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Page 4 of 5 Sammarco et al. Mini-invasive Surg 2019;3:31 I http://dx.doi.org/10.20517/2574-1225.2019.33

One of the main data available reading this review, is the pauperism of cases of synchronous resection.
Only few series described resection for colorectal liver metastasis, most of them described as wedge
resection. In all literature, only 8 case on 85 describe simultaneous resection, demonstrating that the
synchronous approach still remains limited to few cases, despite the technical advantage of robotic
surgery. As described in our paper, few synchronous procedure were performed, with two main
limitations evidenced by the data, evidencing the difficulties to perform synchronous resection with major
hepatectomies (only one series describe 13.5% of major resection) and to perform colorectal anastomosis,
due to the higher risk of anastomotic leak in patients who underwent pedicle clamping for control of
bleeding during liver resection.

In synchronous resection, usually liver resection anticipates colon resection. The management of bleeding
remains a priority in this kind of resection and prolonged portal vein occlusion should be avoided in
order to reduce the risk of damage the colonic anastomosis [6,13] : the prolonged vascular clamping leads
to the transient portal hypertension with edema of the intestinal mucosa, responsible of the colorectal
[14]
anastomotic failure , so the use of the intermittent Pringle’s maneuver has to be carefully shrewd.

Another important data evidenced by review is that despite an augmented duration of surgery due to the
necessity to perform synchronous operation, operative time still remains acceptable and comparable to
laparoscopic, non-impacting the length of stay.

[15]
Conversion rate still remains low, comparable to laparoscopic series , confirming how the augmented
dexterity probably associated to the high selection of patients guarantee a reduced rate of conversion.

Postoperative morbidity and mortality are acceptable, confirming the data reported by minimally invasive
[11]
surgery. In the series of Dwyer et al. , an anastomotic leakage is described, and this event strongly impact
postoperative course due to the necessity of reoperation, questioning the risk of performing the colorectal
anastomosis during synchronous resection.

Even if more studies are still required to define the oncologic outcome, RAS seems also expendable in
a one-stage minimally invasive approach for the treatment of the simultaneous resection of primary
colorectal neoplasm with synchronous liver metastases, showing advantages over conventional surgery in
terms of postoperative short-term couse .
[14]
Nowadays, the benefit of the robotic approach on the laparoscopic one is still a matter of debate, because
of the heterogeneity of patients and the lack of long-term outcomes. This paucity of data makes difficult to
draw a conclusion but, based on the few data available in this review, synchronous robotic liver and colic
resection seems feasible in highly selected cases.

DECLARATIONS
Authors’ contributions
Contributed to the concept and writing of the paper: Sammarco A
Contributed to the writing and revision of the paper: de’Angelis N, Testini M
Contributed to the writing and editing of the paper: Memeo R

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.