Page 76 - Read Online

Page 12 of 15 Ruzzenente et al. Mini-invasive Surg 2020;4:91 I http://dx.doi.org/10.20517/2574-1225.2020.90

In conclusion, in the era of MIS in which surgical innovations are increasing, even if the younger surgeons
are more confident with MIS, both open and laparoscopic surgical experiences are necessary in order to
shorten the learning curve of robotic liver surgery and all the surgeons should receive specific training for
RS.

Even though robotic liver surgery allows attainment of excellent oncologic results with adequate R0
margins, long-term outcomes are still lacking, probably because of the recent introduction of this
technique.

Regarding the type of liver resection, robotic LLS is considered inappropriate in comparison with the
laparoscopic one, which is actually the standard of care. In fact, while perioperative outcomes are similar,
costs are markedly higher for RS. On the contrary, complex cases could take advantages from RS, thus
increasing the rate of MIS.

Even for other type of resections, the results available in the current literature encourage the use of robotic
surgery in complex cases, for example for lesions located in postero-superior segments. Furthermore, many
studies reported easier management of major intraoperative complications, such as bleeding, that could
explain the lower rate of conversion compared with laparoscopy.

Among the comparative studies between MIS techniques, many of them reported a greater number of
major resections for robotic surgery. Some authors explained these results with the reduced difficulty of
robotic major hepatectomies in comparison with laparoscopy, allowing a potential increase of MIS in more
complex cases [24,40,41] .

One of the most relevant drawbacks of robotic surgery remain higher costs. Almost all the comparative
[23]
studies confirmed robotic perioperative higher costs with reduced postoperative ones . Even for this
reason, many authors encouraged the use of RS only in complex cases.

It is possible that the increasing spread of robotic surgery and the introduction of new robotic platforms
with industry competition could lead to a consistent reduction of these costs.

Regarding the application of the robotic approach in specific diseases, RS for HCC and liver metastases
achieved good results, allowing parenchymal sparing resections, even in difficult locations.

Furthermore, the robotic approach to biliary tumors seems to be the most promising application of
robotic surgery, because of the need for extensive lymph node dissection and of bilio-enteric anastomoses.
Currently, there are discordant opinions regarding hCCC, whereas robotic surgery for GBC can add
relevant benefits, increasing the rate of MIS without compromising oncologic results.

In conclusion, different techniques should be tailored to each patient, applying MIS when possible,
particularly in cirrhotic patients and in the context of liver transplantation [15,34] . Thus, in a modern
hepatobiliary center, both open surgery and MIS should be provided, including the robotic technique, in
[6]
order to safely deal with different liver diseases requiring complex procedures .

In the future the technological innovation could lead to more complete, less expensive and smaller robotic
systems with additional devices or software for RS, that could really change the actual scenario of MIS
overcoming many of the drawbacks of RS. For example, it could become possible to approach the operation
without the second surgeon, the equipment could be smaller, the docking could be easier and quicker and
costs reduced thanks to the market competition.