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Lai et al.                                                                                                                                                                                          Robotic hepatectomy for HCC

           Table 1: Potential advantages of MIS approach of   costs for HCC.
           hepatectomy
           Operation                      Recovery            Studies were identified by searching MEDLINE and
           Improved visualization  Less postoperative pain    PubMed databases for articles from January 2004
           Reduced blood loss   Earlier mobilization          to June 2017 using the keywords “laparoscopic
           Reduced blood transfusion  Improved perioperative lung function  hepatectomy”, “robotic surgery”, “robotic hepatectomy”,
           requirement          Fewer wound complications
           Less intra-abdominal   Reduced perioperative immune   and “hepatocellular carcinoma”. Case reports were not
           adhesion formation   suppression                   included.
                                Improved cosmetic outcome
                                Shorter recovery time
                                Shorter hospital stay         PERIOPERATIVE OUTCOMES
                                Decreased ascites in patients with
                                portal hypertension
                                                              Robotic vs. open partial hepatectomy
           MIS: minimally invasive surgery
                                                              Three nonrandomized comparative studies
           in 2014, respectively [3,4] . The jury in the second   compared robotic and open partial hepatectomy [15-17] .
                                                                        [15]
                                                                           from Italy compared outcomes between
                                                              Patriti et al.
           consensus meeting concluded that minor laparoscopic   robotic partial hepatectomy (n = 19) and open (n = 69)
           hepatectomy should be a standard practice, and major   partial hepatectomy at 2 centers for lesions in the right
           laparoscopic hepatectomy is still in exploration phase.   posterior section between January 2007 and June
           Continued cautious introduction of laparoscopic major   2012. Matched patients undergoing robotic and open
           hepatectomy was recommended. In a recent review,   partial hepatectomy showed no significant differences
           over 9,000 cases of laparoscopic hepatectomies     in blood loss (376.3 vs. 457.5 mL), intraoperative
           were performed worldwide, and 65% of cases were    transfusion rate (31.6% vs. 15%), postoperative
                                           [5]
           performed for malignant pathologies .              transfusion rate (10.5% vs. 7%), mean hospital stay
                                                              (6.7 vs. 7.9 days), overall complication rate (15.8%
           The recent introduction of robotic surgical systems has   vs. 13%) and mortality rate (0% vs. 0%). According
           given a new face of MIS. It was developed to overcome   to the Clavien-Dindo classification, major (grades
           the disadvantages of conventional laparoscopic     2-4) complications were not significantly different
           surgery. Well-known advantages of the robotic system   between the 2 groups (5.3% vs. 1.4%). Robotic group
           such as improved vision via three-dimensional view,   had significantly longer mean operative time (303 vs.
           magnification, tremor suppression, and the flexibility   233 min) and inflow occlusion time (75 vs. 29 min)
           of the instruments have allowed precise operating   compared with open group. In malignancies, tumor-
           techniques in a variety of procedures in general   free margin rates were similar in both groups (R1
           surgery. These features allow the surgeons to perform   resections, 10.5% vs. 9%). Kingham et al. [16]  from
           delicate tissue dissection and precise intra-corporeal   United States compared outcomes between robotic
           suturing. The main drawback of robotic system is the   partial hepatectomy (n = 64) during 2010-2014 and
           associated cost.                                   open (n = 64) partial hepatectomy during 2004-2012. In
                                                              the robotic group, 41% were segmental and 34% were
           Hepatocellular carcinoma (HCC) is the sixth most   wedge resections. There was a 6% open conversion
           common malignancy worldwide and the most common    rate. There was a significant shorter median operating
           primary liver cancer. Over 80% of cases HCC grown   time (163 vs. 210 min), lower median estimated blood
           in a cirrhotic liver [6,7] . In view of the benefit of MIS,   loss (100 vs. 300 mL), and shorter median hospital
           minimally invasive approach for HCC treatment is   stay (4 vs. 7 days) in robotic group. The complications
           increasing continuously adopted [8-11] . The postoperative   rates (10.9% vs. 14.1%) and mortality rates (3% vs.
           course after MIS approach of partial hepatectomy   1.6%) were similar in both groups. Eleven of the
           may also be improved in patients with liver cirrhosis   robotic operations were isolated resections of tumors
           because the abdominal wall is preserved, kinetics of   in segments 2, 7, and 8. The resection margins of
           the diaphragm is improved, collateral venous drainage   the malignant tumors were similar using both groups.
           is better and there is less postoperative ascites.   Margins > 10 mm were found in 16% of robotic group
           Systematic reviews or meta-analyses suggests that   and 17% of open group. Daskalaki et al. [17]  from United
           laparoscopic partial hepatectomy of HCC is safe    States compared robotic (n = 68) and open partial
           and can provide improved patient outcomes when     hepatectomies (n = 55) during 2009-2013. There was
           compared to the open approach [12-14] . Herein, we review   an 8.8% open conversion rate. Mean estimated blood
           the literature to compare robotic partial hepatectomy to   loss was significantly less in the robotic group (438 vs.
           conventional laparoscopic or open partial hepatectomy   727.8 mL). Overall morbidity was significantly lower
           in terms of perioperative, oncologic, and healthcare   in the robotic group (22% vs. 40%). Clavien-Dindo

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