ASO Author Reflections: The Role of the Robot in Liver Surgery: An Evolution in Progress

PAST

For years, hepatopancreatobiliary surgery stood as a final frontier for minimally invasive surgery (MIS). As experience with laparoscopic hepatectomy has grown and solidified in the last decade, the benefits of MIS observed for other disease sites have likewise been realized in the field of liver surgery.^1–3 These benefits include shorter hospital stay, reduced pain medication requirement, earlier recovery to baseline function, and more timely return to intended oncologic therapy.^1–4 More recently, surgeons have expanded the application of the robotic platform to include the performance of liver surgery. The current report details some of the advantages this technology offers surgery for liver tumors.⁵

PRESENT

The robot can be a useful tool for the management of both benign and malignant liver pathology. This report demonstrates resection of a single colorectal liver metastasis in segment 8 of the liver using the robot.⁵ In choosing an approach for hepatectomy, clinicians should weigh the benefits and limitations of each surgical approach. Although liver resection can be approached safely through a laparotomy, a minimally invasive approach offers several benefits that have previously been demonstrated, with appropriately maintained oncologic principles. In selecting an MIS technique for hepatectomy, the authors preferentially use the robotic platform for lesions in the superior segments of the liver, for multifocal tumors located in disparate parts of the liver that would require an increased number of laparoscopic ports and/or patient repositioning with laparoscopy, and for any resection with anticipated bile duct reconstruction. An additional important consideration is coordination of the approach in dealing with synchronous resection of other intraabdominal tumors, including the primary tumor. The authors find that the robotic camera’s stable stereoscopic vision and wristed movements add to the precision of resection and ease of suturing when necessary. The surgeon can compensate for the loss of haptic feedback by minding visual feedback, by careful review of high-quality preoperative imaging, and by liberal use of intraoperative ultrasound, as demonstrated in this video report.⁵ Ultimately, the choice of surgical approach must balance the patient’s overall clinical status, the biology and location(s) of the tumor(s), and the surgeon’s technical comfort and ability to perform a margin-negative resection safely.

FUTURE

Partial hepatectomy is an established and essential tool in the treatment of secondary hepatic neoplasms. Moving forward, the approach chosen for performing the hepatectomy must be framed in the context of improving locoregional therapies and the burgeoning field of immuneoncology. As adjunctive therapies improve, the number of patients who stand to benefit from resection of their hepatic malignancies will continue to increase. The decision to use robotic or laparoscopic resection, however, remains a subjective one. Further work is needed to quantify the benefits of robotic hepatectomy and weigh them against the platform’s cost.⁶ Although a randomized trial comparing techniques may not be possible given the multifactorial decision-making in selection of a technique for each unique patient, the authors believe that the robot expands the options for minimally invasive hepatectomy and may ultimately allow for a greater proportion of patients to receive the benefits of MIS. Regardless of the preferred approach, it remains true that the treatment of advanced primary or secondary hepatic malignancies should involve a multi-disciplinary team well versed in available contemporary systemic, locoregional, and surgical methods of treatment.