Abstract
Background
Blood loss is a major determinant of outcomes following hepatectomy. Robotic technology enables hepatobiliary surgeons to mimic open techniques for inflow control and parenchymal transection during major hepatectomy, increasing the ability to minimize blood loss and perform safe liver resections.
Methods
Initial experience of 20 consecutive major robotic hepatectomies from November 2018 to July 2020 at two co-located institutions was reviewed. All cases were performed with extrahepatic inflow control and parenchymal transection with the laparoscopic cavitron ultrasonic surgical aspirator (CUSA), and a technical description is illustrated. Clinical characteristics, operative data, and surgical outcomes were retrospectively analyzed.
Results
The median (range) patient age was 58 years (20–76) and the majority of 14 (70%) patients were ASA III–IV. There were 12 (60%) resections for malignancy and the median tumor size was 6.2 cm (1.2–14.6). Right or extended right hepatectomy was the most common procedure (12 or 60% of cases). There were 7 (35%) left or extended left hepatectomies and 1 (5%) central hepatectomy. The median operative time was 420 (177–622) minutes. Median estimated blood loss was 300 mL (25–800 mL). One (5%) case was converted to open. Two (10%) patients required blood transfusion. The median length of stay was 3 (1–6) days. Major complications included 1 (5%) Clavien–Dindo IIIa bile leak requiring percutaneous drainage placement. There was no 90-day mortality.
Conclusion
Advanced techniques to reduce blood loss in robotic hepatectomy may optimize safety and minimize morbidity in these complex minimally invasive procedures.
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References
Hallet J et al (2015) The impact of perioperative red blood cell transfusions on long-term outcomes after hepatectomy for colorectal liver metastases. Ann Surg Oncol 22(12):4038–4045
Bui LL et al (2002) Minimising blood loss and transfusion requirements in hepatic resection. HPB 4(1):5–10
Kooby DA et al (2003) Influence of transfusions on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases. Ann Surg 237(6):860–869
Melendez JA et al (1998) Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of postoperative renal dysfunction. J Am Coll Surg 187(6):620–625
Wang WD et al (2006) Low central venous pressure reduces blood loss in hepatectomy. World J Gastroenterol 12(6):935–939
Smyrniotis V et al (2004) The role of central venous pressure and type of vascular control in blood loss during major liver resections. Am J Surg 187(3):398–402
Gurusamy KS et al (2012) Cardiopulmonary interventions to decrease blood loss and blood transfusion requirements for liver resection. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD007338.pub3
Gurusamy KS et al (2009) Techniques for liver parenchymal transection in liver resection. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD006880.pub2
Sanjay P et al (2013) Meta-analysis of intermittent Pringle manoeuvre versus no Pringle manoeuvre in elective liver surgery. ANZ J Surg 83(10):719–723
Jarnagin WR et al (2002) Improvement in perioperative outcome after hepatic resection: analysis of 1803 consecutive cases over the past decade. Ann Surg 236(4):397–406
Buell JF et al (2009) The international position on laparoscopic liver surgery: the Louisville statement, 2008. Ann Surg 250(5):825–830
Nguyen KT, Gamblin TC, Geller DA (2009) World review of laparoscopic liver resection-2804 patients. Ann Surg 250(5):831–841
Ocuin LM, Tsung A (2015) Robotic liver resection for malignancy: current status, oncologic outcomes, comparison to laparoscopy, and future applications. J Surg Oncol 112(3):295–301
Giulianotti PC et al (2011) Robotic liver surgery: results for 70 resections. Surgery 149(1):29–39
Strasberg SM (2005) Nomenclature of hepatic anatomy and resections: a review of the Brisbane 2000 system. J Hepatobiliary Pancreat Surg 12(5):351–355
Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213
Vigano L et al (2009) The learning curve in laparoscopic liver resection: improved feasibility and reproducibility. Ann Surg 250(5):772–782
Chen PD et al (2017) Robotic versus open hepatectomy for hepatocellular carcinoma: a matched comparison. Ann Surg Oncol 24(4):1021–1028
Hawksworth J et al (2020) Robotic hepatectomy is a safe and cost-effective alternative to conventional open hepatectomy: a single-center preliminary experience. J Gastrointest Surg. https://doi.org/10.1016/j.hpb.2020.04.753
Eeson G, Karanicolas PJ (2016) Hemostasis and hepatic surgery. Surg Clin North Am 96(2):219–228
Spampinato MG et al (2014) Perioperative outcomes of laparoscopic and robot-assisted major hepatectomies: an Italian multi-institutional comparative study. Surg Endosc 28(10):2973–2979
Fruscione M et al (2019) Robotic-assisted versus laparoscopic major liver resection: analysis of outcomes from a single center. HPB 21(7):906–911
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Jason Hawksworth, Pejman Radkani, Brian Nguyen, Leonid Belyayev, Nathaly Llore, Matthew Holzner, Rodrigo Mateo, Erin Meslar, Emily Winslow, and Thomas Fishbein have no conflicts of interest or financial ties to disclose.
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Hawksworth, J., Radkani, P., Nguyen, B. et al. Improving safety of robotic major hepatectomy with extrahepatic inflow control and laparoscopic CUSA parenchymal transection: technical description and initial experience. Surg Endosc 36, 3270–3276 (2022). https://doi.org/10.1007/s00464-021-08639-z
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DOI: https://doi.org/10.1007/s00464-021-08639-z