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Lai et al.                                                                                                                                                                                          Robotic hepatectomy for HCC

           Table 2: Advantages and disadvantages of conventional laparoscopic and robotic approaches
                            Conventional laparoscopic approach       Robotic approach
           Advantages       Well-developed technology                3-dimensional magnified view
                            Less start-up cost                       Good dexterity
                            Less maintenance cost                    7 degrees of freedom in movement
                                                                     Elimination of fulcrum effect
                                                                     Elimination of physiologic tremors
                                                                     Good in suturing
                                                                     Tele-surgery
                                                                     More ergonomic in working position
           Disadvantages    Loss of tactile feedback                 Total absence of tactile feedback
                            Compromised dexterity                    High start-up cost
                            Limited degrees of motion                Very expensive in maintenance
                            Fulcrum effect                           New technology with limited evidence
                            Magnification of physiologic tremors

           grade 3/4 complications were also significantly lower   laparoscopic hepatectomy, robotic surgical system
           (4.4% vs. 16.3%). The length of stay in the intensive   was developed to overcome the disadvantages
           care unit (ICU) was significantly shorter for patients   of conventional laparoscopic approach and hand-
           who underwent a robotic procedure (2.1 vs. 3.3 days).   assisted laparoscopic approach. When robotic system
           The mean operating time (293.4 vs. 256 min), 30-day   compared to conventional laparoscopic approach, the
           mortality (0% vs. 1.8%) and mean hospital stay (6.8 vs.   pros and cons of each approach were shown in Table 2.
           9.2 days) were similar in both groups. Robotic group   Robot-assisted laparoscopic partial hepatectomy
           had less overall morbidity, ICU, and hospital stay. This   was increasingly studied in recent years. Up till
           translates into decreased average costs for robotic   now, no randomized trials are available for robotic
           surgery. The mean total cost, including readmissions,   hepatectomy. All data have been reported as case
           was $37,518 for robotic approach and $41,948 for   series or nonrandomized comparative studies. Most
           open approach.                                     data were obtained from prospectively maintained
                                                              databases. Tables 3 and 4 showed the results of
           Based on current limited nonrandomized comparative   nonrandomized  comparative  studies  comparing
           studies, robotic approach has better perioperative   robotic and laparoscopic partial hepatectomy in
           outcomes, particularly blood loss and hospital stay,   patients with minor hepatectomies [18-25]  and in patients
           than open approach.                                with minor and major hepatectomies [26-29] . Although
                                                              the perioperative outcomes seemed to be similar
           Robotic vs. conventional laparoscopic partial      in both groups, the benefit of robotic approach has
           hepatectomy                                        been shown in several studies. The potential benefits
           Traditionally, conventional laparoscopic partial   included less open conversion rate, higher proportion
           hepatectomy can either be pure laparoscopic or hand-  of major hepatectomies and easier for resection of
           assisted laparoscopic approach. Techniques of hand-  those tumours located over superior and posterior
           assisted laparoscopic approach has been attempted   segments [22,26,28,30-33] .
           to bridge the gap between open and pure laparoscopic
           approach. The benefits of hand-assisted laparoscopic   Based on current nonrandomized comparative studies,
           approach in hepatectomy are: (1) facilitation in manual   robot-assisted laparoscopic partial hepatectomy
           retraction, which may be the best atraumatic tool; (2)   appears to be similar to conventional laparoscopic
           feasibility in assessing margins of resection with the   approach in terms of blood loss, morbidity, mortality
           use of tactile sensation; (3) safety in parenchymal   rate and hospital stay. Robot-assisted laparoscopic
           dissection laparoscopically; and (4) possibility of   hepatectomy  may  have  longer  operation  time.
           immediate hemostasis and prevents air embolism     However, the definition of operation time was variable.
           in case the hepatic vein is severed. Obviously, pure   Some authors refer to a “total operation time” and
           laparoscopic procedure is superior to hand-assisted   specify an included “robot set-up and docking time”,
           approach in terms of wound pain, and cosmetic      whereas others refer to a “procedure time” with a
           outcome as hand-assisted laparoscopic hepatectomy   separate “system time” (from positioning the robot
           usually required a 6-8 cm incision for the placement   over the patient to disconnection of the robot) and
           of the hand-port. Another possible disadvantage    “dissection time” (surgeon’s active time at the console);
           of hand-assisted laparoscopic approach includes    others calculate the time from “induction of anesthesia
           possible obstruction of the visual field by the surgeon’s   to incision” or from “incision to extubation”. However,
           hand during the operation. Based on the platform of   robotic approach is more expensive than laparoscopic
           the development and experiences of conventional    approach.

            280                                                                                                     Hepatoma Research ¦ Volume 3 ¦ November 27, 2017
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