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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