s pathology showed three RCC metastases (1–3.2 cm) resected with negative margins, three negative lymph nodes, and chronic cholecystitis. The patient also had no readmissions or other complications at 23 months of follow-up. These cases illustrate the feasibility of multivisceral robotic resection of pancreatic or other intraabdominal resections in combination with hepatic resection.
Table 2 displays a comparative summary of simultaneous robotic liver resection and other abdominal resection.
Table 2. Summary of simultaneous robotic hepatic and non-colorectal resections for synchronous CRCLM.
Study Pathology Liver Resection Other Resection Performed Operative Time (min) EBL (mL) LOS (Days) Complications Other
NR, not reported; NET, neuroendocrine tumor; ACC, acinar cell carcinoma; PDA, pancreatic ductal adenocarcinoma; DP, distal pancreatectomy.
 

4. Combined Hepatic and Extra-Abdominal Resection

To date, there is one published case of a hepatic resection combined with an extra-abdominal thoracic resection. Xu et al. [27] report a 59-year-old man diagnosed with a cT3N0 rectal adenocarcinoma with solitary liver and lung metastases who underwent combined lung, liver, and rectal resections using robotic approaches for each. In this case, a right lower lobe wedge resection of the lung was carried out first, followed by repositioning the patient supine and segmental hepatectomy of the liver metastasis. Finally, the patient was placed in a modified lithotomy position. Anterior resection of the rectum with a distal staple line of 5 cm from the anal verge and a primary anastomosis were performed. The lung resection was performed in 30 min, the liver resection in 270 min, and the rectal resection in 90 min; in total, the procedure was completed in 480 min when including docking time of 90 min in addition to the console time of 390 min. EBL was 600 mL, and the patient had an uneventful postoperative course with LOS of 7 days. The final pathology was pT3N1M1, with all margins negative. In a highly selected patient, this case report illustrates the ability to perform three simultaneous operations as a one-stage procedure with a short overall recovery time, with the limitation of prolonged operative time for multiple instances of repositioning and re-docking the robot.

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