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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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